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Hereditary Angioedema in Older Adults and Considerations
for Dental Treatment
:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::
Angioedema hereditario en adultos mayores y consideraciones
para el tratamiento dental
Abstract:
Introduction:
Hereditary angioedema (HAE) is a rare inherited disease characterized
by recurrent episodes of non-pruritic, non-pitting edema in cutaneous or
submucosal tissues. This clinical syndrome is distinguished by a rapid increase
in vascular permeability of the affected tissues, not caused by allergic reactions
as in common cases of edema. Most research focuses on diagnosing young
individuals, but few publications address the topic in the eld of geriatrics, and
even fewer in dentistry.
Objective:
To analyze the clinical and dental implications of hereditary angioedema
(HAE) in older adult patients in order to establish recommendations for their
comprehensive care in geriatric dentistry.
Methodology:
A narrative review with a structured search was conducted, following the
principles of the PRISMA 2020 guidelines, including 28 scientic sources published
between 2010 and 2025. Due to the lack of studies addressing hereditary
angioedema, aging, and dentistry simultaneously, we selected publications
relevant to the pathophysiology and pharmacologic management of HAE, clinical
and pharmacological considerations in older adults, and dental implications
including potential drug interactions. The evidence was integrated to propose a
clinical framework applicable to the dental care of geriatric patients with HAE.
Results:
Multiple clinical and systemic factors were identied that must be considered
in the dental care of older adults with HAE, including the risks associated with
invasive procedures, pharmacological interactions, and oral side effects related to
treatment.
Conclusions:
Dental management of patients with HAE is already complex on its own, and when
combined with age-related changes, the patient becomes extremely complex.
Key aspects must be considered, such as the history of attacks, their triggers and
López Torres, A.C., Castro Mora, S. (2025) Hereditary Angioedema in Older Adults and Considerations for Dental Treatment. Odontología Vital, 2(43) 3-17. https://doi.org/10.59334/ROV.v1i44.682
Article info
Recibido: 2025-07-18
Revisado: 2025-10-06
Aceptado: 2025-10-08
Keywords:
Hereditary angioedema
Older adult
Elderly
Dentistry
Geriatric dentistry
a. DDS. Residente Posgrado de
Odontogeriatría, Esp. Estomatología
de Pacientes Especiales, Docente,
Universidad Latina de Costa Rica,
San José, Costa Rica
b. Msc. Medicina y Patología Bucal y
Maxilofacia, Director Académico,
Universidad Latina de Costa Rica,
San José, Costa Rica
López-Torres, A.C.a, Castro-Mora, S.b
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consequences, comorbidities, polypharmacy and its side effects, drug interactions, loss of physical and intellectual function,
and the economic investment in the patient’s health.
Introduction
Hereditary angioedema (HAE) is a rare chronic
autosomal dominant inherited disease, with
an estimated prevalence of 1 in 50,000 people.
However, it is reported that 25% of affected
individuals have no family history (Betschel et al.,
2019). It is characterized by recurrent episodes of
non-pruritic, non-pitting edema in cutaneous or
submucosal tissues.
It most commonly affects the skin, upper
airways, gastrointestinal tract, urogenital region,
and face (Longhurst & Valerieva, 2023; Maurer
et al., 2022; Sarkar et al., 2023). This clinical
syndrome is distinguished by a rapid increase
in vascular permeability of the affected tissues,
not caused by allergic reactions as in typical
histamine-mediated edema.
HAE specically depends on bradykinin, which
is why the use of drugs such as epinephrine,
antihistamines, or corticosteroid therapies does
not relieve the symptoms and causes delays
in crisis and emergency management (Alfaro-
Murillo et al., 2020; Rodrigues et al., 2013; Sarkar
et al., 2023).
In 2021, the World Allergy Organization (WAO)
and the European Academy of Allergy and
Clinical Immunology (EAACI) conducted
a review and update of the international
guidelines for the diagnosis and treatment of
HAE. The panel consisted of scientists, patients,
patient advocates, and medical experts in HAE
from different regions of the world. This expert
panel had specializations in various medical
elds; however, dentistry and geriatrics were not
mentioned.
These organizations acknowledge that the
current evidence is limited for making treatment
decisions and that access to diagnostic testing
and modern therapies for these patients is
highly restricted in several countries (Maurer
et al., 2022).
HAE can be caused by a deciency (type I) or
dysfunction (type II) of C1 inhibitors (C1-INH),
resulting in excessive production of bradykinin
and activation of B2 receptors. In the year 2000,
a type of HAE was described without alteration
in C1-INH levels, predominantly in females.
