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Case reports

DENTAL MANAGEMENT IN STROKE PATIENTS

Dana Cristina Bodnar, Constantin Marian Varlan, Virginia Varlan,


Teodor Vaideanu, Mariana Brandusa Popa

REZUMAT
Accidentul vascular cerebral este un eveniment neurologic serios i adeseori letal, cauzat de o brusc ntrerupere a sngelui oxigenat ctre creier. El
reprezint o cauz frecvent de deces (dup infarctul de miocard i cancer), cu frecven mai mare dup 65 de ani i produce invalidri mai mult sau
mai puin grave: deficit de vorbire, hemiplegie sau pareze, o form de paralizie cu pierderea funciei senzoriale, capacitate motorie diminuat. Pacientul
cu o astfel de suferin major trebuie s beneficieze de un managment medical foarte bine condus. Principala grij a medicului dentist este aceeea de
depistare a acestui pacient printr-o anamnez bine condus, prevenirea unui nou accident vascular cerebral (oricnd posibil), depistarea factorilor de risc
individuali asociai (cu consecinele lor) i a efectelor secundare ale medicaiei anticoagulante administrate. Comportamentul medicului dentist trebuie s
fie foarte atent: nu se va face nici un tratament stomatologic n primele 6 luni de la producerea accidentului vascular, dup care, dac acest tratament
este necesar, se poate face, dup ntreruperea temporar a anticoagulantului i innd cont de deficienele fizice i de complicaiile orale consecutive bolii,
sub supravegherea medicului neurolog. Toate aceste elemente privind managmentul dentar al pacientului care a suferit un accident vascular cerebral fac
obiectul lucrrii de fa, autorii dorind s atrag astfel atenia asupra msurilor de protecie necesare a fi luate n cabinetul dentar pentru acest pacient.
Cuvinte cheie: accident vascular cerebral, management, pacientul dentar

ABSTRACT
Stroke (produced by cerebral haemorrhage or cerebral ischaemia) is a serious neurological accident, often fatal, due to a sudden interruption of the
oxygenated blood supply to the brain. This is a frequent cause of death (the first one after myocardial infarction and cancer) and, if not fatal, it can
provoke several disabilities, more or less serious: speech deficiency, hemiplegia or paresis, different forms of paralysis or palsy with diminished or lost
sensorial capacity, motor deficiency. The patients in such a serious medically compromised condition must benefit from a very good management of the
therapeutical approach. The dental practitioners main concern is to detect these individuals, by means of accurate anamnesis, to avoid any accidents
or complications as an outcome of the basic disease (another stroke can occur anytime), to detect the connected specific risk factors or the systemic
anticoagulant medication side effects. The approach should be very careful after the stroke: there will be no dental treatment within the following 6
months. After that, if the treatment is really necessary, it will be carried out only after temporarily suspending the anticoagulant medication, taking into
consideration the oral cavity complications and the existing disabilities, if any, with the assistance of the neurologist. The present article aims to describe
the dental care management in stroke patients. The authors wish to draw the attention to the appropriate therapeutical approach, both medical and dental,
pointing out the due preventive measures for such patients in the dental office.
Key Words: stroke, management, dental patient

INTRODUCTION severe neurological condition caused by a sudden


interruption or decrease of the cerebral blood flow,
In most developed countries, the cerebro-vascular due to one or more pathological processes involving
diseases represent the third cause of death, after the cervical and/or the cerebral skull blood vessels,
cardiovascular diseases and cancer, with a prevalence and is considered to be a serious neurological and/
of 5% in individuals over 65 years old.1 This is a or neurosurgical emergency, which imposes a prompt
and effective response.1-3
The stroke is often fatal; if not fatal, it can
Department of Operative Dentistry, Faculty of Dental Medicine, Carol determine several disabilities, more or less serious:
Davila University of Medicine and Pharmacy, Bucharest, Romania
speech deficiency, hemiplegia or paresis, different
Correspondence to: forms of paralysis or palsy with diminished or lost
Dr. Dana Bodnar, Faculty of Dental Medicine, Carol Davila University of sensorial capacity and/or motor deficiency. Social
Medicine and Pharmacy, Bucharest, Romania, Tel. +40-722-698600 and professional disabling due to stroke, as well as
Email: dana21bodnar@gmail.com
hospitalization duration, have a very strong economic
Received for publication: Mar. 15, 2008. Revised: Aug. 22, 2008. impact.1,3,4

