Vol. 110 No. 2 August 2010
MEDICAL MANAGEMENT AND PHARMACOLOGY UPDATE Editor: F. John Firriolo and Nelson I. Rhodus
A new management approach for dental treatment after a cerebrovascular event: a comparative retrospective study Sharon Elad, DMD, MSc,a Yehuda Zadik, DMD, MHA,b Eliezer Kaufman, DMD,c Ronen Leker, MD,d Ori Finfter, BS,e and Mordechai Findler, MD, DMD, MS,f Jerusalem, Israel HEBREW UNIVERSITY-HADASSAH
Objective. Current literature recommends postponing dental treatment until 6-12 months after a stroke, based on the presumed risk of recurrent stroke. The purpose of this study was to suggest that the importance of dental care during this period exceeds the risk of medical complications in this patient population. Study design. Two groups were compared: 1) a cerebrovascular (CrbV) study group: patients (n ⫽ 16) who had suffered from a CrbV event within the 12 months preceding their dental procedure; and 2) a cardiovascular (CV) control group: patients (n ⫽ 25) suffering from ischemic CV disease. Patients were monitored during and after the dental treatment. Treatment parameters and outcome were compared. Results. Patients received various essential dental treatments with intense monitoring during their dental management. Dental procedures were invasive in 68.8% and 0% of CrbV and CV groups, respectively. Dental treatments were completed uneventfully. No clinical CrbV or CV complications were noted in either group after the dental treatment. Conclusion. Within the limits of this small retrospective study, it appears that dental treatment may be safely administered in patients a few weeks after the CrbV event as long as these patients are kept under optimal medical surveillance. (Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;110:145-150)
Approximately 700,000 people in the U.S. are hospitalized annually suffering from stroke, 200,000 of whom had previously experienced a stroke. The risk of recurrent stroke in a patient who had a recent stroke or transient ischemic attack (TIA) is greater than that of a first stroke.1-3 The risk of recurrence is highest immediately after the initial event, but may remain high for up to
Lecturer, Department of Oral Medicine, Hebrew University-Hadassah School of Dental Medicine. b Postgraduate student, Department of Oral Medicine, Hebrew University-Hadassah School of Dental Medicine. c Professor, Department of Oral Medicine, Hebrew University-Hadassah School of Dental Medicine. d Senior Lecturer, Cerebrovascular Unit, Department of Neurology, Hadassah School of Medicine. e Undergraduate student, Department of Oral Medicine, Hebrew University-Hadassah School of Dental Medicine. f Department of Oral Medicine, Hadassah-University Medical Center. Received for publication Oct 7, 2009; returned for revision Feb 15, 2010; accepted for publication Mar 16, 2010. 1079-2104/$ - see front matter © 2010 Mosby, Inc. All rights reserved. doi:10.1016/j.tripleo.2010.03.023
a year.4 Up to 70% of ischemic recurrences are reported to occur within 1 month after the initial stroke.2,5 Because of this high rate of recurrent stroke, a great portion of dental literature recommends deferring elective dental care for the first 6 months after a stroke, TIA, or reversible ischemic neurologic defect.6-9 However, recent findings shed light on other medical conditions that may affect the decision to defer dental treatment of patients after a cerebrovascular (CrbV) event. Cohort studies have analyzed the reasons for readmission and mortality among patients surviving the initial cerebral ischemic insult. A large-scale study was conducted on Medicare beneficiaries aged ⱖ65 in the U.S.1 According to that study, the reasons for readmission included pneumonia as well as recurrent CrbV and cardiovascular (CV) diseases. The frequency of readmission due to pneumonia was ⬃50% higher than that of recurrent CrbV or CV diseases. A study in the general Japanese population demonstrated that the death rate after readmission due to pneumonia was as high as the death rate due to recurrent CrbV events.3 These studies demonstrated that the risk for recurrent CrbV event is only partially caused by CV etiology and 145
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mostly related to pulmonary complications related to aspiration. This new insight raises 2 suggestions related to dental practice: 1) The risk for cardiovascular complications after dental treatment is not as imminent as was previously presumed, and, therefore, deferring dental treatment for 6 months after a stroke is questionable; and 2) adequate oral function for the prevention of aspirating events is mandatory, and therefore, postponing dental treatment is problematic. We therefore hypothesized that the risk for CrbV complication after dental treatment is lower than previously presumed in the dental setting. A similar attitude was recommended in the past for patients suffering from CV diseases owing to the risk of ischemic or thrombotic cardiac events during stressful interventions, such as dental treatments. However, that risk is not considered today to be a limiting factor for receiving dental treatment within a month after an acute myocardial infarct.7 Considering the