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RISK STRATIFICATION RISK STRATIFICATION AND DENTAL AND DENTAL
MANAGEMENT OF MANAGEMENT OF PATIENTS WITH PATIENTS WITH
ENDOCRINE-METABOLICENDOCRINE-METABOLICDISORDERSDISORDERS
GGééza T. Terza T. Teréézhalmy, D.D.S., M.A. zhalmy, D.D.S., M.A. Professor and Dean Emeritus Professor and Dean Emeritus
School of Dental Medicine Case School of Dental Medicine Case Western Reserve UniversityWestern Reserve University
Terezhalmy 204/11/23
Risk stratification of patients with DMRisk 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
Terezhalmy 304/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
• Oral hypoglycemic agents: sulfonylureasglyburide
– Mechanisms of action• Decreases hepatic glucose production• Stimulates the release of insulin from pancreatic
beta-cells• Decreases insulin resistance, i.e., improves insulin’s
effectiveness
– Clinical indications• Type 2 DM
Terezhalmy 404/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
• Biguanide oral hypoglycemic agentsmetformin
– Mechanisms of action• Decreases intestinal absorption of glucose• Decreases hepatic glucose production• Decreases insulin resistance, i.e., improves insulin’s
effectiveness
– Clinical indications• Type 2 DM
Terezhalmy 504/11/23
Risk stratification of patients with DMRisk 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 insulin’s
effectiveness
– Clinical indications• Type 2 DM
Terezhalmy 604/11/23
Risk stratification of patients with DMRisk 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• Bell’s palsy• Trigeminal
neuralgia
Terezhalmy 704/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
– Periodontal disease• The association
between uncontrolled or poorly controlled DM and periodontal disease is well established
*J Periodontol 1999;70:935-949
Terezhalmy 804/11/23
Risk stratification of patients with DMRisk 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 1992;15:900-904
*Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 2001:92:281-291
Terezhalmy 904/11/23
Risk stratification of patients with DMRisk 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 2001:92:281-291
Terezhalmy 1004/11/23
Risk stratification of patients with DMRisk 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 1987;16:282-284
Terezhalmy 1104/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
• Strategies for the dental management of patients with DM– Glycemic control– Cardiac function– Physiological
“stress” of the procedure
Terezhalmy 1204/11/23
Risk stratification of patients with DMRisk 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
Terezhalmy 1304/11/23
Risk stratification of patients with DMRisk 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
Terezhalmy 1404/11/23
Risk stratification of patients with DMRisk 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
Terezhalmy 1504/11/23
Risk stratification of patients with DMRisk 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 2002;39:542-553.
Terezhalmy 1604/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
– Excellent functional activities (>10 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
Terezhalmy 1704/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
– Poor functional capacity (<4 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
Terezhalmy 1804/11/23
Risk stratification of patients with DMRisk 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 (<001%)
* Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:42-46.
*Arch Intern Med 2001;161:1509-1512.
Terezhalmy 1904/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
• Physical examination– Blood pressure
• Useful marker for coronary artery disease• BP <180/110 mm Hg is not an independent risk
factor for cardiovascular risk • BP >180/110 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 <50 or >120 beats/min constitutes a
medical emergency• PVCs
– Significant finding
Terezhalmy 2004/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
• Timing and length of appointments– Patients should preferably be treated in the
morning• Long stressful procedures should be avoided
Terezhalmy 2104/11/23
Risk stratification of patients with DMRisk 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 2000;90:171-181.
