Prepared by:Umar Ali

Stroke

University Of SulaimaniFaculty Of Medical

SciencesSchool Of Dentistry

Oral Diagnosis Department

2 How Serious Is Stroke in the US?

About 700,000 strokes occur each year. Over 167,000 deaths each year. #3 killer. A leading cause of serious long-term disability in adults. 4.7 million stroke survivors.

3 Introduction

New emerging therapies offer hope, however the following MUST occur: Education of at-risk patients. Early recognition of stroke signs. Prompt transport to the hospital. Rapid hospital triage and evaluation.

4 Definition of Stroke(CVA)

A stroke is a neurological impairment caused by a disruption in blood supply to a region of the brain.

Also called Cerebrovascular Accident (CVA)

5 Classification of Stroke

Two major categories:

Ischemic strokes, caused when a blood vessel supplying the brain is occluded by a clot. Responsible for 75% of all strokes.

Hemorrhagic strokes, caused when a cerebral artery ruptures.

Both forms are life threatening.

6

7

Hemorrhagic Stroke Hypertension is the most

common cause of intracerebral hemorrhage.

Other causes: Aneurysms and Arteriovenous

malformations.

8 Risk Factors for StrokeAlthough some strokes occur without warning, most stroke victims have prior risk factors.

Major strokes can be prevented in many cases, but only if early signs and symptoms are heeded.

9 Well-Documented

Modifiable Risk Factors

Hypertension Smoking Diabetes Asymptomatic

Carotid Stenosis

Atrial Fibrillation Hyperlipidemia Sickle Cell Disease Other cardiac

diseases

Goldstein et al. Circulation. 2001:103:163

10 Less Well Documented

Potentially Modifiable Risk Factors

Obesity

Physical Inactivity

Poor Diet/Nutrition

Alcohol Abuse

Drug Abuse

Hypercoagulability

Hormone Replacement Therapy

Oral Contraceptive Use

Inflammatory Process

Goldstein et al. Circulation. 2001:103:163

11 Non-modifiable Risk Factors

Age Sex Race/Ethnicity Family History

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Stroke Diagnosis

Signs and Symptoms of Stroke

13

Signs and Symptoms of Stroke

Consider in anyone who has:

Sudden numbness or weakness of face, arm, or leg, especially on one side of the body

Sudden confusion, trouble speaking or understanding

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Signs and Symptoms of Stroke

Sudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss of balance or coordination

Sudden severe headache with no known cause

15 Signs and Symptoms of Stroke

THIS IS A LIFE THREATENING EMERGENCY!

Emergency healthcare providers must: Recognize the importance of these symptoms. Respond quickly with medical and / or surgical interventions.

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Stroke Signs and Symptoms: Hemorrhagic Stroke

May present similar to Ischemic stroke.

Distinguishing Features: Appear more seriously ill Deteriorate more rapidly Severe headache Alteration in consciousness Nausea and/or vomiting Neck pain Intolerance of noise or light

17 Transient Ischemic Attack

“Temporary” or “mini” stroke.

The signs and symptoms of a TIA are similar to those of a completed stroke; however, they typically last only a few minutes to several hours before resolving.

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Transient Ischemic Attack

TIA is the most important forecaster of impending stroke.

MEDICAL MANAGEMENTPrevention

The first aspect of stroke management is prevention. This is accomplished by identifying risk factors inindividuals (e.g., hypertension, diabetes, atherosclerosis, cigarette smoking) and attempting to reduce or eliminate as many of these as possible.

Blood pressure lowering, antiplatelet therapy, and statin therapy are primary stroke prevention methods. Carotid endarterectomy is a secondary stroke prevention method.

The benefit of lowering blood pressure is evident in the fact that a reduction of systolic blood pressure by 10 mm Hg is associated with a one-third reduction in risk for stroke.

Aspirin, ticlopidine, and extendedrelease dipyridamole are accepted preventive therapies for ischemic stroke in patients who have experienced TIAs, or who have had a stroke.

Aspirin dosed at 81 to 325 mg daily reduces the risk of stroke by about 25% in this at-risk population. Similarly, statin therapy reduces risk by about 20%.

Also, surgical intervention through endarterectomy reduces the risk by about 1% per year, such that one stroke is prevented for every 20 patients who undergo surgery over a 5-year period

Stroke Treatment

If an individual has a stroke, treatment is generally threefold. The immediate task is to sustain life during the period immediately after the stroke. This is done by means of life support measures and transport to a hospital.

The second task involves emergency efforts to prevent further thrombosis or hemorrhage, andto attempt to lyse the clot in cases of thrombosis or embolism.

If the patient survives, the third and final task consists of institution of preventive therapy, administration of medications that reduce the risk of another stroke (statins and antihypertensive drugs), and initiation of rehabilitation.

