the yellow brick road to managing the medically complex...

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The Yellow Brick Road to Managing the Medically

Complex Patient:Complex Patient:

In search of Brains, Heart, and Courage

Lauren L. Patton, DDSProfessor, Department of Dental Ecology

UNC School of Dentistry May 13, 2011

Leading Teaching

C iCaring

“Toto, I have a feeling we’re not in Kansas anymore”• 21st century trends.

Aging US populationIncreasing diversity of US population C ti d h i diContinued chronic disease occurrence from tobacco useIncreased pharmaceutical research and developmentEpidemics of obesity, diabetes and arthritisEmerging and reemerging viral diseases

An Aging PopulationPercentage of U.S. Population over age 65

15

20

25

P l ti

ent

Projected

0

5

10

1930 1950 1970 1990 2000 2010 2030 2050

Population

Source: From Baby Boom to Elder Boom: Providing Health Care for an Aging Population. Washington, DC: Watson Wyatt Worldwide, 1996.

Perc

e

Year

Medical profile of a dental school patient population Ref: Radfar L, Suresh L. J Dent Educ 2007;71:682-6.

• The year: 2000• 1,041 consecutive patients seeking

comprehensive dental care at the School of Dental Medicine, SUNY Buffalo.Dental Medicine, SUNY Buffalo.

• Mean age: 52 years (SD±18)• Female to male ratio: 1.2 : 1 • More than half of the patients had one or more

systemic illnesses or were taking medication.

Disease categories and frequency of diseases in 1,041 SUNY Buffalo patients (yr 2000)

Disease Category % Types of DiseaseHypertension 22Allergy to medication 17Diabetes 14Osteoarthritis 13Dyslipidemia 10Cardiac disease 9 Angina, CHF, coronary bypass, heart murmur, mitral

valve prolapse, valve replacement, arrhythmia

Psych. disorders 9 Depression, others

GI disorders 8 Gastrointestinal reflux, diverticulitis, celiac disease, colitis, ulcer, pancreatitis, IBS, hiatus hernia

Respiratory disease 5 Asthma, emphysema

Musculoskeletal pain 3 Low back pain, chronic fatigue syndrome

Others at 0.8-2% frequency: Stroke, Seizure, Renal disease, Liver disease, Autoimmune disease, Malignancies, Miscellaneous others J Dent Educ 2007;71:682-6

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Medications used in 1,041 SUNY Buffalo patients at the time of dental visit (yr 2000)

Medication Class %Antihypertensives 35Pain medications 19Antidepressants 17Antidyslipidemic agents 10Antiplatelet medications 9Antiplatelet medications 9Thyroid hormones 8Bronchodilators 7Antacids 6Vitamins, Hypoglycemic agents, Cardiovascular drugs, Neurologic drugs

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Antibacterial prophylaxis, Bisphosphonates, Immunosuppressants, Estrogen and progesterone, Anticoagulants

1-4

J Dent Educ 2007;71:682-6

TEN LEADING CAUSES OF DEATH IN THE US• Heart disease is the leading cause of death of Americans 24 years

of age and older, 30.3% or 724,269 annual deaths are due to heart disease.

Heart DiDisease

North Carolina — Heart Disease Death Rates Total Population, Ages 35+, 1996 – 2000 Age-adjusted

Average (Annual)

Deaths per

100,000

Age-adjusted Average(Annual)

Deaths per 100,000State Rate 534

National Rate 536

TEN LEADING CAUSES OF DEATH IN THE US• Cancer is the second leading cause of death causing 23% or

538,947 deaths.

Cancer

28%

2010

28%15%

10%

5% Th id7%9%

14

5% Thyroid

3% Kidney & Renal Pelvis

5%

All Sites 100% 100% All Sites

3% Ovary

3% Leukemia

4%Kidney & Renal Pelvis 4%

Oral cavity & pharynx 3%

3%

4% Non Hodgkin’s Lymphoma

North Carolina Age-Adjusted Invasive Cancer Incidence Rates for the 10 Primary Sites with the Highest Rates

Rates are per 100,000 persons; age-adjustedage adjusted to the 2000 U.S. standard

population

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Diabetes Epidemic

23.6 million people in the United States (7.8% of the total population) have diabetes. Of these, 5.7 million are undiagnosed. (CDC, 2009) 4

5

6

7

th D

iabe

tes

10

12

14

16

18

20

iabe

tes

(Mill

ionsPercent with Diabetes

Number with Diabetes

Number and Percentage of U.S. Population with Diagnosed Diabetes, 1958-2008

0

1

2

3

1958 61 64 67 70 73 76 79 82 85 88 91 94 97 00 03 06

Year

Perc

ent w

i

0

2

4

6

8

10

Num

ber w

ith D

CDC’s Division of Diabetes Translation. National Diabetes Surveillance System available at http://www.cdc.gov/diabetes/statistics

2007 Age-Adjusted Estimates of the Percentage of Adults withDiagnosed Diabetes in NC

≥ 20 years old.

Arthritis

ArthritisBased on 2003-2005 data from the NHIS, an estimated46 million (22%) US adults have self-reported doctor-diagnosed arthritis.

19 million (9%) US adults have arthritis and arthritis-attributable activity limitation.

North Carolina (2007)29% of adults with arthritis

Adults with arthritis- 1,927,000; Adults limited by arthritis- 770,000

The New Epidemic: Obesity

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NC 28% obesity rate in 2007

Percent of Obese (BMI > 30) in U.S. Adults

2008 Age-Adjusted Estimates of the Percentage of Adults Who Are Obese in North Carolina

Buncombe: 22.2

McDowell: 33.8

Swain/Cleveland: 32.0

Haywood: 29.3

Henderson: 26.1

Madison: 26.6

≥ 20 years old. Obesity based on self-reported height and weight.

Emerging and Reemerging Viral Disease• Hepatitis C• HIV• West Nile• SARS• Bovine Encephalitis• Avian Influenza H5N1• Swine flu H1N1

Welcome to munchkin land! (Your Practice 2011)

• Congratulations! Along with Dorothy and Toto you have killed the Wicked Witch of the EastWitch of the East.

• Put on the Ruby Slippers, you are now ready for the journey.

Your Patient, Your Practice

• Medical Risk Assessment– Medical History– Review of Systems (patient

symptom report)symptom report)– Physical Exam

4 Key Considerations for Safe Dental Care

• Infection• Hemostasis• Drugs and drug interactions• Ability to withstand treatment/Stress

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InfectionEvidence and Expert based Recommendations for Systemic or Distant Site Infection Prevention

• 2007 AHA Guidelines: Prevention of Infective Endocarditis

• 2003/2010 AHA Scientific Statements: N l l C di l D i R l t dNonvalvular Cardiovascular Device-Related Infections, including Implantable Electronic Devices

• 2009 AAOS Information Statement: Antibiotic Prophylaxis for Bacteremia in Patients with Joint Replacements vs. 2003 ADA/AAOS Advisory Statement: Antibiotic Prophylaxis for Dental Patients with Total Joint Replacements

2007 AHA Guidelines for IE Prevention• History and Rationale

– AHA guidelines have been evolving for over 50 years (first published in 1955).

– Expert opinion has been the basis of guidelines; Additional research findings improved the evidence base; Prospective randomized controlled trials are still not available.

