Dental hygienists must be ready to manage poststroke patients to avoid complications during procedures and identify high-risk patients.
Thomas A. Viola, RPH, CCP
“Excuse me, sir,” she said, softly.
I almost didn’t hear her. It was a typically busy morning in our pharmacy, and I was in full production mode. I managed to tear both eyes away from what I was working on and glance up to acknowledge her. The woman standing in front of me looked to be in her late 60s or early 70s. She also looked troubled; I could tell she needed my help.
“I’ll be right with you,” I replied politely. I looked down for a moment, but after hearing no reply, I looked back up at her again. It was a rather surreal moment. Against the backdrop of frenzied business going on around her, she stood there in front of me and just stared.
Was she annoyed? Was it something I said?
I resolved to finish what I was working on as quickly as I could and assist her. But when I looked up again, the woman was gone. How had she managed to disappear so quickly? I walked around the prescription counter to try to find her so I could apologize for the delay.
I didn’t have to walk very far. I found her on the floor. I turned to ask for help, but my fellow employees were already calling 911. When EMS arrived a few minutes later, the woman was responsive again. A week later, she returned to the pharmacy to explain what had happened and thank us. The diagnosis? She’d had a ministroke, or transient ischemic attack.
Stroke: Just the facts
According to the U.S. Centers for Disease Control and Prevention, about 795,000 Americans experience a new or recurrent stroke each year. Approximately 600,000 of these are first occurrences, and 185,000 are recurrent attacks. Stroke is the third leading cause of death, behind heart disease and cancer, in the United States—where, on average, someone has a stroke every 40 seconds and more than 140,000 people die each year from the disease.
Nearly 75% of all strokes occur in people over age 65. The risk of having a stroke more than doubles each decade after age 55. Men younger than age 75 have a higher incidence of stroke than women of the same age. Ironically, since women live longer than men, more women die of stroke each year than men. However, strokes can and do occur at any age, and almost 25% occur in people under the age of 65. Stroke is also the leading cause of serious, long-term disability.
Stroke, or cerebrovascular accident (CVA), is caused by the sudden interruption of blood supply and oxygen to the brain. While 75% of those who suffer a stroke survive, 20% initially require some type of institutional care and 15% or more suffer permanent disabilities. This is because stroke almost always results in damage to brain tissue.
The most common type of stroke is ischemic stroke, which occurs when cerebral arterial blood flow is disrupted. Ischemic stroke may be caused either by a blood clot that forms in intracranial vessels (as a result of atherosclerosis) or by a clot that forms elsewhere in the body (in the heart, for example, as a result of atrial fibrillation) and then migrates to the brain. Since certain functions are linked to specific regions of the brain, the patient with ischemic stroke will display symptoms of changes in physical or mental status, based on the specific location in the brain where the ischemic damage occurred.
Stroke may also result from hemorrhage. Hemorrhagic stroke results from intracerebral and subarachnoid hemorrhage when bleeding occurs directly into brain and central nervous system tissues. Symptoms resulting from hemorrhagic stroke are more difficult to interpret and predict, since additional tissue trauma, resulting from increased intracranial pressure and edema, may exacerbate brain tissue damage caused by the initial hemorrhage.
Stroke: Damage and disabilities
It is critical to identify and diagnose the type of stroke involved before beginning treatment. Procedures intended to increase blood flow to parts of the brain affected by ischemic stroke may have catastrophic consequences for patients who have experienced hemorrhagic stroke. Regardless of its origin, stroke almost always results in brain tissue damage. Disabilities that result from a stroke are directly related to the extent and location of the damaged tissue. Right-side brain damage results in left-side paralysis, impaired cognitive function, impulsive behavior, memory deficits, and difficulty performing tasks. Left-side brain damage results in right-side paralysis, slow and disorganized behavior, memory deficits, and difficulty with language and speech. While normal function may return, patients who experience a stroke are frequently left with some sort of permanent disability.
Three events are associated with stroke: transient ischemic attack (TIA), reversible ischemic neurologic deficit (RIND), and stroke-in-evolution. A transient ischemic attack is caused by a temporary disturbance in blood supply to a specific area of the brain but with no detectable tissue damage. Symptoms usually last less than 10 minutes and include numbness of the face or limbs on one side of the body, weakness, and speech impairment. A reversible ischemic neurologic deficit is similar to a transient ischemic attack, but symptoms persist for 24 hours or more. Stroke-in-evolution is characterized by the emergence of symptoms of ischemic injury that persist for hours and continue to worsen over a period of time.
Stroke: Risk factors and prevention
The first step in managing stroke is preventing it. This is done by identifying modifiable risk factors and employing therapies to attempt to reduce or eliminate them. However, since many patients who experience a stroke also had the same risk factors prior to the event, these same therapies are often employed for the management of the post-stroke patient.
Hypertension is considered a major risk factor for both ischemic and hemorrhagic stroke, as well as a risk factor for other concurrent diseases, such as congestive heart failure, myocardial infarction, and renal failure. While no one class of antihypertensive agent demonstrates superior stroke prevention, blood pressure control is often achieved through combinations of two or more agents. In addition, lifestyle modifications (improved diet, weight loss, and increased exercise) also assist in achieving blood pressure control.
