RISK STRATIFICATION AND DENTAL MANAGEMENT OF PATIENTS WITH ENDOCRINEMETABOLIC DISORDERS

1
RISK STRATIFICATION AND DENTAL MANAGEMENT OF
PATIENTS WITH ENDOCRINE-METABOLICDISORDERS

• Géza T. Terézhalmy, D.D.S., M.A. Professor and
  Dean Emeritus School of Dental Medicine Case
  Western Reserve University

2
Risk stratification of patients with DM

• Insulin
• Lantus (long-acting insulin glargine)
• Mechanisms of action
• Stimulates cellular glucose uptake, i.e., it is a
  hypoglycemic agent
• Clinical indications
• Type 1 and type 2 DM

3
Risk stratification of patients with DM

• Oral hypoglycemic agents sulfonylureas
• glyburide
• Mechanisms of action
• Decreases hepatic glucose production
• Stimulates the release of insulin from pancreatic
  beta-cells
• Decreases insulin resistance, i.e., improves
  insulins effectiveness
• Clinical indications
• Type 2 DM

4
Risk stratification of patients with DM

• Biguanide oral hypoglycemic agents
• metformin
• Mechanisms of action
• Decreases intestinal absorption of glucose
• Decreases hepatic glucose production
• Decreases insulin resistance, i.e., improves
  insulins effectiveness
• Clinical indications
• Type 2 DM

5
Risk stratification of patients with DM

• Thiazolidinediones oral hypoglycemic agents
• Actos (pioglitazone)
• Avandia (rosiglitazone)
• Mechanisms of action
• Inhibit hepatic gluconeogenesis
• Decrease insulin resistance, i.e., improve
  insulins effectiveness
• Clinical indications
• Type 2 DM

6
Risk stratification of patients with DM

• The oral disease burden of patients with
  DM

• Periodontal disease
• Xerostomia
• Dental caries
• Candidiasis
• Other
• Burning mouth syndrome
• Altered taste
• Lichen planus
• Bells palsy
• Trigeminal neuralgia

7
Risk stratification of patients with DM

• Periodontal disease
• The association between uncontrolled or poorly
  controlled DM and periodontal disease is well
  established
• J Periodontol
  199970935-949

8
Risk stratification of patients with DM

• Xerostomia
• An association has been demonstrated between
  lower resting and stimulated saliva flow and
  elevated HbA1c as well as elevated plasma glucose
  concentrations
• Diabetes Care 199215900-904
• Oral Surg Oral Med Oral Pathol Oral Radiol Endod
  200192281-291

9
Risk stratification of patients with DM

• Dental caries
• 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
• Oral Surg Oral Med Oral Pathol Oral Radiol Endod
  200192281-291

10
Risk stratification of patients with DM

• Candidiasis
• The reported frequency in patients with DM is as
  high as 51 and its presence is inversely related
  to glycemic control
• J Oral Pathol
  198716282-284

11
Risk stratification of patients with DM

• Strategies for the dental management
  of patients with DM
• Glycemic control
• Cardiac function
• Physiological stress of the procedure

12
Risk stratification of patients with DM

• Risk stratification
• 8 million cases of DM undiagnosed
• Polyuria, nocturia, polydipsia, polyphasia,
  weakness, obesity, weight loss, pruritus
• Co-morbidities
• Hypertension
• Dyslipidemia

13
Risk stratification of patients with DM

• Microvascular disease
• Retinopathy
• Renal dysfunction
• Macrovascular disease
• Coronary artery disease
• Unstable coronary syndromes
• Cardiac arrhythmias
• Heart failure
• Cerebrovascular disease
• Peripheral vascular disease

14
Risk stratification of patients with DM

• Neuropathy
• Peripheral sensory neuropathy
• Peripheral autonomic neuropathy
• Tachycardia
• Silent myocardial ischemia
• Exercise intolerance, i.e., reduced functional
  capacity
• Glycemic control
• SMBG
• HbA1c

15
Risk stratification of patients with DM

• Functional capacity
• An individuals ability to perform a spectrum of
  common daily tasks
• Expressed in terms of metabolic equivalents
  (METs).
• 1 MET
• The oxygen consumption of a 70-kg, 40-year-old
  man in a resting state, i.e., 3.5 ml per kg per
  minute
• J Am Coll Cardiol 200239542-553.