– Evolution that violates longstanding practice patterns and expectations.

– Fewer patients eligible for IE prophylaxis.

Source: Wilson W, et al. JADA 2007;138,739-60.

Primary reasons for revision• IE is much more likely to result from frequent exposure to

random bacteremias assoc. with daily activities than from bacteremia caused by a dental, GI tract, or GU tract procedure.

• Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in individuals who undergo a dental, GI tract, or GU tract procedure.tract, or GU tract procedure.

• The risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy.

• Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE.


2007 AHA Guidelines for IE Prevention• Major Changes/Conclusions for Evidence Review:

(1) Only an extremely small number of cases of IE might be prevented by antibiotic prophylaxis for dental procedures even if such prophylactic therapy were 100% effective.

(2) IE prophylaxis for dental procedures should be recommended only for patients with underlying cardiac conditions associated with the highest risk of adverse outcome from IE.

(3) For patients with these underlying cardiac conditions, prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of teeth or perforation of the oral mucosa.

(4) Prophylaxis is not recommended based solely on an increased lifetime risk of acquisition of IE.

(5) Administration of antibiotics solely to prevent endocarditis is not recommended for patients who undergo a genitourinary or gastrointestinal tract procedure.


Preventive antibiotics prior to a dental procedure are advised for patients with:

– artificial heart valves – history of infective endocarditis – certain specific, serious congenital (present from

birth) heart conditions, including • unrepaired or incompletely repaired cyanotic

congenital heart disease, including those with palliative shunts and conduitspalliative shunts and conduits

• completely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedure

• any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device

– cardiac transplant that develops a problem in a heart valve.


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Cardiac conditions no longer recommended for antibiotic coverage

• mitral valve prolapse • rheumatic heart disease• bicuspid valve diseasebicuspid valve disease• calcified aortic stenosis• congenital heart conditions such as

ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy


2007 AHA Guidelines for IE Prevention• Dental procedures for which prophylaxis is

recommended:– All dental procedures that involve manipulation of

gingival tissue or the periapical region of teeth, or perforation of the oral mucosa*

• * Dental procedures for which prophylaxis is p p p yNOT recommended:– routine anesthetic injections through noninfected tissue; – taking dental radiographs; – placement of removable prosthodontic or orthodontic

appliances;– adjustment of orthodontic appliances; – placement of orthodontic brackets; and – shedding of deciduous teeth and bleeding from trauma to the

lips or oral mucosa.


Regimens for a Dental ProcedureSituation Agent Regimen – Single Dose 30-60

minutes before procedure

Oral AmoxicillinAdults Children2 gm 50 mg/kg

Unable to take oral medication

Ampicillin or 2 g IM or IV* 50 mg/kg IM or IV

Cefazolin or ceftriaxone

1 g IM or IV 50 mg/kg IM or IV


ceftriaxone IV

Allergic to penicillins or ampicillin

Oral

Cephalexin**† or 2 g 50 m/kgClindamycin 600 mg 20 mg/kg

Azithromycin or clarithromycin

500 mg 15 mg/kg

Allergic to penicillins or ampicillin and

unable to take oral medication

Cefazolin or ceftriaxone†

1 g IM or IV 50 mg/kg IM or IV

Clindamycin phosphate

600 mg IM or IV 20 mg/kg IM or IV

*IM – intramuscular; IV – intravenous.**or other first or second generation oral cephalosporin in equivalent adult or pediatric dosage.†Cephalosporins should not be used in an individual with a history of anaphylaxis, angioedema, or urticaria with penicillins or ampicillin

When Guidelines Change: Communication with physicians and patients

• Physician:– Know and share the current guidelines. “The most

recent guidelines state…” “The current AHA guidelines state the risk benefit weighs against….” “We are not in the habit of… Are you OK with that?”OK with that?

– Who writes the prescription?• Patient:

– “More recent evidence shows…”– “Good news! There is no longer a need to require

antibiotics prior to your dental visits. The risks may not have changed but new recommendations of the AHA state that for patients like you there is no proven benefit from antibiotic premedication.”

2003/2010 AHA Scientific Statement: Nonvalvular Cardiovascular Device Infections

• 2003 Statement: – Prophylaxis for [dental] procedures in patients with indwelling

devices, is largely unstudied. – There is no convincing evidence that microorganisms associated

with [dental] procedures cause infection of nonvalvular vascular devices at any time after implantation.

– These infections are most often caused by staphylococci, Gram-negative bacteria, or other microorganisms in association with implantation of the device or resulting from wound or other active infections.

– This committee does not recommend antibiotic prophylaxis after device placement for patients who undergo dental, respiratory, GI, or GU procedures.

• 2010 Statement:– Antibiotic prophylaxis is not recommended for dental or other

invasive procedures not directly related to device manipulation to prevent cardiovascular implantable electronic device infection.

–Sources: Baddour LM, et al Nonvalvular Cardiovascular Device–Related Infections. Circulation 2003;108:2015-31. Baddour LM et al Update on Cardiovascular Implantable Electronic Device Infections and Their Management. Circulation 2010;121:458-77.

2003/2010 AHA Scientific Statement: Nonvalvular Cardiovascular Device Infections

• Intracardiac Devices:– Pacemakers and Implantable Cardioverter-Defibrillators (focus of 2010 update)– Left Ventricular Assist Devices, Artificial Heart– Ventriculoatrial (CSF) Shunts– Devices for Patent Ductus Arteriosus, Atrial Septal Defect, and Ventricular

Septal Defect Occlusion

• Specific Devices—Arterial:– Peripheral Vascular Stents– Prosthetic Vascular Grafts– Hemodialysis Prosthetic Vascular Grafts– Intra-Aortic Balloon Counterpulsation Catheters– Coronary Angiography and Percutaneous Coronary Artery Intervention– Coronary Artery Stents– Vascular Closure Devices– Dacron Carotid Patches

• Specific Device—Venous:– Vena Caval Filters, e.g. Greenfield Filter

Source: Baddour LM, et al Nonvalvular Cardiovascular Device–Related InfectionsCirculation 2003;108;2015-31.

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Prosthetic Joints: Dental Management

• Current controversy surrounds the approach to antibiotic prophylaxis for total joint patients.

• We will review first the 2003 joint ADA/AAOS statement:– ADA & American Academy of Orthopedic Surgeons [AAOS],

Advisory Statement – Antibiotic prophylaxis for dental patients ith t t l j i t l t JADA 2003 134 895 9

politicsscience

with total joint replacements. JADA 2003;134:895-9.• We will review second the Feb 2009 unilateral AAOS statement:

– http://www.aaos.org/about/papers/advistmt/1033.asp• Discuss AAOM June 2010 advice on approaches to take until

controversy is resolved.– Little JW, Jacobson JJ, Lockhart PB, for AAOM. The dental

treatment of patients with joint replacements. A position paper from the American Academy of Oral Medicine. JADA 2010; 141: 667-71.

2003 ADA/AAOS Guidelines for Coverage of Prosthetic Joints• Rare cases of bacteremias causing

distant hematogenous seeding of joints, few from dental procedures or acute dental disease

• Recommended:• Recommended:– Dental exam and erradication

of acute oral infection prior to joint replacement and effective oral hygiene after surgery

– Vigorous treatment of acute orofacial infection in patients with total joint prostheses

Source: ADA & Amer Acad Orthopedic Surgeons, Advisory Statement. JADA 2003;134:895-9.

