Transcript Medical issues for dental procedures

Systemic diseases for dental
procedures
นายแพทย์ เอลวิล เพชรปลูก
อายุรแพทย์ เฉพาะทางระบบทางเดินอาหาร
16/9/2010
Topics
• Antiplatelet and Anticoagulant therapy in
dental procedures
• Hypertension in dental procedures
• Diabetes in dental procedures
• Steroid treatment patient in dental procedures
• Chronic liver diseases in dental procedures
Antiplatelet
Antiplatelet and Anticoagulant in
dental procedures
• Antiplatelet Therapy for Prevention of Ischemic
Cardiovascular Events and Stent Thrombosis
• Management of Oral Anticoagulant Therapy
Antiplatelet Therapy for Prevention
of Ischemic Cardiovascular Events and
Stent Thrombosis
Recommendations for the prevention of stent thrombosis after
coronary stent implantation , at a minimum
• 1 month after bare-metal stent implantation patients should be
treated with clopidogrel 75 mg and aspirin 325 mg
• 3 months after sirolimus drug eluting stent (DES) implantation
• 6 months after paclitaxel DES implantation and ideally, up to 12
months if they are not at high risk for bleeding
Circulation. 2007;115:813-818.
Recommendations for the prevention of stent thrombosis
after coronary stent implantation , at a minimum
• Stent thrombosis most commonly occurs in the first month after
stent implantation
• In patients treated with DES, stent thrombosis occurred in 29%
of whom antiplatelet therapy was discontinued prematurely
Circulation. 2007;115:813-818.
Antiplatelet in dental procedures
• prospective study of single tooth extractions on patients
randomized to aspirin versus a placebo failed to show a
statistically significant difference in postoperative bleeding
• no well-documented cases of clinically significant bleeding after
dental procedures, including multiple dental extractions
Circulation. 2007;115:813-818.
Antiplatelet in dental procedures
• Clopidogrel was combined with aspirin and administered for
prolonged duration (up to 28 months), an absolute increase
(ranging from 0.4% to 1.0%) in major bleeding, compared with
aspirin alone
• Many procedures (eg, minor surgery, teeth cleaning, and tooth
extraction) can likely be performed at no or only minor risk of
bleeding or could be delayed until the prescribed antiplatelet
regimen is completed
Circulation. 2007;115:813-818.
Antiplatelet in dental procedures
conclusion
Unlikely occurrence of bleeding once an initial clot
has formed.
With local measures during surgery (eg,
absorbable gelatin sponge and sutures), there is
little or no indication to interrupt antiplatelet
drugs for dental procedures.
Circulation. 2007;115:813-818.
Ischemic Heart Disease: Dental
Management Considerations


Patient with stable angina can usually undergo routine
dental care safely
Patient with unstable angina is considered danger for
dental procedures,
angina is considered unstable if it is changing for the worse
in some parameter
 Angina is now occurring more frequently
 Angina appears at lower levels of exertion than in the past
 Angina requires larger doses of nitrates for relief
 Angina relief takes longer than in prior episodes
Ischemic Heart Disease: Dental
Management Considerations


In the past, myocardial infarctions, limit noncardiac surgical interventions
on these patients for at least 6 months.
Nowadays, early and rapid interventions, myocardial damage can be
minimal, no reason to delay even elective dental procedures.
Dent Clin N Am 50 (2006) 483–491
Anticoagulant
Anticoagulant in dental procedures
Clotting Cascade
Vitamin K-Dependent Clotting Factors
Vitamin K
VII
IX
X
II
Synthesis of
Functional
Coagulation
Factors
Warfarin Mechanism of Action
Vitamin K
Antagonism
of
Vitamin K
VII
IX
X
II
Warfarin
Synthesis of
Non
Functional
Coagulation
Factors
Anticoagulant in dental procedures
Warfarin: Indications
• Prophylaxis and/or treatment of:
– Venous thrombosis and its extension
– Pulmonary embolism
– Thromboembolic complications associated with AF and
cardiac valve replacement
• Post MI, to reduce the risk of death, recurrent MI, and
thromboembolic events such as stroke or systemic embolization
• Prevention and treatment of cardiac embolism
Antithrombotic Agents: Mechanism of Action