16
Risk stratification of patients with DM

• Excellent functional activities (gt10 METs)
• Strenuous recreational activities
• Good functional capacity (7-10 METs)
• Scrubbing floors, lifting or moving heavy
  furniture
• Moderate recreational activities
• Moderate functional capacity (4-7 METs)
• Climb a flight of stairs or walk up a hill
• Mow the grass, rake leafs, do light carpentry
• Walk a block on level ground at 6.4 km/h
• Run a short distance

17
Risk stratification of patients with DM

• Poor functional capacity (lt4 METs)
• Dress, eat, or use the toilet
• Walk around the house indoors
• Do light work around the house (dusting, washing
  dishes)
• Walk a block on level ground at 3.2 km/h
• Cardiac risk is increased in patients unable to
  meet 4-METs
• DM is an intermediate predictor of cardiovascular
  risk association with non-cardiac procedures
• Peripheral autonomic neuropathy leads to reduced
  exercise tolerance, i.e., reduced functional
  capacity

18
Risk stratification of patients with DM

• Procedure-related CV risk with non-cardiac
  surgical procedures
• Predicated on procedure-specific variables
• Fluid shifts
• Blood loss
• Duration of the procedure
• Physiological stress
• Cardiac risk for various dental procedures
• Low to very low risk (lt001)
• Oral Surg Oral Med Oral Pathol Oral Radiol
  Endod 19968242-46.
• Arch Intern Med 20011611509-1512.

19
Risk stratification of patients with DM

• Physical examination
• Blood pressure
• Useful marker for coronary artery disease
• BP lt180/110 mm Hg is not an independent risk
  factor for cardiovascular risk
• BP gt180/110 mm Hg constitutes a medical emergency
• Pulse pressure, rate, and rhythm
• Pulse pressure correlates closely with systolic
  BP
• Reliable cofactor to either rule out or confirm
  significant CAD
• Pulse rate lt50 or gt120 beats/min constitutes a
  medical emergency
• PVCs
• Significant finding

20
Risk stratification of patients with DM

• Timing and length of appointments
• Patients should preferably be treated in the
  morning
• Long stressful procedures should be avoided

21
Risk stratification of patients with DM

• Local anesthetic agents
• Provide the greatest margin of safety when
  treating patients with DM
• Absence of profound anesthesia
• Increased insulin utilization
• Myocardial ischemia
• The physiological stress associated with 4 METs
• Equivalent to the effect of 0.045 mg of
  epinephrine
• Epinephrine has an action opposite of that of
  insulin
• No appreciable rise in blood glucose levels
• Oral Surg Oral Med Oral Pathol Oral Radiol Endod
  200090171-181.

22
Risk stratification of patients with DM

• Antibacterial agents
• Uncontrolled or poorly controlled DM and
  increased susceptibility to oral infections
• No studies directly support antibacterial
  prophylaxis
• Pain management
• Opioid-based analgesics contribute to
  cardiovascular stability
• ASA to prevent thromboembolic events
• Opioid w/ASA
• Opioid w/ibuprofen
• Opioid w/APAP

23
Risk stratification of patients with DM
24
Risk stratification of patients with DM
25
Risk stratification of patients with DM
26
Risk stratification of patients with DM
27
Risk stratification of patients with DM

• Postoperative glycemic control
• Procedures may affect the patients ability to
  eat
• Consult with patients physician
• Ensure that targeted BG levels are maintained
• Balanced intake and appropriate regimen of
  medications

28
Risk stratification of patients with DM

• Preventive strategies
• Oral hygiene
• Conventional vs. electromechanical toothbrushes
• Antibacterial mouthwashes
• Topical fluorides
• Sialagogues
• Pilocarpine (Salagen)
• Cevimeline (Evoxac)

29
Risk stratification of patients with DM

• Potential medical emergencies
• Hypoglycemia
• Syncope
• Postural hypotension
• Hypertensive crises
• Arrhythmias
• Angina pectoris
• Myocardial infarction
• Silent

30
Risk stratification of patients with DM

• 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 200536779-795.