Prosthetic Joints: Dental Management for Infection Prevention

• Risk/benefit and cost/effectiveness ratios fail to justify routine prophylaxis

• Prophylaxis should be considered for patients at potential increased risk:

All patients during the first 2 years after joint replacementp g y j pImmunocompromised/immunosuppressed patients

inflammatory arthropathies: rheumatoid arthiritis, SLEdrug-,or radiation-induced immunosuppression

Patients with comorbidities: (these are examples only)Previous prosthetic joint infectionsMalnurishmentHemophiliaHIV infectionIDDMMalignancy


Incidence stratification of bacteremic dental procedures

Dental extractions Restorative dentistry w/ or w/o retraction cord

Periodontal procedures including surgery subgingival placement of antibiotic fibers, scaling &

root planing, probing, recall maintenance

Local anesthetic injections (nonintraligamentary and

nonintraosseous)

Dental implant placement and reimplantation of avulsed teeth

Intracanal endodontic treatment; post placement and

buildup

Higher Incidence Lower Incidence

Endodontic instrumentation or surgery beyond apex Placement of rubber dam

Initial placement of ortho bands but not brackets Postoperative suture removal

Intraligamentary and intraosseous local anesthetic injections

Placement of removable pros/ortho appliances

Prophylactic cleaning of teeth or implants where bleeding is anticipated

Taking of oral impressions

Fluoride treatments

Taking of oral radiographs

Ortho appliance adjustment


2003 ADA/AAOS Guidelines for Coverage of Prosthetic Joints• Suggested Antibiotic Prophylaxis Regimens:

– Patients not allergic to penicillin: • cephalexin (Keflex®), cephadrine (Velocef®), or

amoxicillin 2 g, 1 hr prior to appointment – Patients not allergic to penicillin and unable to

take oral medications:take oral medications: • cefazolin (Kefzol®) 1 g or ampicillin 2 g IM or IV 1

hour prior to the procedure– Patients allergic to penicillin:

• clindamycin 600 mg 1 hour prior to the dental procedure

– Patients allergic to penicillin and unable to take oral medications:

• clindamycin 600 mg IV 1 hour prior to the procedure


2003 ADA/AAOS Guidelines for Coverage of Prosthetic Joints

Antibiotic prophylaxis is not indicated for patients with

orthopedic pins,

plates or

screws


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Prosthetic Joints: Dental Management(Feb 2009 AAOS statement)

• “Given the potential adverse outcomes and cost of treating an infected joint replacement, the AAOS recommends that clinicians consider antibioticthat clinicians consider antibiotic prophylaxis for all total joint replacement patients prior to any invasive procedure that may cause bacteremia. This is particularly important for those patients with one or more of the following risk factors.”


• Patients at Potential Increased Risk of Hematogenous Total Joint Infection– All patients with prosthetic joint replacement. – Immunocompromised/immunosuppressed patients – Inflammatory arthropathies (e.g.: rheumatoid arthritis, systemic

lupus erythematosus) – Drug-induced immunosuppression – Radiation-induced immunosuppression – Patients with co-morbidities (e.g.: diabetes, obesity, HIV, smoking) – Previous prosthetic joint infections – Malnourishment – Hemophilia – HIV infection – Insulin-dependent (Type 1) diabetes – Malignancy – Megaprostheses


• Prophylactic antibiotics prior to any procedure that may cause bacteremia. (no suggested procedure risk stratification)

• Recommended antibiotic: cephalexin, cephradine, amoxicillin; 2 gm po; 1 hr prior to procedure (no alternatives for penicillin allergic patients)for penicillin allergic patients)

• Consultation with the patients’ orthopedic surgeon is recommended.

• Any perceived potential benefit of antibiotic prophylaxis must be weighed against the known risks of antibiotic toxicity, allergy, and development, selection and transmission of microbial resistance.

• Practitioners must exercise their own clinical judgment in determining whether or not antibiotic prophylaxis is appropriate.

Prosthetic Joints: Dental Management(June 2010 American Academy of Oral Medicine Position Statement)

Potential harms of the “antibiotic premedication (AP) for all with prosthetic joints” approach:

1. antibiotic resistant strains (S. viridansincreasing resistance in last decade)increasing resistance in last decade)

2. cost (antibiotic cost; cost of cancelled dentalvisits for arriving without AP)

3. risk of adverse drug event (anaphylaxis orother) from antibiotic use.

Estimated prevalence of prosthetic joints in the US=7,000,000. If 2 dental visits/yr, then 14,000,000 potential AP use. Single dose Amoxicillin ($4.26) x 14 million visits = $59.6 million/year for AP use for dental appointments.


• With all options: dentists should note in dental record the content of discussions with patients and other clinicians.

• Option 1: Dentist informs joint patient of lack of scientific evidence to support AP (antibiotic prophylaxis) and adverse pp ( p p y )potential drug reaction so patient can make informed decision. – Problem- patient confusion

• Option 2: Dentist bases clinical decision on 2003 ADA/AAOS consensus statement and literature since then.– Problem- potential medicolegal jeopardy if not contact

orthopedist for recommendations and follow them.


• Option 3 (preferred): Dentist contacts orthopedic surgeon, briefly discusses or outlines in a letter current dilemma and suggests they both follow the 2003 guidelines until a new joint consensus statement is approved. – If orthopedist wants to follow 2009 AAOS statement for patients

not covered by 2003 ADA/AAOS guidelines, he/she writes Rx– If dentist follows 2003 ADA/AAOS guidelines, he/she writes Rx.– RATIONALE: Contrast between lack of evidence for practice of

administering AP and real concerns about drug reactions, resistant bacterial strains, and costs to health care system.

– Problem- inevitable increase in phone calls or communication with orthopedists and possible conflict if orthopedist is asked to write Rx. Telephone conversations are considered a “gray” area should litigation arise.

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Hemostasis

Assess for inherited and acquired defects of hemostasis

• Known coagulation disorder e. g. Hemophilia or thrombocytopenia

• Systemic disease affecting hemostasis Li kid di l k ie.g. Liver or kidney disease, leukemia

• Medication usage e.g. coumarin (Coumadin®), clopidogrel (Plavix®), aspirin, heparin, long term antibiotic use

• Family history of clotting problems

Review of Systems Findings in the Bleeding Disorder PatientPrevious episode of excessive or prolonged bleeding following injury or surgeryEpistaxisEasy bruisingHeavy menstruationSpontaneous gingival bleeding

Physical Examination Findings in the Bleeding Disorder Patient

Skin and/or mucosaPetechiaeEchymosesPurpurap


Skin and/or mucosaSpider angiomas

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Skin and/or mucosaJaundiceHematoma


JointsHemarthroses

Hemarthrosis of elbow

Physical Examination Findings in the Bleeding Disorder PatientGingiva and teethBlood oozing from gingiva


Gingiva and teethHyperplastic/Hyperemic Gingiva

Hemosiderin-stained teeth

Bleeding Risk Assessment• Patient-related

– None – Mild – Moderate– SevereSevere

• Procedure-related– None (non-invasive)– Mild – Moderate– Severe

Surgical Hemorrhage Control

• Normal Control of Bleeding Involves Four Phases:Phases:

