RISK STRATIFICATION AND DENTAL MANAGEMENT OF PATIENTS WITH ...

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RISK STRATIFICATION AND DENTAL MANAGEMENT OF PATIENTS WITH ...

  1. 1. RISK STRATIFICATION AND DENTAL MANAGEMENT OF PATIENTS WITH ENDOCRINE-METABOLIC DISORDERS G é za T. Ter é zhalmy, D.D.S., M.A. Professor and Dean Emeritus School of Dental Medicine Case Western Reserve University
  2. 2. Risk stratification of patients with DM <ul><li>Insulin </li></ul><ul><li>Lantus (long-acting insulin glargine) </li></ul><ul><ul><li>Mechanisms of action </li></ul></ul><ul><ul><ul><li>Stimulates cellular glucose uptake, i.e., it is a hypoglycemic agent </li></ul></ul></ul><ul><ul><li>Clinical indications </li></ul></ul><ul><ul><ul><li>Type 1 and type 2 DM </li></ul></ul></ul>
  3. 3. Risk stratification of patients with DM <ul><li>Oral hypoglycemic agents: sulfonylureas </li></ul><ul><li>glyburide </li></ul><ul><ul><li>Mechanisms of action </li></ul></ul><ul><ul><ul><li>Decreases hepatic glucose production </li></ul></ul></ul><ul><ul><ul><li>Stimulates the release of insulin from pancreatic beta-cells </li></ul></ul></ul><ul><ul><ul><li>Decreases insulin resistance, i.e., improves insulin’s effectiveness </li></ul></ul></ul><ul><ul><li>Clinical indications </li></ul></ul><ul><ul><ul><li>Type 2 DM </li></ul></ul></ul>
  4. 4. Risk stratification of patients with DM <ul><li>Biguanide oral hypoglycemic agents </li></ul><ul><li>metformin </li></ul><ul><ul><li>Mechanisms of action </li></ul></ul><ul><ul><ul><li>Decreases intestinal absorption of glucose </li></ul></ul></ul><ul><ul><ul><li>Decreases hepatic glucose production </li></ul></ul></ul><ul><ul><ul><li>Decreases insulin resistance, i.e., improves insulin’s effectiveness </li></ul></ul></ul><ul><ul><li>Clinical indications </li></ul></ul><ul><ul><ul><li>Type 2 DM </li></ul></ul></ul>
  5. 5. Risk stratification of patients with DM <ul><li>Thiazolidinediones oral hypoglycemic agents </li></ul><ul><li>Actos (pioglitazone) </li></ul><ul><li>Avandia (rosiglitazone) </li></ul><ul><ul><li>Mechanisms of action </li></ul></ul><ul><ul><ul><li>Inhibit hepatic gluconeogenesis </li></ul></ul></ul><ul><ul><ul><li>Decrease insulin resistance, i.e., improve insulin’s effectiveness </li></ul></ul></ul><ul><ul><li>Clinical indications </li></ul></ul><ul><ul><ul><li>Type 2 DM </li></ul></ul></ul>
  6. 6. Risk stratification of patients with DM <ul><li>The oral disease burden of patients with DM </li></ul><ul><ul><li>Periodontal disease </li></ul></ul><ul><ul><li>Xerostomia </li></ul></ul><ul><ul><ul><li>Dental caries </li></ul></ul></ul><ul><ul><ul><li>Candidiasis </li></ul></ul></ul><ul><ul><li>Other </li></ul></ul><ul><ul><ul><li>Burning mouth syndrome </li></ul></ul></ul><ul><ul><ul><li>Altered taste </li></ul></ul></ul><ul><ul><ul><li>Lichen planus </li></ul></ul></ul><ul><ul><ul><li>Bell’s palsy </li></ul></ul></ul><ul><ul><ul><li>Trigeminal neuralgia </li></ul></ul></ul>
  7. 7. Risk stratification of patients with DM <ul><ul><li>Periodontal disease </li></ul></ul><ul><ul><ul><li>The association between uncontrolled or poorly controlled DM and periodontal disease is well established </li></ul></ul></ul><ul><ul><ul><li>*J Periodontol 1999;70:935-949 </li></ul></ul></ul>
  8. 8. Risk stratification of patients with DM <ul><ul><li>Xerostomia </li></ul></ul><ul><ul><ul><li>An association has been demonstrated between lower resting and stimulated saliva flow and elevated HbA1c as well as elevated plasma glucose concentrations </li></ul></ul></ul><ul><ul><ul><li>*Diabetes Care 1992;15:900-904 </li></ul></ul></ul><ul><ul><ul><li>*Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001:92:281-291 </li></ul></ul></ul>
  9. 9. Risk stratification of patients with DM <ul><ul><li>Dental caries </li></ul></ul><ul><ul><ul><li>An association has been observed between resting salivary flow rates less than 0.01 mL/min (normal: 0.3-0.5 mL/min) and a slightly higher incidence of dental caries </li></ul></ul></ul><ul><ul><ul><li>*Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001:92:281-291 </li></ul></ul></ul>
  10. 10. Risk stratification of patients with DM <ul><ul><li>Candidiasis </li></ul></ul><ul><ul><ul><li>The reported frequency in patients with DM is as high as 51% and its presence is inversely related to glycemic control </li></ul></ul></ul><ul><ul><ul><li>*J Oral Pathol 1987;16:282-284 </li></ul></ul></ul>
  11. 11. Risk stratification of patients with DM <ul><li>Strategies for the dental management of patients with DM </li></ul><ul><ul><li>Glycemic control </li></ul></ul><ul><ul><li>Cardiac function </li></ul></ul><ul><ul><li>Physiological “stress” of the procedure </li></ul></ul>
  12. 12. Risk stratification of patients with DM <ul><li>Risk stratification </li></ul><ul><ul><li>8 million cases of DM undiagnosed </li></ul></ul><ul><ul><ul><li>Polyuria, nocturia, polydipsia, polyphasia, weakness, obesity, weight loss, pruritus </li></ul></ul></ul><ul><ul><li>Co-morbidities </li></ul></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>Dyslipidemia </li></ul></ul></ul>
  13. 13. Risk stratification of patients with DM <ul><ul><li>Microvascular disease </li></ul></ul><ul><ul><ul><li>Retinopathy </li></ul></ul></ul><ul><ul><ul><li>Renal dysfunction </li></ul></ul></ul><ul><ul><li>Macrovascular disease </li></ul></ul><ul><ul><ul><li>Coronary artery disease </li></ul></ul></ul><ul><ul><ul><ul><li>Unstable coronary syndromes </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Cardiac arrhythmias </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Heart failure </li></ul></ul></ul></ul><ul><ul><ul><li>Cerebrovascular disease </li></ul></ul></ul><ul><ul><ul><li>Peripheral vascular disease </li></ul></ul></ul>
  14. 14. Risk stratification of patients with DM <ul><ul><li>Neuropathy </li></ul></ul><ul><ul><ul><li>Peripheral sensory neuropathy </li></ul></ul></ul><ul><ul><ul><li>Peripheral autonomic neuropathy </li></ul></ul></ul><ul><ul><ul><ul><li>Tachycardia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Silent myocardial ischemia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Exercise intolerance, i.e., reduced functional capacity </li></ul></ul></ul></ul><ul><ul><li>Glycemic control </li></ul></ul><ul><ul><ul><li>SMBG </li></ul></ul></ul><ul><ul><ul><li>HbA1c </li></ul></ul></ul>
  15. 15. Risk stratification of patients with DM <ul><li>Functional capacity </li></ul><ul><ul><li>An individuals ability to perform a spectrum of common daily tasks </li></ul></ul><ul><ul><ul><li>Expressed in terms of metabolic equivalents (METs). </li></ul></ul></ul><ul><ul><ul><ul><li>1 MET </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>The oxygen consumption of a 70-kg, 40-year-old man in a resting state, i.e., 3.5 ml per kg per minute </li></ul></ul></ul></ul></ul><ul><li>J Am Coll Cardiol 2002;39:542-553. </li></ul>