31
Risk stratification of patients with AD

• Glucocorticosteroids
• methylprednisolone
• prednisone
• Advair Diskus (fluticasone propionate w/
  salmeterol)
• Flovent (fluticasone propionate)
• fluticasone propionate
• Nasonex (mometasone furoate)
• Mechanisms of action
• Decrease inflammation
• Suppress the immune system

32
Risk stratification of patients with AD

• Clinical indications
• Allergic rhinitis and asthma
• Treatment of a variety of inflammatory and
  autoimmune diseases
• Therapeutic immunosuppression in organ transplant
  patients
• Neoplastic diseases
• Lymphocytic leukemia
• Adrenocortical insufficiency
• Addisons disease

33
Risk stratification of patients with AD

• The oral disease burden of patients with AD

• Addisons disease
• Patchy brown pigmentation
• Face, buccal mucosa, tongue, gingivae, lips
• Chronic mucocutaneous candidiasis
• Cushing syndrome
• Red cheek, moon face, hirsutism, acne
• Arrested dental development
• Oral candidiasis
• Mucocutaneous pigmentation

34
Risk stratification of patients with AD

• Addison disease

35
Risk stratification of patients with AD

• Cushing syndrome

36
Risk stratification of patients with AD

• Strategies for the dental management
  of patients with DM
• Adaptive stress response
• Physiological stress of the procedure

37
Risk stratification of patients with AD

• Risk stratification
• Cushing syndrome
• Hypothalamic abnormalities
• Pituitary tumors
• Adrenal adenoma or carcinoma
• Small cell lung carcinoma
• Chronic use of glucocorticoids

38
Risk stratification of patients with AD

• Addison disease
• Autoimmune adrenal disease
• Autoimmune thyroid disease
• Type 1 and 2 DM
• Pituitary abnormalities
• Tuberculosis
• AIDS
• Mucocutaneous candidiasis
• HPA-axis suppression

39
Risk stratification of patients with AD

• Physical examination
• Blood pressure
• Useful marker for both Cushing syndrome Addison
  disease
• BP lt180/110 mm Hg is not an independent risk
  factor for cardiovascular risk
• BP gt180/110 or lt90/50 mm Hg constitutes a medical
  emergency
• Pulse pressure, rate, and rhythm
• Pulse pressure correlates closely with systolic
  BP
• Reliable cofactor to either rule out or confirm
  significant CAD
• Pulse rate lt50 or gt120 beats/min constitutes a
  medical emergency
• PVCs
• Significant finding

40
Risk stratification of patients with AD

• Adrenal insufficiency
• HPA axis suppression in patients on exogenous
  glucocorticoids
• Addisonian crisis
• Precipitated by an overwhelming stressor
• Surgery
• Sepsis
• Fever
• Characterized by
• Hypotension
• Cardiogenic shock

41
Risk stratification of patients with AD

• Suppression of the HPA axis
• Wide variability in HPA axis suppression in
  patients on exogenous glucocorticoids
• In general, it does not correlate well with the
• patients age and sex
• dosage administered
• duration of treatment
• The persistence of HPA axis suppression after
  cessation of systemic glucocorticoid therapy is
  equivocal
• Topical and inhaled corticosteroids can suppress
  the HPA axis but rarely cause clinical adrenal
  insufficiency

42
Risk stratification of patients with AD

• Factors related to HPA axis suppression
• No HPA axis suppression
• Less than 5 mg of prednisone or equivalent per
  day for any duration
• Alternate-day single morning dose of short-acting
  glucocorticoid, such as hydrocortisone, of any
  dose or duration
• Any dose of glucocorticoids for less than 3 weeks
• HPA axis suppression uncertain
• 5-20 mg of prednisone or equivalent for more than
  3 weeks within the past year
• Low-dose ACTH stimulatory test to determine HPA
  axis suppression

