The RDH & stroke awareness: Dental hygienists can participate in stroke prevention

By Elicia Lupoli, RDH, BSDH

May is National Stroke Awareness Month. We are in contact with people every single day, whether in our treatment rooms, in public health clinics, or even casual conversations in the community about oral health. We may be able to recognize the signs and symptoms a person may exhibit in the first few seconds of a stroke. Everyone we encounter can be a potential patient if an emergency arises, and every minute counts. We need to act F.A.S.T.

By acting F.A.S.T, dental hygienists should be ready to identify a stroke by checking for:

Face for signs of drooping
Body for Arm weakness
Listening for Speech difficulty
If yes, then Time to call 911

Following the 911 call, maintain the ABCs (Airway, Breathing, Circulation) of life support until help arrives.

What is a stroke?

According to the American Stroke Association (ASA) and the American Heart Association (AHA), the two types of strokes are ischemic and hemorrhagic.

Ischemic stroke has a number of subtypes, including a cryptogenic stroke, which is one that has "no definitive causes." This subtype of ischemic stroke will not be covered in this particular article due to ongoing research for the next two years through the Cryptogenic Stroke Initiative.

A transient ischemic attack (TIA) is not a true stroke and is often referred to as a mini stroke. The most agreed upon definition of a TIA does not include central nervous system infarction and is definitely a risk factor for a future stroke.

The ASA/AHA also categorize strokes into primary and secondary. Secondary means the patient has had a prior stroke.

As with most every condition, there are modifiable and nonmodifiable risk factors, and that's where dental hygienists come in-changing the modifiable risk factors.

Prevention

Patients come to us as smokers, overweight, and/or malnourished. Patients often present with undiagnosed conditions such as high blood pressure, diabetes mellitus, and/or obstructive sleep apnea.

Dental hygienists are in a position to intervene and start the process of assessment, education, and then referral every time the patient comes into our treatment room. Our profession is at the forefront to make a change and to collaborate with other health-care professionals.

Treatment of hypertension is possibly the most important intervention for secondary prevention of ischemic stroke, defined as greater or equal to 140/90mmHg.¹ If a patient has diabetes or chronic kidney disease, then their high blood pressure is defined as 130/80 mmHg or higher.² Taking a patient's blood pressure is simple, quick, and can be a lifesaver.

Low birth weight has been associated in several populations with risk of a stroke in later life.³ Patients born with a low birth weight may always have a higher risk for a stroke, even in absence of other risk factors. Dental hygienists who are educating patients about the effects of smoking and periodontal disease can also include the potential correlation of low birth weight and strokes.

ASA/AHA produces guidelines for health-care professionals from evidence-based research and updates these suggestions every two to three years for stroke prevention strategies. In May 2014, these guidelines were updated and now include obstructive sleep apnea as a risk factor for recurrent (secondary) strokes. You can view a helpful table about these guidelines at stroke.ahajournals.org.¹

Pharmacology

During health history verification, we commonly see listed medications that many of us may not recognize. No states currently require pharmacology updates for continuing education for dental hygienists. Pharmacologic therapies are constantly changing with research and successful clinical trials. We may feel overwhelmed by trying to stay abreast of the emerging medications that arise frequently. (As a side note, dental hygienists can subscribe to FDA.org for a drug approval list to receive by email.)

Anticoagulants and antiplatelets are particularly relevant for the dental profession. Patients who have had an ischemic stroke, TIA, or are at a high risk for a stroke due to another medical condition are typically on an anticoagulant, antiplatelet, or combination therapy. Traditionally, Coumadin/Jantoven (warfarin) has been the most commonly seen anticoagulant in dentistry, and Plavix (clopidogrel) and aspirin are the most common antiplatelet agents.

With periodontal therapy, soft tissue lasers, prophylaxis, and "incidental" soft-tissue curettage, excessive bleeding can compromise treatment in a number of ways. How many of us ask our patients who are on warfarin if they know what their international normalized ratio (INR) is? Do we know why we are asking, or what the number means? What is "normal" for that patient? How many patients even know what their INR is? Who remembers why this number is important to the dental hygienist anyway?