Anticoagulants: prevent clot formation and extension
Antiplatelet drugs: interfere with platelet activity
Thrombolytic agents: dissolve existing thrombi
INR Equation
(
)
Patient’s PT in Seconds ISI
INR =
Mean Normal PT in Seconds
INR = International Normalized Ratio
ISI = International Sensitivity Index
How Different Thromboplastins
Influence the PT Ratio and INR
Blood from a
single patient
Thromboplastin
Reagent
Patient’s Mean
PT
Normal
PTR
(Seconds)
(Seconds)
A
16
12
1.3
B
18
12
1.5
C
21
13
1.6
D
24
11
2.2
E
38
14.5
2.6
ISI
INR
How Different Thromboplastins
Influence the PT Ratio and INR
Blood from a
single patient
Thromboplastin
reagent
Patient’s Mean
PT
Normal
PTR
ISI
INR
(Seconds)
(Seconds)
A
16
12
1.3
3.2
2.6
B
18
12
1.5
2.4
2.6
C
21
13
1.6
2.0
2.6
D
24
11
2.2
1.2
2.6
E
38
14.5
2.6
1.0
2.6
INR: International Normalized Ratio




A mathematical “correction” (of the PT ratio) for differences in the
sensitivity of thromboplastin reagents
Relies upon “reference” thromboplastins with known sensitivity to
antithrombotic effects of oral anticoagulants
INR is the PT ratio one would have obtained if the “reference”
thromboplastin had been used
Allows for comparison of results between labs and standardizes
reporting of the prothrombin time
J Clin Path 1985; 38:133-134; WHO Tech Rep Ser. #687 983.
Skin bleeding time




Technical variability: Despite attempts at standardization, the test
remains poorly reproducible and subject to a large number of variables.
Technique-related factors include location and direction of the incision
The skin bleeding time does not necessarily reflect bleeding from any
other site.
The bleeding time may be within the normal range in VWD, and in aspirin
users
British Journal of Haematology, 2008, 140, 496–504
Guidelines for the management of patients on oral
anticoagulants requiring dental surgery
Summary of key recommendations
1. The risk of significant bleeding in patients on oral anticoagulants and with
a stable INR in the therapeutic range 2-4 (i.e. <4) is very small and the
risk of thrombosis may be increased in patients in whom oral
anticoagulants are temporarily discontinued. Oral anticoagulants should
not be discontinued in the majority of patients requiring out-patient dental
surgery including dental extraction (grade A level Ib).
British Committee for Standards in Haematology 2007
Guidelines for the management of patients on oral
anticoagulants requiring dental surgery
Summary of key recommendations
2. Recommendations: For patients stably anticoagulated on warfarin (INR 24) and who are prescribed a single dose of antibiotics as prophylaxis
against endocarditis, there is no necessity to alter their anticoagulant
regimen (grade C, level IV).
British Committee for Standards in Haematology 2007
Guidelines for the management of patients on oral
anticoagulants requiring dental surgery
Summary of key recommendations
3. The risk of bleeding may be minimised by:
a. The use of oxidised cellulose (Surgicel) or collagen sponges and
sutures (grade B, level IIb).
b. 5% tranexamic acid mouthwashes used four times a day for 2 days
(grade A, level Ib).
4. For patients who are stably anticoagulated on warfarin, a check INR is
recommended 72 hours prior to dental surgery (grade A, level Ib)
British Committee for Standards in Haematology 2007
Best evidence statement (BESt). Management of
warfarin therapy

It is recommended, for patients undergoing dental
extractions, consider use of tranexamic mouthwash or
epsilon aminocaproic acid mouthwash without interruption
of anticoagulation therapy
CHEST 2008 Anticoagulation Guidelines
The risk of thrombosis if anticoagulants are
discontinued

The risk of thrombosis associated with temporarily discontinuing
anticoagulants prior to dental surgery is small but potentially fatal.

In the review of Wahl, 5/493 (1%) patients undergoing 542 dental
procedures and in whom anticoagulants were withdrawn specifically for
surgery, had serious embolic complications of which 4 were fatal
Arch Intern Med 1998;158(15):1610-6.
The risk of major bleeding in patients undergoing
oral surgery if anticoagulants are continued

Metanalysis, comprising 2014 dental surgical procedures in 774 patients
receiving continuous warfarin therapy, undergoing single, multiple
extractions and full mouth extractions , included patients with an INR up
to 4.0, more that 98% of patients receiving continuous anticoagulants
had no serious bleeding problems.