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228 TMJ 2008, Vol. 58, No. 3 - 4
Table 1: Risk factors, related systemic disea
biological factors able to increase severity of
On the other hand, dental and periodontal Table 1. Risk factors, related systemic diseases and biological factors able to
lesions occur very often in individuals with a cerebral increase severity of stroke. Modified with permission from Little JW et al. (2008)
vascular accident in their medical history, especially
for those suffering from ischaemia of the carotidian Risk factors High blood pressure

vascular system, since the external carotid artery with Diabetes melitus
its branches provides blood supply for the dento- Chronic heavy smoking
maxillary region. The importance of ischemia for the Hyperlipidemia
local vascular and neurological structures of the dental Alcoholism
and periodontal system is increased, since it induces Contraceptive medication
functional disorders and morphological disturbances,
Old age
which can operate like a pathological chain, its
Obesity
links being able to trigger insufficiently known
physiopathological mechanisms. According to this Periodontal diseases
assumption, the dental and periodontal lesions can be Related systemic Coronary diseases
very often fastened first of all due to affected arterial diseases Lower limbs arterial disease
afferent system, while the local etiological factors, Migraines
very important and very well known otherwise, are Biological factors TIA in medical history
to be considered risk factors tightly connected to the
Asymptomatic carotid stenosis
morbid process.5
Polyglobulia
There are two main issues regarding the dental
management in ischemic stroke patients: the risk Hyperuricemia
of dental treatment upon a patient suffering from
cerebrovascular ischemic disease, as well as the dental A patient
Modified surviving
from Little J.W. stroke presents
and colab. (2008)an increased
and periodontal lesions that can be induced by ischemia risk of a new episode: for 33.3% of the patients, it
of the carotidian afferent branches.6,7 can occur within one month, the risk remains high
during the first six months and decreases to 14%
MEDICAL MANAGEMENT OF THE after one year. Fifty percent of patients surviving
STROKE PATIENT a stroke present little disabilities, 15-30% present
disabilities that need special care and 10-20% need to
The first target in medical approach of cerebral be institutionalised.1,6,16
vascular accident is prevention, since the risk of a
stroke increases with 1.5% for every known risk factor. DENTAL MANAGEMENT OF THE
Therefore, it is important to identify these factors and STROKE PATIENT
also the related systemic diseases and biological factors
able to increase the seriousness of the stroke, as well as it A patient with stroke in his record shall get special
is to try to reduce or eliminate them, as much as possible. care during dental treatment: appointments shall be
In 60-80% of the cases, ischemic stroke is for choice in the morning, shall be short and without
induced by thrombosis of cerebral blood vessels. stress. Clinical approach shall take into consideration
Cerebrovascular diseases are related to atheromatosis several aspects:17,18
and cardiac diseases (myocardial infarction, atrial - Disabled patients shall be helped by the nurse to
fibrillation), to other known risk factors among which sit on dental chair, their airways shall be free and they
there are periodontal diseases.8-14 (Table 1) shall be accompanied by the persons taking care of
Calcified atheromas of the carotid artery can be them, especially if speech difficulties are present;
sometimes revealed by the dentist, examining the X-ray - Anamnesis shall be simple and optimistic, dentist
orthopantomography of elderly or diabetic patients. If shall stand in front of the patient, without mask, shall
attentively and appropriately examined, this can be a look him in the eyes, shall move slowly and questions
warning about the risk of stroke.15 shall be simple and clear, for plain answers (yes/no);
Specific therapy during stroke is vital and aims at - Anamnesis should reveal patients risk factors:
keeping patients alive during and immediately after the if the medical record shows high blood pressure,
attack. This is neurologists attribute and it must also cardiac diseases, transient vascular accidents, diabetes,
take into consideration the prevention of a second dyslipidemia, coronary atheromatosis, (heavy) smoking,
stroke by prescribing appropriate treatment. old age, then such a patient is prone to stroke and/or

