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Medically Compromised Patients Pharmacology Supporting Your Practice

Dealing with systemic diseases in the elderly patient

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Human AnatomyThis summary is based on the article published in Dental Clinics of North America: Systemic Diseases and Oral Health (October 2014)

Mary Tavares, DMD, MPH; Kari A. Lindefjeld Calabi, DMD; Laura San Martin, DDS, PhD, MDPH

 

 

 

 

 

Context

  • Inflammation has been recognized as the key factor that connects oral diseases and systemic chronic diseases. 1
  • Chronic diseases are defined as long-lasting illnesses, with duration of more than 3 months that affect a person’s life and require constant medical treatment.
  • The complexity of dental treatment in the elderly is greater because of the effects of these chronic diseases, the medications prescribed, and their adverse effects.
  • Systemic diseases can influence oral health, and oral health has an impact on overall health. Social interactions, self-esteem, dietary choices, and nutrition are enhanced by good oral health.
  • It is important for oral health professionals to understand and recognize the impact of systemic diseases on oral health. With this expanded knowledge, they will be better able to recommend adequate prevention mechanisms and design appropriate oral health treatment plans.

Scope of the Article

The authors have chosen to select cardiovascular diseases (CADs), hypertension, diabetes, arthritis, osteoporosis, and stroke to discuss in this article.

Their connection to oral health is highlighted and oral recommendations are provided. 

Key Messages

  • Oral disease management is more complex in patients with several systemic diseases.
  • Severe periodontitis adversely affects diabetes control.
  • Additional considerations exist for diabetic patients in a dental office setting.
  • Osteoarthritis of the hands reduces manual dexterity and constrains the patient’s capability of maintaining adequate oral hygiene.

Separator

Diabetes Mellitus

DM is a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action, or both.

Oral Health Implications of Diabetes

  • Gingivitis and periodontal disease
  • Xerostomia
  • Dental caries
  • Oral mucosa lesions
  • Fungal infections

Drug Interactions and Effects

  • Insulin: extended doses of aspirin can enhance the hypoglycemic effect of insulin.2 Consequently, these drugs should not be used for prolonged periods of time.
  • Ketoconazole: antifungal agent (tablet form) can enhance the hypoglycemic effect.3
  • Metformin (oral antidiabetic drug): May cause an increased hypoglycemic effect with extended use of nonsteroidal anti-inflammatory drugs (NSAIDs) and aspirin. Long-term use of metformin can lead to vitamin B12 deficiency4 which is associated with atrophic glossitis, angular cheilitis, candidiasis, and recurrent aphthous stomatitis.5
  • Epinephrine: the quantity of epinephrine contained in the dental anesthetic has no significant effect on the diabetic patient’s blood sugar level.6

Recommendations for Providing Dental Care to Diabetics

  • Assess glycemic control routinely before any invasive procedures.
  • Ask the patient about any changes in insulin dosage, hypoglycemic medications, and diet before their dental appointment.
  • Consult with an interdisciplinary health team when needed.
  • Perform routine screening for diabetes complications and closely monitor patients at each visit.
  • Emphasize preventive procedures, periodic oral examinations, and prevention of periodontal disease as patients with diabetes require good oral hygiene habits for maintenance of their oral health.

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Hypertension

Hypertension is defined as systolic blood pressure greater than 140 mm Hg or diastolic blood pressure greater than 90 mm Hg. It is one of the most common and potentially dangerous medical conditions among the elderly, affecting approximately two-thirds of men and three-quarters of women 75 years and older.7-8

Oral Health Implications of Hypertension

  • Xerostomia: potentially causes extensive tooth decay, mouth sores, and oral infections, difficulty in swallowing and glossodynia. Thiazide diuretics, α-/β-blockers, angiotensin-converting-enzymes inhibitors, and calcium channel blockers increase the risk of xerostomia.9
  • Gingival hyperplasia: a side effect of Nifedipine, Diltiazepan, Verapamil, and Amlodipine (calcium channel blockers) used in the treatment of hypertension.10 In severe cases, surgical removal of tissue may be required.11
  • Mucosa lesions: such as lichenoid reactions may also be caused by several hypertensive medications.