similar etiology and pathophysiology of CrbV and CV diseases, the CV patients is a good standard for comparison. This article aimed to assess the risk of developing ischemic CrbV complications after dental treatment in patients who experienced a CrbV insult within the preceding year. METHODS This retrospective observational comparative study comprised 2 groups. The study group, referred to as the CrbV group, consisted of 16 patients who had sustained any type of neurovascular event (stroke or TIA). The control group, referred to as the CV group, consisted of 25 CV patients belonging to one of the following categories: 1) controlled hypertension (HTN): blood pressure not exceeding values of 160/100 mm Hg; 2) stable CV disease; or 3) congestive heart failure (New York Heart Association class I-II). All patients in the CrbV group were treated within 12 months after having suffered a stroke or TIA. Patients were classified according to the length of time between their last CrbV event and their dental treatment: A) up to 1 month; B) 1-3 months; C) 3-6 months; or D) 6-12 months. Some of these patients had a residual neurologic deficit. The medical background, medications, type of dental treatment, type of local anesthesia, duration of treatment, use of adjunctive stress reduction protocol, and blood pressure (BP) values were retrieved from the files. Special attention was given to concurrent diagnoses of HTN, atrial fibrillation, antiplatelet therapy, and anticoagulant therapy. The dental treatments were classified according to the level of invasion: 1) examination; 2) restorative; 3) periodontal; 4) extraction; or 5) multiple extractions. Parameters of the dental treatment included duration, use of local
Table I. Patients’ characteristics
Gender (male:female) Age, y (mean ⫾ SD) Medical background, n (%) HTN AF IHD Other Medications, n (%) Anti-HTN Antiplatelet Anticoagulant Other
Cardiovascular (n ⫽ 25)
Cerebrovascular (n ⫽ 16)
21:4 60.4 ⫾ 10.0
12:4 66.5 ⫾ 10.6
15 (60%) 5 (20%) 18 (72%) 25 (100%)
12 (75%) 5 (31%) 4 (25%) 13 (81%)
23 (92%) 20 (80%) 2 (8%) 22 (88%)
15 (88%) 9 (56.3%) 5 (31.3%) 15 (93%)
HTN, Hypertension; AF, atrial fibrillation; IHD, ischemic heart disease.
anesthesia, and stress reduction protocol (inhalation or intravenous sedation). Patients were followed-up to ensure that their medical condition remained stable after dental treatment. The study was approved by the Institutional Ethics Review Board. Data were analyzed using descriptive statistics. Comparisons between the CrbV and the CV groups for age, BP values, treatment duration, and consumption of anticoagulants and antiplatelets were performed. The nonparametric Mann-Whitney test was used in the comparisons of the numeric variables (age, BP values, and treatment duration). For the comparisons of the dichotomies “anticoagulants” and “antiplatelets,” Fisher exact test was used. Differences were considered to be significant at a P value of ⬍.05. The statistical analyses were performed using SPSS 12.0 (SPSS, Chicago, IL). RESULTS Patient characteristics Average age was higher in the CrbV patients than in the CV patients, though not statistically significant (P ⫽ .095; Table I). The male:female ratio showed male predilection in both groups. Hypertension was common in both groups (Table I). Atrial fibrillation was the second most common diagnosis in the CrbV patients whereas ischemic heart disease (IHD) was the second most common underlying disease in the CV patients. Diabetes mellitus was observed in 4 patients in the CrbV group and 3 patients in the cardiovascular group. Multiple medication use was reported by all patients except 1 patient in the CrbV group. Antiplatelets were frequently used in both groups similarly (P ⫽ .16; Table I). Antiplatelets included aspirin, combination of aspirin and dipyridamole, and combination of aspirin and clopidogrel. Anticoagulants were prescribed to a
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TABLE II. Description of cerebrovascular event Patient Post-CrbV event no. Gender Age category*
1 2 3 4 5 6 7 8 9 10 11 12 13 14
M M F F M M M M M F M M M M
77 62 78 58 71 67 76 48 60 69 82 64 83 57
A A B B D A D D D A C A D D
TIA Stroke–ischemic Stroke–ischemic Stroke–ischemic Stroke–NA Stroke–hemorrhagic Stroke–ischemic Stroke–ischemic Stroke–ischemic Stroke–ischemic Stroke–ischemic Stroke–ischemic Stroke–ischemic Stroke–ischemic
Aphasia Lt. hemiparesis NA Dysarthria Rt. hemiparesis Spastic hemiplegia, hydrocephalus Lt. hemiparesis Rt. hemiparesis, aphasia Hemiplegia Aphasia — Dysarthria, headache Mild rt. weakness, confusion Rt. sided weakness (arm, leg, face), aphasia Facialis, hearing loss lt. ear, minimal loss of gross power lt. arm Global aphasia, rt. hemiplegia
Residual damage None Lt. hemiparesis None Dysarthria None Spastic hemiplegia Lt. hemiparesis Rt. hemiparesis, aphasia None Aphasia None Facialis Mild rt. hemiparesis None Facialis, hearing loss lt. ear, minimal loss of gross power lt. arm None
CrbV, cerebrovascular; TIA, transient ischemic attack; NA, not available; Lt, left; Rt, right. *A: Up to 1 month after CrbV event; B: 1-3 months after CrbV event; C: 3-6 months after CrbV event; D: 6-12 months after CrbV event.