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Dana Cristina Bodnar et al 229
myocardial infarction; sensitivity of the tissues, with flaccid, multiple pleated
- History of past strokes needs to be elicited: date, and possibly asimmetrically positioned tongue, with
seriousness, treatment, disabilities. There are situations dysphagia, may present accumulation of food residues
when patients speech is not affected, but he cannot on teeth, tongue, oral mucosa. They must learn to
realize the extent of the palsy (he is not aware of it) or clean their teeth and oral cavity using only one hand or
situations when a patient with brain injury on his right to get/accept another persons help, in order to avoid
side is neglecting his left side of the body; caries, periodontitis, halitosis or oral mucosa diseases.
- Blood pressure and pain should be monitored Edentulous patients are advised to get fixed
and under control during the entire intervention. prosthodontic treatment, because of the difficulties
Emergency dental treatment is allowed six months of insertion and desinsertion of removable
after stroke, it should be performed carefully, by dentures.
neurologists advice and some precautions are needed,
according to the specific characters of the stroke:1,16,19 CASE REPORTS
- If needed, dental treatment produces bleeding
(teeth extraction, pulpectomy, subgingival scaling, To exemplify dental and periodontal pathology
periodontal surgery), anticoagulant systemic of patients with stroke in their medical record, we
medication may cause serious haemorrhage, therefore will present some cases of patients aged between 40-
anticoagulant drugs like heparin should be stopped 50 years, suffering from ischemic stroke. Patients are
at least 6-12 hours before treatment. Six hours after part of a multidisciplinary extensive study, regarding
bleeding, when blood clots are built up, heparin neurovascular diseases, with implications in related
systemic treatment can be resumed.7 If there is some dental and periodontal diseases, carried out during the
other anticoagulant medication involved, it should be past 5 years.
stopped several hours or days before bleeding dental
treatment, after determining the International Clotting Case report No. 1
Rate (ICR) and decision depends on neurologists Name: R.Z., gender - female, age 46 years, medical
advice.19 record No. 8253.
- The dentist should be ready for emergency Systemic clinical diagnosis:
intervention in case of local hemorrhage, with - Central vestibular syndrome;
haemostatic medication and cautery, blood pressure - Leucoaraiosis;
should be monitored and oxygen therapy device is - Dyslipidemia;
needed in dental office. - Systolic hypertension;
- The minimal amount of anaesthetic solutions - Angina pectoris.
should be injected, concentration of added epinephrine Oral, dental and periodontal diagnosis:
should be very low (1:100.000 or 1:200.000). Use - Simple and complicated carious lesions;
of gingival retraction cord soaked with epinephrine - Abfraction cervical lesions;
should be avoided. - Chronic dystrophic progressive periodontitis;
- Metronidazolum and tetracycline should be avoided, - Kennedy Class III edentulous maxilla;
since they may affect blood clotting. - Kennedy modified (1 modification) Class II
- If the patient shows symptoms of stroke, he edentulous mandible, with pronounced bone atrophy
should get oxygen therapy immediately and should be of edentulous areas.
referred to a hospital as soon as possible.
Patients with transient ischemic attack (TIA) or
with stroke in their medical record have a very complex
dental and periodontal pathology.20-24
If patients show minor physical disabilities
after stroke, they can present poor oral hygiene. For
such patients, dentists will advise the use of electric
toothbrushes, easier to handle, use of dental floss, oral
irrigation and prophylaxis using chlorhexydine and
fluoride.
Patients with speech and deglutition disabilities
due to paralysis of oro-facial muscles, with loss of Figure 1. Clinical aspect of the oral cavity.

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230 TMJ 2008, Vol. 58, No. 3 - 4
Figure 6. Doppler-confirmed multiple calcified carotid artery atheromas.
Figure 2. Clinical aspect of the oral cavity.
Dental and periodontal lesions occur related
Fig. 1, 2, 3, 4 Clinical aspects of the oral cavity;
Fig. 5 Orthopantomography: radiological aspect of chronic dystrophic progressive
with important bilateral vascular carotid lesions. The
periodontitis, impacted 38, malpositioned 48, bone atrophy (mostly horizontal) of the
edentulous areas;
etiological mechanism is probably the hemodynamic
Fig. 6 Doppler-confirmed multiple calcified carotid artery atheromata.

vascular disease in association with local factors.

Case report No. 2


Name: S.I., gender - male, age 47 years, medical
record No. 8985.
Systemic clinical diagnosis:
- Recurrent ischemic stroke;
- Right side cerebellum infarction;
- Atheromatosis of carotid artery system;
Figure 3. Clinical aspect of the oral cavity. - Old septal myocardial infarction;
- Sinus bradycardia;
3
- Mixed dyslipidemia; 7

- Transient ischemic attack in vertebral/basilar


artery system.
Oral, dental and periodontal diagnosis:
- Carious and non-carious cavitated lesions
(extended loss of hard dental tissues);
- Chronic dystrophic progressive periodontitis;
- Kennedy modified (2 modifications) Class III
edentulous maxilla, fixed prosthodontic restorations
(crowns) in teeth 1.1., 2.5.,2.8.;
Figure 4. Clinical aspect of the oral cavity. - Kennedy Class III edentulous mandible.