Hypertension is often accompanied by other cardiovascular comorbidities, such as hyperlipidemia, which may also increase the risk of stroke. Low-density lipoproteins (LDLs) are the main contributor to the development of atherosclerosis, often referred to as “hardening of the arteries.” In fact, cardiovascular disease begins with atherosclerosis or the weakening of arterial walls. As the arterial walls weaken, inflammatory mediators and fatty deposits enter the intima, forming atheromas within the vessel wall. These atheromas may rupture, leaving a roughened surface upon which circulating platelets may aggregate. The resulting thrombus may break off and ultimately lodge in and block smaller vessels, resulting in infarctions. HMG-CoA reductase inhibitors (statins) are the drugs of choice to lower LDL.
Patients who have experienced a recent stroke, TIA, or RIND are at high risk for stroke or stroke recurrence and should not undergo elective dental procedures.
Atrial fibrillation is an independent risk factor for stroke. The risk of stroke is about five times greater in patients with atrial fibrillation, and risk increases with age. Atrial fibrillation is characterized by rapid beating of the atria, which limits their effective contraction to provide blood to the ventricles. As a result, blood may pool and thrombi may form. Coumadin (warfarin) is the drug of choice for most patients with atrial fibrillation, although some patients are adequately treated with aspirin and/or Plavix (clopidogrel). While combination therapy is more effective in reducing stroke risk, it also increases the risk of bleeding. Newly approved antiplatelet alternatives to Plavix include Effient (prasugrel) and Brilinta (ticagrelor). Newly approved anticoagulant alternatives to Coumadin include Pradaxa (dabigatran), Xarelto (rivaroxaban), and Eliquis (apixaban).
Cigarette smoking is associated with an increased risk for both ischemic and hemorrhagic stroke. The risk of ischemic stroke in current smokers is about double that of nonsmokers after adjustment for other risk factors. Nicotine replacement products (gum, inhalers, lozenges, transdermal patches) for smoking cessation include a variety of formulations to reduce cravings while minimizing withdrawal symptoms. Other medications, such as Chantix (varenicline), are also effective in easing nicotine withdrawal.
Stroke: The oral-systemic factor
The oral-systemic connection has been well documented for many conditions. Elimination of periodontal disease has long been thought to be an important factor in overall health. The concept that oral conditions can significantly influence events elsewhere in the body has undergone a number of iterations over the years. Now, there is little doubt that the effect of management for oral conditions is not limited to the oral cavity. Numerous studies have associated periodontitis with systemic conditions, especially cardiovascular disease. Accumulation of bacteria causes the local periodontal tissue to become inflamed. If left untreated, this inflammation will progress to periodontal disease.
In addition, in the presence of inflammation, bacteria associated with periodontal disease may enter systemic circulation. Oral-hematogenic spread of Porphyromonas gingivalis may be one of the important events in the development of cardiovascular lesions and atherosclerosis. In fact, P. gingivalis is the most abundant bacterial species detected in coronary and femoral arteries. Recent studies strongly correlate periodontal bacterial co-occurrence and periodontal bacterial adhesion factor to the development of atherosclerosis.
Circulating oral bacteria and inflammatory mediators may also provoke a secondary systemic inflammatory response. This systemic inflammatory response has been implicated in contributing to, or complicating, those diseases and conditions that may have an inflammatory origin, such as atherosclerosis. Thus, while the goal of treatment of periodontal disease is to remove inflammation-causing oral bacteria, an added benefit is the reduction of related systemic inflammation and associated diseases and risk factors.
Stroke: Where do dental hygienists fit in?
Current guidelines from the American Dental Association indicate that initial treatment of periodontal disease should be scaling and root planing (SRP). For moderate periodontal disease, scaling and root planing has been combined with antimicrobial therapy. Since mechanical removal of plaque remains the primary means of controlling periodontal inflammation, dental hygienists will continue to have a dramatic impact on the overall health of their patients.
With stroke and its related conditions, dental hygienists must not only successfully manage poststroke patients to avoid complications during dental procedures, but they must also identify and manage those patients at high risk for stroke. Assessment of patient risk, including referral for medical consultation, is necessary in the determination of the patient’s suitability for elective dental procedures and the planning and timing of those procedures. Patients who have experienced a recent stroke, TIA, or RIND are at high risk for stroke or stroke recurrence and should not undergo elective dental procedures. Although this risk decreases after six months, it is always present.
Patients who take anticoagulants or antiplatelet agents are at risk for exaggerated bleeding. While assessment of the INR is helpful in determining the risk of bleeding for patients taking Coumadin, the INR is not available for patients taking the newer anticoagulants. If medical consultation reveals that the risk of exaggerated bleeding is significant, a reduction in dose rather than interruption of therapy should be considered to reduce the potential for life-threatening thrombosis. The use of metronidazole should be avoided in patients taking Coumadin, as this may result in decreased metabolism of Coumadin and potentiation of its anticoagulant effects. The use of acetaminophen instead of ibuprofen or other nonsteroidal anti-inflammatory agents (NSAIAs) for pain control may be warranted to reduce the risk of postsurgical bleeding.
My new patient and friend is doing well with no recurrences of her TIA. Ever since that busy Monday, however, I must admit that I have a tendency to keep one eye on my patients at all times.
THOMAS A. VIOLA,RPH, CCP, In addition to his daily practice of the profession of pharmacy, Thomas A. Viola, RPh, CCP, also serves the professions of dentistry, dental hygiene, and dental assisting as an educator, published writer, and professional speaker. As an educator, Viola is a member of the faculty of seven dental hygiene and dental assisting programs, as well as several national board exam review courses. Visit Viola’s website: www.tomviola.com.