43
Risk stratification of patients with AD

• HPA axis suppression presumed or documented
• More than 20 mg of prednisone or equivalent for
  more than 3 weeks within the past year
• Cushingoid appearance
• Biochemical adrenal insufficiency documented by
  low-dose ACTH stimulation test

44
Risk stratification of patients with AD

• Supplemental glucocorticoid regimens
• The decision to give supplemental glucocorticoids
  must weigh the risks
• Fluid retention
• Hypertension
• Hyperglycemia
• Increased risk of infection
• Impaired wound healing
• Gastrointestinal bleeding
• Psychiatric disturbances
• Administer glucocorticoids only in the amount
  equivalent to the normal physiological response
  to surgical stress (stress dose)

45
Risk stratification of patients with AD

• Anticipated magnitude of stress
• Major surgical stress
• Examples
• Pancreatoduodenectomy, esophagogastrectomy, total
  proctolectomy, cardiac surgery involving
  cardiopulmonary bypass
• Recommended prophylaxis
• 100 to 150 mg of hydrocortisone or equivalent for
  2 to 3 days
  OR
• 100 mg IV hydrocortisone prior to induction of
  anesthesia, 50 mg hydrocortisone q8h for 48-72 h,
  then resume normal regimen

46
Risk stratification of patients with AD

• Moderate surgical stress
• Examples
• Nonlaporoscopic cholecystectomy, lower extremity
  revascularization, segmental colon resection,
  total joint replacement, abdominal hystorectomy
• Recommended prophylaxis
• 50 to 75 mg of hydrocortisone or equivalent for 1
  to 2 days
  OR
• 50 mg IV hydrocortisone prior to induction of
  anesthesia, 25 mg hydrocortisone q8h for 24-48 h,
  then resume normal regimen

47
Risk stratification of patients with AD

• Minor surgical stress
• Examples
• Local anesthesia
• Inguinal herniography
• Recommended prophylaxis
• Usual daily glucocorticoid dose during
  perioperative period

48
Risk stratification of patients with AD

• Procedure-specific variables
• Fluid shifts
• Blood loss
• Duration of the procedure
• Physiological stress
• General anesthesia
• Dental procedures
• Low to very low risk
• Recommended prophylaxis
• Usual daily glucocorticoid dose during
  perioperative period
• Oral Surg Oral Med Oral Pathol Oral Radiol Endod
  19968242-46.
• Arch Intern Med 20011611509-1512.
• ADA 20011321570-1579.

49
Risk stratification of patients with AD

• Local anesthetic agents
• Physiological stress with the use of local
  anesthetic agents in patients with adrenal
  dysfunction is low
• Cortisol plays a permissive role for epinephrine
• Cardiac risk is increased in patients unable to
  meet a 4-MET demand for oxygen
• Equivalent to the effect of 0.045 mg of
  epinephrine
• Oral Surg Oral Med Oral Pathol Oral Radiol Endod
  200090171-181.
• Med Clin North Am 200387175-192.

50
Risk stratification of patients with AD
51
Risk stratification of patients with AD
52
Risk stratification of patients with AD
53
Risk stratification of patients with AD

• Potential medical emergencies
• The likelihood of an Addisonian crisis in the
  oral health care setting is extremely remote
• Other medical emergencies may be anticipated
  based on the patients medical history and vital
  signs

54
Risk stratification of patients with AD

• Huber MA, Terezhalmy GT. Risk stratification and
  dental management of patients with adrenal
  dysfunction. Quintessence Int 200738325-338.

