NBDE PART II REVIEW

MEDICALLY COMPROMISED PATIENT CARE

Saravanan Ram DDS, MSDiplomat American Board of Orofacial PainDiplomat American Board of Oral MedicineAssistant Professor of Clinical DentistryHerman Ostrow School of Dentistry of USC

TOPICS1. Bleeding problems2. Infective Endocarditis3. Hypertension and epinephrine use4. Diabetes5. Adrenal insufficiency and Steroid use6. Total joint replacement

NEW CPR GUIDELINES!!

30 compressions:2 breaths

BLEEDING PROBLEMSWarfarin or Coumadin therapy, INR, PT and PTTAspirin and Plavix therapy

CLOTTING CASCADE, PT AND PTTCommonly used pathway? – Extrinsic – PT – Warfarin or CoumadinIntrinsic – PTT or aPTT - Heparin

INR – INTERNATIONAL NORMALIZED RATIO

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 1Your 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 surgeryC. Perform the surgery with local hemostaticmeasuresD. 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 hemostaticmeasures 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 2Your 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 clopidogrelB. Obtain the bleeding timeC. NOT discontinue clopidogrelD. 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 valvesa history of infective endocarditisa cardiac transplant that develops a heart valve problemthe following congenital (present from birth) heart conditions:*

unrepaired or incompletely repaired cyanotic congenital heart disease, including those with palliative shunts and conduitsa 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 procedureany 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 3Ms. Sanchez is a 6 year old girl with a history of mitral valve prolapse. Does she need premedication prior to invasive dental procedures?A. YesB. No Conditions that no longer need prophylaxis:mitral valve prolapserheumatic heart diseasebicuspid valve diseasecalcified aortic stenosiscongenital (present from birth) heart conditions such as ventricular septal defect, atrial septal defect and hypertrophiccardiomyopathy

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.

QUESTION 4Maria has a previous history of infective endocarditis and requires an intraligamentaryinjection for #15. Should you premedicate?A. YesB. No

Source: JADA

ANTIBIOTIC REGIMEN

Source: JADA

Cephalosporins should NOT be used in a person with a history of anaphylaxis,angioedema or urticaria with penicillins or ampicillin

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?A. Yell and swear at your associate!B. Stop all procedures and reschedule the patientC. Say a prayer and cross your fingers!D. Premedicate immediately

"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 stentsPatient 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 – VasoconstrictionAlpha 2 – act in concert with alpha 1Beta 1 – Heart – Increase cardiac output and heart rateBeta 2 – Skeletal muscle arterioles – cause vasodilationEpinephrine 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 low1 to 2 cartridges of 1:100,000 epinephrine is safe in most hypertensive patientsAvoid epinephrine use in uncontrolled or severe hypertensionAvoid gingival retraction cords with epinephrine for all cases of hypertension. Alternatives – cord soaked in A. Tetrahydrozoline, or B. Oxymetazolineor C. Phenylephrine

QUESTION 6Your patient is on Propranolol for hypertension. His blood pressure today is 140/80. Can you administer lidocaine with 1:100,000 epinephrine?A. YesB. No C. 1 to 2 cartridges of lido with 1:100,000 epi can be administered safely (try a test dose of 1 mLfirst!)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 plaqueImpaired chemotaxis of PolymorphonuclearLeucocytes, defective phagocytosis and impaired adherenceHyperglycemia Nonenzymatic glycosylation of proteins and matrix molecules Advanced glycation endproducts (AGEs) linked to Periodontal disease

Source: Mosby’s Review NBDE II

QUESTION 7Mr. 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 diabeticB. Uncontrolled diabeticC. Not a diabetic anymore

HEMOGLOBIN A1C – HgA1CFasting 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 8Mr. Khan needs extraction of #3 and 4 (grade III mobility with periodontal abscesses) and his HgA1c is 8%. Should you:A. Extract using atraumatic procedureB. Get a physician consult and then pre medicate the patient prior to extractionC. Administer insulin shot 2 hours prior to procedure, check glucose levels and then extractD. Do not extract, postpone procedure until diabetes is controlled

ADRENAL INSUFFICIENCY AND STEROID USE

QUESTION 9Mr. Padilla is on Prednisone 5mg every other dayfor 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 surgeryB. Mr. Padilla MUST take 5mg of Prednisone 2 hours before procedureC. Mr. Padilla MUST take 25 mg of Hydrocortisone equivalent on day of surgeryD. Mr. Padilla must have a ACTH or HPA axis stimulation test

MANAGEMENT GUIDELINES FOR PT ON CHRONIC STEROID THERAPY

Steroid equivalency table: Hydrocortisone or Cortisone 25 mg is equivalent to:Prednisone 5 mgTriamcinolone 4mgMethylprednisolone 4 mgBeta or Dexamethasone 0.75 mgCurrent recommendation on supplementation:Minor surgical stress – 25 mg of hydrocortisone equivalent on the day of surgeryModerate surgical stress – 50-75 mg of hydrocortisone equivalent for up to 1 to 2 daysMajor 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 fractureswhich 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 procedureC. No premedicationD. 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.

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):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 hematogenousseeding by microorganisms."

Source: AAOS and ADA

THANK YOU & GOOD LUCK WITH YOUR EXAM