NBDE PART II REVIEW MEDICALLY COMPROMISED PATIENT CARE
Saravanan Ram DDS, MS Diplomat American Board of Orofacial Pain Diplomat American Board of Oral Medicine Assistant Professor of Clinical Dentistry Herman Ostrow School of Dentistry of USC
TOPICS 1. 2. 3. 4. 5. 6.
Bleeding problems Infective Endocarditis Hypertension and epinephrine use Diabetes Adrenal insufficiency and Steroid use Total joint replacement
NEW CPR GUIDELINES!! |
30 compressions:2 breaths
BLEEDING PROBLEMS Warfarin or Coumadin therapy, INR, PT and PTT | Aspirin and Plavix therapy |
CLOTTING CASCADE, PT AND PTT Commonly used pathway? | – Extrinsic – PT – Warfarin or Coumadin | Intrinsic – PTT or aPTT - Heparin |
INR – INTERNATIONAL NORMALIZED RATIO |
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All results are standardized using the international sensitivity index for the particular thromboplastin reagent and instrument combination utilized to perform the test. For example, a person taking the anticoagulant ("blood thinner") warfarin (brand name: Coumadin) might optimally maintain a prothrombin time (PT) of 2 to 3 INR. No matter what laboratory checks the prothrombin time, the result should be the same even if different thromboplastins and instruments are used. Must be measured within 24 hours before the procedure
Source: Little and Fallace
QUESTION 1 Your 60 year old female patient who is on Warfarin needs extraction of #30. Her INR on the day of the surgery is 4.0. What should you do? | A. Postpone surgery and decrease Warfarin dose until INR becomes 3.0 | B. Perform the surgery | C. Perform the surgery with local hemostatic measures | D. Avoid local anesthetics and perform surgery under general anesthesia. |
GUIDELINES FOR WARFARIN THERAPY The weight of evidence in the dental clinical literature does NOT support the long-held belief that an oral anticoagulant regimen must be altered or discontinued before most dental procedures, including oral surgery. | Minor dental surgical procedures can safely be carried out with the INR within the therapeutic range of 2.0 to 4.0 when local hemostatic measures are used to control bleeding. | INR values greater than 4.0, however, contraindicate a patient undergoing a surgical procedure without consultation with the physician. |
Source: JADA 2003 and Journal of Oral Science 2007
QUESTION 2 Your 68 year old patient is on clopidogrel to prevent blood clot formation. You need to extract #14, 15 and 16. Would you: | A. Discontinue the clopidogrel | B. Obtain the bleeding time | C. NOT discontinue clopidogrel | D. Obtain platelet function tests |
GUIDELINES FOR ASPIRIN OR CLOPIDOGREL (Plavix®) THERAPY Current research shows that patients on either Aspirin or Clopidogrel should NOT have the dose altered prior to dental procedures. | Aspirin or Clopidogrel should NOT be discontinued prior to dental surgical procedures. | If patient takes both Aspirin and Clopidogrel then they should be referred to a dental hospital or hospital based oral surgeon |
Source: JADA 2003 and Journal of Oral Science 2007
INFECTIVE ENDOCARDITIS
WHY THE NEW GUIDELINES? The risk of adverse reactions to antibiotics outweigh the benefits of prophylaxis for most patients. | Concern about the development of drug-resistant bacteria also was a factor. | Also, the data are mixed as to whether prophylactic antibiotics taken prior to a dental procedure prevent IE. | People who are at risk for IE are regularly exposed to oral flora during basic daily activities such as brushing or flossing, suggesting that IE is more likely to occur as a result of these everyday activities than from a dental procedure. |
Source: ADA
WHO SHOULD BE PREMEDICATED? | | | |
artificial heart valves a history of infective endocarditis a cardiac transplant that develops a heart valve problem the following congenital (present from birth) heart conditions:* y unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduits y a 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 y any repaired congenital heart defect with residual defect at the site or adjacent to the site of a prosthetic patch or a prosthetic device
Source: ADA
QUESTION 3 |
Ms. Sanchez is a 6 year old girl with a history of mitral valve prolapse. Does she need premedication prior to invasive dental procedures?