Rehabilitation generally is accomplished by intense physical, occupational, and speechtherapy (if indicated). Although marked improvement is common, many patients are left with some degree of permanent deficit.

Dental Management of the Patient With Stroke1. Identify risk factors.a. Hypertension*b. Congestive heart failure*c. Diabetes mellitus*d. TIA or previous stroke*e. Increasing age ≥75 years*f. Elevated blood cholesterol or lipid levelsg. Coronary atherosclerosish. Cigarette smokingi. Note: Risk of stroke increases by a factor of 1.5 for each condition above indicatedby*. Thus, having multiple risk factors listed above greatly increases the risk of astroke. 2. Encourage control of risk factors (referral to physician, if appropriate).3. Obtain thorough history of stroke.a. Note date of event, current status, medical therapy, and any residual disabilities.b. Provide only urgent dental care during first 6 months after a stroke, TIA, or RIND.

c. Avoid elective care in patients who have had recent TIAs or RINDs.

d. Determine risk for bleeding problems in patients taking anticoagulant drugs, andminimize perioperative bleeding.

(1) Aspirin ± dipyridamole (Aggrenox), clopidogrel (Plavix), abciximab(ReoPro), or ticlopidine (Ticlid); obtain pretreatment PFA-100.

(2) Coumarin—Pretreatment INR ≤3.5. Higher levels require consultationwith physician to reduce dose.

(3) Heparin (IV)—Use palliative emergency dental care only, or 6 to 12 hoursbefore surgery, discontinue heparin and start another anticoagulant (e.g.,coumadin) with physician's approval. Then, restart heparin after clotforms (6 h later). Heparin (subcutaneous, low molecular weight)—generally, no changes required.

(4) Use measures that minimize hemorrhage (atraumatic surgery, pressure,gelfoam, suturing), as needed.

(5) Have available nonadrenergic hemostatic agents and devices (stents,electrocautery).

4. Schedule short, stress-free, midmorning appointments. Provide N2O-O2 inhalation asneeded.5. Monitor blood pressure and oxygen saturation.6. Use minimum amount of anesthetic containing vasoconstrictor.7. Avoid epinephrine in retraction cord.8. Recognize signs and symptoms of a stroke, provide emergency care, and activateemergency medical support system.9. A prior stroke may require assistance for patient transfer to the chair, effective oralevacuation and airway management, and rigorous oral hygiene measures delivered by ahealth care provider.

INR, International normalized ratio; IV, intravenous; PFA, platelet function analyzer; RIND, reversibleischemic neurologic deficits; TIA, transient ischemic attack.

Effective Communication Techniques for the Patient With Stroke• Face the patient.• Use a slower, more deliberate, less complex pattern of speech.• Communicate at eye level.• Be positive.• Ask yes/no questions—Be simple and brief.• Give frequent, accurate, and immediate feedback.• Use simple drawings to explain procedures.• Do not underestimate or overestimate abilities.• Do not raise voice or use baby talk.• Do not wear a mask when talking to the patient.• Communicate also with significant other/personal care provider.

Data from Henry R. Personal communication, 1995; and Ostuni E. Stroke and the dental patient. J AmDent Assoc 1994;125:721-727.

Technical modifications may be required for patients with residual physical deficits who have difficultypractice adequate oral hygiene. For these patients, extensive bridgework is not a good choice.

However,fixed prostheses may be more desirable than removable ones because of difficulties associated with daily placement and removal. Individualized treatment plans are important. All restorations should be placed with ease of cleansability in mind. Hygiene is often facilitated by an electric toothbrush, a large-handled toothbrush, or a water irrigation device. Flossing aids should be prescribed, and loved ones and personal care providers should be instructed on how and when these services should be provided. Frequent professional prophylaxis and the provision of topical fluoride and chlorhexidine are advisable.

Treatment Planning Modifications

Oral Complications and Manifestations A stroke-in-evolution may become apparent through slurred speech, a weak palate, or difficulty

swallowing. After a stroke, loss or difficulty in speech, unilateral paralysis of the orofacial musculature,

and loss of sensory stimuli of oral tissues may occur. The tongue may be flaccid, with multiple folds, and

may deviate on extrusion. Dysphagia is common, along with difficulty in managing liquids and solids.

Patients with right-sided brain damage may neglect the left side. Thus, food and debris may accumulate

around teeth, beneath the tongue, or in alveolar folds. Patients may need to learn to clean teeth or dentures with only one hand, or they may require assistance to maintain oral hygiene; otherwise,

caries,

periodontal disease, and halitosis occur commonly. Calcified atherosclerotic plaques have been demonstrated in the carotid arteries of elderly and

diabetic However, the exact causative relationship between periodontal disease and stroke remains to be

defined. Although periodontal treatment can reduce serum inflammatory markers potentially involved in

stroke,

THANK YOU!

Reference

1-Dental management of Medically compromised patients 2-American stroke association.