smaller proportion of the patients compared with antiplatelets (Table I). There was no statistically significant difference in anticoagulants use between the CrbV and CV groups (P ⫽ .09). Anticoagulants included sodium warfarin, enoxaparin sodium, or both. Cerebrovascular events background Nine patients were treated within 6 months after having suffered the CrbV ischemic attack (groups A, B, and C; Table II). Six of these patients were treated within 1 month after having suffered the stroke (group A). A TIA had been diagnosed in only 1 patient; the remaining patients had been diagnosed with strokes. Ischemia was the etiology for stroke in 13 patients, and hemorrhagic event was the etiology for the stroke in 2 patients. Three of the patients had a history of a previous stroke (patient nos. 1, 3, and 10; Table II). Residual neurologic damage was observed in 9 patients; this status persisted during their dental treatment (Table II). Dental treatment Uneventful dental treatment was completed in all patients in the CrbV group (Table III). One case of local adverse effect (transient local mental neuropathy) occurred in a patient from the CV group, which lasted 4 weeks. This adverse event was associated with the mandibular block type of injection that was used. The description of the dental treatments appears in Table III. The average duration of treatment was longer in the CrbV group than in the CV group (P ⬍ .00001).
TABLE III. Dental treatment
BP before, mm Hg (mean ⫾ SD) Treatment type,* n (%) 1 2 3 4 5 Treatment duration, min (mean ⫾ SD) LA, n (%) Lidocaine 2% ⫹ adrenalin 1:100,000 Mepivacaine 3% No LA Uneventful outcome, n (%)
Cardiovascular (n ⫽ 25)
Cerebrovascular (n ⫽ 16)
137/81 ⫾ 21/10
141/78 ⫾ 20/11
0 25/25 (100%) 0 0 0 15.8 ⫾ 8.1
1 (6%) 4 (25%) 2 (12%) 7 (44%) 2 (12%) 54.4 ⫾ 52.5
0 0 24/25 (96%)
7/16 (44%) 3 (25%) 16/16 (100%)
BP, Blood pressure; LA, local anesthetics. *1: Examination; 2: restorative; 3: periodontal; 4: extraction; 5: multiple extractions.
This was due to 1 patient in the CrbV group who was treated in the undergraduate student clinic where, owing to procedural factors, management was prolonged. This patient, who was at the clinic for 240 minutes, was relaxed during the entire period and the dental chair was in a semisupine position for most of the procedure. Local anesthesia was used in 12 (75%) and in 25 (100%) of the procedures in the CrbV and CV groups,
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TABLE IV. Dental treatment parameters Patient no.
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
4 4 4 2 2 5 4 4 4 4 2 2 5 3 1 3
30 30 30 60 30 60 30 60 30 30 30 240 45 90 45 30
w/ w/ w/ w/ w/ w/ w/ w/ w/ w/ w/ w/o w/ w/o w/o w/o
Type of LA Lidocaine 2% ⫹ Mepivacaine 3% Mepivacaine 3% Lidocaine 2% ⫹ Mepivacaine 3% Mepivacaine 3% Mepivacaine 3% Lidocaine 2% ⫹ Lidocaine 2% ⫹ Mepivacaine 3% Mepivacaine 3% NA Lidocaine 2% ⫹ NA NA NA
adrenalin 1:105 adrenalin 1:105
140/85 160/90 160/80 120/80 190/90 130/80 145/90 140/90 140/80 120/70 160/60 134/77 140/70 135/80 NA 106/56
On sodium warfarin On sodium warfarin Treated in the student clinic
On sodium warfarin
INR, international normalized ratio; other abbreviations as in Table III. *1: Examination; 2: restorative; 3: periodontal; 4: extraction; 5: multiple extractions.