This form is known as type III HAE or estrogen-
dependent HAE, and episodes may occur in
the presence of elevated estrogen levels (oral
contraceptives, hormone replacement therapy,
and pregnancy).
Unlike types I and II, type III does not show
decreased levels or dysfunction of C1-INH
(Morimoto et al., 2020), and its symptoms
tend to present during adulthood or old age
(Rodrigues et al., 2013).
Eight types of HAE have been identied, and
there are also patients with this disease who
have unknown mutations (López, 2021; Maurer
et al., 2022), which is why this article addresses
the topic in a general sense.
The onset of HAE (except for type III) does not
favor any particular sex and may begin at any
age. The frequency, intensity, triggers, and
affected body regions of episodes may vary.
Literature indicates that episodes can last 2 to 5
days and occur every one to two weeks. Triggers
are diverse and sometimes unclear.
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They include mild accidental physical trauma
or trauma from medical and dental procedures,
emotional factors (such as anxiety and fear),
physical stressors (such as exercise), and others
(Jean-Baptiste et al., 2022; Kuhlen & Banerji, 2015;
Sarkar et al., 2023; Sinnathamby et al., 2023), all
of which signicantly impact the quality of life of
these patients.
Most studies focus on diagnosing young
individuals; however, few publications address
the topic within the eld of geriatrics, and even
fewer within dentistry.
Therefore, this article aims to highlight the
importance of dentists being familiar with
HAE, while also recognizing that older adults
present unique challenges due to the aging
process, requiring special care during this
stage, in addition to the presence of potential
comorbidities and HAE.
The geriatric dentist must be aware of this
condition, as although the disease itself is rare,
documented cases from the perspective of
therapeutic dental management in older adults
are even rarer.
Patients may have lived with HAE for many
years or may be experiencing the onset of
the condition during old age (type III HAE). The
absence of literature addressing hereditary
angioedema (HAE), aging, and dentistry
simultaneously motivated the development
of this narrative review, whose objective is
to integrate the best available evidence in
each axis and propose a clinical framework
applicable to dental practice.
Methodology
A narrative review with a structured search was
conducted, inspired by the principles of the
PRISMA 2020 guidelines, to ensure transparency
and reproducibility in the process of identifying
and selecting the literature.
The bibliographic search was carried out
between 2010 and 2025 in the databases
PubMed, ScienceDirect, SciELO, and Google
Scholar, as well as in clinical guidelines and
institutional documents from international
organizations (WHO, WAO/EAACI).
Combinations of MeSH descriptors and free-
text terms were used, such as: (“Hereditary
Angioedema” OR “C1-INH deciency” OR
“bradykinin-mediated angioedema”)
AND (“Aged” OR “older adults” OR “geriatric”) AND
(“Dentistry” OR “Oral health” OR “Dental care” OR
“Dental procedures”)
The specic search did not identify studies
addressing hereditary angioedema, aging,
and dental care simultaneously. In view of this
absence, the strategy was expanded to include
three complementary axes of evidence:
• Pathophysiology and pharmacologic
management of hereditary angioedema.
• Clinical characteristics, comorbidities, and
polypharmacy in older adults.
• Drug interactions and dental considerations
relevant to patients with HAE.
Original articles, case reports, reviews, clinical
guidelines, and institutional documents
published in English or Spanish between 2010
and 2025 that provided information relevant to
at least one of these three axes were included.
Studies in animals or in vitro, publications
without full-text access, and articles published
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prior to 2010 (except for essential references on
HAE pathophysiology) were excluded.
The search identied a total of 82 records. After
removing duplicates (n = 21) and screening titles
and abstracts, 33 were excluded for not meeting
the thematic criteria. Finally, 28 publications
were assessed in full text and included in the
narrative synthesis.
The results were organized into a thematic table
(Table 1) summarizing the ndings according to
the three dened axes.
Due to the heterogeneity of study designs
(guidelines, reviews, case reports, multicenter
surveys), no quantitative risk-of-bias scales
were applied. Instead, a critical appraisal of the
clinical relevance, currency, and applicability of
each source was performed.