55
Risk stratification of patients with TD

• Thyroid hormones
• levothyroxine sodium
  
• Levoxyl (levothyroxine sodium)
• Synthroid (levothyroxine sodium)
• Mechanisms of action
• Regulate carbohydrate, protein, and lipid
  metabolism and oxygen consumption
• Thermoregulation, calorigenesis
• Act synergistically with epinephrine
• ? Glycogenolysis and hyperglycemia
• Clinical indications
• Hypothyroidism

56
Risk stratification of patients with TD

• The oral disease burden of patients with TD

• Hypothyroidism
• Cretinism
• Puffy face
• Large cranium
• Flat and broad nose
• Macroglossia
• Thick elevated lips
• Open mouth
• Altered calcification of teeth
• Delayed eruption of teeth

57
Risk stratification of patients with TD

• Hypothyroidism
• Myxedema
• Edematous nose, eyelids, and lips
• Macroglossia
• Possible increased caries risk
• Possible impaired periodontal health
• Dysgeusia
• Enlarged salivary glands

58
Risk stratification of patients with TD

• Hyperthyroidism
• Exophthalmos
• Early loss of deciduous teeth
• Early eruption of permanent teeth
• Tremor of the lips and tongue
• Increased risk of caries
• Accelerated alveolar ridge atrophy

59
Risk stratification of patients with AD

• Strategies for the dental management
  of patients with DM
• Cardiac function
• Physiological stress of the procedure

60
Risk stratification of patients with TD

• Risk stratification
• Hyperthyroidism
• Increased cardiac output may limit cardiac
  reserve during surgery
• T3 exerts direct inotropic and chronotropic
  effects on cardiac muscle
• T3 appears to act synergistically with
  epinephrine
• Hypothyroidism
• Co-morbidities
• Dyslipidemia
• CAD

61
Risk stratification of patients with DM

• Functional capacity
• An individuals ability to perform a spectrum of
  common daily tasks
• Expressed in terms of metabolic equivalents
  (METs).
• 1 MET
• The oxygen consumption of a 70-kg, 40-year-old
  man in a resting state, i.e., 3.5 ml per kg per
  minute
• J Am Coll Cardiol 200239542-553.

62
Risk stratification of patients with DM

• Excellent functional activities (gt10 METs)
• Strenuous recreational activities
• Good functional capacity (7-10 METs)
• Scrubbing floors, lifting or moving heavy
  furniture
• Moderate recreational activities
• Moderate functional capacity (4-7 METs)
• Climb a flight of stairs or walk up a hill
• Mow the grass, rake leafs, do light carpentry
• Walk a block on level ground at 6.4 km/h
• Run a short distance

63
Risk stratification of patients with DM

• Poor functional capacity (lt4 METs)
• Dress, eat, or use the toilet
• Walk around the house indoors
• Do light work around the house (dusting, washing
  dishes)
• Walk a block on level ground at 3.2 km/h
• Cardiac risk is increased in patients unable to
  meet 4-METs
• Increased cardiac output associated with
  hypothyroidism may limit cardiac reserve during
  surgery

64
Risk stratification of patients with DM

• Procedure-related CV risk with non-cardiac
  surgical procedures
• Predicated on procedure-specific variables
• Fluid shifts
• Blood loss
• Duration of the procedure
• Physiological stress
• Cardiac risk for various dental procedures
• Low to very low risk (lt001)
• Oral Surg Oral Med Oral Pathol Oral Radiol Endod
  19968242-46.
• Arch Intern Med 20011611509-1512.
• JADA 20011321570-1579.

65
Risk stratification of patients with TD

• Physical examination
• Blood pressure
• Useful marker for coronary artery disease
• BP lt180/110 mm Hg is not an independent risk
  factor for cardiovascular risk
• BP gt180/110 or lt90/50 mm Hg constitutes a medical
  emergency
• Pulse pressure, rate, and rhythm
• Pulse pressure correlates closely with systolic
  BP
• Reliable cofactor to either rule out or confirm
  significant CAD
• Pulse rate lt50 or gt120 beats/min constitutes a
  medical emergency
• PVCs
• Significant finding

66
Risk stratification of patients with TD

• The use of local anesthetic agents with
  epinephrine
• The hypothyroid patient
• There is no evidence to justify deferring needed
  surgery in patients with mild to moderate
  hypothyroidism
• No evidence of adverse effects associated with
  epinephrine infusion in patients with
  hypothyroidism
• Clin Endocrinol 199543747-751.
• Am J Med 198314893-897.
• Am J Med 198477261-266.