Twelve patients (<2%) had postoperative bleeding problems that were
not controlled by local measures.

Major bleeding was rare (4/2012, 0.2%) for patients with a therapeutic
INR (<4) undergoing dental surgery.
Arch Intern Med 1998;158(15):1610-6.
Blood pressure in HT
Dental Management of Patients
with Hypertension
The seventh revision by the Joint National Committee on the Prevention,
Detection, Evaluation and Treatment of High Blood Pressure and is
known as the JNC-7 Report
Above which BP values should the dentist not
treat?

Many well-respected authors have published 180/110 for the absolute
cutoff for any dental treatment

In fact, this value may be too high for patients who have had previous
hypertensive-related organ damage, such as myocardial infarctions,
strokes, or labile angina.

Conversely, healthy patient with a negative medical history with values
around 200/110 may be treated without any perioperative complications.
Dent Clin N Am 50 (2006) 547–562
‘‘Risk assessment’’
Key in determining the likelihood of complications

Physical classification system of the American Society of
Anesthesiologists (ASA) has been in use since 1941.

The higher the ASA class, the more at-risk the patient is both from a
surgical and anesthetic perspective [31].
ASA Class I. A normal healthy patient
ASA Class II. A patient with mild systemic disease
ASA Class III. A patient with severe systemic disease
ASA Class IV. A moribund patient who is not expected to
survive without the operation
‘‘Risk assessment’’

Metabolic equivalent or METS, one MET is defined as 3.5 mL of
02/Kg/min

It essentially is a test of the patient’s ability to perform physical work.
1 to 4 METS: eating, dressing, walking around house,
dishwashing
4 to 10 METS: climbing at least one flight of stairs, walking
level ground 6.4 km/hr, running short distance, game of golf
>=10 METS: swimming, singles tennis, football
Dent Clin N Am 50 (2006) 547–562
‘‘Risk assessment’’

People with capacities of 4 METS or less are at high risk for medical
complications.

Those who can perform 10 METS or more are at very low risk.
Example; a person who is anxious with a BP 200/115 but can
perform 10 METS of work would likely have no problems with
a simple extraction.
Dent Clin N Am 50 (2006) 547–562
Algorithm for
treating the
hypertensive
dental patient.
The algorithm assumes
no other medical
contraindications such
as a recent stroke,
unstable dysrhythmias,
myocardial infarction, or
pregnancy.
Dent Clin N Am 50 (2006) 547–562
Blood sugar and DM
Dental Management of Patients
with Diabetes
American Diabetic Association (ADA)


Normal plasma glucose : FPG < 100mg/dL
Diagnosis of DM is the patient who presents with classic symptoms of
polyuria, thirst, weight loss, fatigue, visual blurring, and a FPG >126
mg/dL, or a random value of at least 200 mg/dL.
Dental Management of Patients with Diabetes
American Diabetic Association (ADA)



In the absence of these classic symptoms, glucose intolerance may exist
as impaired fasting glucose (IFG) when the FPG is between 100 and 125
mg/dL.
Plasma glucose of 140 to 199 mg/dL following OGTT defines impaired
glucose tolerance (IGT).
The classification of IFG and IGT is important because individuals with
IFG and IGT are at greater risk of developing diabetes and
atherosclerotic cardiovascular disease even if they do not develop DM
Glucose Control Study Summary
The intensive glucose control policy maintained a lower HbA1c by mean 0.9 %
over a median follow up of 10 years from diagnosis of type 2 diabetes with
reduction in risk of:
12%
25%
16%
24%
for any diabetes related endpoint
for microvascular endpoints
for myocardial infarction
for cataract extraction
p=0.029
p<0.01
p=0.052
p=0.046
21%
33%
for retinopathy at twelve years
for albuminuria at twelve years
p=0.015
p<0.001
UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:837-853.
Conclusion
The UKPDS has shown that intensive blood glucose control
reduces the risk of diabetic complications, the greatest
effect being on microvascular complications
UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:837-853.
Dental consideration in DM patient


Aspirin Therapy (for adults) – 75-162 mg/day as
primary and secondary prevention of cardiovascular
disease unless contraindicated.
Systemic complications from DM
 hypertension
 cardiodiovascular disease
 renal insufficiency
Basic guidelines for diabetes care. California Diabetes Program; 2008.
Performing dental procedures on diabetic patients

Main concern is
 to avoid acute incidents hyper
or hypo-glycemic comas
during the operation
 to secure a smooth post-operational course (wound healing
and infection)
Above which blood sugar level should the
dentist not treat?