We are their treatment providers and should have a general understanding of what is going on with patients while in our care. The simplest explanation is that normal for a healthy person is 1.0 on the INR scale. The higher the number on the INR scale, the more likely the bleeding and less likely the clotting. For example, for patients on long-term warfarin therapy for conditions such as nonvalvular atrial fibrillation (NVAF), the therapeutic target ranges may be 2.0-3.0.4 If your patient tells you his INR is >5, and he is elderly, please do not let him leave your building unassisted.

Patients routinely have their blood drawn to obtain their INR for many reasons. For example, if a patient were to start an antibiotic, antifungal, or corticosteroid, the INR may need to be rechecked. If a patient were to have jaw soreness in our chair and requested ibuprofen, that could increase their bleeding risk and send their INR up. Beware of recommending botanicals such as COQ10, which can decrease the effects of Coumadin, or ginkgo biloba, which can increase the effects.

Within the past few years, new medications have entered the health-care field that are referred to as novel oral anticoagulants (NOACs)6 or a few other names depending on author and association. Many of these pharmacological therapies have gained popularity among patients and some physicians due to a few advantages, including fewer food and drug interactions, faster onset, and a broader therapeutic window.⁶ Patients no longer have to go to facilities and have lab work completed frequently and repeatedly, or worry about major lifestyle changes as much as before when their only option was anticoagulant therapy with vitamin K antagonists (VKAs) such as warfarin.

The dental prescriber should always discuss with the patient’s pharmacist when a prescription is necessary for patients on anticoagulant therapy, including the NOACs, for potential drug interactions. Additionally, no NSAIDS or aspirin should be dispensed in office to any patient on blood thinners.

Table 1 discusses the four most recent Food and Drug Administration (FDA) approved NOACs.

Table 1

Recently approved NOACs

1. Pradaxa (dabigatran etexilate mesylate)

FDA approved in October 2010 and is a direct thrombin inhibitor. Pradaxa was the first NOAC on the market and is currently the only NOAC to have a reversal agent. The reversal agent is idarucizumab and was FDA approved in October 2015.

Pradaxa has a half-life of about 12 to 17 hours and is eliminated in the kidneys.

Used to:

reduce the risk of stroke and SE in patients with NVAF
treat DVT or PE and reduce the risk of reoccurrence
prevent DVT and PE in patients who have just had hip replacement surgery

2. Xarelto (rivaroxaban)

FDA approved in July 2011 and is a factor Xa inhibitor. No known reversal agent. Half-life is 6 to 9 hours for individuals who are healthy and 20-45 years of age and 11-13 hours average in the elderly. Eliminated through kidneys.

Used to:

reduce the risk of stroke and SE in patients with NVAF
treat DVT or PE and reduce the risk of reoccurrence
prevent DVT and PE in patients who have just had knee or hip replacement surgery

3. Eliquis (apixaban)

FDA approved in December 2012 and is also a factor Xa inhibitor with no current reversal agent. Half-life is approximately 12 hours. Eliminated through kidneys.

Used to:

reduce the risk of stroke and SE in patients with NVAF
reduce the risk of developing DVT or PE in patients who have just had knee or hip replacement surgery
treat DVT or PE and to reduce the risk of reoccurrence

4. Savaysa (edoxaban tosylate)

FDA approved in January 2015 and is the newest and most recent factor Xa inhibiting drug. Half-life is approximately 10-15 hours. Eliminated through kidneys.

Used to:

reduce the risk of strokes and SE in patients with NVAF
treat DVT or PE following 5 to 10 days of initial therapy with parental anticoagulants

There is a limitation for use with this medication compared to the others with treatment of NVAF patients with a certain creatine clearance (relates to kidney function).

The evidence suggests these four NOACs are not to be used in patients with prosthetic (metal or plastic) heart valves.^5,7

Visit the Food and Drug Administration website for full labeling information.

Medical history

As part of a dental health-care team, collaboration with all of the patient’s treatment providers should be discussed ahead of time, and that starts with our initial assessment—the medical history. Please make sure to review that document thoroughly at every visit. A stroke patient may often be accompanied by a personal caregiver; however, it is ultimately the patient’s immediate family member that has power of attorney or is the conservator of health care whom we should contact for accurate and pertinent medical information outside of other practitioners.