Drug Interactions and Effects

  • Diuretics: NSAIDs can decrease the efficacy of thiazide diuretics and β-blockers if used for more than 5 days.12-13 Elderly patients should be prescribed the lowest effective NSAID dose for the shortest duration possible. NSAIDs may also induce new onset hypertension or worsen pre-existing hypertension. Blood pressure should be routinely monitored in patients prescribed NSAIDs.14
  • Nonselective β-blockers: may cause acute hypertensive episodes if they receive vasopressors (i.e., epinephrine) in local anesthetics.13 α-/β-Blockers and diuretics may potentiate the actions of anti-anxiety medications and sedative drugs.15
  • β-Blockers: may cause orthostatic hypotension, resulting in fainting and falls after a patient gets up from the dental chair.16
  • Calcium blockers: cause vasodilation and reduction in heart rate.17
  • Calcium blockers: such as Verapamil and Diltiazem, compete with macrolide antibiotics, such as erythromycin and azithromycin, for liver metabolism. The potentially elevated levels of macrolides could result in cardiac toxicity, and elevated levels of calcium blockers can cause bradycardias and atrioventricular block.17

Recommendations for Providing Dental Care 

  • Measure a patient’s blood pressure before the initiation of any dental treatment.
  • Consult with an interdisciplinary team to establish a parameter in which a patient can be safely treated in the dental office.
  • Use caution when administrating local anesthetics that contain epinephrine. Limit their usage to 1 or 2 cartridges of 2% lidocaine with 1:100,000 epinephrine.
  • In patients with uncontrolled and severe hypertension, use anesthetics without vasoconstrictors. Avoid vasoconstrictors impregnated in gingival cords.
  • Minimize the potential of orthostatic hypotension by raising the dental chair gradually and allowing the patient to remain in an upright seated position before standing.18
  • Reduce stress and anxiety to avoid an acute elevation in blood pressure as a result of the released of endogenous catecholamines.

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Cardiovascular Diseases (CVDs)

CVD refers to any disease that affects the heart, the blood vessels (arteries, capillaries, and veins), or both.

Oral Health Implications of Hypertension

No oral manifestations are related to CVDs per se; however, side effects of medications used to treat CVDs affect the oral cavity. Dry mouth, burning of the mouth, taste changes, and lichenoid reactions are linked to side effects of heart failure medications.19

Drug Interactions and Effects

  • Digitalis glycosides: If digoxin toxicity occurs, signs and symptoms include hypersalivation, nausea, and vomiting. Digoxin may also increase the gag reflex.20
  • Because hypertension is a risk factor for stroke, many stroke patients take antihypertensive medications, such as β-blockers, calcium channel blockers, and anti-arrhythmics. Therefore, the same considerations as described in the section of hypertensive patients should be taken into account.

Recommendations for Providing Dental Care 

  • Evaluate vital signs before any dental procedure.
  • Schedule short appointments, preferably in the morning.
  • Use caution when administering epinephrine (maximum 0.036 mg epinephrine or 0.20 mg levonordefrin) and anticholinergics; the use of these drugs may lead to cardiac excitation.20
  • For patients taking digoxin, avoid the use of vasoconstrictors; these may cause arrhythmias. Watch for signs of digoxin toxicity, such as hypersalivation, because macrolide and tetracycline antibiotics may lead to digoxin toxicity.20
  • Avoid the use of NSAIDs.20
  • Avoid the use of gingival retraction cords impregnated with epinephrine in all patients with CVDs. Use alternatives, such as tetrahydrozoline HCl 0.05% or ocymetazoline HCl 0.05%.
  • Be cautious when using electrical devices that might interfere (e.g., ultrasound scalers) in patients with pacemakers or implantable defibrillators.21
  • Measure the INR or the prothrombin time laboratory values when performing dental procedures in patients with anticoagulant therapy to assure that they are in the acceptable range.