67
Risk stratification of patients with TD

• The hyperthyroid patient
• Increased cardiac output may limit cardiac
  reserve during surgery
• The effects of undiagnosed or undertreated
  hyperthyroidism on the heart carries
  perioperative risks
• Thyroid hormones act synergistically with
  epinephrine
• Use epinephrine with caution
• N Engl J Med 2001344501-509

68
Risk stratification of patients with TD

• The use of analgesics
• The hypothyroid patient
• Hyper-reactive to opioid analgesics
• Use judiciously
• The hyperthyroid patient
• ASA displaces thyroid hormones from their protein
  binding sites

69
Risk stratification of patients with TD
70
Risk stratification of patients with TD
71
Risk stratification of patients with TD
72
Risk stratification of patients with TD
73
Risk stratification of patients with TD

• Preventive strategies
• Oral hygiene
• Conventional vs. electromechanical toothbrushes
• Antibacterial mouthwashes
• Topical fluorides
• Sialagogues
• Pilocarpine (Salagen)
• Cevimeline (Evoxac)

74
Risk stratification of patients with TD

• Potential medical emergencies
• The likelihood of myxedema coma or a thyroid
  crisis in the oral health care setting is
  extremely remote
• Other medical emergencies may be anticipated
  based on the patients medical history and vital
  signs

75
Risk stratification of patients with TD

• Huber MA, Terezhalmy GT. Risk stratification and
  dental management of the patient with thyroid
  dysfunction. Quintessence Int 200839139-150.

76
Risk stratification of patients with RTD

• Contraceptives
• Nuvaring (ethinyl estradiol w/etonogestrel)
• Ortho Tri-Cycline (ethinyl estradiol
  w/norgestimate)
• Trinessa-28 (ethinyl estradiol w/norgestimate)
• Yasmin (ethinyl estradiol w/drospirenone)
• Yaz-28 (ethinyl estradiol w/drospirenone)
• Mechanisms of action
• Inhibit LH and FSH release
• Suppresses follicular development
• Prohibit proper transport of both egg and sperm
• Indications
• Prevention of pregnancy

77
Risk stratification of patients with RTD

• Estrogens
• Premarin (conjugated estrogen)
• Mechanism of action
• Promotes growth and development of female
  reproductive system
• Conserves calcium and phosphorus and encourages
  bone formation
• Overrides stimulatory effect of testosterone
• Indications
• Hypogonadism, menopause, uterine bleeding
• Prevention and treatment of osteoporosis
• Metastatic prostate cancer

78
Reproductive tract dysregulation

• Selective estrogen receptor modulators
• Evista (raloxifene)
• Mechanism of action
• Estrogen receptor agonist activity in bone
• Estrogen antagonist activity in breast and
  endometrial tissue
• Indications
• Prevention of osteoporosis in post menopausal
  women
• Palliative and supportive care in metastatic
  breast and endometrial carcinoma

79
Risk stratification of patients with RTD

• The oral disease burden of patients with RTD

• Periods of hormonal imbalance are associated with
  subtle but definite tissue changes
• ? hormones
• Gingivitis
• ? hormones
• Mucosal atrophy
• Burning mouth syndrome

80
Risk stratification of patients with RTD

• Strategies for the dental management
  of patients with RTD
• Cardiac function
• Physiological stress of the procedure

81
Risk stratification of patients with RTD

• Risk stratification
• Drug history
• Contraceptives
• Hormone agonists or antagonists
• Tumors
• Breast
• Prostate
• CVD
• Stroke

82
Risk stratification of patients with RTD

• Functional capacity
• An individuals ability to perform a spectrum of
  common daily tasks
• Expressed in terms of metabolic equivalents
  (METs).
• 1 MET
• The oxygen consumption of a 70-kg, 40-year-old
  man in a resting state, i.e., 3.5 ml per kg per
  minute
• J Am Coll Cardiol 200239542-553.