  16. 16. Risk stratification of patients with DM <ul><ul><li>Excellent functional activities (>10 METs) </li></ul></ul><ul><ul><ul><ul><li>Strenuous recreational activities </li></ul></ul></ul></ul><ul><ul><li>Good functional capacity (7-10 METs) </li></ul></ul><ul><ul><ul><li>Scrubbing floors, lifting or moving heavy furniture </li></ul></ul></ul><ul><ul><ul><li>Moderate recreational activities </li></ul></ul></ul><ul><ul><li>Moderate functional capacity (4-7 METs) </li></ul></ul><ul><ul><ul><li>Climb a flight of stairs or walk up a hill </li></ul></ul></ul><ul><ul><ul><li>Mow the grass, rake leafs, do light carpentry </li></ul></ul></ul><ul><ul><ul><li>Walk a block on level ground at 6.4 km/h </li></ul></ul></ul><ul><ul><ul><li>Run a short distance </li></ul></ul></ul>
  17. 17. Risk stratification of patients with DM <ul><ul><li>Poor functional capacity (<4 METs) </li></ul></ul><ul><ul><ul><li>Dress, eat, or use the toilet </li></ul></ul></ul><ul><ul><ul><li>Walk around the house indoors </li></ul></ul></ul><ul><ul><ul><li>Do light work around the house (dusting, washing dishes) </li></ul></ul></ul><ul><ul><ul><li>Walk a block on level ground at 3.2 km/h </li></ul></ul></ul><ul><ul><li>Cardiac risk is increased in patients unable to meet 4-METs </li></ul></ul><ul><ul><ul><li>DM is an intermediate predictor of cardiovascular risk association with non-cardiac procedures </li></ul></ul></ul><ul><ul><ul><li>Peripheral autonomic neuropathy leads to reduced exercise tolerance, i.e., reduced functional capacity </li></ul></ul></ul>
  18. 18. Risk stratification of patients with DM <ul><ul><li>Procedure-related CV risk with non-cardiac surgical procedures </li></ul></ul><ul><ul><ul><li>Predicated on procedure-specific variables </li></ul></ul></ul><ul><ul><ul><ul><li>Fluid shifts </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Blood loss </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Duration of the procedure </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Physiological stress </li></ul></ul></ul></ul><ul><ul><ul><li>Cardiac risk for various dental procedures </li></ul></ul></ul><ul><ul><ul><ul><li>Low to very low risk (<001%) </li></ul></ul></ul></ul><ul><li>* Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:42-46. </li></ul><ul><li>*Arch Intern Med 2001;161:1509-1512. </li></ul>
  19. 19. Risk stratification of patients with DM <ul><li>Physical examination </li></ul><ul><ul><li>Blood pressure </li></ul></ul><ul><ul><ul><li>Useful marker for coronary artery disease </li></ul></ul></ul><ul><ul><ul><li>BP <180/110 mm Hg is not an independent risk factor for cardiovascular risk </li></ul></ul></ul><ul><ul><ul><li>BP >180/110 mm Hg constitutes a medical emergency </li></ul></ul></ul><ul><ul><li>Pulse pressure, rate, and rhythm </li></ul></ul><ul><ul><ul><li>Pulse pressure correlates closely with systolic BP </li></ul></ul></ul><ul><ul><ul><ul><li>Reliable cofactor to either rule out or confirm significant CAD </li></ul></ul></ul></ul><ul><ul><ul><li>Pulse rate <50 or >120 beats/min constitutes a medical emergency </li></ul></ul></ul><ul><ul><ul><li>PVCs </li></ul></ul></ul><ul><ul><ul><ul><li>Significant finding </li></ul></ul></ul></ul>
  20. 20. Risk stratification of patients with DM <ul><li>Timing and length of appointments </li></ul><ul><ul><li>Patients should preferably be treated in the morning </li></ul></ul><ul><ul><ul><li>Long stressful procedures should be avoided </li></ul></ul></ul>
  21. 21. Risk stratification of patients with DM <ul><li>Local anesthetic agents </li></ul><ul><ul><li>Provide the greatest margin of safety when treating patients with DM </li></ul></ul><ul><ul><ul><li>Absence of profound anesthesia </li></ul></ul></ul><ul><ul><ul><ul><li>Increased insulin utilization </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Myocardial ischemia </li></ul></ul></ul></ul><ul><ul><ul><li>The physiological stress associated with 4 METs </li></ul></ul></ul><ul><ul><ul><ul><li>Equivalent to the effect of 0.045 mg of epinephrine </li></ul></ul></ul></ul><ul><ul><ul><li>Epinephrine has an action opposite of that of insulin </li></ul></ul></ul><ul><ul><ul><ul><li>No appreciable rise in blood glucose levels </li></ul></ul></ul></ul><ul><li>* Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:171-181. </li></ul>
  22. 22. Risk stratification of patients with DM <ul><li>Antibacterial agents </li></ul><ul><ul><li>Uncontrolled or poorly controlled DM and increased susceptibility to oral infections </li></ul></ul><ul><ul><ul><li>No studies directly support antibacterial prophylaxis </li></ul></ul></ul><ul><li>Pain management </li></ul><ul><ul><li>Opioid-based analgesics contribute to cardiovascular stability </li></ul></ul><ul><ul><ul><li>ASA to prevent thromboembolic events </li></ul></ul></ul><ul><ul><ul><ul><li>Opioid w/ASA </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Opioid w/ibuprofen </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Opioid w/APAP </li></ul></ul></ul></ul>
  23. 23. Risk stratification of patients with DM Routine referral for medical management and risk factor modification Comprehensive care Blood pressure < 80/110 mm Hg AND Normal pulse pressure, rate, and rhythm AND Functional capacity >4 METs FBG 70 to 200 mg/dL AND Minor or intermediate predictors of cardiovascular risk Consultation or referral Treatment options Physical examination Diabetic and CV risk
  24. 24. Risk stratification of patients with DM Routine referral for medical management and risk factor modification Limited care Blood pressure <180/110 mm Hg AND Normal pulse pressure, rate, and rhythm AND Functional capacity <4 METs FBG 70 to 200 mg/dL AND Minor or intermediate predictors of cardiovascular risk Consultation or referral Treatment options Physical examination Diabetic and CV risk
  25. 25. Risk stratification of patients with DM If patient is asymptomatic, routine referral for medical management and risk factor modification If patient is symptomatic, immediate referral for medical management and risk factor modification Emergency care Blood pressure >180/110 mm Hg AND/OR Abnormal pulse pressure, rate, and rhythm FBG 70 to 200 mg/dL AND Minor or intermediate predictors of cardiovascular risk Consultation or referral Treatment options Physical examination Diabetic and CV risk
  26. 26. Risk stratification of patients with DM Immediate referral for medical management and risk factor modification Emergency care Establish baseline vital signs FBG <70 or >200 mg/dL AND/OR Major predictors of cardiovascular risk Consultation or referral Treatment options Physical examination Diabetic and CV risk
  27. 27. Risk stratification of patients with DM <ul><li>Postoperative glycemic control </li></ul><ul><ul><li>Procedures may affect the patient’s ability to eat </li></ul></ul><ul><ul><ul><li>Consult with patient’s physician </li></ul></ul></ul><ul><ul><ul><ul><li>Ensure that targeted BG levels are maintained </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Balanced intake and appropriate regimen of medications </li></ul></ul></ul></ul></ul>