Terezhalmy 2204/11/23
Risk stratification of patients with DMRisk 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
Terezhalmy 2304/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
Diabetic and CV risk
Physical examination
Treatment options
Consultation or referral
FBG 70 to 200 mg/dLANDMinor or intermediate predictors of cardiovascular risk
Blood pressure < 80/110 mm HgANDNormal pulse pressure, rate, and rhythmANDFunctional capacity >4 METs
Comprehensive care
Routine referral for medical management and risk factor modification
Terezhalmy 2404/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
Diabetic and CV risk
Physical examination
Treatment options
Consultation or referral
FBG 70 to 200 mg/dLANDMinor or intermediate predictors of cardiovascular risk
Blood pressure <180/110 mm HgANDNormal pulse pressure, rate, and rhythmANDFunctional capacity <4 METs
Limited care
Routine referral for medical management and risk factor modification
Terezhalmy 2504/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
Diabetic and CV risk
Physical examination
Treatment options
Consultation or referral
FBG 70 to 200 mg/dLANDMinor or intermediate predictors of cardiovascular risk
Blood pressure >180/110 mm HgAND/ORAbnormal pulse pressure, rate, and rhythm
Emergency care
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
Terezhalmy 2604/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
Diabetic and CV risk
Physical examination
Treatment options
Consultation or referral
FBG <70 or >200 mg/dL AND/OR Major predictors of cardiovascular risk
Establish baseline vital signs
Emergency care
Immediate referral for medical management and risk factor modification
Terezhalmy 2704/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
• Postoperative glycemic control– Procedures may affect the patient’s ability to
eat• Consult with patient’s physician
– Ensure that targeted BG levels are maintained» Balanced intake and appropriate regimen of
medications
Terezhalmy 2804/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
• Preventive strategies– Oral hygiene
• Conventional vs. electromechanical toothbrushes
– Antibacterial mouthwashes– Topical fluorides– Sialagogues
• Pilocarpine (Salagen)• Cevimeline (Evoxac)
Terezhalmy 2904/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
• Potential medical emergencies– Hypoglycemia– Syncope– Postural
hypotension– Hypertensive
crises– Arrhythmias– Angina pectoris
• Myocardial infarction– Silent
Terezhalmy 3004/11/23
Risk stratification of patients with DMRisk 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 2005;36:779-795.
Terezhalmy 3104/11/23
Risk stratification of patients with ADRisk stratification of patients with AD
• Glucocorticosteroidsmethylprednisolone
prednisoneAdvair Diskus (fluticasone propionate w/
salmeterol)Flovent (fluticasone propionate)
fluticasone propionateNasonex (mometasone furoate)
– Mechanisms of action• Decrease inflammation • Suppress the immune system
Terezhalmy 3204/11/23
Risk stratification of patients with ADRisk 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
– Addison’s disease
Terezhalmy 3304/11/23
Risk stratification of patients with ADRisk stratification of patients with AD
• The oral disease burden of patients with AD
– Addison’s 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
Terezhalmy 3404/11/23
• Addison disease
Risk stratification of patients with ADRisk stratification of patients with AD
Terezhalmy 3504/11/23
• Cushing syndrome
Risk stratification of patients with ADRisk stratification of patients with AD
Terezhalmy 3604/11/23
Risk stratification of patients with ADRisk stratification of patients with AD
• Strategies for the dental management of patients with DM– Adaptive stress
response– Physiological
“stress” of the procedure
Terezhalmy 3704/11/23
Risk stratification of patients with ADRisk 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
Terezhalmy 3804/11/23
Risk stratification of patients with ADRisk 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
Terezhalmy 3904/11/23
Risk stratification of patients with ADRisk stratification of patients with AD
• Physical examination– Blood pressure
• Useful marker for both Cushing syndrome Addison disease
• BP <180/110 mm Hg is not an independent risk factor for cardiovascular risk
• BP >180/110 or <90/50 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 <50 or >120 beats/min constitutes a medical emergency
• PVCs– Significant finding
Terezhalmy 4004/11/23
Risk stratification of patients with ADRisk 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
Terezhalmy 4104/11/23
Risk stratification of patients with ADRisk 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
– patient’s 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
Terezhalmy 4204/11/23
Risk stratification of patients with ADRisk 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
Terezhalmy 4304/11/23
Risk stratification of patients with ADRisk 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
Terezhalmy 4404/11/23
Risk stratification of patients with ADRisk 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”)
Terezhalmy 4504/11/23
Risk stratification of patients with ADRisk 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
Terezhalmy 4604/11/23
Risk stratification of patients with ADRisk 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
Terezhalmy 4704/11/23
Risk stratification of patients with ADRisk stratification of patients with AD
– Minor surgical stress• Examples
– Local anesthesia– Inguinal herniography
• Recommended prophylaxis– Usual daily glucocorticoid dose during
perioperative period
Terezhalmy 4804/11/23
Risk stratification of patients with ADRisk 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 1996;82:42-46.Arch Intern Med 2001;161:1509-1512.