83
Risk stratification of patients with RTD

• Excellent functional activities (gt10 METs)
• Strenuous recreational activities
• Good functional capacity (7-10 METs)
• Scrubbing floors, lifting or moving heavy
  furniture
• Moderate recreational activities
• Moderate functional capacity (4-7 METs)
• Climb a flight of stairs or walk up a hill
• Mow the grass, rake leafs, do light carpentry
• Walk a block on level ground at 6.4 km/h
• Run a short distance

84
Risk stratification of patients with RTD

• Poor functional capacity (lt4 METs)
• Dress, eat, or use the toilet
• Walk around the house indoors
• Do light work around the house (dusting, washing
  dishes)
• Walk a block on level ground at 3.2 km/h
• Cardiac risk is increased in patients unable to
  meet 4-METs

85
Risk stratification of patients with RTD

• Procedure-related CV risk with non-cardiac
  surgical procedures
• Predicated on procedure-specific variables
• Fluid shifts
• Blood loss
• Duration of the procedure
• Physiological stress
• Cardiac risk for various dental procedures
• Low to very low risk (lt001)
• Oral Surg Oral Med Oral Pathol Oral Radiol Endod
  19968242-46.
• Arch Intern Med 20011611509-1512.
• JADA 20011321570-1579.

86
Risk stratification of patients with RTD

• Physical examination
• Blood pressure
• Useful marker for coronary artery disease
• BP lt180/110 mm Hg is not an independent risk
  factor for cardiovascular risk
• BP gt180/110 or lt90/50 mm Hg constitutes a medical
  emergency
• Pulse pressure, rate, and rhythm
• Pulse pressure correlates closely with systolic
  BP
• Reliable cofactor to either rule out or confirm
  significant CAD
• Pulse rate lt50 or gt120 beats/min constitutes a
  medical emergency
• PVCs
• Significant finding

87
Risk stratification of patients with RTD

• Local anesthetic agents
• Provide the greatest margin of safety when
  treating patients with CVD
• Absence of profound anesthesia
• Myocardial ischemia
• The physiological stress associated with 4 METs
• Equivalent to the effect of 0.045 mg of
  epinephrine
• Oral Surg Oral Med Oral Pathol Oral Radiol Endod
  200090171-181.

88
Risk stratification of patients with RTD

• Contraceptives and antibacterial agents
• Scientific evidence regarding the alleged
  interaction between antibacterial agents and
  contraceptives does not satisfy the Daubert
  standard of causality
• J Law Med Ethics 199624273-274.
• There are no pharmacokinetic data to support the
  contention that antibacterial agents reduce the
  efficacy of contraceptives
• J Am Acad Dermato 200246917-923.

89
Risk stratification of patients with RTD

• Preventive strategies
• Oral hygiene
• Conventional vs. electromechanical toothbrushes
• Antibacterial mouthwashes
• Topical fluorides
• Sialagogues
• Pilocarpine (Salagen)
• Cevimeline (Evoxac)

90
Risk stratification of patients with RTD

• Potential medical emergencies
• Anticipate medical emergencies based on the
  patients medical history and vital signs

91
Risk stratification of patients with RTD
92
Risk stratification of patients on bisphosphonates

• Bisphosphonates
• Fosamax (alendronate)
• Actonel (risendronate)
• Boniva (ibandronate)
• Mechanisms of action
• Inhibit osteoclastic and reduce osteoblastic
  activity
• Indications
• Prevention and treatment of osteoporosis
• Pagets disease
• Hypercalcemia of malignancy (IV formulations)

93
Risk stratification of patients on bisphosphonates

• The oral disease burden of patients with DBM

• An increasing body of literature suggests that
  bisphosphonate use, especially intravenous
  preparations, may be associated with
  osteonecrosis of the jaws

94
Risk stratification of patients on bisphosphonates

• Bisphosphonate-related osteonecrosis of the jaw
  (BRONJ)
• Systematic review of the literature from 1966
  through 31 January 2006 - 368 cases
• Female to male ration - 32
• Mandible - 65 maxilla - 26 both jaws - 9
• Multifocal or bilateral involvement
• Maxilla - 31 Mandible 23
• Most lesions were posterior to the lingual
  mandible near the mylohyoid ridge
• 60 of the cases occurred after a tooth
  extraction or other dentoalveolar surgery
• 94 of the patients were treated with IV
  bisphosphonates
• (Ann Intern Med 2006144753-761.)

