Systemic diseases for dental

procedures

นายแพทย์ เอลวิล เพชรปลูก

อายุรแพทย์ เฉพาะทางระบบทางเดิน
อาหาร16/9/2010
 Topics

• Antiplatelet and Anticoagulant therapy in dent

al procedures
• Hypertension in dental procedures
• Diabetes in dental procedures
• Steroid treatment patient in dental procedures
• Chronic liver diseases in dental procedures
Antiplatelet
Antiplatelet and Anticoagulant in de
ntal procedures

• Antiplatelet Therapy for Prevention of Ischemic

Cardiovascular Events and Stent Thrombosis

• Management of Oral Anticoagulant Therapy

 Antiplatelet Therapy for Prevention
of Ischemic Cardiovascular Events and
Stent Thrombosis

Recommendations for the prevention of stent thrombosis after

coronary stent implantation , at a minimum

• 1 month after bare-metal stent implantation patients should be tr

eated with clopidogrel 75 mg and aspirin 325 mg
• 3 months after sirolimus drug eluting stent (DES) implantation
• 6 months after paclitaxel DES implantation and ideally, up to 12
months if they are not at high risk for bleeding

Circulation. 2007;115:813-818
Recommendations for the prevention of stent thrombosis af
ter coronary stent implantation , at a minimum

• Stent thrombosis most commonly occurs in the first month after

stent implantation
• In patients treated with DES, stent thrombosis occurred in 29%
of whom antiplatelet therapy was discontinued prematurely

Circulation. 2007;115:813-818
 Antiplatelet in dental procedures
• prospective study of single tooth extractions on patients random
ized to aspirin versus a placebo failed to show a statistically sig
nificant difference in postoperative bleeding
• no well-documented cases of clinically significant bleeding after
dental procedures, including multiple dental extractions

Circulation. 2007;115:813-818
 Antiplatelet in dental procedures

• Clopidogrel was combined with aspirin and administered for prol

onged duration (up to 28 months), an absolute increase (ranging
from 0.4% to 1.0%) in major bleeding, compared with aspirin al
one
• Many procedures (eg, minor surgery, teeth cleaning, and tooth e
xtraction) can likely be performed at no or only minor risk of ble
eding or could be delayed until the prescribed antiplatelet regim
en is completed

Circulation. 2007;115:813-818
 Antiplatelet in dental procedures
conclusion

Unlikely occurrence of bleeding once an initial clot

has formed.

With local measures during surgery (eg, absorbabl

e gelatin sponge and sutures), there is little or n
o indication to interrupt antiplatelet drugs for den
tal procedures.

Circulation. 2007;115:813-818
Ischemic Heart Disease: Dental
Management Considerations
 Patient with stable angina can usually undergo routine dent
al care safely
 Patient with unstable angina is considered danger for denta
l procedures,
 angina is considered unstable if it is changing for the worse i
n some parameter
 Angina is now occurring more frequently
 Angina appears at lower levels of exertion than in the past
 Angina requires larger doses of nitrates for relief
 Angina relief takes longer than in prior episodes
Ischemic Heart Disease: Dental
Management Considerations

 In the past, myocardial infarctions, limit noncardiac surgical interventions

on these patients for at least 6 months.
 Nowadays, early and rapid interventions, myocardial damage can be mini
mal, no reason to delay even elective dental procedures.

Dent Clin N Am 50 (2006) 483–491

Anticoagulant
Anticoagulant in dental procedures
Clotting Cascade
Vitamin K-Dependent Clotting Factors

Vitamin K

VII
Synthesis of
IX Functional
X Coagulation
Factors
II
Warfarin Mechanism of Action

Vitamin K

Antagonism VII
of Synthesis of
Vitamin K IX Non
X Functional
Coagulation
II Factors

Warfarin
 Anticoagulant in dental procedures
Warfarin: Indications
• Prophylaxis and/or treatment of:
– Venous thrombosis and its extension
– Pulmonary embolism
– Thromboembolic complications associated with AF and cardi
ac valve replacement
• Post MI, to reduce the risk of death, recurrent MI, and thromboe
mbolic events such as stroke or systemic embolization
• Prevention and treatment of cardiac embolism
Antithrombotic Agents: Mechanism of Action

 Anticoagulants: prevent clot formation and extension

 Antiplatelet drugs: interfere with platelet activity
 Thrombolytic agents: dissolve existing thrombi
INR Equation