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Cerebrovascular disease

Stroke is a cerebrovascular disorder characterized by a sudden interruption of blood flow to the brain, causing oxygen deprivation. It is frequently seen in patients with current CVDs.60 Stroke is the fourth leading cause of death in the United States and a major cause of adult disability.22-23

Oral Health Complications of Stroke

Stroke patients are very vulnerable to oral diseases because of the limitations in the activities of daily living and impaired manual dexterity.24

Inadequate oral hygiene combined with xerostomia leads to additional oral problems, such as candidiasis, dental caries, periodontitis, mucosal lesions, and tooth loss.

Drug Interactions and Effects

These drug interactions and effects are similar to those discussed in the CVDs section.

Recommendations for Providing Dental Care  

  • More frequent recall appointments are recommended and preventive oral care is critical.
  • Electric toothbrush or adaptive holders are recommended when impaired manual dexterity exists.
  • Dentists should defer elective and invasive dental care for patients within the first 3 months after a stroke.
  • Seat the patient in an upright position and use caution to avoid aspiration of foreign objects by the patient during dental treatment.25

Separator

Arthritis

Arthritis is a musculoskeletal disorder characterized by the inflammation of one or more joints, causing pain and stiffness in the affected joints.26

Oral Health Implications of Arthritis

  • Arthritis can affect the temporomandibular joint, compromising the range of jaw aperture and affecting mastication.
  • Osteoarthritis (OA) of the hands causes pain and reduces manual dexterity, which can affect oral hygiene by making routine brushing and flossing more challenging.
  • Patients with prosthetic joints need antibiotic prophylaxis before invasive dental treatment to prevent oral bacteria from traveling through the bloodstream to the prosthetic joint.

Drug Interactions and Effects

  • Aspirin and NSAIDs may increase bleeding during dental procedures, but it is usually not clinically significant.27-28-29
  • Blood pressure should be routinely monitored in patients taking NSAIDs because these drugs may induce new onset hypertension or worsen pre-existing hypertension by causing fluid retention or edema.14

Recommendations for Providing Dental Care to Patients with Arthritis

  • The use of an electric toothbrush and floss with a long handle can facilitate daily oral hygiene for patients with manual limitations.
  • Short appointments are preferable in patients with multiple joint problems because these patients may have joint discomfort and pain in numerous regions of their bodies. Patients should also be allowed to adjust their positioning as needed.27
  • Additional pillows, cushioning, and/or adjustments of the dental chair can aid in patient comfort.
  • For patients with removable partial dentures, clasps should be designed to maximize ease of placement and removal.

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Osteoporosis

Osteoporosis is defined as a skeletal disorder that compromises bone strength, predisposing a person to an increased risk of bone fracture due to inhibited calcium intake and mineral loss.

Oral Health Implications of Osteoporosis

Studies have shown that mandibular and maxillary bone densities, as well as alveolar BMD and height, are modestly correlated with other skeletal sites. However, whether low BMD in the jaw results in other adverse changes, such as missing teeth, gingival bleeding, greater probing depth, and gingival recession, is still unclear.30

Drug Interactions and Effects

Bisphosphonates: Patients treated with IV bisphosphonates have a risk of developing bisphosphonates-related osteonecrosis of the jaw (BRONJ). This risk increases when the duration of the therapy exceeds 3 years.31 Patients taking oral bisphosphonates are at a considerably lower risk.32

Recommendations for Providing Dental Care to Patients with Osteoporosis

Dentists should be aware of the implications and possible risks when patients are under bisphosphonates therapy.33

Oral bisphosphonate therapy, Beginning IV bisphosphonate therapy, IV bisphosphonate therapy for <3 mo with no osteonecrosis of the jaw

  • Treat active oral infections
  • Eliminate sites at high risk for infection
  • Remove nonrestorable teeth and teeth with substantial periodontal bone loss
  • Encourage routine dental care, oral examinations, and cleanings. Minimization of periodontal inflammation, restorative treatment of caries, and endodontic therapy where indicated

IV bisphosphonate therapy for 3 mo or more with no osteonecrosis of the jaw

  • Seek alternatives to surgical oral procedures with appropriate local and systemic antibiotics
  • Conduct extractions and other surgery using as little bone manipulation as possible, appropriate local and systemic antibiotics, and close follow-up to monitor healing