Vascular phasePlatelet phaseCoagulation phaseFibrinolytic phase

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Vascular phase• Mechanism

– Vasoconstriction in the area of injury

• Vascular Disorders– Elderly – Scurvy– Cushing’s syndrome– Hereditary hemorrhagic

telangiectasias– Ehlers-Danlos

Platelet phase• Mechanism

– Platelets and vessel wall become "sticky“

– Mechanical plug of platelets seals off openings of cut

lvessels– Begins seconds after injury

• Platelet Disorders– Thrombocytopenia– Thrombocytopathies– Platelet-type von

Willebrand’s disease

Coagulation phase• Mechanism

• Blood lost into surrounding area coagulates through extrinsic and common pathways

• Blood in vessels in area of injury coagulates through intrinsic and common pathways

• Coagulation Disorders• Inherited, e.g. hemophilia• Acquired, e.g.

coumarin/heparin drug-induced, liver failure

Metabolic (fibrinolytic) phase

• Mechanism– Release of antithrombotic

agents– Destroyed by spleen and liver

Fib i l ti Di d• Fibrinolytic Disorders– Inherited, e.g. deficiency of

alpha-2 antiplasmin– Acquired, e.g. liver cirrhosis,

acute promyelocytic leukemia

Local Measures to Control BleedingLocal Hemostatic Measures

Extended pressure with gauze compress, suturing, or surgical acrylic stentsAbsorbable hemostatic material (e.g. Avitene ®, Gelfoam ®, Surgicel ®, Collaplug®, ActCel® hemostatic gauze)Epinephrine containing local anestheticEpinephrine containing local anestheticTopical Thrombin, Fibrin glueElectrocautery

Local Measures to Control BleedingAntifibrinolytic Agents Mechanism: inhibition

of fibrinolysis by competitively inhibiting the activation of plasminogen to plasmin, hence fibrin degradation blocked

Epsilon-aminocaproic acid (EACA) (Amicar®, VersaPharm, Inc.)

25% (250mg/ml) syrup- 50 mg/kg body weight every 6 hrs x 7-10 days as swish and swallowevery 6 hrs x 7 10 days as swish and swallowTablet, adults, 5 gm, then 1-1.25 gm per hour for 8 hours.

Tranexamic acid (AMCA) (Cyklokapron®, Pharmacia & Upjohn)

Used in Europe as 4.8% oral solutionOnly tablet and IV injection forms available in US and CanadaTablet, 25 mg/kg body weight every 6-8 hrs, beginning one day before surgery and for 7-10 days.10 times stronger than EACA in vitro

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Drugs used– Aspirin– Plavix®– Aggrenox® (25mg

ASA and 200 mg dipyrimadole)

Prevention of

py )– NSAIDs– Heparin– LMWH– Warfarin

(coumarin;Coumadin®)

Natural Products– Ginkgo– Garlic– Vitamin E

Drugs used– Heparin– LMWHs

• Fragmin®I h ®

Prevention of

• Innohep®• Lovenox®

– Warfarin– Arixtra®

(fondaparinux sodium) sq Injection; inhibitor of activated FX

Does Warfarin need to be discontinued for the dental surgical procedure?

?“I don’t want my

patient to BLEED!”“I don’t want my

patient to CLOT!”

?X X

Procedure-related Risk Stratification for Bleeding Sequelae

Low Risk Dental Procedures:prophylaxis, scaling and root planing, restorative and prosthetic dental proceduresrestorative and prosthetic dental procedures, endodontic therapy, single extractions, simple biopsy

Higher Risk Dental Procedures:surgical procedures such as multiple extractions, alveoloplasty, tori removal, vestibuloplasty, periodontal surgery

Patient taking Warfarin: Individualized Risk Assessment

• Risk of bleeding:– Patient-related

• Coagulation defect from coumarin intensity

• Additional hemostatic defects

• Risk of thromboembolic complications:– Goal of anticoagulation therapy

defects– Procedure-related

Risk of Thromboembolic Stroke (Annual risk without anticoagulation)

• Low risk (<4% /year) conditions:– Atrial fibrillation without history of stroke– Cardiomyopathy without atrial fibrillation

• Moderate risk (4%-7% /year) conditions:– Mechanical aortic valve

• High risk (>7% /year) conditions:– Atrial fibrillation with history of stroke– Mechanical mitral valve– First 3 months after deep venous thrombosis

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Recommended therapeutic range for coumarin therapy

• Low-intensity (INR goal 2.5 with a range of 2.0 to 3.0)– Prophylaxis of venous thrombosis (high-risk surgery)– Treatment of venous thrombosis– Treatment of pulmonary embolism– Prevention of systemic embolism

Ti h t l– Tissue heart valves– Acute MI– Atrial fibrillation– Valvular heart disease

• High-intensity (INR goal 3.0 with a range of 2.5 to 3.5)– Mechanical prosthetic heart valves– Prevention of recurrent myocardial infarction– Treatment of thrombosis associated with antiphospholipid antibodies

Little JW, et al. Antithrombotic agents: Implications in dentistry. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2002;93:544-51.

True incidence of thrombotic complications from withdrawal of coumarin for dental procedures??? Few reported cases

Source, year Cessations for dental exts

Time of cessations

Patients with Complications

Akbarian et al, 1968

1 Not reported 1 fatal embolism

Behrman & Wright, 1961

1 Not reported 1 fatal cerebral thrombosis 17 d after d/c warfarin

Wahl MJ. Dental surgery in anticoagulated patients. Arch Intern Med 1998;158:1610-6. Wahl MJ. Myths of dental surgery in patients receiving anticoagulant therapy. JADA 2000;131:77-81.

g ,Marshall, 1963 1 9 days 1 fatal MI 19 d after d/c warfarin for 9 dOgiuchi et al, 1985

128 Dose ↓ 3-7 d preop then d/c

1 fatal cerebral thrombosis 5 d postop

Tulloch & Wright, 1954

13 4 d most cases 1 nonfatal cerebral emboli 8d after d/c warfarin

Multiple authors 1954-1998

431 1 d, up to 2 wks, not reported

none

Total 575 4 deaths, 1 nonfatal emboli

Approach to Patient Based on Procedure, Risk of Thromboembolism & Additional Hemostatic Defects

• Low risk for Bleeding Sequelae• Low, Moderate, and High Risk for

Thromboembolism– Mild-Moderate additional hemostatic defects


• Low risk for Bleeding Sequelae• Low, Moderate, and High Risk for

Thromboembolism– Mild-Moderate additional hemostatic defects

Use local measures.

No need to modify anticoagulant therapy as long as INR is in therapeutic range (e.g. <3.5).


• Higher risk for Bleeding Sequelae– Low Risk for Thromboembolism– Mild-Severe additional hemostatic defects*


• Higher risk for Bleeding Sequelae– Low Risk for Thromboembolism– Mild-Severe additional hemostatic defects*

Use local measures.

Withhold oral anticoagulation 2-3 days prior to surgery to allow INR to fall to 1.5-2.0. Check INR the morning of surgery. Resume oral anticoagulant therapy the day of surgery.