  28. 28. Risk stratification of patients with DM <ul><li>Preventive strategies </li></ul><ul><ul><li>Oral hygiene </li></ul></ul><ul><ul><ul><li>Conventional vs. electromechanical toothbrushes </li></ul></ul></ul><ul><ul><li>Antibacterial mouthwashes </li></ul></ul><ul><ul><li>Topical fluorides </li></ul></ul><ul><ul><li>Sialagogues </li></ul></ul><ul><ul><ul><li>Pilocarpine (Salagen) </li></ul></ul></ul><ul><ul><ul><li>Cevimeline (Evoxac) </li></ul></ul></ul>
  29. 29. Risk stratification of patients with DM <ul><li>Potential medical emergencies </li></ul><ul><ul><li>Hypoglycemia </li></ul></ul><ul><ul><li>Syncope </li></ul></ul><ul><ul><li>Postural hypotension </li></ul></ul><ul><ul><li>Hypertensive crises </li></ul></ul><ul><ul><li>Arrhythmias </li></ul></ul><ul><ul><li>Angina pectoris </li></ul></ul><ul><ul><ul><li>Myocardial infarction </li></ul></ul></ul><ul><ul><ul><ul><li>Silent </li></ul></ul></ul></ul>
  30. 30. Risk stratification of patients with DM <ul><li>Miley DD, Terezhalmy GT. The patient with diabetes mellitus: etiology, epidemiology, principles of medical management, oral disease burden, and principles of dental management. Quintessence Int 2005;36:779-795. </li></ul>
  31. 31. Risk stratification of patients with AD <ul><li>Glucocorticosteroids </li></ul><ul><li>methylprednisolone </li></ul><ul><li>prednisone </li></ul><ul><li>Advair Diskus (fluticasone propionate w/ salmeterol) </li></ul><ul><li>Flovent (fluticasone propionate) </li></ul><ul><li>fluticasone propionate </li></ul><ul><li>Nasonex (mometasone furoate) </li></ul><ul><ul><li>Mechanisms of action </li></ul></ul><ul><ul><ul><li>Decrease inflammation </li></ul></ul></ul><ul><ul><ul><li>Suppress the immune system </li></ul></ul></ul>
  32. 32. Risk stratification of patients with AD <ul><ul><li>Clinical indications </li></ul></ul><ul><ul><ul><li>Allergic rhinitis and asthma </li></ul></ul></ul><ul><ul><ul><li>Treatment of a variety of inflammatory and autoimmune diseases </li></ul></ul></ul><ul><ul><ul><li>Therapeutic immunosuppression in organ transplant patients </li></ul></ul></ul><ul><ul><ul><li>Neoplastic diseases </li></ul></ul></ul><ul><ul><ul><ul><li>Lymphocytic leukemia </li></ul></ul></ul></ul><ul><ul><ul><li>Adrenocortical insufficiency </li></ul></ul></ul><ul><ul><ul><ul><li>Addison’s disease </li></ul></ul></ul></ul>
  33. 33. Risk stratification of patients with AD <ul><li>The oral disease burden of patients with AD </li></ul><ul><ul><li>Addison’s disease </li></ul></ul><ul><ul><ul><li>Patchy brown pigmentation </li></ul></ul></ul><ul><ul><ul><ul><li>Face, buccal mucosa, tongue, gingivae, lips </li></ul></ul></ul></ul><ul><ul><ul><li>Chronic mucocutaneous candidiasis </li></ul></ul></ul><ul><ul><li>Cushing syndrome </li></ul></ul><ul><ul><ul><li>Red cheek, moon face, hirsutism, acne </li></ul></ul></ul><ul><ul><ul><li>Arrested dental development </li></ul></ul></ul><ul><ul><ul><li>Oral candidiasis </li></ul></ul></ul><ul><ul><ul><li>Mucocutaneous pigmentation </li></ul></ul></ul>
  34. 34. <ul><li>Addison disease </li></ul>Risk stratification of patients with AD
  35. 35. <ul><li>Cushing syndrome </li></ul>Risk stratification of patients with AD
  36. 36. Risk stratification of patients with AD <ul><li>Strategies for the dental management of patients with DM </li></ul><ul><ul><li>Adaptive stress response </li></ul></ul><ul><ul><li>Physiological “stress” of the procedure </li></ul></ul>
  37. 37. Risk stratification of patients with AD <ul><li>Risk stratification </li></ul><ul><ul><li>Cushing syndrome </li></ul></ul><ul><ul><ul><li>Hypothalamic abnormalities </li></ul></ul></ul><ul><ul><ul><li>Pituitary tumors </li></ul></ul></ul><ul><ul><ul><li>Adrenal adenoma or carcinoma </li></ul></ul></ul><ul><ul><ul><li>Small cell lung carcinoma </li></ul></ul></ul><ul><ul><ul><li>Chronic use of glucocorticoids </li></ul></ul></ul>
  38. 38. Risk stratification of patients with AD <ul><ul><li>Addison disease </li></ul></ul><ul><ul><ul><li>Autoimmune adrenal disease </li></ul></ul></ul><ul><ul><ul><li>Autoimmune thyroid disease </li></ul></ul></ul><ul><ul><ul><li>Type 1 and 2 DM </li></ul></ul></ul><ul><ul><ul><li>Pituitary abnormalities </li></ul></ul></ul><ul><ul><ul><li>Tuberculosis </li></ul></ul></ul><ul><ul><ul><li>AIDS </li></ul></ul></ul><ul><ul><ul><li>Mucocutaneous candidiasis </li></ul></ul></ul><ul><ul><ul><li>HPA-axis suppression </li></ul></ul></ul>
  39. 39. Risk stratification of patients with AD <ul><li>Physical examination </li></ul><ul><ul><li>Blood pressure </li></ul></ul><ul><ul><ul><li>Useful marker for both Cushing syndrome Addison disease </li></ul></ul></ul><ul><ul><ul><li>BP <180/110 mm Hg is not an independent risk factor for cardiovascular risk </li></ul></ul></ul><ul><ul><ul><li>BP >180/110 or <90/50 mm Hg constitutes a medical emergency </li></ul></ul></ul><ul><ul><li>Pulse pressure, rate, and rhythm </li></ul></ul><ul><ul><ul><li>Pulse pressure correlates closely with systolic BP </li></ul></ul></ul><ul><ul><ul><ul><li>Reliable cofactor to either rule out or confirm significant CAD </li></ul></ul></ul></ul><ul><ul><ul><li>Pulse rate <50 or >120 beats/min constitutes a medical emergency </li></ul></ul></ul><ul><ul><ul><li>PVCs </li></ul></ul></ul><ul><ul><ul><ul><li>Significant finding </li></ul></ul></ul></ul>
  40. 40. Risk stratification of patients with AD <ul><li>Adrenal insufficiency </li></ul><ul><ul><li>HPA axis suppression in patients on exogenous glucocorticoids </li></ul></ul><ul><ul><ul><li>Addisonian crisis </li></ul></ul></ul><ul><ul><ul><ul><li>Precipitated by an overwhelming stressor </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Surgery </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Sepsis </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Fever </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><li>Characterized by </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Hypotension </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Cardiogenic shock </li></ul></ul></ul></ul></ul>
  41. 41. Risk stratification of patients with AD <ul><li>Suppression of the HPA axis </li></ul><ul><ul><li>Wide variability in HPA axis suppression in patients on exogenous glucocorticoids </li></ul></ul><ul><ul><ul><li>In general, it does not correlate well with the </li></ul></ul></ul><ul><ul><ul><ul><li>patient’s age and sex </li></ul></ul></ul></ul><ul><ul><ul><ul><li>dosage administered </li></ul></ul></ul></ul><ul><ul><ul><ul><li>duration of treatment </li></ul></ul></ul></ul><ul><ul><ul><li>The persistence of HPA axis suppression after cessation of systemic glucocorticoid therapy is equivocal </li></ul></ul></ul><ul><ul><ul><li>Topical and inhaled corticosteroids can suppress the HPA axis but rarely cause clinical adrenal insufficiency </li></ul></ul></ul>