No absolute cutoff value for any dental treatment (generally acceptable
value of 100-200mg/dl in elective minor procedures without NPO)
In fact, any level of blood sugar should be treated for abscess which
need drainage procedures, may be in case of periodontitis with poor
glycemic control
In well-controlled diabetes, probably no greater risk of postoperative
infection than is the nondiabetic
When surgery is necessary in the poorly controlled diabetic (random
blood sugar >200mg/dl), prophylactic antibiotics should be considered
Periodontal Treatment on Glycemic Control of
Diabetic Patients

Meta-analysis suggests that periodontal treatment leads to an improvement of
glycemic control in type 2 diabetic patients for at least 3 months (periodontal
therapy is favorable and can reduce A1C levels on average by 0.40% more than in
nonintervention control subjects)
Diabetes Care. 2010; 33; 421-427
Steroid
Steroid treatment patient in dental procedures

Secondary adrenocortical insufficiency (AI) results from the
administration of exogenous corticosteroids

In secondary AI, normal mineralocorticoid function is preserved and less
likely for patients to experience adrenal crisis than it is for patients with
primary AI.
Long term steroid treatment in medicine




Autoimmune disease; SLE, AIHA, ITP, RA,
vasculitis syndromes, nephrotic-nephritis
syndromes, AIH, IBD, autoimmune pancreatitis,
etc.
Allergic diseases; asthma
Post organ transplantation
Adrenal insufficiency; primary or secondary
Steroid treatment in dental procedures

Adrenal crisis, event can occur when a patient with AI ( most commonly in
the form of Addison’s disease), is challenged by stress (for example,
illness, infection or surgery), and, in response, is unable to synthesize
adequate amounts of cortisol and aldosterone.

Adrenal crisis is rare in patients with secondary AI, because the majority of
these patients have normal aldosterone levels
Steroid treatment in surgical procedures

Risk of adrenal crisis appears to be low in minor surgery

Majority of patients who regularly take the daily equivalent dose of steroid
(5-10 mg of prednisone daily) maintain adrenal function and do not require
supplementation for minor surgical procedures
 Minor surgical stress the glucocorticoid target is about 25 mg of
hydrocortisone equivalent on the day of surgery
 Moderate surgical stress the glucocorticoid target is about 50-75 mg/day of
hydrocortisone equivalent for 1-2 days
 Major surgical stress the glucocorticoid target is 100-150 mg/day of
hydrocortisone equivalent for 2-3 days
Who is at risk of experiencing adrenal crisis
during dental procedures?
Adrenal crisis is rare in dentistry
Patients receiving therapeutic doses of corticosteroids who undergo a
surgical procedure do not routinely require stress doses of
corticosteroids so long as they continue to receive their usual daily
dose of corticosteroid.
J Am Dent Assoc 2001;132;1570-1579
Arch Surg. 2008;143(12):1222-1226
Who is at risk of experiencing adrenal crisis
during dental procedures?
In patients who receive physiologic replacement doses of
corticosteroids, these patients are unable to increase endogenous
cortisol production in the face of stress
These patients require adjustment of their glucocorticoid dose
during surgical stress under all circumstances.
Arch Surg. 2008;143(12):1222-1226
Who is at risk of experiencing adrenal crisis
during dental procedures?
J Am Dent Assoc 2001;132;1570-1579
Cirrhosis
Chronic liver diseases in dental procedures

Potential for impaired hemostasis and bleeding diathesis due to
thrombocytopenia or reduced hepatic synthesis of coagulation factors

Increased risk of infection, or spread of infection
Chronic liver diseases in dental procedures

If any significantly abnormal result in platelet count, PT or INR is detected in
a patient with cirrhosis, medical consultation is recommended

Currently, no evidence-based data to support the recommendation that
patients with cirrhosis should have antibiotic prophylaxis before routine
dental procedures.