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A. Yes
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B. No
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Conditions that no longer need prophylaxis:
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mitral valve prolapse
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rheumatic heart disease
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bicuspid valve disease
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calcified aortic stenosis
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congenital (present from birth) heart conditions such as ventricular septal defect, atrial septal defect and hypertrophic cardiomyopathy Source: ADA
FOR WHAT PROCEDURES SHOULD THE PATIENT BE PREMEDICATED? |
Prophylaxis is recommended for all dental procedures that involve manipulation of gingival tissue or the periapical region of the teeth, or perforation of the oral mucosa.
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Maria has a previous history of infective endocarditis and requires an intraligamentary injection for #15. Should you premedicate? | A. Yes | B. No |
Source: JADA
ANTIBIOTIC REGIMEN
Cephalosporins should NOT be used in a person with a history of anaphylaxis, angioedema or urticaria with penicillins or ampicillin Source: JADA
QUESTION 5 |
Mr. Kato needs antibiotic prophylaxis but forgot to take his medication today. Your new associate failed to check with the patient and started the subgingival placement of antibiotic fibers and strips. What should you do?
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A. Yell and swear at your associate!
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B. Stop all procedures and reschedule the patient
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C. Say a prayer and cross your fingers!
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D. Premedicate immediately
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"If the dosage of antibiotic is inadvertently not administered before the procedure, the dosage may be administered up to two hours after the procedure."
OTHER SITUATIONS: Coronary artery stents? | Antibiotic prophylaxis for dental procedures is not recommended for patients with coronary artery stents | Patient is already on Penicillin? | Select an antibitoic from another class rather than to increase the dose of the currently administered antibiotic. | For example, if a patient is already taking amoxicillin, the dentist should select clindamycin, azithromycin, or clarithromycin for IE prophylaxis. |
Source: JADA
HYPERTENSION AND EPINEPHRINE USE Alpha 1 – Peripheral arterioles – Vasoconstriction | Alpha 2 – act in concert with alpha 1 | Beta 1 – Heart – Increase cardiac output and heart rate | Beta 2 – Skeletal muscle arterioles – cause vasodilation | Epinephrine is a potent stimulator of alpha and beta receptors |
HYPERTENSION AND EPINEPHRINE USE GUIDELINES Reported risk of adverse events with epinephrine use in local anesthetics is minimal! | Risk for adverse events among uncontrolled hypertension is low | 1 to 2 cartridges of 1:100,000 epinephrine is safe in most hypertensive patients | Avoid epinephrine use in uncontrolled or severe hypertension | Avoid gingival retraction cords with epinephrine for all cases of hypertension. Alternatives – cord soaked in A. Tetrahydrozoline, or B. Oxymetazoline or C. Phenylephrine |
QUESTION 6 Your patient is on Propranolol for hypertension. His blood pressure today is 140/80. Can you administer lidocaine with 1:100,000 epinephrine? | A. Yes | B. No | C. 1 to 2 cartridges of lido with 1:100,000 epi can be administered safely (try a test dose of 1 mL first!) | D. Refer patient to his physician to change the Propranolol to Atenolol |
DIABETES
DIABETES, PERIODONTAL DISEASE & AGES Higher prevalence and severity of periodontal disease due to altered response of periodontal tissues to bacterial plaque | Impaired chemotaxis of Polymorphonuclear Leucocytes, defective phagocytosis and impaired adherence | Hyperglycemia Nonenzymatic glycosylation of proteins and matrix molecules | Advanced glycation endproducts (AGEs) linked to Periodontal disease |
Source: Mosby’s Review NBDE II
QUESTION 7 Mr. Khan has a long standing history of Diabetes. Mr. Khan’s Hemoglobin A1c (HgA1c) level is 7.5% and his post prandial blood glucose on the day of the test is 140 mg/dL. Is he: | A. Controlled diabetic | B. Uncontrolled diabetic | C. Not a diabetic anymore |