respectively (Table III). Both local anesthetic solutions were used in the CrbV group (lidocaine 2% with adrenalin 1:100,000, and mepivacaine 3% with no vasoconstrictor) whereas 1 solution was used in the CV group (lidocaine 2% with adrenalin 1:100,000). A volume of 1.8 mL was sufficient for quality anesthesia in all cases, with the exception of 1 patient from the CrbV group (patient no. 13, injected with 4 cartridges for a total volume of 7.2 mL). All of the patients were treated in accordance with the recommended stress reduction protocol, including establishing good rapport, appointment at the convenience of the patient, and encouraging the patients to express their fear. None of the patients were treated with tranquilizers or anxiolytic medication. Blood pressure was slightly higher in the CrbV group than in the CV group, though this difference was not statistically significant for either the systolic BP (P ⫽ .46) or the diastolic BP (P ⫽ .49; Table III). In all of the patients, BP was good-to-moderately balanced, except in 1 patient in the CrbV group (no. 5) with isolated systolic HTN (Table IV). In patients treated with sodium warfarin, international normalized ratio (INR) values taken within a 24-hour period before the dental treatment were within the therapeutic range and did not exceed 2.9 (Table IV). In the CrbV group, 11 dental procedures (68.8%) were defined as invasive (i.e., periodontal and surgical; Table III, treatment types 3-5) whereas in the CV group none of the dental procedures were defined as invasive. Dental treatment was well tolerated overall. Hemostasis was achieved after the dental treatment for all patients
by local hemostatic means (suture or pressure with gauze soaked with tranexamic acid). No CrbV adverse events were noted immediately after treatment in either group. Within the month after treatment, no neurologic or cardiac deteriorations were observed. DISCUSSION Patients discharged from the hospital after strokes were found to have poor oral hygiene that exacerbated during rehabilitation if special precautions regarding oral hygiene were not taken.10,11 A major concern of stroke survivors should be chewing capability and the comprehensive swallowing of food,12 because oral and dental disabilities are significant risk factors for aspiration pneumonia.13,14 Restoration of an optimal chewing apparatus is imperative for better mastication, which in turn eases swallowing and prevents aspiration of oral content. The dental health care provider is in an optimal position to address these needs. However, according to the literature, elective dental treatment should be avoided during the first 6 months after a stroke,6-8 and preferably should be postponed until the end of the first year after the neurologic event. A lack of well designed studies makes it impossible for us to provide evidence-based clinical dental guidelines, and as mentioned by Fatahzadeh and Glick,6 dental guidelines are based on intuitive extrapolation from medical practice. We advocate immediate dental treatment to establish oral function, but suggest that this treatment should be provided only if the patient’s CrbV and CV risk factors are under control. The risk factors for
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a second CrbV or CV event should be monitored concurrently with the dental treatment. The latest reports show the major causes for deterioration of the patient’s well-being after a stroke1,3,15: 1) Complications derived from the disabilities induced by a CrbV event are often aggravated by incomplete rehabilitation; one such complication is aspiration pneumonia1,13; 2) the risk factors for the primary CrbV event, i.e., HTN, IHD, and atrial fibrillation, may cause another CrbV event and are often treated with antiplatelets or anticoagulants16-20; and 3) hospital-borne and iatrogenic disabilities, such as hospital-acquired infections, deep vein thrombosis, pulmonary embolism, aspiration pneumonia, and decubitus ulcers, are potential medical complications.21 According to the above grouping of risk factors, elements in the second group should be of greatest concern for the dental health care provider i.e., HTN and bleeding tendency. Because there are clear management guidelines for dental treatment of patients with HTN or at risk for bleeding22 we suggest that an early dental intervention should be considered. In this study, we suggest that essential dental care can be provided safely to CrbV patients similarly to CV patients. The outcomes of dental management of post–CrbV event patients in this study were compared with outcomes of dental management of CV patients. All dental procedures were completed uneventfully in the CrbV group of patients, with no late complications during follow-up, compared with the CV control group. This control group was selected because of similar etiology and risk factors for both CV and CrbV diseases. This positive outcome is encouraging, considering the risk level associated with invasive procedures that have been performed. Because the risks for recurrent stroke are minimized under proper medical treatment, there is no apparent logic for postponing needed dental treatment, which, nevertheless, may require certain modifications, as follow. 