Figure 5. Orthopantomography: radiological aspect of chronic dystrophic


progressive periodontitis, impacted 38, malpositioned 48, bone atrophy
(mostly horizontal) of the edentulous areas; Figure 7. Clinical aspect of the oral cavity.

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Dana Cristina Bodnar et al 231
Dental and periodontal lesions occur related
with cerebral microvascular lesions (leucoaraiosis),
due to diffuse bilateral carotid artery atheromatosis,
cerebellum infarction and chronic myocardial
infarction. There is a high probability of atheroma
located in the aortic curvature.

Case report no. 3


Name: M.E., gender - female, age 48 years, medical
record No. 8117.
Systemic clinical diagnosis:
- Sequelae of right side thalamus infarction;
Figure 8. Clinical aspect of the oral cavity. - Transient ischemic attack in vertebral/basilar
artery system;
- High blood pressure;
- Ischemic coronary heart disease;
- Dyslipidemia.

Figure 9. Clinical aspect of the oral cavity.

Figure 12. Clinical aspect of the oral cavity.

Figure 10. Orthopantomography: radiological aspect of chronic dystrophic


progressive periodontitis with bone loss and pockets in all remaining molars
and 3.4., defective treatments in 1.1., 2.5.

10

Figure 13. Clinical aspect of the oral cavity.

Oral, dental and periodontal diagnosis:


- Simple and complicated carious lesions;
- Non-carious wear lesions (attrition/abrasion) 13

located on incisal edges of maxillar and


- Mandibular incisors;
- Slow-progressive chronic periodontitis;
- Kennedy modified (2 modifications) Class III
edentulous maxilla;
Figure 11. Doppler echo-tomography, showing multiple hypo/hyper-echo-
- Kennedy modified (1 modification) Class III
genic atheromata. 11
edentulous mandible.

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232 TMJ 2008, Vol. 58, No. 3 - 4


Dental and periodontal lesions occur probably disease. In some cases, acute lesion of external carotid
related with bilateral hemodynamic vascular disease, artery with dental and periodontal associated lesions,
but without any present stroke lesion. could be revealed.
The interpretation of the role of these factors related
to major arterial lesion that produced brain infarction
must be made with caution, taking into consideration
that hypertension, diabetes and other diseases are
considered risk factors and not etiological ones.
Ischemia is important to the local dental and
periodontal vascular and nervous structures, while it
causes disturbance of normal function at this level.
Thus endorses a chain with multiple links, which can
trigger insufficiently known mechanisms, altering the
entire complex morphologic and functional oral cavity
balance. This could explain many of the failures that
occur in dental and periodontal therapy.
Lesions producing this ischemia may be located
mainly in: aortic curvature, common carotid artery,
carotid bifurcation, external carotid artery and main
branches that irrigate the components of the dento-
maxillar system.
Systemic diseases that may intervene in this area,
such as vasculitis, collagen diseases, liver diseases,
Figure 14. CT image, showing remainders of right side lacunar infarction. disgenesis, some imunopathies, toxic illnesses,
drugs, iatrogenics, a.s.o., should always be taken into
consideration when dealing about an appropriate
therapy, mainly when prevention programs or
minimum risk interventions are to be performed.
In many cases, one can assume that the dento-
15
maxilar injuries may be explained primarily by vascular
lesions of the arterial system, while local factors,
both important and well known at present, may be
considered as risk factors or related to the morbid
process.
Dental and periodontal lesions in stroke are very
frequent. They occur in 94% of studied cases. In
Parkinsons disease, frequency of these lesions is 20%
less and in Alzheimers disease is 30% less frequently.
Highest frequency of lesions occurs in male patients
Figure 15. Doppler echo-tomography, showing slight thickening of carotid in the 61-70 years age decade, followed by 71-80 years
Fig. 12, 13 Clinical aspects of the oral cavity;
Fig. 14 CTartery wall,
image, withoutremainders
showing atheroma. of right side lacunar infarction; age decade, and in 11.7% of the cases, injuries were
Fig. 15 Doppler echo-tomography, showing slight thickening of carotid artery wall, also recorded at ages under 50 years.
without atheroma.
DISCUSSIONS Patients stroke were located in a proportion of
26.9% in the carotid artery system and 9.7% in the
It is not correct trying to explain dental and vertebral/basilar artery system. This is explained by
periodontal lesions only by one or more risk factors, the fact that the latter is participating in the irrigation
such as hypertension or diabetes, in patients with of dento-maxillar device only by anastomosis, that is
stroke. Stroke existence in medical record of a patient why our observation represents an indirect argument
leads to mandatory evaluation of causality and cerebral for a possible vascular cause of dental and periodontal
mechanisms lesions that typically occur during lesions.
development of dental and periodontal lesions. It is In 655 patients (65.5% of cases) vascular lesions
the case of stroke occurred within a chronic vascular were diffuse and not defined in only one particular

