Title: RISK STRATIFICATION AND DENTAL MANAGEMENT OF PATIENTS WITH ENDOCRINEMETABOLIC DISORDERS
1RISK 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
2Risk 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
3Risk 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
4Risk 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
5Risk 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
6Risk 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
7Risk 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
8Risk 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
9Risk 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
10Risk 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
11Risk stratification of patients with DM
- Strategies for the dental management
of patients with DM - Glycemic control
- Cardiac function
- Physiological stress of the procedure
12Risk 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
13Risk 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
14Risk 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
15Risk 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.
16Risk 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
17Risk 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
18Risk 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.
19Risk 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
20Risk stratification of patients with DM
- Timing and length of appointments
- Patients should preferably be treated in the
morning - Long stressful procedures should be avoided
21Risk 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.
22Risk 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
23Risk stratification of patients with DM
24Risk stratification of patients with DM
25Risk stratification of patients with DM
26Risk stratification of patients with DM
27Risk 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
28Risk stratification of patients with DM
- Preventive strategies
- Oral hygiene
- Conventional vs. electromechanical toothbrushes
- Antibacterial mouthwashes
- Topical fluorides
- Sialagogues
- Pilocarpine (Salagen)
- Cevimeline (Evoxac)
29Risk stratification of patients with DM
- Potential medical emergencies
- Hypoglycemia
- Syncope
- Postural hypotension
- Hypertensive crises
- Arrhythmias
- Angina pectoris
- Myocardial infarction
- Silent
30Risk 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.
31Risk 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
32Risk 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
33Risk 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
34Risk stratification of patients with AD
35Risk stratification of patients with AD
36Risk stratification of patients with AD
- Strategies for the dental management
of patients with DM - Adaptive stress response
- Physiological stress of the procedure
37Risk 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
38Risk 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
39Risk 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
40Risk 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
41Risk 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
42Risk 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
43Risk 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
44Risk 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)
45Risk 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
46Risk 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
47Risk stratification of patients with AD
- Minor surgical stress
- Examples
- Local anesthesia
- Inguinal herniography
- Recommended prophylaxis
- Usual daily glucocorticoid dose during
perioperative period
48Risk 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.
49Risk 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.
50Risk stratification of patients with AD
51Risk stratification of patients with AD
52Risk stratification of patients with AD
53Risk 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
54Risk stratification of patients with AD
- Huber MA, Terezhalmy GT. Risk stratification and
dental management of patients with adrenal
dysfunction. Quintessence Int 200738325-338.
55Risk 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
56Risk 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
57Risk 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
58Risk 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
59Risk stratification of patients with AD
- Strategies for the dental management
of patients with DM - Cardiac function
- Physiological stress of the procedure
60Risk 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
61Risk 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.
62Risk 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
63Risk 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
64Risk 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.
65Risk 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
66Risk 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.
67Risk 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
68Risk 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
69Risk stratification of patients with TD
70Risk stratification of patients with TD
71Risk stratification of patients with TD
72Risk stratification of patients with TD
73Risk stratification of patients with TD
- Preventive strategies
- Oral hygiene
- Conventional vs. electromechanical toothbrushes
- Antibacterial mouthwashes
- Topical fluorides
- Sialagogues
- Pilocarpine (Salagen)
- Cevimeline (Evoxac)
74Risk 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
75Risk stratification of patients with TD
- Huber MA, Terezhalmy GT. Risk stratification and
dental management of the patient with thyroid
dysfunction. Quintessence Int 200839139-150.
76Risk 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
77Risk 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
78Reproductive 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
79Risk 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
80Risk stratification of patients with RTD
- Strategies for the dental management
of patients with RTD - Cardiac function
- Physiological stress of the procedure
81Risk stratification of patients with RTD
- Risk stratification
- Drug history
- Contraceptives
- Hormone agonists or antagonists
- Tumors
- Breast
- Prostate
- CVD
- Stroke
82Risk 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.
83Risk 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
84Risk 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
85Risk 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.
86Risk 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
87Risk 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.
88Risk 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.
89Risk stratification of patients with RTD
- Preventive strategies
- Oral hygiene
- Conventional vs. electromechanical toothbrushes
- Antibacterial mouthwashes
- Topical fluorides
- Sialagogues
- Pilocarpine (Salagen)
- Cevimeline (Evoxac)
90Risk stratification of patients with RTD
- Potential medical emergencies
- Anticipate medical emergencies based on the
patients medical history and vital signs
91Risk stratification of patients with RTD
92Risk 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)
93Risk 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
94Risk 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.)
95Risk 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.)
96Risk 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.)
97Risk 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.)
98Risk stratification of patients on bisphosphonates
- Strategies for the dental management
of patients on bisphosphonates
99Risk 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.)
100Risk 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.)
101Risk 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.)
102Risk 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.)
103Risk 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.)
104Risk stratification of patients on bisphosphonates