Bisphosphonate therapy with osteonecrosis of the jaw

  • Follow all recommendations for group 2 above
  • Consider additional imaging studies such as computed tomography scans.
  • Remove necrotic bone as necessary with minimal trauma to adjacent tissue
  • Prescribe oral rinses, such as chlorhexidine gluconate 0.12%
  • Prescribe systemic antibiotics and analgesics if needed
  • Fabricate a soft acrylic stent to cover areas of exposed bone, protect adjacent soft tissues, and improve comfort 34
  • Suggest cessation of bisphosphonate therapy until osteonecrosis heals or the underlying diseases progresses (discussion with patient’s medical providers)

 

References

  1. O. Freire, T.E. Van Dyke. The oral-systemic health connection. A guide to patient care. M. Glick (Ed.), Chapter 5: the mechanisms behind oral-systemic interactions (1st edition), International Quintessence Publishing Group, Chicago (2014), pp. 103–117.
  2. Appendix C. Drug interactions of significance to dentistry. Table c-1 J.W. Little (Ed.), Dental management of the medically compromised patient (6th edition), Mosby, Missouri (2002), pp. 541–570.
  3. Insulin, oral hypoglycemics, and glucagon. Chapter 36 J.A. Yagiela (Ed.), Pharmacology and therapeutics for dentistry (5th edition), Mosby, Missouri (2004), pp. 573-582.
  4. de Jager, A. Kooy, P. Lehert, et al. Long term treatment with metformin in patients with type 2 diabetes and risk of vitamin B-12 deficiency: randomized placebo controlled trial. BMJ, 340 (2010), p. c2181
  5. A. Field, J.A. Speechley, F.R. Rugman, et al. Oral signs and symptoms in patients with undiagnosed vitamin B12 deficiency. J Oral Pathol Med, 24 (10) (1995), pp. 468-470.
  6. Box 31.14 Principles of dental management of diabetics R.A. Cawson (Ed.), Cawson’s essentials of oral pathology and oral medicine e-book (8th edition), Churchill Livingstone, Edinburgh (2012) VitalBook file.
  7. Lipsitz LA. A 91-year-old woman with difficult-to-control hypertension. Aclinical review. JAMA 2013;310:1274–80. Available at: http://jama.jamanetwork.com.ezpprod1.
  8. Lloyd-Jones D, Adams R, Camethon M, et al, American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics- 2009 update. Circulation 2009;119 (3):e21–181.
  9. Herman WW, Konzelman JL Jr, Prisant LM, Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure. New national guidelines on hypertension. A summary for dentistry. J Am Dent Assoc 2004; 135:576–84.
  10. Kerr AR, Phelan JA. Benign lesions of the oral cavity. Chapter 6. Drug-induced gingival enlargement. In: Greenberg MS, editor. Burket’s oral medicine. 11th Hamilton: B.C. Decker; 2007. p. 129–52.
  11. Dental Considerations for Geriatric Patients. CME resource. 2013. p. 8. Available at: http://www.netce.com/839/Course_3956.pdf.
  12. Dental Considerations for Geriatric Patients. CME resource. 2013. p. 7. Available at: http://www.netce.com/839/Course_3956.pdf.
  13. Becker DE. Cardiovascular drugs: implications for dental practice part 1-cardiotonics, diuretics and vasodilators. Anesth Prog 2007;54:178–86 DDS2007 by the American Dental Society of Anesthesiology. p. 180. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2213250/.
  14. Texas Health and Human Services Commission. Criteria for outpatient Use Guidelines. Nonsteroidal Anti-Inflammatory Drugs. Available at: http://www.txvendordrug.com/downloads/criteria/nsaids.shtml.
  15. Little JW, Falace DA, Miller CS, et al. Hypertension. In: Dental management of the medically compromised patient. 7th edition. Missouri: Mosby; 2008. p. 34–66.
  16. Dental Considerations for Geriatric Patients. CME resource. 2013. p. 6. Available at: http://www.netce.com/839/Course_3956.pdf.
  17. Becker DE. Cardiovascular drugs: implications for dental practice part 1-cardiotonics, diuretics and vasodilators. Anesth Prog 2007;54:178–86 DDS2007 by the American Dental Society of Anesthesiology. p. 181. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2213250/?report5classic.