1. Stress reduction protocol. Generally, it is important to hold stress-free treatment sessions during the day that are compatible with the patient’s schedule whenever needed.6 Thus, the clinician may consider a stress-reduction protocol similar to that for high-risk cardiovascular patients with modification.7,23 In this study, only behavioral stress reduction was used, because tranquilizers at the immediate stage after the CrbV event may alter level of consciousness and in turn may confuse the health care provider. 2. Drug therapy considerations. Because the use of antiplatelet drugs is common in this patient population, postoperative hemostasis should be assured. When anticoagulation therapy is administered, extra steps should be taken before and during the dental procedure to reduce the risk of bleeding, such as INR monitoring, good surgical
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techniques, and use of local hemostatic agents.22,24 Potential interactions between prescribed dental medications and oral anticoagulants should be assessed. The patients reported in the present study had no bleeding complications after their dental treatment, even though the majority were treated with antiplatelets or anticoagulants. Antihypertensive drugs are being sought for modification of dental treatment regarding possible drug-drug interaction with the local anesthetic solution (specifically, the adrenergic blockers), and to the possible side effect of orthostatic hypotension.7 Therefore, adrenalin in a local anesthesia solution should be used cautiously, and not in excess (up to 0.36 mg adrenalin during 1 session). The patient should be instructed to rise slowly from the dental chair. The implications and effects of other drugs on dental management are extensively described in the literature.7 3. Neurologic deficit considerations. When neurologic deficits exist, the dentist should be aware of difficulties with communication, mobility, and oral function (mastication and swallowing). When there is loss of protective reflexes, such as swallowing and gag reflexes, adjustment of the patient’s head position is advised to assure an open airway, and if possible, it is advised to treat the patient in an upright position. Good evacuation of access water using a powerful suction should be at hand to prevent aspiration. If the patient is edentulous, or wearing a nonfitted denture, dental implants should be considered to secure denture position and function. Oral hygiene instructions should be individualized based on the patient’s motor capabilities. The residual neurologic deficits of our patients neither impaired communication with them nor halted the dental procedure. 4. Control of the underlying disease and risk factors. Atherosclerosis and thromboembolic events are the main etiologies for ischemic stroke, as can be observed from the present group of patients. Other etiologies of stroke are evident, such as vasculitis and hypercoagulability disorders. The dentist should assure that the underlying disease is controlled to minimize the risk for repeated stroke. Good communication with the physician regarding the status of the underlying disease is the key requirement for the treatment of such a patient. The dentist’s treatment approach should consider the systemic risks once the plan of dental treatment has been decided. The patient’s BP should be monitored, and adrenalin in local anesthesia solution should be limited whenever an underlying diagnosis of HTN or cardiovascular disease is known. In the present case series, monitoring confirmed a balanced BP in all patients with the exception of 1 (no. 5) with isolated systolic HTN, in whom antihypertensive drugs were expected to have a negative effect on the diastolic BP. Therefore, that pa-
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tient’s usual systolic BP values were above the normal range. In addition to minimizing the risk for recurrent strokes, any underlying disease should be addressed according to accepted practice.7 It is noteworthy that during the last decade there was a trend in the literature to recommend reduction of the duration of lag period until initiation of dental treatment following an acute myocardial infarction. According to the current literature, there is no necessity to defer dental treatment for longer than 1 month after acute myocardial infarction.7 The limitation of the present study is that it is a small cohort, which questions the generalizability of results. A closer follow-up of patients prospectively is needed to closely evaluate for potential CrbV events. In conclusion, this comparative study suggests that dental treatment may be safely administered for patients a few weeks after an adverse CrbV event, just as in CV patients. We believe that as long as the patients are kept under optimal medical surveillance, dental management of a post–CrbV event patient can be successfully resumed within weeks after the event. A large-scale study is warranted to confirm the conclusion of this pilot study.
The author thanks Mr. Scott Drucker for his kind assistance with English editing.
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Reprint requests: Dr. Sharon Elad, DMD, MSc Lecturer, Department of Oral Medicine Hebrew University–Hadassah School of Dental Medicine POB 12272 Jerusalem 91120 Israel [email protected]