* severe hemostatic defect in platelets may require management

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• Higher Risk for Bleeding Sequelae– Moderate-Severe Risk for

ThromboembolismMild Severe additional hemostatic defects*– Mild-Severe additional hemostatic defects*


• Higher Risk for Bleeding Sequelae– Moderate-Severe Risk for

Thromboembolism– Mild-Severe additional hemostatic defects*

U l lUse local measures.

Withhold oral anticoagulation 2-3 days prior to surgery to allow INR to fall to 1.5-2.0. Consider treatment with subcutaneous LMWH or IV heparin while INR is subtherapeutic. Check INR the morning of surgery. Resume oral anticoagulant therapy the day of surgery.* severe hemostatic defect in platelets may require management

Bridging Therapy

BRIDGING: PRE & POST COUMADIN®: taken in eveningLow molecular weight heparin (LMWH): once/day

Couma-din®

PM Last dose

none none nonePM*…mg

PM*…mg

PM*…mg

PM*…mg

PM*…mg

LMWH # none none AM AM none AM AM AM AM

Days -4 -3 -2 -1 0 surgery 1 2 3 4

*Restart Coumadin® (warfarin) at your previous dose.

# Low molecular weight heparin: 1. Lovenox® dose is mg (1.5 mg/kg) once per day; or 2. Fragmin® dose is U (200 U/kg) once per day; or 3. Innohep® dose is U (175 U/kg) once per day.

American Heart Association and American College of Cardiology Scientific Statements

• “For patients undergoing dental procedures, tranexamic acid or epsilon-

i i id (A i ®) th haminocaproic acid (Amicar®) mouthwash can be applied without interrupting anticoagulant therapy.”

Hirsh et al. American Heart Association/American College of Cardiology Foundation guide to warfarin therapy. J Am Coll Cardiol 2003;41(9):1633-52.

Eighth American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic and Thrombolytic Therapy

– “5.1. In patients who are undergoing minor dental procedures and are receiving vitamin K antagonists (VKAs, e.g. coumadin), we recommend continuing VKAs around the time of the procedure and coadministering an oral prohemostatic agent (Grade 1B).”

Hirsch et al. Managing oral anticoagulant therapy. Chest 2008;133(Suppl):71S-105S.

Safety of Outpatient Dental Treatment for Patients Receiving Coumarin Anticoagulant Therapy

Source: Herman WW, et al. JADA 1997;128:327–35.

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Identification of Patient Receiving Coumarin Therapy

Determine Evaluate dental treatment needsName of attending physician Types of therapy requiredReason for coumarin therapy Potential for hemorrhageAnticipated duration of therapy Presence of local factors that Frequency of monitoring Stability of therapyincrease the potential for Number of visitshemorrhage Block anesthesia requirement

Duration > 6 months

Consult with physicianVerify patient information and

anticipated duration of treatment

Duration ≤ 6 months

Consider deferring treatment until no longer receiving

Elect to treat

Plan for treatment

Acceptable Unacceptable

Algorithm for nonurgent dental care of patients receiving anticoagulant therapy

anticipated duration of treatmentDetermine PT/INRDescribe proposed dental treatment

and indicate whether it can be safely performed with present INR

longer receiving anticoagulant therapy

Acceptable INR for anticipated treatment

Unacceptable INR for anticipated treatment

Adjustment required because of unacceptable INR for anticipated dental treatment or for INR outside therapeutic target range

Elect to defer treatment

Scheduled cessation of

coumarin therapy

Treatment with local measures as needed

Partial withdrawal of coumarin therapy

Cessation of coumarin therapy

Substitution therapy


Therapeutically anticoagulated patient (INR=2.5): Extraction #4 and 51) Local Anesthetic Delivery 2) Immediate Post-Extraction

3) Gelfoam, Suture, 20 min pressure 4) Continued Oozing

Consult with physician

2- (or 3-) day cessation/ reduction of coumarin therapy

Determine INR Unacceptable INR Defer for an additional day

Coumarin therapy: cessation or partial withdrawal protocol

Acceptable INR Repeat INR

Perform dental treatment

Resume coumarin therapy on the evening of the same day


AspirinLow-dose, long-term aspirin use irreversibly blocks the formation of thromboxane A2 (TxA2) in platelets producingin platelets, producing an inhibitory effect on platelet aggregation.


– “5.1. In patients who are undergoing i d t l d dminor dental procedures and are

receiving aspirin, we recommendcontinuing aspirin around the time of the procedure (Grade 1C).”


Plavix®• clopidogrel bisulfate is an

inhibitor of ADP-induced platelet aggregation acting by direct inhibition of adenosine diphosphate (ADP) bi di t it(ADP) binding to its receptor and of the subsequent ADP-mediated activation of the glycoprotein GPIIb/IIIa complex.

16

2007 AHA Science Advisory for Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients with Coronary Artery Stents.• Dual antiplatelet therapy with aspirin

and a thienopyridine (e.g. clopidogrel, Plavix® or ticlopidine, Ticlid ®) reduces cardiac events (thrombosis) after coronary stentingafter coronary stenting.

• Patients and other healthcare providers planning surgical procedures should consult the patients’ cardiologist prior to stopping antiplatelet therapy.

Source: Grines CL, et al. J Am Coll Cardiol 2007;49:734-7. Grines CL, et al. JADA 2007;138:652-5.

2007 AHA Science Advisory for Prevention of Premature Discontinuation of Dual Antiplatelet Therapy in Patients with Coronary Artery Stents.• Elective procedures with significant

bleeding risk should be deferred a minimum 1 month for bare metal stents and 12 months for drug-eluting stentsstents.

• If patients will undergo procedures that mandate discontinuation of thienopyridine therapy, aspirin should be continued and the thienopyridine therapy restarted as soon as possible.

Source: Grines CL, et al. J Am Coll Cardiol 2007;49:734-7.Grines CL, et al. JADA 2007;138:652-5.


In patients who are undergoing minor dental procedures and are receiving clopidogrel (Plavix®)….

– 4.5. For patients who are not at high risk for cardiac events, we recommend interruption of antiplatelet drugs (Grade 1C).

– For patients at high risk of cardiac events (exclusive of coronary stents) scheduled for noncardiac surgery, we suggest continuing aspirin up to and beyond the time of surgery (Grade 2C); if patients are receiving clopidogrel, we suggest interrupting clopidogrel at least 5 days and, preferably, within 10 days prior to surgery (Grade 2C).


Eighth American College of Chest Physicians (ACCP) Consensus Conference on Antithrombotic and Thrombolytic TherapyIn patients who are undergoing minor dental procedures

and are receiving clopidogrel (Plavix®)….– 4.6. In patients with a bare metal coronary stent who require

surgery within 6 weeks of stent placement, we recommendsurgery within 6 weeks of stent placement, we recommendcontinuing aspirin and clopidogrel in the perioperative period (Grade 1C).

– In patients with a drug-eluting coronary stent who require surgery within 12 months of stent placement, we recommend continuing aspirin and clopidogrel in the perioperative period (Grade 1C).

– In patients with a coronary stent who have interruption of antiplatelet therapy before surgery, we suggest against the routine use of bridging therapy with UFH, LMWH, direct thrombin inhibitors, or glycoprotein (GP) IIb/IIIa inhibitors (Grade 2C).