95
Risk stratification of patients on bisphosphonates

• IV bisphosphonate-related osteonecrosis of the
  jaw (BRONJ)
• 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
• Absolute risk of inflammatory conditions or
  surgery of the jaw at 6 years
• 5.48 events per 100 patients using IV BPs
• 0.30 events per 100 patients not using B
• (J Natl Cancer Inst 2007991016-1024.)

96
Risk stratification of patients on bisphosphonates

• Oral bisphosphonate-related osteonecrosis of the
  jaw (BRONJ)
• Data from the fracture intervention trial (FIT)
  long-term extension (FLEX) - 1099 women with
  osteoporosis
• After being on alendronate for 5 years, 5 mg or
  10 mg
• 5 year extension alendronate, 5mg (n329
  alendronate 10 mg (n333) placebo (n537 for 5
  years)
• No cases of BRONJ
• Even the long-term use of oral BPs caries little
  risk of BRONJ
• (JAMA 20062962927-2938.)

97
Risk stratification of patients on bisphosphonates

• Bisphosphonate-related osteonecrosis of the jaw
  (BRONJ)
• Case definition must meet all of the following
• Current or previous treatment with BPs
• Exposed, necrotic bone in the maxillofacial
  region that has persisted for more than 8 weeks
• No history of radiation therapy to the jaws
• (J Oral Maxillofac Surg 200765369-376.)

98
Risk stratification of patients on bisphosphonates

• Strategies for the dental management
  of patients on bisphosphonates

99
Risk stratification of patients on bisphosphonates

• Risk stratification
• At risk category A
• Patients who have been treated with oral BPs
• No apparent exposed/necrotic bone
• Treatment strategies
• Patient education
• No alteration or delay in planned dental care
• (J Oral Maxillofac Surg 200765369-376.)

100
Risk stratification of patients on bisphosphonates

• At risk category B
• Patients who have been treated with IV BPs
• No apparent exposed/necrotic bone
• Treatment strategies
• Patient education
• Non-restorable teeth may be treated by removal of
  the crown
• Endodontic treatment of the remaining roots
• (J Oral Maxillofac Surg 200765369-376.)

101
Risk stratification of patients on bisphosphonates

• Stage 1 BRONJ
• Exposed/necrotic bone in patients who are
  asymptomatic
• No evidence of infection
• Treatment strategies
• Antimicrobial mouth rinse
• Removal of mobile segments of bony sequestrum
• Clinical follow-up on a quarterly basis
• Patient education
• (J Oral Maxillofac Surg 200765369-376.)

102
Risk stratification of patients on bisphosphonates

• Stage 2 BRONJ
• Exposed/necrotic bone associated with infection
• Pain and erythema in the region of the exposed
  bone with or without purulent drainage
• Treatment strategies
• Symptomatic treatment with a broad-spectrum oral
  antibacterial agent
• Antimicrobial mouth rinse
• Pain control
• Superficial debridement to relieve soft tissue
  irritation
• Patient education
• (J Oral Maxillofac Surg 200765369-376.)

103
Risk stratification of patients on bisphosphonates

• Stage 3 BRONJ
• Exposed/necrotic bone in patients
• Pain, infection, and one or more of the following
  
• Pathologic fracture
• Extraoral sinus tract
• Osteolysis extending to the inferior border
• Treatment strategies
• As in Stage 2 BRONJ
• Surgical debridement/resection for longer term
  palliation of infection and pain
• (J Oral Maxillofac Surg 200765369-376.)

104
Risk stratification of patients on bisphosphonates