( )
Patient’s PT in Seconds ISI
INR =
Mean Normal PT in Seconds

INR = International Normalized Ratio

ISI = International Sensitivity Index
How Different Thromboplastins
Influence the PT Ratio and INR
Blood from a
single patient
Thromboplastin Patient’s Mean
Reagent PT Normal PTR ISI INR
(Seconds) (Seconds)

A 16 12 1.3

B 18 12 1.5

C 21 13 1.6

D 24 11 2.2
E 38 14.5 2.6
How Different Thromboplastins
Influence the PT Ratio and INR
Blood from a
single patient
Thromboplastin Patient’s Mean
reagent PT Normal PTR ISI INR
(Seconds) (Seconds)

A 16 12 1.3 3.2 2.6

B 18 12 1.5 2.4 2.6

C 21 13 1.6 2.0 2.6

D 24 11 2.2 1.2 2.6

E 38 14.5 2.6 1.0 2.6
INR: International Normalized Ratio
 A mathematical “correction” (of the PT ratio) for differences in the sensitivi
ty of thromboplastin reagents
 Relies upon “reference” thromboplastins with known sensitivity to antithro
mbotic effects of oral anticoagulants
 INR is the PT ratio one would have obtained if the “reference” thrombopla
stin had been used

 Allows for comparison of results between labs and standardizes reporting

of the prothrombin time

J Clin Path 1985; 38:133-134; WHO Tech Rep Ser. #687 983.
Skin bleeding time

 Technical variability: Despite attempts at standardization, the test remains

poorly reproducible and subject to a large number of variables.
 Technique-related factors include location and direction of the incision
 The skin bleeding time does not necessarily reflect bleeding from any oth
er site.
 The bleeding time may be within the normal range in VWD, and in aspirin
users

British Journal of Haematology, 2008, 140, 496–504

Guidelines for the management of patients on oral antic
oagulants requiring dental surgery

Summary of key recommendations

1. The risk of significant bleeding in patients on oral anticoagulants and with
a stable INR in the therapeutic range 2-4 (i.e. <4) is very small and the ris
k of thrombosis may be increased in patients in whom oral anticoagulants
are temporarily discontinued. Oral anticoagulants should not be discontin
ued in the majority of patients requiring out-patient dental surgery includin
g dental extraction (grade A level Ib).

British Committee for Standards in Haematology 2007

Guidelines for the management of patients on oral antic
oagulants requiring dental surgery

Summary of key recommendations

2. Recommendations: For patients stably anticoagulated on warfarin (INR 2-4
) and who are prescribed a single dose of antibiotics as prophylaxis agai
nst endocarditis, there is no necessity to alter their anticoagulant regimen
(grade C, level IV).

British Committee for Standards in Haematology 2007

Guidelines for the management of patients on oral antic
oagulants requiring dental surgery

Summary of key recommendations

3. The risk of bleeding may be minimised by:
a. The use of oxidised cellulose (Surgicel) or collagen sponges and suture
s (grade B, level IIb).
b. 5% tranexamic acid mouthwashes used four times a day for 2 days (gra
de A, level Ib).

4. For patients who are stably anticoagulated on warfarin, a check INR is rec
ommended 72 hours prior to dental surgery (grade A, level Ib)

British Committee for Standards in Haematology 2007

Best evidence statement (BESt). Management of w
arfarin therapy

 It is recommended, for patients undergoing dental extractio

ns, consider use of tranexamic mouthwash or epsilon amin
ocaproic acid mouthwash without interruption of anticoagul
ation therapy
CHEST 2008 Anticoagulation Guidelines
The risk of thrombosis if anticoagulants are
discontinued

 The risk of thrombosis associated with temporarily discontinuing anticoag

ulants prior to dental surgery is small but potentially fatal.

 In the review of Wahl, 5/493 (1%) patients undergoing 542 dental procedu
res and in whom anticoagulants were withdrawn specifically for surgery, h
ad serious embolic complications of which 4 were fatal

Arch Intern Med 1998;158(15):1610-6.

The risk of major bleeding in patients undergoing
oral surgery if anticoagulants are continued

 Metanalysis, comprising 2014 dental surgical procedures in 774 patients

receiving continuous warfarin therapy, undergoing single, multiple extracti
ons and full mouth extractions , included patients with an INR up to 4.0, m
ore that 98% of patients receiving continuous anticoagulants had no seri
ous bleeding problems.