Drugs and Drug Interactions

“Anticoagulants (warfarin and heparin) are the #1 class of drugs implicated in drug-related deaths in North Carolina.”

17

Pharmacologic Considerations

Drug Actions of Importance in the Dental SettingCommon Drug Interactions in the Dental S ttiSettingPatients with Altered Drug Metabolism or SusceptibilityOral Consequences of Medication Use

Drug Actions of Importance in the Dental Setting• Alteration of hemostasis

– coagulation: heparin, warfarin– platelet function and aggregation: ASA,

clopidogrel, NSAIDsp g ,• Immune suppression

– corticosteroids, cytotoxic agents, others• Ability to withstand treatment

– adrenal suppression via exogenous corticosteriods

72 year-old with clear cell adenocarcinoma of the ovary treated with Taxol®Absolute neutrophil count= 200Platelet count= 42,000

GingivalGingival bleeding and mucositis

Common Drug Interactions in the Dental Setting• Minor to life-threatening• Pharmacologically predictable• Interactions are not absoluteInteractions are not absolute

contraindications

Antimicrobial drugs and….• Oral contraceptives + (Amoxicillin, Erythromycin,

Tetracyclines, others)→ Contraceptive failure (low risk)

• Coumarin + (Erythromycin, Metronidazole, Tetracycline, Ketaconazole)→ Enhanced anticoagulation effect

• Phenytoin + (Fluconazole, Ketoconazole, Metronidazole)→ Increased plasma levels of phenytoin

• Cyclosporine + (Fluconazole, Itraconazole, Ketoconazole, Amphotericin)→ Increased risk of nephrotoxicity

• Digoxin + (Erythromycin, Tetracyclines, Itraconazole)→ Digoxin toxicity

Antimicrobial drugs and….

• Carbamazepine + (Erythromycin)→ Increased risk of carbamazepine toxicity

• Midazolam + (Erythromycin)→ Profound sedation→ o ou d sedat o

• Atorvastatin, Simvastatin, Pravastatin + (Erythromycin)→ Muscle weakness and breakdown

• Theophylline + (Erythromycin, Clarithromycin)→Theophylline toxicity

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Antimicrobial drugs and….

• Lithium + (Metronidazole)→ Increased lithium toxicity

• Alcohol + (Metronidazole)→ Nausea vomiting headache flushing→ Nausea, vomiting, headache, flushing

• Antacids & Iron supplements + (Tetracyclines)→ Loss of antibacterial action of tetracyclines

• Methotrexate + (Penicillins)→ Methotrexate toxicity

Anti-inflammatory drugs and….• Heparin, Coumarin + (Aspirin, NSAIDs)

→ Risk of hemorrhage• Captopril, other ACE inhibitors + (Aspirin,

Ibuprofen, Rofecoxib)→ Reduction in antihypertensive effect

• Methotrexate + (Aspirin, Ibuprofen, Naproxen, Rofecoxib)→ Methotrexate toxicity

• Insulin, Chlorpropamide, other hypoglycemics + (Aspirin)→ Risk of hypoglycemia

• Valproic acid + (Aspirin)→ Increased valproate toxicity→ Risk of hemorrhage

Anti-inflammatory drugs and….

• Alcohol + (Aspirin)→ Increased risk of damage to gastric mucosa

• Corticosteroids + (Aspirin)→ Risk of salicylate toxicity on steroid withdrawaly y→ Increased risk of damage to gastric mucosa

• Digoxin + (Aspirin, Ibuprofen)→ Digoxin toxicity

• Lithium + (Ibuprofen, Naproxen, Rofecoxib, Celecoxib)→ Lithium toxicity

Other drugs and….• Propranolol + (Epinephrine)→ Marked hypertension & reflex bradycardia

• Levothyroxine + (Epinephrine)→ Coronary insufficiency in patients with coronary

artery diseaseartery disease• Tricyclic antidepressants + (Epinephrine)→ Hypertensive reaction and possible cardiac arrhythmias

• Alcohol, Sedative H1 antagonists, Neuroleptics, Antiepileptics + (Diazepam)→ Excessive sedation→ Impaired psychomotor skills→ Possible respiratory depression

Patients with Altered Drug Metabolism/ Susceptibility• Renal Impairment• Liver Disease• ElderlyElderly• Pregnancy• Myasthenia gravis• Diabetes

Analgesics/Anesthetics Commonly Used in Dentistry

Contra-indicated or used with caution in

Aceta mino phen

Ibupro fen

Codeine Hydro codone

Lido caine

Bupiva caine

Epine phrine

Renal Disease

Yes Yes No No No No No

Hepatic Disease

Yes Yes Yes Yes Yes Yes NoDiseaseElderly No Yes Yes Yes Yes Yes NoPregnancy* No Yes B/D Yes C Yes C No Yes C Yes B/CMyasthenia Gravis

No No Yes Yes Yes Yes No

Diabetes Yes Yes No No No No Yes* FDA categories of drug safety in Pregnancy: A- Adequate human studies show no increased fetal risk.B- Animal studies show no increased fetal risk and there are no adequate human studies OR animal studies show

adverse effect but adequate human studies do not show fetal risk.C- Animal studies show adverse effect and there are no adequate human studies OR no animal or adequate

human studies exist.D- Adequate human studies show risk to fetus, but benefits of therapy may outweigh risk.

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Antibiotics Commonly Used in DentistryContra-indicated or used with caution in

Amoxicillin

Clindamycin

Tetra cycline

Cephalexin

Vanco mycin

Fluconazole

Chlor hexidine

Renal Disease

Yes Yes Yes Yes Yes Yes No

Hepatic Disease

No Yes Yes Yes No Yes NoDiseaseElderly No No No No Yes No NoPregnancy* No No Yes D No Yes C Yes C Yes CMyasthenia Gravis

No Yes Yes No Yes No No

Diabetes Yes No Yes No No No No* FDA categories of drug safety in Pregnancy: A- Adequate human studies show no increased fetal risk.B- Animal studies show no increased fetal risk and there are no adequate human studies OR animal studies show adverse effect but adequate human studies do not show fetal risk.C- Animal studies show adverse effect and there are no adequate human studies OR no animal or adequate human studies exist.D- Adequate human studies show risk to fetus, but benefits of therapy may outweigh risk.