  18. Gangavati A, Hajjar I, Quach L, et al. Hypertension, orthostatic hypotension and the risk of falls in a community-dwelling elderly population: the maintenance of balance, independent living, intellect, and zest in the elderly of Boston study. J Am Geriatr Soc 2011;59:383–9. Available at: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3306056/.
  19. Little JW, Falace DA, Miller CS, et al. Heart failure. In: Dental management of the medically compromised patient. Table 6-1 drugs used in the treatment of patients with heart failure. 7th edition. Missouri: Mosby; 2008. p. 81–9.
  20. Little JW, Falace DA, Miller CS, et al. Heart failure. In: Dental management of the medically compromised patient. 7th edition. Missouri: Mosby; 2008. p. 81–9. Box 6–7.
  21. Oral health topics: ultrasonis devices and cardiac pacemarkers. American Dental Association. Available at: http://www.ada.org/4933.aspx?currentTab52.
  22. Go AS, Mozaffarian D, Roger VL, et al. Heart disease and stroke statistics-2013 update: a report from the American Heart Association. Circulation 2013;127: e6–245. Available at: http://www.cdc.gov/Other/disclaimer.html.
  23. Kochanek KD, Xu JQ, Murphy SL, et al. Deaths: final data for 2009. Natl Vital Stat Rep 2011;60(3):1–116.
  24. Yoshida M, Murakami T, Yoshimura O, et al. The evaluation of oral health in stroke patients. Gerodontology
  25. Scully C, Ettinger The influence of systemic diseases on oral health care in older adults. J Am Dent Assoc 2007;138:7S–14S. Available at: http://jada.ada.org.
  26. Arthritis Foundation. Available at: http://www.arthritis.org/conditions-treatments/understanding-arthritis/.
  27. Little JW, Falace DA, Miller CS, et al. Arthritic Diseases. In: Dental management of the medically compromised patient. 6th edition. Missouri: Mosby; 2002. p. 478–500.
  28. Amrein PC, Ellman L, Harris WH. Aspirin-induced prolongation of bleeding time and perioperative blood loss. J Am Med Assoc 1981;245:1825–8.
  29. Ferraris VA, Swanson E. Aspirin usage and perioperative blood loss in patients undergoing unexpected operations. Surg Gynecol Obstet 1983;156:439–42.
  30. Lamster IB, Northridge ME. Improving oral health for the elderly. New York: Springer; 2008. p. 127–56.
  31. Ruggiero SL, et al. American Association of Oral and Maxillofacial Surgeons. Position paper on bisphosphonates-related osteonecrosis of the jaw- 2009 updated. Available at: http://www.aaoms.org/docs/position_papers/bronj_update.pdf.
  32. Migliorati CA. Bisphosphonate-associated osteoradionecrosis: position statement. J Am Dent Assoc 2005;136:12.
  33. Hupp JR. Dental management of osteoporosis. C.V. Mosby; 2006. Dental Clinical Advisor. VitalBook file.
  34. Woo SB, Hellstein JW, Kalmar JR. Systematyc review: bisphosphonates and osteonecrosis of the jaws. Ann Intern Med 2006;144:753–61.

 

2 Comments

  1. David Tessier November 22, 2014

    A particularly long BUT thorough article from Oasis;one of the best that I can say I will put to use as reference at the office on Monday.
    This is what I like to refer to as a professional “Recipe”,that I always look forward to take “home” with after a great course/lecture.
    My only wish was,especially this week having had to extract an anterior tooth in a patient on blood thinners,is a suggested range of INR that we can follow.Again,with this weeks experience with an extraction(no complications post-op,by the way),brought got my attention that there is no consistency in practice for whether to cease blood thinners(AT ALL!),or as to when to cease(Day of,1 day before,3…?)

    Reply
    1. Sremac November 25, 2014

      Great article, as far as CVA’s are concerned, some neurologists recommend postponing elective treatment up to 6 months.

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