Systemic diseases for dental

procedures

นายแพทย ์เอลวิล เพชรปลู ก

อายุรแพทย ์เฉพาะทางระบบ
ทางเดินอาหาร16/9/2010
 Topics

• Antiplatelet and Anticoagulant therapy in

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

• Antiplatelet Therapy for Prevention of Ischemic

Cardiovascular Events and Stent Thrombosis

• Management of Oral Anticoagulant Therapy

 Antiplatelet Therapy for Prevention
of Ischemic Cardiovascular Events and
Stent Thrombosis

Recommendations for the prevention of stent thrombosis after

coronary stent implantation , at a minimum

• 1 month after bare-metal stent

implantation patients should be treated
with clopidogrel 75 mg and aspirin 325
mg
• 3 months after sirolimus drug eluting
stent (DES) implantation
• 6 months after paclitaxel DES Circulation. 2007;115:813-
Recommendations for the prevention of stent thrombosis
after coronary stent implantation , at a minimum

• Stent thrombosis most commonly occurs

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

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

• prospective study of single tooth

extractions on patients randomized to
aspirin versus a placebo failed to show
a statistically significant difference in
postoperative bleeding
• no well-documented cases of clinically
significant bleeding after dental
procedures, including multiple dental
extractions

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

• Clopidogrel was combined with aspirin

and administered for prolonged duration
(up to 28 months), an absolute increase
(ranging from 0.4% to 1.0%) in major
bleeding, compared with aspirin alone
• Many procedures (eg, minor surgery, teeth
cleaning, and tooth extraction) can likely
be performed at no or only minor risk of
bleeding or could be delayed until the
prescribed antiplatelet regimen Circulation
is . 2007;115:813-
 Antiplatelet in dental procedures
conclusion

Unlikely occurrence of bleeding once an initial clot

has formed.

With local measures during surgery (eg,

absorbable gelatin sponge and sutures), there is
little or no indication to interrupt antiplatelet
drugs for dental procedures.

Circulation. 2007;115:813-
Ischemic Heart Disease: Dental
Management Considerations

 Patient with stable angina can usually undergo routine

dental care safely
 Patient with unstable angina is considered danger for
dental procedures,
angina is considered unstable if it is
changing for the worse in some
parameter
 Angina is now occurring more
frequently
 Angina appears at lower levels of
exertion than in the past
 Angina requires larger doses of
Ischemic Heart Disease: Dental
Management Considerations

 In the past, myocardial infarctions, limit

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

Dent Clin N Am 50 (2006) 483–491

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

Vitamin K

VII
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 cardiac valve
replacement
• Post MI, to reduce the risk of death,
recurrent MI, and thromboembolic events
such as stroke or systemic embolization
Antithrombotic Agents: Mechanism of Action

 Anticoagulants: prevent clot formation and extension

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

INR =( Patient’s PT in Seconds ISI

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 sensitivity of thromboplastin
reagents
 Relies upon “reference” thromboplastins with
known sensitivity to antithrombotic effects of
oral anticoagulants
 INR is the PT ratio one would have obtained if
the “reference” thromboplastin had been used

 Allows for comparison of results between

labs and standardizes reporting of the
prothrombin time J Clin Path 1985; 38:133-134; WHO Tech Rep Ser. #687 983.
Skin bleeding time

 Technical variability: Despite attempts at

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

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

Guidelines for the management of patients on oral
anticoagulants requiring dental surgery

Summary of key recommendations

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

British Committee for Standards in Haematology 2007

Guidelines for the management of patients on oral
anticoagulants requiring dental surgery

Summary of key recommendations

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

British Committee for Standards in Haematology 2007

Guidelines for the management of patients on oral
anticoagulants requiring dental surgery

Summary of key recommendations

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

4. For patients who are stably anticoagulated on

warfarin, a check INR is recommended 72
hours prior to dental surgery (grade A, level Ib)
British Committee for Standards in Haematology 2007
Best evidence statement (BESt). Management of
warfarin therapy

 It is recommended, for patients undergoing dental

extractions, consider use of tranexamic mouthwash or
epsilon aminocaproic acid mouthwash without interruption
of anticoagulation therapy
CHEST 2008 Anticoagulation Guidelines
The risk of thrombosis if anticoagulants are
discontinued

 The risk of thrombosis associated with

temporarily discontinuing anticoagulants prior to
dental surgery is small but potentially fatal.

 In the review of Wahl, 5/493 (1%) patients

undergoing 542 dental procedures and in whom
anticoagulants were withdrawn specifically for
surgery, had serious embolic complications of
which 4 were fatal

Arch Intern Med

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

 Metanalysis, comprising 2014 dental surgical

procedures in 774 patients receiving continuous
warfarin therapy, undergoing single, multiple
extractions and full mouth extractions , included
patients with an INR up to 4.0, more that 98%
of patients receiving continuous
anticoagulants had no serious bleeding
problems.

 Twelve patients (<2%) had postoperative

bleeding problems that were not controlled by
local measures.
Arch Intern Med
Blood pressure in HT
Dental Management of Patients
with Hypertension
The seventh revision by the Joint National
Committee on the Prevention, Detection,
Evaluation and Treatment of High Blood
Pressure and is known as the JNC-7 Report
Above which BP values should the dentist not
treat?
 Many well-respected authors have published
180/110 for the absolute cutoff for any
dental treatment

 In fact, this value may be too high for patients

who have had previous hypertensive-related
organ damage, such as myocardial infarctions,
strokes, or labile angina.