ADA 2001;132:1570-1579.
Terezhalmy 4904/11/23
Risk stratification of patients with ADRisk 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 2000;90:171-181.Med Clin North Am 2003;87:175-192.
Terezhalmy 5004/11/23
Risk stratification of patients with ADRisk stratification of patients with AD
Addisonian or cardiac risk
Physical examination
Treatment options
Consultation or referral
Minor procedure-related stress level
–Dental care
AND–Local
anesthesia
Blood pressure <180/110 mm HgANDNormal pulse pressure, rate, and rhythmANDFunctional capacity >4 METs
Comprehensive care
• Usual daily corticosteroid dose during perioperative period
Routine referral for medical management and risk factor modification
Terezhalmy 5104/11/23
Risk stratification of patients with ADRisk stratification of patients with AD
Addisonian or cardiac risk
Physical examination
Treatment options
Consultation or referral
Minor procedure-related stress level
–Dental care
AND–Local
anesthesia
Blood pressure <180/110 mm HgANDNormal pulse pressure, rate, and rhythmANDFunctional capacity <4 METs
Limited care• Usual daily
corticosteroid dose during perioperative period
Routine referral for medical management and risk factor modification
Terezhalmy 5204/11/23
Risk stratification of patients with ADRisk stratification of patients with AD
Addisonian or cardiac risk
Physical examination
Treatment options
Consultation or referral
Minor procedure-related stress level
–Dental care
AND–Local
anesthesia
Blood pressure >180/110 mm Hg OR<90/50 mm Hg AND/ORAbnormal pulse pressure, rate, and rhythm
Emergency care
• Usual daily corticosteroid dose during perioperative period
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
Terezhalmy 5304/11/23
Risk stratification of patients with ADRisk 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 patient’s medical history and vital signs
Terezhalmy 5404/11/23
Risk stratification of patients with ADRisk stratification of patients with AD
• Huber MA, Terezhalmy GT. Risk stratification and dental management of patients with adrenal dysfunction. Quintessence Int 2007;38:325-338.
Terezhalmy 5504/11/23
Risk stratification of patients with TDRisk 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
Terezhalmy 5604/11/23
Risk stratification of patients with TDRisk 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
Terezhalmy 5704/11/23
Risk stratification of patients with TDRisk 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
Terezhalmy 5804/11/23
Risk stratification of patients with TDRisk 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
Terezhalmy 5904/11/23
Risk stratification of patients with ADRisk stratification of patients with AD
• Strategies for the dental management of patients with DM– Cardiac function– Physiological
“stress” of the procedure
Terezhalmy 6004/11/23
Risk stratification of patients with TDRisk 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
Terezhalmy 6104/11/23
Risk stratification of patients with DMRisk 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 2002;39:542-553.
Terezhalmy 6204/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
– Excellent functional activities (>10 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
Terezhalmy 6304/11/23
Risk stratification of patients with DMRisk stratification of patients with DM
– Poor functional capacity (<4 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
Terezhalmy 6404/11/23
Risk stratification of patients with DMRisk 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 (<001%)
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:42-46.
Arch Intern Med 2001;161:1509-1512. JADA 2001;132:1570-1579.
Terezhalmy 6504/11/23
Risk stratification of patients with TDRisk stratification of patients with TD
• Physical examination– Blood pressure
• Useful marker for coronary artery disease• BP <180/110 mm Hg is not an independent risk
factor for cardiovascular risk • BP >180/110 or <90/50 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 <50 or >120 beats/min constitutes a
medical emergency• PVCs
– Significant finding
Terezhalmy 6604/11/23
Risk stratification of patients with TDRisk 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 1995;43:747-751.Am J Med 1983;14:893-897.Am J Med 1984:77:261-266.