  42. 42. Risk stratification of patients with AD <ul><li>Factors related to HPA axis suppression </li></ul><ul><ul><li>No HPA axis suppression </li></ul></ul><ul><ul><ul><li>Less than 5 mg of prednisone or equivalent per day for any duration </li></ul></ul></ul><ul><ul><ul><li>Alternate-day single morning dose of short-acting glucocorticoid, such as hydrocortisone, of any dose or duration </li></ul></ul></ul><ul><ul><ul><li>Any dose of glucocorticoids for less than 3 weeks </li></ul></ul></ul><ul><ul><li>HPA axis suppression uncertain </li></ul></ul><ul><ul><ul><li>5-20 mg of prednisone or equivalent for more than 3 weeks within the past year </li></ul></ul></ul><ul><ul><ul><ul><li>Low-dose ACTH stimulatory test to determine HPA axis suppression </li></ul></ul></ul></ul>
  43. 43. Risk stratification of patients with AD <ul><ul><li>HPA axis suppression presumed or documented </li></ul></ul><ul><ul><ul><li>More than 20 mg of prednisone or equivalent for more than 3 weeks within the past year </li></ul></ul></ul><ul><ul><ul><li>Cushingoid appearance </li></ul></ul></ul><ul><ul><ul><li>Biochemical adrenal insufficiency documented by low-dose ACTH stimulation test </li></ul></ul></ul>
  44. 44. Risk stratification of patients with AD <ul><li>Supplemental glucocorticoid regimens </li></ul><ul><ul><li>The decision to give supplemental glucocorticoids must weigh the risks </li></ul></ul><ul><ul><ul><li>Fluid retention </li></ul></ul></ul><ul><ul><ul><li>Hypertension </li></ul></ul></ul><ul><ul><ul><li>Hyperglycemia </li></ul></ul></ul><ul><ul><ul><li>Increased risk of infection </li></ul></ul></ul><ul><ul><ul><li>Impaired wound healing </li></ul></ul></ul><ul><ul><ul><li>Gastrointestinal bleeding </li></ul></ul></ul><ul><ul><ul><li>Psychiatric disturbances </li></ul></ul></ul><ul><ul><li>Administer glucocorticoids only in the amount equivalent to the normal physiological response to surgical stress (“stress dose”) </li></ul></ul>
  45. 45. Risk stratification of patients with AD <ul><li>Anticipated magnitude of stress </li></ul><ul><ul><li>Major surgical stress </li></ul></ul><ul><ul><ul><li>Examples </li></ul></ul></ul><ul><ul><ul><ul><li>Pancreatoduodenectomy, esophagogastrectomy, total proctolectomy, cardiac surgery involving cardiopulmonary bypass </li></ul></ul></ul></ul><ul><ul><ul><li>Recommended prophylaxis </li></ul></ul></ul><ul><ul><ul><ul><li>100 to 150 mg of hydrocortisone or equivalent for 2 to 3 days OR </li></ul></ul></ul></ul><ul><ul><ul><ul><li>100 mg IV hydrocortisone prior to induction of anesthesia, 50 mg hydrocortisone q8h for 48-72 h, then resume normal regimen </li></ul></ul></ul></ul>
  46. 46. Risk stratification of patients with AD <ul><ul><li>Moderate surgical stress </li></ul></ul><ul><ul><ul><li>Examples </li></ul></ul></ul><ul><ul><ul><ul><li>Nonlaporoscopic cholecystectomy, lower extremity revascularization, segmental colon resection, total joint replacement, abdominal hystorectomy </li></ul></ul></ul></ul><ul><ul><ul><li>Recommended prophylaxis </li></ul></ul></ul><ul><ul><ul><ul><li>50 to 75 mg of hydrocortisone or equivalent for 1 to 2 days OR </li></ul></ul></ul></ul><ul><ul><ul><ul><li>50 mg IV hydrocortisone prior to induction of anesthesia, 25 mg hydrocortisone q8h for 24-48 h, then resume normal regimen </li></ul></ul></ul></ul>
  47. 47. Risk stratification of patients with AD <ul><ul><li>Minor surgical stress </li></ul></ul><ul><ul><ul><li>Examples </li></ul></ul></ul><ul><ul><ul><ul><li>Local anesthesia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Inguinal herniography </li></ul></ul></ul></ul><ul><ul><ul><li>Recommended prophylaxis </li></ul></ul></ul><ul><ul><ul><ul><li>Usual daily glucocorticoid dose during perioperative period </li></ul></ul></ul></ul>
  48. 48. Risk stratification of patients with AD <ul><li>Procedure-specific variables </li></ul><ul><ul><li>Fluid shifts </li></ul></ul><ul><ul><li>Blood loss </li></ul></ul><ul><ul><li>Duration of the procedure </li></ul></ul><ul><ul><li>Physiological stress </li></ul></ul><ul><ul><ul><li>General anesthesia </li></ul></ul></ul><ul><li>Dental procedures </li></ul><ul><ul><li>Low to very low risk </li></ul></ul><ul><ul><ul><li>Recommended prophylaxis </li></ul></ul></ul><ul><ul><ul><ul><li>Usual daily glucocorticoid dose during perioperative period </li></ul></ul></ul></ul><ul><li>Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:42-46. </li></ul><ul><li>Arch Intern Med 2001;161:1509-1512. </li></ul><ul><li>ADA 2001;132:1570-1579. </li></ul>
  49. 49. Risk stratification of patients with AD <ul><li>Local anesthetic agents </li></ul><ul><ul><li>Physiological stress with the use of local anesthetic agents in patients with adrenal dysfunction is low </li></ul></ul><ul><ul><li>Cortisol plays a permissive role for epinephrine </li></ul></ul><ul><ul><ul><li>Cardiac risk is increased in patients unable to meet a 4-MET demand for oxygen </li></ul></ul></ul><ul><ul><ul><ul><li>Equivalent to the effect of 0.045 mg of epinephrine </li></ul></ul></ul></ul><ul><li>Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:171-181. </li></ul><ul><li>Med Clin North Am 2003;87:175-192. </li></ul>
  50. 50. Risk stratification of patients with AD Routine referral for medical management and risk factor modification <ul><li>Comprehensive care </li></ul><ul><li>Usual daily corticosteroid dose during perioperative period </li></ul>Blood pressure <180/110 mm Hg AND Normal pulse pressure, rate, and rhythm AND Functional capacity >4 METs <ul><li>Minor procedure-related stress level </li></ul><ul><ul><li>Dental care </li></ul></ul><ul><ul><li>AND </li></ul></ul><ul><ul><li>Local anesthesia </li></ul></ul>Consultation or referral Treatment options Physical examination Addisonian or cardiac risk
  51. 51. Risk stratification of patients with AD Routine referral for medical management and risk factor modification <ul><li>Limited care </li></ul><ul><li>Usual daily corticosteroid dose during perioperative period </li></ul>Blood pressure <180/110 mm Hg AND Normal pulse pressure, rate, and rhythm AND Functional capacity <4 METs <ul><li>Minor procedure-related stress level </li></ul><ul><ul><li>Dental care </li></ul></ul><ul><ul><li>AND </li></ul></ul><ul><ul><li>Local anesthesia </li></ul></ul>Consultation or referral Treatment options Physical examination Addisonian or cardiac risk
  52. 52. Risk stratification of patients with AD If patient is asymptomatic, routine referral for medical management and risk factor modification If patient is symptomatic, immediate referral for medical management and risk factor modification <ul><li>Emergency care </li></ul><ul><li>Usual daily corticosteroid dose during perioperative period </li></ul>Blood pressure >180/110 mm Hg OR <90/50 mm Hg AND/OR Abnormal pulse pressure, rate, and rhythm <ul><li>Minor procedure-related stress level </li></ul><ul><ul><li>Dental care </li></ul></ul><ul><ul><li>AND </li></ul></ul><ul><ul><li>Local anesthesia </li></ul></ul>Consultation or referral Treatment options Physical examination Addisonian or cardiac risk
  53. 53. Risk stratification of patients with AD <ul><li>Potential medical emergencies </li></ul><ul><ul><li>The likelihood of an Addisonian crisis in the oral health care setting is extremely remote </li></ul></ul><ul><ul><ul><li>Other medical emergencies may be anticipated based on the patient’s medical history and vital signs </li></ul></ul></ul>
