Systemic diseases for dental procedures

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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 Circulation 6 months after paclitaxel DES . 2007;115:813-8

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;115:813-8

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;115:813-8

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 Circulation. 2007;115:813-8 only minor risk of bleeding or

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;115:813-8

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

Ischemic Heart Disease: Dental Management Considerations  

In the past, myocardial infarctions, limit past, myocardial infarctions, noncardiac surgical interventions on these patients for at least 6 months. Nowadays, early and rapid interventions, myocardial damage can be minimal, no minimal, 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 KVitamin 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

Antithrombotic Agents: Mechanism of Action 

 

Anticoagulants: prevent clot formation and extension Antiplatelet drugs: interfere with platelet activity Thrombolytic agents: dissolve existing thrombi

INR Equation
ISI Patient¶s PT in Seconds 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 PT
(Seconds)

Mean Normal
(Seconds)

PTR 1 .3 1 .5 1 .6 2 .2 2 .6

ISI

INR

A B C D E

16 18 21 24 38

12 12 13 11 14.5 14.

How Different Thromboplastins Influence the PT Ratio and INR
Blood from a single patient
Thromboplastin reagent

Patient¶s PT
(Seconds)

Mean Normal
(Seconds)

PTR 1 .3 1 .5 1 .6 2 .2 2 .6

ISI 3 .2 2 .4 2 .0 1 .2 1 .0

INR 2 .6 2 .6 2 .6 2 .6 2 .6

A B C D E

16 18 21 24 38

12 12 13 11 14.5 14.

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 J Clin Path 1985; 38:133-134; WHO 1985; 38:133-134; #687 983 between labs and standardizes 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. TechniqueTechnique-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 outoutpatient 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 2-4) 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 British Committee anticoagulated on warfarin, for Standards in Haematology 2007 a check INR

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 etanalysis, 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% 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. 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 JNC-

Above which BP values should the dentist not treat? 

Many well-respected authors have well180/ 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 hypertensivehypertensive-related organ damage, such damage, as myocardial infarctions, strokes, or labile angina. Conversely, healthy patient with a negative medical history with valuesAm 50 (2006) 547 562 Dent Clin N  

µµRisk assessment¶¶ µµR
Key in determining the likelihood of complications 

Physical classification system of the American Society of Anesthesiologists 1941. (ASA) has been in use since 1941. The higher the ASA class, the more at-risk atthe patient is both from a surgical and anesthetic perspective [31]. [31]. 

Class I. A normal healthy patient ASA Class II. A patient with mild systemic disease ASA Class III. A patient with 
ASA

µµRisk assessment¶¶ µµR 

Metabolic equivalent or METS, one MET is METS, 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, METS: walking around house, dishwashing 4 to 10 METS: climbing at least METS: one flight of stairs, walking level ground 6.4 km/hr, running short distance, game of golf >=10 METS: swimming, singles >=10 METS: tennis, football

Dent Clin N Am 50 (2006) 547 562

µµRisk assessment¶¶ µµR 

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. risk. 
Example; 

a person who is anxious with a BP 200/115 but can perform 200/ 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 contraindicati ons such as a recent stroke, unstable dysrhythmias, myocardial infarction, or Dent Clin N Am 50 (2006) 547 562 pregnancy.

Blood sugar and DM

Dental Management of Patients with Diabetes
American Diabetic Association (ADA) 


Normal plasma glucose : FPG < 100mg/dL 100mg/dL Diagnosis of DM is the patient who presents with classic symptoms of polyuria, thirst, weight loss, fatigue, visual mg/dL, 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

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% for any diabetes related endpoint p=0.029 25% for microvascular endpoints p<0.01 16% for myocardial infarction p=0.052 24% for cataract extraction p=0.046 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 adults) 75and secondary prevention of cardiovascular disease unless contraindicated. 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

hypohypo-glycemic comas

during the operation  to secure a smooth post-operational course (wound healing postand 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 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 welldiabetes, greater risk of postoperative infection than is the nondiabetic When surgery is necessary in the poorly controlled diabetic (random blood sugar

Periodontal Treatment on Glycemic Control of Diabetic Patients 

MetaMeta-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 A1 40% than in nonintervention control subjects) 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, nephroticautoimmune 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 crisis, 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 AI, 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 (5 prednisone daily) maintain adrenal function and do not require supplementation for minor surgical procedures
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 50 Minor 

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 2001;13 J Am Dent Assoc dose of corticosteroid. Arch Surg. 2008;143(12

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 Arch Surg. 2008;143(12 surgical stress under all

Who is at risk of experiencing adrenal crisis during dental procedures?

J Am Dent Assoc 2001;13

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 evidencesupport the recommendation that patients with cirrhosis should have antibiotic prophylaxis before routine dental procedures. 

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