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Management of Patients with Chronic Diseases

Course Number: 567


A cerebrovascular accident due to a lack of blood flow to the brain. This causes a lack of oxygen and brain cells begin to die. This can result in death or disability. Clinical signs and symptoms of a stroke are listed in Figure 20. If the dental provider observes any of these signs and symptoms, it is critical to act fast. Treatment must be started within 3 hours of having a stroke to be effective.

Figure 20. Clinical Signs and Symptoms of a Stroke.99

  • A severe headache with unknown cause
  • Sudden numbness of the face, arm, or leg on one side of the body
  • Sudden confusion, trouble speaking, or difficulty understanding speech
  • Sudden trouble with vision in one or both eyes
  • Sudden trouble walking, dizziness, loss of balance, or loss of coordination

Epidemiology and Etiology

Stroke affects 795,000 people living in the United States.99 It is a primary or contributing cause in 1 out of 20 deaths.99 High blood pressure is the leading cause of strokes. Other risk factors include previous stroke or Transient Ischemic Attack (TIA), high cholesterol, heart disease, diabetes, and sickle cell disease. An unhealthy diet, lack of physical activity, obesity, too much alcohol, tobacco use, family history, age, gender, and race also increase a person’s risk for developing this condition. Figure 21 lists additional stroke statistics.

Figure 21. Stroke Statistics.59,99

  • After age 55 the chance of developing a stroke doubles every 10 years
  • Nearly 1 in every 4 strokes occur in people who have had a previous stroke
  • Pregnancy and birth control increase the risk of stroke in women
  • Blacks, Hispanics, American Indians, and Alaska Natives are at higher risk for having a stroke than non-Hispanic whites and Asians

Patient Management and Oral Health Considerations for Stroke

When providing care to patients who have had a stroke, dental providers should assess the patient’s risk for complications before providing any dental care. Items to consider include the timing of the stroke and type and magnitude of dental procedure."Super Script - 49" Patients who are have experienced a TIA or stroke within the last 6 months are unstable. Elective care should be postponed.49 A consultation with the patient’s physician is recommended. Patients who are taking Warfarin should report their international normalized ratio (INR). A therapeutic range is 3.5 or less. Metronidazole and tetracycline interact with warfarin which can increase the INR. Dental providers should avoid concurrent use of these drugs. Short stress-free appointments scheduled in the morning reduce the risk for complications. Dental providers should avoid placing a retraction cord impregnated with epinephrine.

Effective pain control during the procedure and post-operative will reduce stress and the risk for complications. Dental providers may administer nitrous oxide with oxygen. Local anesthesia should have a limited amount of vasoconstrictor (epinephrine). Patients can be safely given local anesthesia with epinephrine 1:100,000 or 1:200,000. The amount of vasoconstrictor should be ≤ 0.04 mg.

Oral manifestations associated with a stroke include unilateral paralysis of the face, loss of sensory stimuli or oral tissues, a flaccid tongue with multiple folds, and dysphagia. You may also notice that patients neglect oral self-care on one side of their mouth. This is associated with the brain damage that has occurred.49 Increased caries, periodontal disease, and halitosis is also common due to challenges with oral self-care. Dental providers should recommend rigorous preventive measures such as 3-month recall appointments and application of fluoride varnish.