  54. 54. Risk stratification of patients with AD <ul><li>Huber MA, Terezhalmy GT. Risk stratification and dental management of patients with adrenal dysfunction. Quintessence Int 2007;38:325-338. </li></ul>
  55. 55. Risk stratification of patients with TD <ul><li>Thyroid hormones </li></ul><ul><li>levothyroxine sodium </li></ul><ul><li>Levoxyl (levothyroxine sodium) </li></ul><ul><li>Synthroid (levothyroxine sodium) </li></ul><ul><ul><li>Mechanisms of action </li></ul></ul><ul><ul><ul><li>Regulate carbohydrate, protein, and lipid metabolism; and oxygen consumption </li></ul></ul></ul><ul><ul><ul><li>Thermoregulation, calorigenesis </li></ul></ul></ul><ul><ul><ul><li>Act synergistically with epinephrine </li></ul></ul></ul><ul><ul><ul><ul><li> Glycogenolysis and hyperglycemia </li></ul></ul></ul></ul><ul><ul><li>Clinical indications </li></ul></ul><ul><ul><ul><li>Hypothyroidism </li></ul></ul></ul>
  56. 56. Risk stratification of patients with TD <ul><li>The oral disease burden of patients with TD </li></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Cretinism </li></ul></ul></ul><ul><ul><ul><ul><li>Puffy face </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Large cranium </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Flat and broad nose </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Macroglossia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Thick elevated lips </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Open mouth </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Altered calcification of teeth </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Delayed eruption of teeth </li></ul></ul></ul></ul>
  57. 57. Risk stratification of patients with TD <ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Myxedema </li></ul></ul></ul><ul><ul><ul><ul><li>Edematous nose, eyelids, and lips </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Macroglossia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Possible increased caries risk </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Possible impaired periodontal health </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Dysgeusia </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Enlarged salivary glands </li></ul></ul></ul></ul>
  58. 58. Risk stratification of patients with TD <ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>Exophthalmos </li></ul></ul></ul><ul><ul><ul><li>Early loss of deciduous teeth </li></ul></ul></ul><ul><ul><ul><li>Early eruption of permanent teeth </li></ul></ul></ul><ul><ul><ul><li>Tremor of the lips and tongue </li></ul></ul></ul><ul><ul><ul><li>Increased risk of caries </li></ul></ul></ul><ul><ul><ul><li>Accelerated alveolar ridge atrophy </li></ul></ul></ul>
  59. 59. Risk stratification of patients with AD <ul><li>Strategies for the dental management of patients with DM </li></ul><ul><ul><li>Cardiac function </li></ul></ul><ul><ul><li>Physiological “stress” of the procedure </li></ul></ul>
  60. 60. Risk stratification of patients with TD <ul><li>Risk stratification </li></ul><ul><ul><li>Hyperthyroidism </li></ul></ul><ul><ul><ul><li>Increased cardiac output may limit cardiac reserve during surgery </li></ul></ul></ul><ul><ul><ul><ul><li>T 3 exerts direct inotropic and chronotropic effects on cardiac muscle </li></ul></ul></ul></ul><ul><ul><ul><ul><li>T 3 appears to act synergistically with epinephrine </li></ul></ul></ul></ul><ul><ul><li>Hypothyroidism </li></ul></ul><ul><ul><ul><li>Co-morbidities </li></ul></ul></ul><ul><ul><ul><ul><li>Dyslipidemia </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>CAD </li></ul></ul></ul></ul></ul>
  61. 61. Risk stratification of patients with DM <ul><li>Functional capacity </li></ul><ul><ul><li>An individuals ability to perform a spectrum of common daily tasks </li></ul></ul><ul><ul><ul><li>Expressed in terms of metabolic equivalents (METs). </li></ul></ul></ul><ul><ul><ul><ul><li>1 MET </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>The oxygen consumption of a 70-kg, 40-year-old man in a resting state, i.e., 3.5 ml per kg per minute </li></ul></ul></ul></ul></ul><ul><li>J Am Coll Cardiol 2002;39:542-553. </li></ul>
  62. 62. Risk stratification of patients with DM <ul><ul><li>Excellent functional activities (>10 METs) </li></ul></ul><ul><ul><ul><ul><li>Strenuous recreational activities </li></ul></ul></ul></ul><ul><ul><li>Good functional capacity (7-10 METs) </li></ul></ul><ul><ul><ul><li>Scrubbing floors, lifting or moving heavy furniture </li></ul></ul></ul><ul><ul><ul><li>Moderate recreational activities </li></ul></ul></ul><ul><ul><li>Moderate functional capacity (4-7 METs) </li></ul></ul><ul><ul><ul><li>Climb a flight of stairs or walk up a hill </li></ul></ul></ul><ul><ul><ul><li>Mow the grass, rake leafs, do light carpentry </li></ul></ul></ul><ul><ul><ul><li>Walk a block on level ground at 6.4 km/h </li></ul></ul></ul><ul><ul><ul><li>Run a short distance </li></ul></ul></ul>
  63. 63. Risk stratification of patients with DM <ul><ul><li>Poor functional capacity (<4 METs) </li></ul></ul><ul><ul><ul><li>Dress, eat, or use the toilet </li></ul></ul></ul><ul><ul><ul><li>Walk around the house indoors </li></ul></ul></ul><ul><ul><ul><li>Do light work around the house (dusting, washing dishes) </li></ul></ul></ul><ul><ul><ul><li>Walk a block on level ground at 3.2 km/h </li></ul></ul></ul><ul><ul><li>Cardiac risk is increased in patients unable to meet 4-METs </li></ul></ul><ul><ul><ul><li>Increased cardiac output associated with hypothyroidism may limit cardiac reserve during surgery </li></ul></ul></ul>
  64. 64. Risk stratification of patients with DM <ul><ul><li>Procedure-related CV risk with non-cardiac surgical procedures </li></ul></ul><ul><ul><ul><li>Predicated on procedure-specific variables </li></ul></ul></ul><ul><ul><ul><ul><li>Fluid shifts </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Blood loss </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Duration of the procedure </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Physiological stress </li></ul></ul></ul></ul><ul><ul><ul><li>Cardiac risk for various dental procedures </li></ul></ul></ul><ul><ul><ul><ul><li>Low to very low risk (<001%) </li></ul></ul></ul></ul><ul><li>Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:42-46. </li></ul><ul><li>Arch Intern Med 2001;161:1509-1512. </li></ul><ul><li>JADA 2001;132:1570-1579. </li></ul>
  65. 65. Risk stratification of patients with TD <ul><li>Physical examination </li></ul><ul><ul><li>Blood pressure </li></ul></ul><ul><ul><ul><li>Useful marker for coronary artery disease </li></ul></ul></ul><ul><ul><ul><li>BP <180/110 mm Hg is not an independent risk factor for cardiovascular risk </li></ul></ul></ul><ul><ul><ul><li>BP >180/110 or <90/50 mm Hg constitutes a medical emergency </li></ul></ul></ul><ul><ul><li>Pulse pressure, rate, and rhythm </li></ul></ul><ul><ul><ul><li>Pulse pressure correlates closely with systolic BP </li></ul></ul></ul><ul><ul><ul><ul><li>Reliable cofactor to either rule out or confirm significant CAD </li></ul></ul></ul></ul><ul><ul><ul><li>Pulse rate <50 or >120 beats/min constitutes a medical emergency </li></ul></ul></ul><ul><ul><ul><li>PVCs </li></ul></ul></ul><ul><ul><ul><ul><li>Significant finding </li></ul></ul></ul></ul>