Oral Consequences of Medication Use

• Xerostomia• Taste alterations• Stomatitis• Lichenoid reactions• Lupus erythematosus like ulcerations• Lupus erythematosus-like ulcerations• Erythema multiforme• Glossitis / Coated tongue• Gingival overgrowth• Tooth discoloration• Angioedema• Chemo-osteonecrosis of the jaw

XerostomiaAnticholinergics Anticonvulsants Antidepressants Antihistamines Antihypertensives Antineoplastics Antiparkinsonians A ti h tiAntipsychotics Antispasmodics CNS stimulants Diuretics Gastrointestinals Muscle relaxants Narcotics HIV protease inhibitors Sympathomimetics Systemic bronchodilators

Taste AlterationACE inhibitors Albuterol Benzodiazepines Carbimazole Chlorhexidine Clofibrate Ethionamide Dimethyl sulfoxide D-penicillamine Gold saltsG i f l i G f iGriseofulvin GuanfacinLevodopa LincomycinLithium Methamphetamines Methocarbamol Metronidazole Nicotine Nortriptyline Phenindione Prednisone Sertraline Tranquilizers

Stomatitis / Oral Ulceration

• Carbamazepine Dideoxycytosine Enalapril Erythromycins Fluoxetine Ketoprofen Ofloxacin Piroxicam

• Cancer chemotherapeutic agents

Lichenoid ReactionsACE inhibitors Allopurinol Chloropropamide Chloroquine Chlorothiazide Dapsone Furosemide Gold salts Methyldopa NSAIDs Palladium Penicillamine Propranolol Phenothiazines Quinidine Spironolactone Streptomycin Tetracyclines Tolbutamide Triprolidine

20

Lupus Erythematosus-like Lesions

Griseofulvin Hydralazine Isoniazid Methyldopa Nitrofurantoin Penicillin PhenytoinPhenytoin Primidone Procainamide Rifampin Streptomycin Sulfonamides Tetracyclines Thiouracil Trimethadione

Erythema MultiformeAntimalarials Barbiturates Busulfan Carbamazepine Cefaclor Chlorpropamide Clindamycin Codeine Isoniazid H2 blockers Methyldopa Penicillins Phenylbutazone Phenytoin Rifampin Salicylates Sulfonamides Tetracyclines

Glossitis / Coated Tongue

Amoxicillin Nitrofurantoin Tetracyclines Triamterine/Hydrochlorothiazide

Gingival Overgrowth

Calcium channel blockers (esp. Nifedipine Verapamil)

CyclosporineCyclosporinePhenytoin

Tooth Discoloration

Chlorhexidine

Nitrofurantoin

Tetracyclines

Angioedema

ACE inhibitors H2 blockers

21

Chemo-osteonecrosis of the jawBisphosphonatesIV: zolendronic acid (Zometa®)

pamidronate (Aredia®) clodronate (Bonefos®)

Oral: alendronate (Fosamax®) ib d t (B i ®)ibandronate (Boniva®) risedronate (Actonel®) etidronte (Didronel®) tilurdronate (Skelid®)

The expected and unexpected….Sections:Entire Monograph

Black Box Warnings

Adult Dosing

Peds Dosing

Contraindications/CautionsContraindications/Cautions

Drug Interactions

Adverse Reactions

Safety Monitoring

Pharmacology

Manufacturer/Pricing

Patient Education

Pill Pictures

http://www.epocrates.com/What about herbal medicines?• 1119 adult dental patients surveyed in 2007 at Medical

College of Georgia• 12.6% reported ≥ herbal supplement • Most consumed in combination with medications• Most common users were middle-aged educated

Ginko biloba

gcaucasian females.

• Most common supplements were:– Green tea (39.5%)– Garlic (14.3%) – Echinacea (9.5%)– Ginko biloba (9.0%)– Ginseng (6.2%)

Source: Abebe W, et al. Herbal supplement use among adult dental patients in a USA dental school clinic: Prevalence, patient demographics, and clinical implications. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2011;111;320-25.

Green tea

Ginseng

Garlic

Echinacea

Top 5 herbal supplements

Herbal supplement

Pharmacologic Effects Potential ClinicalImplications

Green tea Exerts CNS-stimulating, antiinflammatory, antiplatelet, antimicrobial, and antioxidant effects; astringent action of tannins

Enhances risk of bleeding; induces hepatotoxicity with the potential to alter drug metabolism/interactions; causes inhibition of GI drug absorption

Garlic Exerts antiplatelet, antihypertensive, antihyperlipidemic, and antimicrobial effects

Enhances risk of bleeding

Echinacea Exerts antiinflammatory and immunostimulating effects

Induces immunostimulating effect antagonistc to immunosuppression drugs; effects on CYP1A2 and CYP34A and hepatotoxicity cause interactions with drugs

Ginko biloba Exerts vasodilatory, antioxidant, and antiplatelet effects

Enhances risk of bleeding; exerts pharmacologic drug intearction by inhibiting CYP1A2 and CYP2D6

Ginseng Exerts various effects, including CNS stimulation, immunostimulationand antioxidant and antiplateletactivities

Induces immunostimulating effect antagonistic with immunosuppressiondrugs; enhances risk of bleeding; exerts pharmacologic drug interaction by inhibiting CYP2D6

22

Ability to withstand treatment/ Stress

• Physical Stress:– Chair positions – Epinephrine effect and hypertensive patients

ASA Cl ifi i– ASA Classification • Psychological Stress:

– Corticosteroid use; adrenal suppression and “steroid supplementation”

– Stress reduction protocols: antianxiety meds; nitrous oxide/oxygen

– Need for minimal, moderate, deep sedation or general anesthesia

Chair positions

• Select the most comfortable position for the patient– Arthritis and skeletal deformities: frequent

positional changes and extra support pillows.p g pp p• Full supine for most patients, except:

– Congestive heart failure: semi not full reclining.– Third trimester pregnancy: semi not full

reclining. Roll to left to treat supine positional hypotension.

Epinephrine Effect on Hypertensive Patients

• Systematic review in 2001. • 6 studies with 325 patients.• Use of epinephrine in uncontrolled hypertensive

patients was associated with small, nonsig. increases in SBP and DBP. No adverse outcomes were reported.

Source: Bader JD et al. OSOMOPORE 2002;93:647-53.

Max ΔSBP (mm)

Max ΔDBP (mm)

Max ΔHR (bpm)

Hypertensive patient andanesthesia with epinephrineanesthesia without epinephrine

15.311.7

2.33.3

9.34.7

Normotensive patient andanesthesia with epinephrineanesthesia without epinephrine

5.05.0

-0.74.0

6.30.7

ASA Physical Status Classification• 1 A normal healthy patient • 2 A patient with mild systemic disease • 3 A patient with severe systemic disease • 4 A patient with severe systemic disease that p y

is a constant threat to life • 5 A moribund patient who is not expected to

survive without the operation • 6 A declared brain-dead patient whose

organs are being removed for donor purposes

American Society of Anesthesiologists

ASA 1 A normal healthy patientPatient is able to walk up one flight of stairs or two level city blocks without distress. Little or no anxiety. Little or no risk during treatment.

E l h lth 20 ld ti tExample: healthy 20-year old patient

ASA 2 A patient with mild systemic diseasePatient has mild to moderate systemic disease or is a healthy ASA I patient who demonstrates a more extreme anxiety and fear toward dentistry.Patient is able to walk up one flight of stairs or two level city blocks, but will have to stop after completion of the exercise because ofcompletion of the exercise because of distress. Minimal risk during treatment.

Examples: History of well-controlled disease states including Type 2 DM, asthma, HTN (without medication), epilepsy or thyroid problems. ASA I with a respiratory condition, pregnancy, and/or active allergies.

23

ASA 2 A patient with mild systemic diseaseNote: Patients who demonstrate a more extreme anxiety and fear toward dentistry have a baseline of ASA 2 even before their health history is considered.

ASA 3 A patient with severe systemic diseasePatient has severe systemic disease that limits activity, but is not incapacitating. Patient is able to walk up one flight of stairs or two level city blocks, but will have to stop on the way because of distress. If dental care is indicated, stress reduction protocol and other treatment modifications are indicated.