 Twelve patients (<2%) had postoperative bleeding problems that were no

t controlled by local measures.

 Major bleeding was rare (4/2012, 0.2%) for patients with a therapeutic IN
R (<4) undergoing dental surgery.
Arch Intern Med 1998;158(15):1610-6.
Blood pressure in HT
Dental Management of Patients
with Hypertension
The seventh revision by the Joint National Committee on the Prevention, D
etection, Evaluation and Treatment of High Blood Pressure and is known
as the JNC-7 Report
Above which BP values should the dentist not treat
?
 Many well-respected authors have published 180/110 for the absolute cut
off for any dental treatment

 In fact, this value may be too high for patients who have had previous hyp
ertensive-related organ damage, such as myocardial infarctions, strokes,
or labile angina.

 Conversely, healthy patient with a negative medical history with values ar

ound 200/110 may be treated without any perioperative complications.

Dent Clin N Am 50 (2006) 547–562

‘‘Risk assessment’’
Key in determining the likelihood of complications
 Physical classification system of the American Society of Anesthesiologist
s (ASA) has been in use since 1941.

 The higher the ASA class, the more at-risk the patient is both from a surgi
cal and anesthetic perspective [31].
 ASA Class I. A normal healthy patient
 ASA Class II. A patient with mild systemic disease
 ASA Class III. A patient with severe systemic disease
 ASA Class IV. A moribund patient who is not expected to sur
vive without the operation
‘‘Risk assessment’’
 Metabolic equivalent or METS, one MET is defined as 3.5 mL of 02/Kg/min

 It essentially is a test of the patient’s ability to perform physical work.

 1 to 4 METS: eating, dressing, walking around house, dishw
ashing
 4 to 10 METS: climbing at least one flight of stairs, walking l
evel ground 6.4 km/hr, running short distance, game of golf
 >=10 METS: swimming, singles tennis, football

Dent Clin N Am 50 (2006) 547–562

‘‘Risk assessment’’

 People with capacities of 4 METS or less are at high risk for medical com
plications.

 Those who can perform 10 METS or more are at very low risk.
 Example; a person who is anxious with a BP 200/115 but can
perform 10 METS of work would likely have no problems with
a simple extraction.

Dent Clin N Am 50 (2006) 547–562

 Algorithm for treat
ing the hypertensi
ve dental patient.

The algorithm assumes

no other medical
contraindications such
as a recent stroke,
unstable dysrhythmias,
myocardial infarction, or
pregnancy.

Dent Clin N Am 50 (2006) 547–562

Blood sugar and DM
Dental Management of Patients
with Diabetes

American Diabetic Association (ADA)

 Normal plasma glucose : FPG < 100mg/dL

 Diagnosis of DM is the patient who presents with classic symptoms of pol
yuria, thirst, weight loss, fatigue, visual blurring, and a FPG >126 mg/dL,
or a random value of at least 200 mg/dL.
Dental Management of Patients with Diabetes

American Diabetic Association (ADA)

 In the absence of these classic symptoms, glucose intolerance may exist

as impaired fasting glucose (IFG) when the FPG is between 100 and 125
mg/dL.
 Plasma glucose of 140 to 199 mg/dL following OGTT defines impaired gl
ucose tolerance (IGT).
 The classification of IFG and IGT is important because individuals with IF
G and IGT are at greater risk of developing diabetes and atherosclerotic
cardiovascular disease even if they do not develop DM
 Glucose Control Study Summary
The intensive glucose control policy maintained a lower HbA1c by mean 0.9 %
over a median follow up of 10 years from diagnosis of type 2 diabetes with
reduction in risk of:
12% for any diabetes related endpoint p=0.029
25% for microvascular endpoints p<0.01
16% for myocardial infarction p=0.052
24% for cataract extractionp=0.046
21% for retinopathy at twelve years p=0.015
33% for albuminuria at twelve years p<0.001

UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:837-853.

 Conclusion

The UKPDS has shown that intensive blood glucose control

reduces the risk of diabetic complications, the greatest
effect being on microvascular complications

UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:837-853.

Dental consideration in DM patient
 Aspirin Therapy (for adults) – 75-162 mg/day as primary an
d secondary prevention of cardiovascular disease unless c
ontraindicated.