  66. 66. Risk stratification of patients with TD <ul><li>The use of local anesthetic agents with epinephrine </li></ul><ul><ul><li>The hypothyroid patient </li></ul></ul><ul><ul><ul><li>There is no evidence to justify deferring needed surgery in patients with mild to moderate hypothyroidism </li></ul></ul></ul><ul><ul><ul><li>No evidence of adverse effects associated with epinephrine infusion in patients with hypothyroidism </li></ul></ul></ul><ul><li>Clin Endocrinol 1995;43:747-751. </li></ul><ul><li>Am J Med 1983;14:893-897. </li></ul><ul><li>A m J Med 1984:77:261-266. </li></ul>
  67. 67. Risk stratification of patients with TD <ul><ul><li>The hyperthyroid patient </li></ul></ul><ul><ul><ul><li>Increased cardiac output may limit cardiac reserve during surgery </li></ul></ul></ul><ul><ul><ul><ul><li>The effects of undiagnosed or undertreated hyperthyroidism on the heart carries perioperative risks </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Thyroid hormones act synergistically with epinephrine </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Use epinephrine with caution </li></ul></ul></ul></ul></ul><ul><li>N Engl J Med 2001;344:501-509 </li></ul>
  68. 68. Risk stratification of patients with TD <ul><li>The use of analgesics </li></ul><ul><ul><li>The hypothyroid patient </li></ul></ul><ul><ul><ul><li>Hyper-reactive to opioid analgesics </li></ul></ul></ul><ul><ul><ul><ul><li>Use judiciously </li></ul></ul></ul></ul><ul><ul><li>The hyperthyroid patient </li></ul></ul><ul><ul><ul><li>ASA displaces thyroid hormones from their protein binding sites </li></ul></ul></ul>
  69. 69. Risk stratification of patients with TD Routine referral for medical management and risk factor modification Comprehensive care Blood pressure <180/110 mm Hg AND Normal pulse pressure, rate, and rhythm AND Functional capacity >4 METs Euthyroid OR Mild to moderate thyroid dysfunction AND/OR Minor or intermediate predictors of CV risk Consultation or referral Treatment options Physical examination Thyroid or cardiac risk
  70. 70. Risk stratification of patients with TD Routine referral for medical management and risk factor modification Limited care Blood pressure <180/110 mm Hg AND Normal pulse pressure, rate, and rhythm AND Functional capacity <4 METs Euthyroid OR Mild to moderate thyroid dysfunction AND/OR Minor or intermediate predictors of CV risk Consultation or referral Treatment options Physical examination Thyroid or cardiac risk
  71. 71. Risk stratification of patients with TD If patient is asymptomatic, routine referral for medical management and risk factor modification If patient is symptomatic, immediate referral for medical management and risk factor modification Emergency care Blood pressure >180/110 mm Hg OR Systolic BP <90 mm Hg AND/OR Abnormal pulse pressure, rate, and rhythm Euthyroid OR Mild to moderate thyroid dysfunction AND/OR Minor or intermediate predictors of CV risk Consultation or referral Treatment options Physical examination Thyroid or cardiac risk
  72. 72. Risk stratification of patients with TD Immediate referral for medical management and risk factor modification Emergency care Establish baseline vital signs Severe hypo-thyroidism OR Thyrotoxicosis AND/OR Major predictors of CV risk Consultation or referral Treatment options Physical examination Thyroid or cardiac risk
  73. 73. Risk stratification of patients with TD <ul><li>Preventive strategies </li></ul><ul><ul><li>Oral hygiene </li></ul></ul><ul><ul><ul><li>Conventional vs. electromechanical toothbrushes </li></ul></ul></ul><ul><ul><li>Antibacterial mouthwashes </li></ul></ul><ul><ul><li>Topical fluorides </li></ul></ul><ul><ul><li>Sialagogues </li></ul></ul><ul><ul><ul><li>Pilocarpine (Salagen) </li></ul></ul></ul><ul><ul><ul><li>Cevimeline (Evoxac) </li></ul></ul></ul>
  74. 74. Risk stratification of patients with TD <ul><li>Potential medical emergencies </li></ul><ul><ul><li>The likelihood of myxedema coma or a thyroid crisis in the oral health care setting is extremely remote </li></ul></ul><ul><ul><ul><li>Other medical emergencies may be anticipated based on the patient’s medical history and vital signs </li></ul></ul></ul>
  75. 75. Risk stratification of patients with TD <ul><li>Huber MA, Terezhalmy GT. Risk stratification and dental management of the patient with thyroid dysfunction. Quintessence Int 2008;39:139-150. </li></ul>
  76. 76. Risk stratification of patients with RTD <ul><li>Contraceptives </li></ul><ul><li>Nuvaring (ethinyl estradiol w/etonogestrel) </li></ul><ul><li>Ortho Tri-Cycline (ethinyl estradiol w/norgestimate) </li></ul><ul><li>Trinessa-28 (ethinyl estradiol w/norgestimate) </li></ul><ul><li>Yasmin (ethinyl estradiol w/drospirenone) </li></ul><ul><li>Yaz-28 (ethinyl estradiol w/drospirenone) </li></ul><ul><ul><li>Mechanisms of action </li></ul></ul><ul><ul><ul><li>Inhibit LH and FSH release </li></ul></ul></ul><ul><ul><ul><ul><li>Suppresses follicular development </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Prohibit proper transport of both egg and sperm </li></ul></ul></ul></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><li>Prevention of pregnancy </li></ul></ul></ul>
  77. 77. Risk stratification of patients with RTD <ul><li>Estrogens </li></ul><ul><li>Premarin (conjugated estrogen) </li></ul><ul><ul><li>Mechanism of action </li></ul></ul><ul><ul><ul><li>Promotes growth and development of female reproductive system </li></ul></ul></ul><ul><ul><ul><li>Conserves calcium and phosphorus and encourages bone formation </li></ul></ul></ul><ul><ul><ul><li>Overrides stimulatory effect of testosterone </li></ul></ul></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><li>Hypogonadism, menopause, uterine bleeding </li></ul></ul></ul><ul><ul><ul><li>Prevention and treatment of osteoporosis </li></ul></ul></ul><ul><ul><ul><li>Metastatic prostate cancer </li></ul></ul></ul>
  78. 78. Reproductive tract dysregulation <ul><li>Selective estrogen receptor modulators </li></ul><ul><li>Evista (raloxifene) </li></ul><ul><ul><li>Mechanism of action </li></ul></ul><ul><ul><ul><li>Estrogen receptor agonist activity in bone </li></ul></ul></ul><ul><ul><ul><li>Estrogen antagonist activity in breast and endometrial tissue </li></ul></ul></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><li>Prevention of osteoporosis in post menopausal women </li></ul></ul></ul><ul><ul><ul><li>Palliative and supportive care in metastatic breast and endometrial carcinoma </li></ul></ul></ul>