Terezhalmy 6704/11/23
Risk stratification of patients with TDRisk 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 2001;344:501-509
Terezhalmy 6804/11/23
Risk stratification of patients with TDRisk 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
Terezhalmy 6904/11/23
Risk stratification of patients with TDRisk stratification of patients with TD
Thyroid or cardiac risk
Physical examination
Treatment options
Consultation or referral
EuthyroidORMild to
moderate thyroid dysfunction
AND/ORMinor or
intermediate predictors of CV risk
Blood pressure <180/110 mm HgANDNormal pulse pressure, rate, and rhythmANDFunctional capacity >4 METs
Comprehensive care
Routine referral for medical management and risk factor modification
Terezhalmy 7004/11/23
Risk stratification of patients with TDRisk stratification of patients with TD
Thyroid or cardiac risk
Physical examination
Treatment options
Consultation or referral
EuthyroidORMild to
moderate thyroid dysfunction
AND/ORMinor or
intermediate predictors of CV risk
Blood pressure <180/110 mm HgANDNormal pulse pressure, rate, and rhythmANDFunctional capacity <4 METs
Limited care
Routine referral for medical management and risk factor modification
Terezhalmy 7104/11/23
Risk stratification of patients with TDRisk stratification of patients with TD
Thyroid or cardiac risk
Physical examination
Treatment options
Consultation or referral
EuthyroidORMild to
moderate thyroid dysfunction
AND/ORMinor or
intermediate predictors of CV risk
Blood pressure >180/110 mm Hg ORSystolic BP <90 mm HgAND/ORAbnormal pulse pressure, rate, and rhythm
Emergency care
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
Terezhalmy 7204/11/23
Risk stratification of patients with TDRisk stratification of patients with TD
Thyroid or cardiac risk
Physical examination
Treatment options
Consultation or referral
Severe hypo-thyroidism
ORThyrotoxicosisAND/ORMajor
predictors of CV risk
Establish baseline vital signs
Emergency care
Immediate referral for medical management and risk factor modification
Terezhalmy 7304/11/23
Risk stratification of patients with TDRisk stratification of patients with TD
• Preventive strategies– Oral hygiene
• Conventional vs. electromechanical toothbrushes
– Antibacterial mouthwashes– Topical fluorides– Sialagogues
• Pilocarpine (Salagen)• Cevimeline (Evoxac)
Terezhalmy 7404/11/23
Risk stratification of patients with TDRisk 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 patient’s medical history and vital signs
Terezhalmy 7504/11/23
Risk stratification of patients with TDRisk stratification of patients with TD
• Huber MA, Terezhalmy GT. Risk stratification and dental management of the patient with thyroid dysfunction. Quintessence Int 2008;39:139-150.
Terezhalmy 7604/11/23
Risk stratification of patients with RTDRisk stratification of patients with RTD
• ContraceptivesNuvaring (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
Terezhalmy 7704/11/23
Risk stratification of patients with RTDRisk stratification of patients with RTD
• EstrogensPremarin (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
Terezhalmy 7804/11/23
Reproductive tract dysregulationReproductive 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
Terezhalmy 7904/11/23
Risk stratification of patients with RTDRisk 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
Terezhalmy 8004/11/23
Risk stratification of patients with RTDRisk stratification of patients with RTD
• Strategies for the dental management of patients with RTD– Cardiac function– Physiological
“stress” of the procedure
Terezhalmy 8104/11/23
Risk stratification of patients with RTDRisk stratification of patients with RTD
• Risk stratification– Drug history
• Contraceptives• Hormone agonists or antagonists
– Tumors• Breast• Prostate
– CVD– Stroke
Terezhalmy 8204/11/23
Risk stratification of patients with RTDRisk 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 2002;39:542-553.
Terezhalmy 8304/11/23
Risk stratification of patients with RTDRisk stratification of patients with RTD
– Excellent functional activities (>10 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
Terezhalmy 8404/11/23
Risk stratification of patients with RTDRisk stratification of patients with RTD
– Poor functional capacity (<4 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
Terezhalmy 8504/11/23
Risk stratification of patients with RTDRisk 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 (<001%)
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:42-46.
Arch Intern Med 2001;161:1509-1512. JADA 2001;132:1570-1579.