HEMOGLOBIN A1C – HgA1C Fasting plasma glucose more than or equal to 126 mg/dL – DIABETIC! | Post prandial glucose more than or equal to 200 mg/dL - DIABETIC! | HgA1c is used for assessment of long-term level and control of hyperglycemia in patients with diabetes (6-12 weeks) | Normal should be between 4-6% | Well controlled diabetes <7% | > 7% - Poorly controlled DIABETES! |
Source: American Diabetes Association
QUESTION 8 |
Mr. Khan needs extraction of #3 and 4 (grade III mobility with periodontal abscesses) and his HgA1c is 8%. Should you:
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A. Extract using atraumatic procedure B. Get a physician consult and then pre medicate the patient prior to extraction C. Administer insulin shot 2 hours prior to procedure, check glucose levels and then extract D. Do not extract, postpone procedure until diabetes is controlled
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ADRENAL INSUFFICIENCY AND STEROID USE
QUESTION 9 Mr. Padilla is on Prednisone 5mg every other day for his asthma. He needs extraction of #1 and 16 due to severe periodontal disease. What should you do? | A. Inform Mr. Padilla to bring the prednisone and take it only if he has an asthma attack during surgery | B. Mr. Padilla MUST take 5mg of Prednisone 2 hours before procedure | C. Mr. Padilla MUST take 25 mg of Hydrocortisone equivalent on day of surgery | D. Mr. Padilla must have a ACTH or HPA axis stimulation test |
MANAGEMENT GUIDELINES FOR PT ON CHRONIC STEROID THERAPY |
Steroid equivalency table:
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Hydrocortisone or Cortisone 25 mg is equivalent to:
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Prednisone 5 mg
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Triamcinolone 4mg
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Methylprednisolone 4 mg
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Beta or Dexamethasone 0.75 mg
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Current recommendation on supplementation:
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Minor surgical stress – 25 mg of hydrocortisone equivalent on the day of surgery
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Moderate surgical stress – 50-75 mg of hydrocortisone equivalent for up to 1 to 2 days
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Major surgical stress – 100-150 mg of hydrocortisone equivalent on the day of surgery
Source: Little and Fallace
QUESTION 10 Mrs. Smith is a 45 year old female with a long standing history of Rheumatoid Arthritis. She had a car accident and suffered multiple fractures which were plated using metal pins and screws. She is now seeing you for an extraction of fractured #12 and 13. Should you premedicate Mrs. Smith prior to the extraction? | A. Yes, for the first 2 years | B. Yes, any time before a invasive dental procedure | C. No premedication | D. Only Clindamycin premedication |
TOTAL JOINT REPLACEMENT – ANTIBIOTIC PROPHYLAXIS GUIDELINES |
Antibiotic prophylaxis guidelines for patients who have a total joint replacement were updated by the American Academy of Orthopedic Surgeons (AAOS) in 2009.
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ALWAYS CONSIDER PREMEDICATION FOR ALL TOTAL JOINT REPLACEMENT PATIENTS PRIOR TO ANY INVASIVE DENTAL PROCEDURES! Guidelines may change in 2011.
Source: AAOS and ADA
TOTAL JOINT REPLACEMENT – ANTIBIOTIC PROPHYLAXIS GUIDELINES |
Procedures – (Same applies for Infective Endocarditis cases):
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dental extractions; periodontal procedures, including surgery, subgingival placement of antiobiotic fibers/strips, scaling and root planing, probing, recall maintenance; dental implant placement and replantation of avulsed teeth; endodontic (root canal) instrumentation or surgery only beyond the apex; initial placement of orthodontic bands but not brackets; intraligamentary and intraosseous local anesthetic injections; prophylactic cleaning of teeth or implants where bleeding is anticipated. The current statement notes that "patients with pins, plates and screws, or other [orthopedic] hardware that is not within a synovial joint are not at increased risk for hematogenous seeding by microorganisms."
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Source: AAOS and ADA
THANK YOU & GOOD LUCK WITH YOUR EXAM