  79. 79. Risk stratification of patients with RTD <ul><li>The oral disease burden of patients with RTD </li></ul><ul><ul><li>Periods of hormonal imbalance are associated with subtle but definite tissue changes </li></ul></ul><ul><ul><ul><li> hormones </li></ul></ul></ul><ul><ul><ul><ul><li>Gingivitis </li></ul></ul></ul></ul><ul><ul><ul><li> hormones </li></ul></ul></ul><ul><ul><ul><ul><li>Mucosal atrophy </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Burning mouth syndrome </li></ul></ul></ul></ul></ul>
  80. 80. Risk stratification of patients with RTD <ul><li>Strategies for the dental management of patients with RTD </li></ul><ul><ul><li>Cardiac function </li></ul></ul><ul><ul><li>Physiological “stress” of the procedure </li></ul></ul>
  81. 81. Risk stratification of patients with RTD <ul><li>Risk stratification </li></ul><ul><ul><li>Drug history </li></ul></ul><ul><ul><ul><li>Contraceptives </li></ul></ul></ul><ul><ul><ul><li>Hormone agonists or antagonists </li></ul></ul></ul><ul><ul><li>Tumors </li></ul></ul><ul><ul><ul><li>Breast </li></ul></ul></ul><ul><ul><ul><li>Prostate </li></ul></ul></ul><ul><ul><li>CVD </li></ul></ul><ul><ul><li>Stroke </li></ul></ul>
  82. 82. Risk stratification of patients with RTD <ul><li>Functional capacity </li></ul><ul><ul><li>An individuals ability to perform a spectrum of common daily tasks </li></ul></ul><ul><ul><ul><li>Expressed in terms of metabolic equivalents (METs). </li></ul></ul></ul><ul><ul><ul><ul><li>1 MET </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>The oxygen consumption of a 70-kg, 40-year-old man in a resting state, i.e., 3.5 ml per kg per minute </li></ul></ul></ul></ul></ul><ul><li>J Am Coll Cardiol 2002;39:542-553. </li></ul>
  83. 83. Risk stratification of patients with RTD <ul><ul><li>Excellent functional activities (>10 METs) </li></ul></ul><ul><ul><ul><ul><li>Strenuous recreational activities </li></ul></ul></ul></ul><ul><ul><li>Good functional capacity (7-10 METs) </li></ul></ul><ul><ul><ul><li>Scrubbing floors, lifting or moving heavy furniture </li></ul></ul></ul><ul><ul><ul><li>Moderate recreational activities </li></ul></ul></ul><ul><ul><li>Moderate functional capacity (4-7 METs) </li></ul></ul><ul><ul><ul><li>Climb a flight of stairs or walk up a hill </li></ul></ul></ul><ul><ul><ul><li>Mow the grass, rake leafs, do light carpentry </li></ul></ul></ul><ul><ul><ul><li>Walk a block on level ground at 6.4 km/h </li></ul></ul></ul><ul><ul><ul><li>Run a short distance </li></ul></ul></ul>
  84. 84. Risk stratification of patients with RTD <ul><ul><li>Poor functional capacity (<4 METs) </li></ul></ul><ul><ul><ul><li>Dress, eat, or use the toilet </li></ul></ul></ul><ul><ul><ul><li>Walk around the house indoors </li></ul></ul></ul><ul><ul><ul><li>Do light work around the house (dusting, washing dishes) </li></ul></ul></ul><ul><ul><ul><li>Walk a block on level ground at 3.2 km/h </li></ul></ul></ul><ul><ul><li>Cardiac risk is increased in patients unable to meet 4-METs </li></ul></ul>
  85. 85. Risk stratification of patients with RTD <ul><ul><li>Procedure-related CV risk with non-cardiac surgical procedures </li></ul></ul><ul><ul><ul><li>Predicated on procedure-specific variables </li></ul></ul></ul><ul><ul><ul><ul><li>Fluid shifts </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Blood loss </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Duration of the procedure </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Physiological stress </li></ul></ul></ul></ul><ul><ul><ul><li>Cardiac risk for various dental procedures </li></ul></ul></ul><ul><ul><ul><ul><li>Low to very low risk (<001%) </li></ul></ul></ul></ul><ul><li>Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:42-46. </li></ul><ul><li>Arch Intern Med 2001;161:1509-1512 . </li></ul><ul><li>JADA 2001;132:1570-1579. </li></ul>
  86. 86. Risk stratification of patients with RTD <ul><li>Physical examination </li></ul><ul><ul><li>Blood pressure </li></ul></ul><ul><ul><ul><li>Useful marker for coronary artery disease </li></ul></ul></ul><ul><ul><ul><li>BP <180/110 mm Hg is not an independent risk factor for cardiovascular risk </li></ul></ul></ul><ul><ul><ul><li>BP >180/110 or <90/50 mm Hg constitutes a medical emergency </li></ul></ul></ul><ul><ul><li>Pulse pressure, rate, and rhythm </li></ul></ul><ul><ul><ul><li>Pulse pressure correlates closely with systolic BP </li></ul></ul></ul><ul><ul><ul><ul><li>Reliable cofactor to either rule out or confirm significant CAD </li></ul></ul></ul></ul><ul><ul><ul><li>Pulse rate <50 or >120 beats/min constitutes a medical emergency </li></ul></ul></ul><ul><ul><ul><li>PVCs </li></ul></ul></ul><ul><ul><ul><ul><li>Significant finding </li></ul></ul></ul></ul>
  87. 87. Risk stratification of patients with RTD <ul><li>Local anesthetic agents </li></ul><ul><ul><li>Provide the greatest margin of safety when treating patients with CVD </li></ul></ul><ul><ul><ul><li>Absence of profound anesthesia </li></ul></ul></ul><ul><ul><ul><ul><li>Myocardial ischemia </li></ul></ul></ul></ul><ul><ul><ul><li>The physiological stress associated with 4 METs </li></ul></ul></ul><ul><ul><ul><ul><li>Equivalent to the effect of 0.045 mg of epinephrine </li></ul></ul></ul></ul><ul><li>* Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:171-181. </li></ul>
  88. 88. Risk stratification of patients with RTD <ul><li>Contraceptives and antibacterial agents </li></ul><ul><ul><li>Scientific evidence regarding the alleged interaction between antibacterial agents and contraceptives does not satisfy the “ Daubert standard” of causality </li></ul></ul><ul><li>J Law Med Ethics 1996;24:273-274. </li></ul><ul><ul><li>There are no pharmacokinetic data to support the contention that antibacterial agents reduce the efficacy of contraceptives </li></ul></ul><ul><li>J Am Acad Dermato 2002;46:917-923. </li></ul>
  89. 89. Risk stratification of patients with RTD <ul><li>Preventive strategies </li></ul><ul><ul><li>Oral hygiene </li></ul></ul><ul><ul><ul><li>Conventional vs. electromechanical toothbrushes </li></ul></ul></ul><ul><ul><li>Antibacterial mouthwashes </li></ul></ul><ul><ul><li>Topical fluorides </li></ul></ul><ul><ul><li>Sialagogues </li></ul></ul><ul><ul><ul><li>Pilocarpine (Salagen) </li></ul></ul></ul><ul><ul><ul><li>Cevimeline (Evoxac) </li></ul></ul></ul>
  90. 90. Risk stratification of patients with RTD <ul><li>Potential medical emergencies </li></ul><ul><ul><li>Anticipate medical emergencies based on the patient’s medical history and vital signs </li></ul></ul>
  91. 91. Risk stratification of patients with RTD
  92. 92. Risk stratification of patients on bisphosphonates <ul><li>Bisphosphonates </li></ul><ul><li>Fosamax (alendronate) </li></ul><ul><li>Actonel (risendronate) </li></ul><ul><li>Boniva (ibandronate) </li></ul><ul><ul><li>Mechanisms of action </li></ul></ul><ul><ul><ul><li>Inhibit osteoclastic and reduce osteoblastic activity </li></ul></ul></ul><ul><ul><li>Indications </li></ul></ul><ul><ul><ul><li>Prevention and treatment of osteoporosis </li></ul></ul></ul><ul><ul><ul><li>Paget’s disease </li></ul></ul></ul><ul><ul><ul><li>Hypercalcemia of malignancy (IV formulations) </li></ul></ul></ul>