Examples: History of angina, MI, or CVA, CHF over 6 months ago, slight COPD, and controlled Type 1 DM or HTN (with medication).

ASA 4 A patient with severe systemic disease that is a constant threat to life Patient has severe systemic disease that limits activity and is a constant threat to life. Patient is unable to walk up one flight of stairs or two level city blocks. Distress is present even at rest. Patient poses significant risk during treatment.p g gElective dental care should be postponed until such time as the patient's medical condition has improved to at least an ASA 3 classification. Examples: History of unstable angina, MI or CVA in last 6 months, severe CHF, moderate to severe COPD, and uncontrolled HTN, epilepsy, diabetes, or thyroid condition.

Adrenal Suppression: Reconsideration of the Rule of 2s?• Dental patients with primary or secondary AI may be

at risk of experiencing adrenal crisis during or after invasive procedures.

• MEDLINE review through 2000 revealed only 4 reports of purported adrenal crisis in dentistry.

• Factors associated with adrenal crisis included: magnitude of surgery, use of general anesthetics, health status and stability of patient, degree of pain control.

• CONCLUSIONS: The limited number of reported cases strongly suggest that adrenal crisis is a rare event in dentistry.

• Most routine dental procedures can be performed without glucocorticoid supplementation.Source: Miller CS, et al. JADA 2001:132;1570-9.

Rule of Two’s: > 20 mg cortisone daily. for 2 weeks in last 2 years, double steroid dose

Dental Procedures and Recommended Corticosteroid Supplementation in Patients with Adrenal Insufficiency*•• Negligible Risk CategoryNegligible Risk Category

– Nonsurgical dental proceduresRegimen: No supplementation required.

•• Mild Risk CategoryMild Risk Category– Minor oral surgery: A few simple extractions, biopsy.– Minor Periodontal surgeryRegimen: The glucocorticoid target is about 25

mg of hydrocortisone equivalent (5 mg prednisone) the day of surgery.

Source: Miller CS, et al. JADA 2001:132;1570-9.* General anesthesia, infection & pain can increase the risk of adrenal crisis in susceptible patients.

Dental Procedures and Recommended Corticosteroid Supplementation in Patients with Adrenal Insufficiency*•• ModerateModerate--toto--Major Risk CategoryMajor Risk Category

– Major Oral surgery: Multiple extractions, quadrant periodontal surgery, extraction of bony impactions, osseous surgery, osteotomy, bone resections, cancer g y ysurgery, surgical procedures involving general anesthesia, procedures over 1 hr or with signif. blood loss.

Regimen: The glucocorticoid target is about 50-100 mg/day of hydrocortisone equivalent (10-20 mg/day prednisone) the day of surgery and for at least one postop day.

Source: Miller CS, et al. JADA 2001:132;1570-9.* General anesthesia, infection & pain can increase the risk of adrenal crisis in susceptible patients.

24

“Lions and Tigers and Bears, Oh My”• Medical emergencies

– Dental Team and Office Preparedness– Recognition of Signs and Symptoms for

Patient DistressPatient Distress• Position, Airway, Breathing,

Circulation, Definitive care

“Wear the Ruby Slippers and you will be safe” Glinda, Good Witch of the North

• Interprofessional CommunicationInterprofessional Communication– Physician Consultations– Coordination of care

Common Medical Conditions Encountered in Dental Practice

HypertensionCoronary artery disease Kidney disease on hemodialysisOsteoarthritisDiabetesAsthmaCancerHIVPsychological disorders

Key Considerations:I InfectionH HemostasisD Drugs and drug interactionsS Ability to withstand treatment/Stress

HypertensionConcerns Yes NoInfection xHemostasis xDrugs xStress x• Establish baseline BP and assess

BP at each visit.– Consider sedation for surgical procedures if SBP>140 OR DBP>90

[JNC7 Stage I Hypertension]; – Refer for medical consultation if SBP>160 OR DBP>100Refer for medical consultation if SBP 160 OR DBP 100

[JNC7 Stage II Hypertension]; – No dental treatment without medical consult if SBP>180 OR DBP>110.– If SBP≥210 OR DBP≥120, refer to emergency medical care.

• Encourage adherence to antihypertensive drugs, tobacco cessation, diet and exercise.

• Assess antihypertensive drug oral side effects.

Source: Herman WW, et al. JADA 2004;135:576-84.

Kidney disease on hemodialysis

Concerns Yes NoInfection xHemostasis xDrugs xStress x• Consider impaired drug

metabolism.• Consider uremia-induced

bleeding if untreated severe kidney disease; heparin use in hemodialysis.

• Treat on “off” dialysis day.

Coronary Artery Disease

Concerns Yes NoInfection xHemostasis xDrugs x

Stress x• Assess for recent chest pain.

• Consider oxygen therapy support or sedation.

• Stress reduction protocols.

• Consider hemostasis altering drugs.

• Monitor for oral side effects of medications.

25

Diabetes• HbA1C, glycosylated hemoglobin—a test that

reflects average blood glucose over the last 3 months.

• The goal for most people with diabetes is <7. An A1C of 7 corresponds to an estimated average blood glucose level of 154 mg/dL.

• If A1C is over 8 [Est. Avg. Glucose >183 mg/dl],then impaired wound healing and risk of infection increase.

Diabetes, poorly controlled

Concerns Yes NoInfection xHemostasis xDrugs xStress x

• Arrange appointments when insulin is at peak, usually morning. Assess the time of last food intake.last food intake.

• Have the patient bring his glucometer.

• Treat acute infections aggressively.

• Monitor for oral infections and control periodontal disease.

OsteoarthritisConcerns Yes NoInfectionHemostasisDrugs x

Stress x• Monitor drug side effects.

• Afternoon appointments, usually best.

• Frequent chair positional changes.

AsthmaConcerns Yes NoInfection xHemostasis xDrugs xStress x• Consider prophylactic

bronchodilator use.• Reduce stress; consider

sedation.sedation.• Avoid certain drugs: ASA;

NSAIDs; narcotics; erythromycin.

Cancer undergoing chemotherapy


• Consult with physician regarding infection and hemostasis risk and timing of dental treatmenttreatment.

• Monitor for oral side effects of chemotherapy [e.g. mucositis].

• Consider drug interactions.

HIVConcerns Yes NoInfection xHemostasis xDrugs xStress x

• Monitor for oral opportunistic infections.

• Consider medical comorbidities that might predispose to bleedingpredispose to bleeding.

• Consider drug side effects.

• Systematic literature review through 2000 shows: Dental treatment complications from extractions are mild

and amenable to outpatient treatment.

There is no evidence to support a higher complication rate in HIV-positive than HIV-negative patients.Source: Patton LL et al, JADA 2002;133:195-203.

26

Psychological disorders


• Consider side effects of drugs and drug interactions.

• Consider stress reduction orConsider stress reduction or possible sedation.

Conclusions• Each patient is unique.• The Health History is your framework for medical

risk assessment discussion with your patient.• Consider the 4 key risk categories for safe dental

care: care: – Infection– Hemostasis– Drugs and drug interactions– Ability to withstand treatment/Stress

• Consult with the patient’s physician when uncertain of the medical status.

• You have the Brains!• You have the Heart!• Seek and find Courage in

your daily practice.

The reward is yours!

the yellow brick road to managing the medically complex...

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