 Conversely, healthy patient with a negative

medical history with values around 200/110 may
be treated without any perioperativeDent Clin N Am 50 (2006) 547–562
‘‘Risk assessment’’
Key in determining the likelihood of complications
 Physical classification system of the American
Society of Anesthesiologists (ASA) has been in
use since 1941.

 The higher the ASA class, the more at-risk the

patient is both from a surgical and anesthetic
perspective [31].
ASA Class I. A normal healthy patient
ASA Class II. A patient with mild
systemic disease
ASA Class III. A patient with severe
‘‘Risk assessment’’
 Metabolic equivalent or METS, one MET is
defined as 3.5 mL of 02/Kg/min

 It essentially is a test of the patient’s ability to

perform physical work.
1 to 4 METS: eating, dressing, walking
around house, dishwashing
4 to 10 METS: climbing at least one
flight of stairs, walking level ground 6.4
km/hr, running short distance, game of
golf
>=10 METS: swimming, singles tennis,
football Dent Clin N Am 50 (2006) 547–562
‘‘Risk assessment’’

 People with capacities of 4 METS or less are at

high risk for medical complications.

 Those who can perform 10 METS or more are

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

Dent Clin N Am 50 (2006) 547–562

 Algorithm for
treating the
hypertensive
dental patient.

The algorithm
assumes no
other medical
contraindication
s such as a
recent stroke,
unstable
dysrhythmias,
myocardial
infarction, or
pregnancy.
Dent Clin N Am 50 (2006) 547–562
Blood sugar and DM
Dental Management of Patients
with Diabetes

American Diabetic Association (ADA)

 Normal plasma glucose : FPG < 100mg/dL

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

American Diabetic Association (ADA)

 In the absence of these classic symptoms,

glucose intolerance may exist as impaired
fasting glucose (IFG) when the FPG is between
100 and 125 mg/dL.
 Plasma glucose of 140 to 199 mg/dL following
OGTT defines impaired glucose tolerance
(IGT).
 The classification of IFG and IGT is important
because individuals with IFG and IGT are at
greater risk of developing diabetes and
atherosclerotic cardiovascular disease even if
 Glucose Control Study Summary
The intensive glucose control policy maintained a
lower HbA1c by mean 0.9 % over a median follow up
of 10 years from diagnosis of type 2 diabetes with
reduction in risk of:
12% for any diabetes related endpoint
p=0.029
25% for microvascular endpoints p<0.01
16% for myocardial infarction
p=0.052
24% for cataract extraction
p=0.046
UK Prospective Diabetes Study (UKPDS) Group. Lancet. 1998;352:837-853.
 Conclusion
The UKPDS has shown that intensive
blood glucose control reduces the risk
of diabetic complications, the greatest
effect being on microvascular
complications

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

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

 Systemic complications from DM

 hypertension
 cardiodiovascular disease
 renal insufficiency

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

Performing dental procedures on diabetic patients

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

Diabetes Care. 2010; 33; 421-427

Steroid
Steroid treatment patient in dental procedures

 Secondary adrenocortical insufficiency (AI)

results from the administration of exogenous
corticosteroids

 In secondary AI, normal mineralocorticoid

function is preserved and less likely for patients
to experience adrenal crisis than it is for patients
with primary AI.
Long term steroid treatment in medicine
 Autoimmune disease; SLE, AIHA, ITP, RA,
vasculitis syndromes, nephrotic-nephritis
syndromes, AIH, IBD, autoimmune pancreatitis,
etc.
 Allergic diseases; asthma
 Post organ transplantation
 Adrenal insufficiency; primary or secondary
Steroid treatment in dental procedures
 Adrenal crisis, event can occur when a patient with
AI ( most commonly in the form of Addison’s
disease), is challenged by stress (for example,
illness, infection or surgery), and, in response, is
unable to synthesize adequate amounts of cortisol
and aldosterone.

 Adrenal crisis is rare in patients with secondary

AI, because the majority of these patients have
normal aldosterone levels
Steroid treatment in surgical procedures
 Risk of adrenal crisis appears to be low in minor
surgery

 Majority of patients who regularly take the daily

equivalent dose of steroid (5-10 mg of prednisone
daily) maintain adrenal function and do not
require supplementation for minor surgical
procedures
 Minor surgical stress the glucocorticoid target is
about 25 mg of hydrocortisone equivalent on the
day of surgery
 Moderate surgical stress the glucocorticoid target
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;
Arch Surg. 2008;143(12):1
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):1
Who is at risk of experiencing adrenal crisis
during dental procedures?

J Am Dent Assoc 2001;132;

Cirrhosis
Chronic liver diseases in dental procedures

 Potential for impaired hemostasis and bleeding

diathesis due to thrombocytopenia or reduced
hepatic synthesis of coagulation factors

 Increased risk of infection, or spread of infection

Chronic liver diseases in dental procedures

 If any significantly abnormal result in platelet

count, PT or INR is detected in a patient with
cirrhosis, medical consultation is recommended

 Currently, no evidence-based data to support the

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