  93. 93. Risk stratification of patients on bisphosphonates <ul><li>The oral disease burden of patients with DBM </li></ul><ul><ul><li>An increasing body of literature suggests that bisphosphonate use, especially intravenous preparations, may be associated with osteonecrosis of the jaws </li></ul></ul>
  94. 94. Risk stratification of patients on bisphosphonates <ul><li>Bisphosphonate-related osteonecrosis of the jaw (BRONJ) </li></ul><ul><ul><li>Systematic review of the literature from 1966 through 31 January 2006 - 368 cases </li></ul></ul><ul><ul><ul><li>Female to male ration - 3:2 </li></ul></ul></ul><ul><ul><ul><li>Mandible - 65%; maxilla - 26%; both jaws - 9% </li></ul></ul></ul><ul><ul><ul><li>Multifocal or bilateral involvement </li></ul></ul></ul><ul><ul><ul><ul><li>Maxilla - 31%; Mandible 23% </li></ul></ul></ul></ul><ul><ul><ul><li>Most lesions were posterior to the lingual mandible near the mylohyoid ridge </li></ul></ul></ul><ul><ul><ul><li>60% of the cases occurred after a tooth extraction or other dentoalveolar surgery </li></ul></ul></ul><ul><ul><ul><li>94% of the patients were treated with IV bisphosphonates </li></ul></ul></ul><ul><li>(Ann Intern Med 2006;144:753-761.) </li></ul>
  95. 95. Risk stratification of patients on bisphosphonates <ul><li>IV bisphosphonate-related osteonecrosis of the jaw (BRONJ) </li></ul><ul><ul><li>Population-based analysis based on data from the Surveillance, Epidemiology, and End Results (SEER) program linked to Medicare claims - 16,072 cancer patients and 28,698 controls </li></ul></ul><ul><ul><ul><li>Absolute risk of inflammatory conditions or surgery of the jaw at 6 years </li></ul></ul></ul><ul><ul><ul><ul><li>5.48 events per 100 patients using IV BPs </li></ul></ul></ul></ul><ul><ul><ul><ul><li>0.30 events per 100 patients not using B </li></ul></ul></ul></ul><ul><li>(J Natl Cancer Inst 2007;991016-1024.) </li></ul>
  96. 96. Risk stratification of patients on bisphosphonates <ul><li>Oral bisphosphonate-related osteonecrosis of the jaw (BRONJ) </li></ul><ul><ul><li>Data from the fracture intervention trial (FIT) long-term extension (FLEX) - 1099 women with osteoporosis </li></ul></ul><ul><ul><ul><li>After being on alendronate for 5 years, 5 mg or 10 mg </li></ul></ul></ul><ul><ul><ul><ul><li>5 year extension: alendronate, 5mg (n=329; alendronate 10 mg (n=333); placebo (n=537 for 5 years) </li></ul></ul></ul></ul><ul><ul><ul><li>No cases of BRONJ </li></ul></ul></ul><ul><ul><ul><ul><li>Even the long-term use of oral BPs caries little risk of BRONJ </li></ul></ul></ul></ul><ul><li>(JAMA 2006;296:2927-2938.) </li></ul>
  97. 97. Risk stratification of patients on bisphosphonates <ul><li>Bisphosphonate-related osteonecrosis of the jaw (BRONJ) </li></ul><ul><ul><li>Case definition must meet all of the following </li></ul></ul><ul><ul><ul><li>Current or previous treatment with BPs </li></ul></ul></ul><ul><ul><ul><li>Exposed, necrotic bone in the maxillofacial region that has persisted for more than 8 weeks </li></ul></ul></ul><ul><ul><ul><li>No history of radiation therapy to the jaws </li></ul></ul></ul><ul><li>(J Oral Maxillofac Surg 2007;65:369-376.) </li></ul>
  98. 98. Risk stratification of patients on bisphosphonates <ul><li>Strategies for the dental management of patients on bisphosphonates </li></ul>
  99. 99. Risk stratification of patients on bisphosphonates <ul><li>Risk stratification </li></ul><ul><ul><li>At risk category A </li></ul></ul><ul><ul><ul><li>Patients who have been treated with oral BPs </li></ul></ul></ul><ul><ul><ul><ul><li>No apparent exposed/necrotic bone </li></ul></ul></ul></ul><ul><ul><ul><li>Treatment strategies </li></ul></ul></ul><ul><ul><ul><ul><li>Patient education </li></ul></ul></ul></ul><ul><ul><ul><ul><li>No alteration or delay in planned dental care </li></ul></ul></ul></ul><ul><li>(J Oral Maxillofac Surg 2007;65:369-376.) </li></ul>
  100. 100. Risk stratification of patients on bisphosphonates <ul><ul><li>At risk category B </li></ul></ul><ul><ul><ul><li>Patients who have been treated with IV BPs </li></ul></ul></ul><ul><ul><ul><ul><li>No apparent exposed/necrotic bone </li></ul></ul></ul></ul><ul><ul><ul><li>Treatment strategies </li></ul></ul></ul><ul><ul><ul><ul><li>Patient education </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Non-restorable teeth may be treated by removal of the crown </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Endodontic treatment of the remaining roots </li></ul></ul></ul></ul></ul><ul><li>(J Oral Maxillofac Surg 2007;65:369-376.) </li></ul>
  101. 101. Risk stratification of patients on bisphosphonates <ul><ul><li>Stage 1 BRONJ </li></ul></ul><ul><ul><ul><li>Exposed/necrotic bone in patients who are asymptomatic </li></ul></ul></ul><ul><ul><ul><ul><li>No evidence of infection </li></ul></ul></ul></ul><ul><ul><ul><li>Treatment strategies </li></ul></ul></ul><ul><ul><ul><ul><li>Antimicrobial mouth rinse </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Removal of mobile segments of bony sequestrum </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Clinical follow-up on a quarterly basis </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Patient education </li></ul></ul></ul></ul><ul><li>(J Oral Maxillofac Surg 2007;65:369-376.) </li></ul>
  102. 102. Risk stratification of patients on bisphosphonates <ul><ul><li>Stage 2 BRONJ </li></ul></ul><ul><ul><ul><li>Exposed/necrotic bone associated with infection </li></ul></ul></ul><ul><ul><ul><ul><li>Pain and erythema in the region of the exposed bone with or without purulent drainage </li></ul></ul></ul></ul><ul><ul><ul><li>Treatment strategies </li></ul></ul></ul><ul><ul><ul><ul><li>Symptomatic treatment with a broad-spectrum oral antibacterial agent </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Antimicrobial mouth rinse </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pain control </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Superficial debridement to relieve soft tissue irritation </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Patient education </li></ul></ul></ul></ul><ul><li>(J Oral Maxillofac Surg 2007;65:369-376.) </li></ul>
  103. 103. Risk stratification of patients on bisphosphonates <ul><ul><li>Stage 3 BRONJ </li></ul></ul><ul><ul><ul><li>Exposed/necrotic bone in patients </li></ul></ul></ul><ul><ul><ul><ul><li>Pain, infection, and one or more of the following </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Pathologic fracture </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Extraoral sinus tract </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>Osteolysis extending to the inferior border </li></ul></ul></ul></ul></ul><ul><ul><ul><li>Treatment strategies </li></ul></ul></ul><ul><ul><ul><ul><li>As in Stage 2 BRONJ </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Surgical debridement/resection for longer term palliation of infection and pain </li></ul></ul></ul></ul><ul><li>(J Oral Maxillofac Surg 2007;65:369-376.) </li></ul>
  104. 104. Risk stratification of patients on bisphosphonates

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