 Systemic complications from DM

 hypertension
 cardiodiovascular disease
 renal insufficiency

Basic guidelines for diabetes care. California Diabetes Program; 2008.

Performing dental procedures on diabetic patients

 Main concern is
 to avoid acute incidents hyper or hypo-glycemic comas durin
g the operation
 to secure a smooth post-operational course (wound healing
and infection)
Above which blood sugar level should the den
tist not treat?
 No absolute cutoff value for any dental treatment (generally acceptable v
alue of 100-200mg/dl in elective minor procedures without NPO)
 In fact, any level of blood sugar should be treated for abscess which nee
d drainage procedures, may be in case of periodontitis with poor glycemi
c control
 In well-controlled diabetes, probably no greater risk of postoperative infec
tion than is the nondiabetic
 When surgery is necessary in the poorly controlled diabetic (random bloo
d sugar >200mg/dl), prophylactic antibiotics should be considered
 Periodontal Treatment on Glycemic Control of Diab
etic Patients
 Meta-analysis suggests that periodontal treatment leads to an improvement of gly
cemic control in type 2 diabetic patients for at least 3 months (periodontal therapy is
favorable and can reduce A1C levels on average by 0.40% more than in nonintervention contro
l subjects)

Diabetes Care. 2010; 33; 421-427

Steroid
Steroid treatment patient in dental procedures

 Secondary adrenocortical insufficiency (AI) results from the administration

of exogenous corticosteroids

 In secondary AI, normal mineralocorticoid function is preserved and less l

ikely for patients to experience adrenal crisis than it is for patients with pri
mary AI.
Long term steroid treatment in medicine
 Autoimmune disease; SLE, AIHA, ITP, RA, vasculitis s
yndromes, nephrotic-nephritis syndromes, AIH, IBD, a
utoimmune pancreatitis, etc.
 Allergic diseases; asthma
 Post organ transplantation
 Adrenal insufficiency; primary or secondary
Steroid treatment in dental procedures
 Adrenal crisis, event can occur when a patient with AI ( most commonly in t
he form of Addison’s disease), is challenged by stress (for example, illness,
infection or surgery), and, in response, is unable to synthesize adequate am
ounts of cortisol and aldosterone.

 Adrenal crisis is rare in patients with secondary AI, because the majority of t
hese patients have normal aldosterone levels
Steroid treatment in surgical procedures
 Risk of adrenal crisis appears to be low in minor surgery

 Majority of patients who regularly take the daily equivalent dose of steroid (5
-10 mg of prednisone daily) maintain adrenal function and do not require su
pplementation for minor surgical procedures
 Minor surgical stress the glucocorticoid target is about 25 mg of hydrocortiso
ne equivalent on the day of surgery
 Moderate surgical stress the glucocorticoid target is about 50-75 mg/day of h
ydrocortisone equivalent for 1-2 days
 Major surgical stress the glucocorticoid target is 100-150 mg/day of hydrocor
tisone equivalent for 2-3 days
Who is at risk of experiencing adrenal crisis during
dental procedures?

Adrenal crisis is rare in dentistry

Patients receiving therapeutic doses of corticosteroids who undergo a

surgical procedure do not routinely require stress doses of
corticosteroids so long as they continue to receive their usual daily
dose of corticosteroid.

J Am Dent Assoc 2001;132;1570-1579

Arch Surg. 2008;143(12):1222-1226
Who is at risk of experiencing adrenal crisis during
dental procedures?

In patients who receive physiologic replacement doses of

corticosteroids, these patients are unable to increase endogenous
cortisol production in the face of stress

These patients require adjustment of their glucocorticoid dose

during surgical stress under all circumstances.

Arch Surg. 2008;143(12):1222-1226

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

J Am Dent Assoc 2001;132;1570-1579

Cirrhosis
Chronic liver diseases in dental procedures
 Potential for impaired hemostasis and bleeding diathesis due to thromboc
ytopenia or reduced hepatic synthesis of coagulation factors

 Increased risk of infection, or spread of infection

Chronic liver diseases in dental procedures
 If any significantly abnormal result in platelet count, PT or INR is detected in
a patient with cirrhosis, medical consultation is recommended

 Currently, no evidence-based data to support the recommendation that patie

nts with cirrhosis should have antibiotic prophylaxis before routine dental pro
cedures.