Terezhalmy 8604/11/23
Risk stratification of patients with RTDRisk stratification of patients with RTD
• Physical examination– Blood pressure
• Useful marker for coronary artery disease• BP <180/110 mm Hg is not an independent risk
factor for cardiovascular risk • BP >180/110 or <90/50 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 <50 or >120 beats/min constitutes a
medical emergency• PVCs
– Significant finding
Terezhalmy 8704/11/23
Risk stratification of patients with RTDRisk 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 2000;90:171-181.
Terezhalmy 8804/11/23
Risk stratification of patients with RTDRisk 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 1996;24:273-274.
– There are no pharmacokinetic data to support the contention that antibacterial agents reduce the efficacy of contraceptives
J Am Acad Dermato 2002;46:917-923.
Terezhalmy 8904/11/23
Risk stratification of patients with RTDRisk stratification of patients with RTD
• Preventive strategies– Oral hygiene
• Conventional vs. electromechanical toothbrushes
– Antibacterial mouthwashes– Topical fluorides– Sialagogues
• Pilocarpine (Salagen)• Cevimeline (Evoxac)
Terezhalmy 9004/11/23
Risk stratification of patients with RTDRisk stratification of patients with RTD
• Potential medical emergencies– Anticipate medical
emergencies based on the patient’s medical history and vital signs
Terezhalmy 9104/11/23
Risk stratification of patients with RTDRisk stratification of patients with RTD
Terezhalmy 9204/11/23
Risk stratification of patients on Risk stratification of patients on bisphosphonatesbisphosphonates
• BisphosphonatesFosamax (alendronate)Actonel (risendronate)Boniva (ibandronate)
– Mechanisms of action• Inhibit osteoclastic and reduce osteoblastic activity
– Indications• Prevention and treatment of osteoporosis• Paget’s disease• Hypercalcemia of malignancy (IV formulations)
Terezhalmy 9304/11/23
Risk stratification of patients on Risk stratification of patients on bisphosphonatesbisphosphonates
• 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
Terezhalmy 9404/11/23
Risk stratification of patients on Risk stratification of patients on bisphosphonatesbisphosphonates
• Bisphosphonate-related osteonecrosis of the jaw (BRONJ)– Systematic review of the literature from 1966
through 31 January 2006 - 368 cases• Female to male ration - 3:2• 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 2006;144:753-761.)
Terezhalmy 9504/11/23
Risk stratification of patients on Risk stratification of patients on bisphosphonatesbisphosphonates
• 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 2007;991016-1024.)
Terezhalmy 9604/11/23
Risk stratification of patients on Risk stratification of patients on bisphosphonatesbisphosphonates
• 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 (n=329;
alendronate 10 mg (n=333); placebo (n=537 for 5 years)
• No cases of BRONJ– Even the long-term use of oral BPs caries little
risk of BRONJ
(JAMA 2006;296:2927-2938.)
Terezhalmy 9704/11/23
Risk stratification of patients on Risk stratification of patients on bisphosphonatesbisphosphonates
• 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 2007;65:369-376.)
Terezhalmy 9804/11/23
Risk stratification of patients on Risk stratification of patients on bisphosphonatesbisphosphonates
• Strategies for the dental management of patients on bisphosphonates
Terezhalmy 9904/11/23
Risk stratification of patients on Risk stratification of patients on bisphosphonatesbisphosphonates
• 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 2007;65:369-376.)
Terezhalmy 10004/11/23
Risk stratification of patients on Risk stratification of patients on bisphosphonatesbisphosphonates
– 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 2007;65:369-376.)
Terezhalmy 10104/11/23
Risk stratification of patients on Risk stratification of patients on bisphosphonatesbisphosphonates
– 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 2007;65:369-376.)
Terezhalmy 10204/11/23
Risk stratification of patients on Risk stratification of patients on bisphosphonatesbisphosphonates
– 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 2007;65:369-376.)
Terezhalmy 10304/11/23
Risk stratification of patients on Risk stratification of patients on bisphosphonatesbisphosphonates
– 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 2007;65:369-376.)
Terezhalmy 10404/11/23
Risk stratification of patients on Risk stratification of patients on bisphosphonatesbisphosphonates