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233
Dana Cristina Bodnar et al
territory. It is the case of a finding, with the same metabolic processes, without the therapeutic possibility
meaning, attributed to carotid artery system, because we to influence very effective these blood vessels, as can
are dealing with vascular injuries more encompassing, be done for the internal carotid artery. For this reason,
affecting enhanced territories. As an appropriate treatment of dental and periodontal diseases becomes
interpretation, we are entitled to say that 92.4% of the extremely important for both internal and external
observations fall into one ischemic disease affecting carotid artery, knowing that the inflammatory factor
the carotid artery system. is always present in atherosclerosis. Highlighting the
External carotid artery with all its branches which presence of pathogens in carotid artery atheromata
supplies dental and maxillar structures, should be similar to those in microbial flora of the dental and
interpreted in the context of carotidian cervical and periodontal lesions supports this observation.
cerebral axis, and only rarely isolated. In the case of fibromuscular dysplasia of the
Etiological mechanisms of dental and periodontal external carotid artery, the consequences are similar,
lesions in patients with stroke are represented by three but high blood pressure is constantly related.
pathways: The existence of severe trophic disorders has
- Atherotrombosis comprising extracranial and been notified, especially in bone structures (maxilla
intracranial arteries and microcirculation arteries and mandible), such as ostheoporosis and many
(penetrating arteries); other bone reshufflings, well revealed in CT, which
- Arterial embolism from aortic arch and including provides a clear image of opportunities for a specific
common carotid artery, carotid furcation, external type of prosthodontic therapy and, of course,
carotid artery, internal carotid artery and direct contraindications for implant therapy.
cardiac embolism, and also the association of local Dental treatment in such patients must take into
atherotrombosis of cervical and cerebral arterial consideration first the vascular risk factors and the
system with cardiac embolism; removal of periodontal inflammatory factors, and
- Systemic hypoperfusion, with ischemia in the only after that should try to approach dental and
territory of the terminal external and internal carotid periodontal lesions. Surgical treatment for dental
artery usually caused by cardiac and/or iatrogenic and periodontal injuries in these patients should be
reasons. performed according to the neurologists advice, in
Our clinical observations show the following order to avoid recurrent stroke.
decreasing frequency for possible mechanisms in Neurovascular treatment, particularly carotid
determining dental and periodontal lesions related to endarterectomy or carotid angioplasty with or without
cerebral ischemia: stent, in terms of existing dental and periodontal
- Intricate mechanisms; injuries, should not be performed without treating first
- Local atherotrombosis; the periodontal inflammatory source. The risk of blood
- Hemodynamic disease mechanism; dissemination and bacterial endocarditis is well known
- Penetrating vessels affections; and of high seriousness.
- Heart embolism; Although the study does not include specific
- Local hyalinosis; elements related to iatrogenics, the wide range of
- Atherotrombothic local embolism; medicines used for cerebral vascular pathology leads to
- Atherosclerotic occlusion of terminal vessels; the need of assessment regarding the risk of developing
- Carotid artery embolism; dental and periodontal lesions due to side effects of
- Atherotrombosis with progressive extension; medication. It is mainly about anticoagulant medication,
- Microembolism; antiplatelet treatment, and also about antihypertensive
- Dental and periodontal injuries insignificantly and antiepileptic treatment. Evaluation of dental and
explained by risk factors. periodontal risk, related to the benefits of these therapies
We can discuss the existence of local characteristics in avoiding recurrent stroke and vascular death risk,
as risk elements at the level of external carotid artery, should be done in collaboration with the neurologist.
which does not have very effective anastomosis Study of many situations of dental and periodontal
system and has to ensure the energy substrate for the lesions in stroke patients and necessary assimilation of
dental and maxillar structures. There are membrane notions from complementary investigations, should
mechanisms, which are difficult to explain at present. lead to a different approach of the therapeutic decision
Atherotrombosis, local hyalinosis and reduced for elderly patients who suffered of a stroke.
blood flow certainly influence in a negative way local Experience gained from such studies emphasizes

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234 TMJ 2008, Vol. 58, No. 3 - 4
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