Patients often do not know what medications, botanicals, or vitamins they are taking daily, and some patients do not think it is relevant for the dental hygienist to know. If your patient has had a stroke or is on a medication that fits into this category, you may need to consult with their physician to discuss the treatment you and your dentist recommend. There may be a protocol for anticoagulants to be temporarily discontinued before elective surgery or invasive procedures, where excessive bleeding is a risk. Two online charts can be helpful:^8,9

Collaborate with the patient’s prescribing physician and ask for their office to e-mail/fax over recommendations for your office to have documented.

Time is always a factor, especially in private practice and community health settings. It is not uncommon for us to look at a medical history, scan for the familiar “blood thinner” or medication suffix and, if it is not there, assume patients are not taking any of these drugs. One example of why these drugs are important to us is the patients we see who have bruising on their hands and arms; is it from the medication they are on, or something more serious such as a clotting disorder or abuse? The patient may come to our practice four times a year and visit their physician only when needed. It is up to the dental hygienist to assess and refer at all times when a patient is in our presence.

Our profession is not just about teeth. We can save lives as well as teeth every single day. For more information about strokes for the professional, please visit the American Stroke Association at: www.strokeassociation.org and click on “professionals” for an array of resources. RDH

Elicia Lupoli, RDH, BSDH, graduated from University of Bridgeport, Fones School of Dental Hygiene, in 2002. In 2012, she went back to Fones to complete her bachelor’s degree in dental hygiene. She advocates for whole-body health in all her endeavors. Elicia is a CareerFusion 2016 member and credits the start of her professional writing to Shirley Gutkowski, RDH, BSDH, for inspiration and continuous mentoring. She can be reached at [email protected].

References

1. Kernan WN, Ovbiagele B, Black HR, et al., on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Peripheral Vascular Disease. Stroke. A Guideline for Healthcare Professionals from the American Heart Association/American Stroke Association. 2014;45:2160-2236. doi:10.1161/STR.0000000000000024.
2. U.S. Department of Health and Human Services, National Heart, Lung, and Blood Institute. Who is at risk for a stroke? 2015. doi:nhlbi.nih.gov/health/health-topics/topics/stroke/at risk
3. Meschia JF, Bushnell C, Boden-Albala B, et al., on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, Council on Functional Genomics and Translational Biology, and Council on Hypertension. Stroke. Guidelines for the Primary Prevention of Stroke: A Statement for Healthcare Professionals from the American Heart Association/American Stroke Association. 2014. doi:10.1161/STR.0000000000000046.

4. Nelson WW, Wang L, Baser O, Damaraju CV, Schein JR. Out-of-range INR values and outcomes among new warfarin patients with non-valvular atrial fibrillation. International Journal of Clinical Pharmacy. 2015;37:53-59. doi:10.1007/s11096-014-0038-3.
5. Molteni M, Friz HP, Primitz L, Marano G, Boracchi P, Cimminiello C. The definition of valvular and non-valvular atrial fibrillation: results of a physicians’ survey. Europace. 2014;16(12):1720-1725. doi: 10.1093/europace/euu178.
6. Yates SW. Novel oral anticoagulants for stroke prevention in atrial fibrillation: a focus on the older patient. International Journal of General Medicine. 2013;6:167-180. doi:10.2147/IJGM.S39379.
7. U.S. Department of Health and Human Services, Food and Drug Administration. FDA Approved Drugs Products.doi:http://www.accessdata.fda.gov/scripts/cder/drugsatfda/

8. Costantinides F, Rizzo R, Pascazio L, Maglione M. Managing patients taking novel oral anticoagulants (NOAs) in dentistry: a discussion paper on clinical implications. BMC Oral Health. 2016;16:5. doi:10.1186/s12903-016-0170-7.
9. Heidbuchel H, Verhamme P, Alings M, Antz M, Hacke W, Oldgren J, Sinnaeve P, Camm JA, Kirchhof P. European Heart Rhythm Association Practical Guide on the use of new oral anticoagulants in patients with non-valvular atrial fibrillation. Europace. 2013;15:5,625-651. doi:10.1093/europace/eut083.