Table 1. Publications Included in the Narrative Synthesis
Author / Year Type of Study /
Document
Population or
Context
Thematic
Axis 1=HAE &
pharmacotherapy;
2=Geriatric
aspects;
3=Dental/Oral
considerations
Relevance to Geriatric Dental Care for
HAE
Alfaro-Murillo et
al., 2020
National
descriptive study
Patients with HAE
in Costa Rica
1 Provides epidemiological background
and highlights challenges in diagnosis
and access to treatment
Betschel et al.,
2019
International
guideline
HAE in all age
groups
1 Comprehensive recommendations for
diagnosis and treatment
Maurer et al., 2022 WAO/EAACI
guideline
HAE across all
age groups
1 Current reference for acute
management and prophylaxis
Baptist et al., 2024 Multicenter
survey
Older adults with
HAE
1 & 2 Describes impact on quality of life,
anxiety, and barriers to medical care
Singh et al., 2020 Multicenter
survey
HAE patients
with dental
experiences
1 & 3 Demonstrates association between oral
hygiene/procedures and HAE attacks
Morimoto et al.,
2020
Case report Adult with type III
HAE undergoing
tooth extraction
1 & 3 Highlights perioperative dental
management under IV sedation
Forrest et al., 2017 Case report HAE patient
with fatal
post-extraction
laryngeal attack
1 & 3 Emphasizes procedural risk and need for
preventive measures
Kuhlen & Banerji,
2015
Clinical review Special
populations:
children, women,
older adults
1 & 2 Discusses pharmacologic considerations
in vulnerable groups
Diaz-Menindez et
al., 2023
Therapeutic
review
Berotralstat oral
therapy
1 Relevant for drug–drug interaction
considerations in dental care
Reshef et al., 2025 Phase-3 clinical
trial
Garadacimab for
HAE prophylaxis
1 Emerging therapy improving procedural
safety
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Riedl et al., 2024 Clinical trial Donidalorsen for
HAE prophylaxis
1 Monthly subcutaneous treatment
relevant for long-term management
Canio, 2022 Review Polypharmacy in
older adults
2 Highlights interaction risks with
commonly used dental medications
Burghardt et al.,
2018
Systematic
review
Non-
pharmacologic
interventions for
dental anxiety
2 & 3 Provides evidence-based strategies to
reduce stress-induced HAE attacks
Fuentes et al., 2021 Technical article Panoramic
radiography
3 Non-invasive imaging valuable for
geriatric patients at risk of HAE attacks
Tirado et al., 2015 Technical article Safe use of dental
radiography
3 Addresses diagnostic imaging safety
and minimal invasiveness
WHO, 2022 Institutional
report
Global older-
adult population
2 Frames general needs and barriers in
geriatric healthcare
Kaplan & Joseph,
2017
Review Bradykinin-
mediated
mechanisms in
HAE
1 Provides pathophysiological foundation
relevant to procedural risk
López, 2021 Review Pathogenesis of
HAE
1 Supports understanding of clinical
course and therapeutic targets
Sarkar et al., 2023 Clinical review Diagnostic
challenges in HAE
1 & 2 Highlights delayed diagnosis and
psychosocial consequences
Jean-Baptiste et
al., 2022
Review + clinician
interviews
Patient
experience in HAE
1 & 2 Adds psychosocial insights applicable to
dentist-patient communication
Perego et al., 2020 National cohort Italian patients
with HAE
1 & 2 Shows improved life expectancy due to
modern therapies
HAEi, 2025 Scientic
communication
Development of
deucrictibant for
HAE
1 Highlights future perspectives for
preventive therapy
Adatia & Magerl,
2024
Practical guide Use of
berotralstat for
C1-INH deciency
1 Provides clinical safety considerations for
chronic use
Medications for
HAE, 2024 (Drugs.
com)
Drug reference Approved HAE
therapies
1 & 3 Identies potential interactions with
common antibiotics and analgesics in
dental care
Rodrigues et al.,
2013
Case series Estrogen-
dependent type
III HAE
1 Relevant for late-onset cases, often
diagnosed in adult or older patients
Longhurst &
Valerieva, 2023
Review of RCTs Long-term C1-INH
prophylaxis
1Demonstrates efcacy in attack control
facilitating safer dental procedures
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Pathophysiology of HAE
Hereditary angioedema attacks (HAEA) occur
due to a fundamental reaction triggered by the
complement system, the coagulation system,
and/or the brinolytic system, resulting in the
loss of natural control of the kallikrein–kinin
system and leading to the excessive production
of the protein bradykinin.
The increase in bradykinin makes blood vessels
more permeable, causing plasma to leak into
surrounding tissues and resulting in edema
(Kaplan & Joseph, 2017).
The complement system (CS) encompasses
three distinct signaling pathways: the classical
pathway, the lectin pathway, and the alternative
pathway. The symptoms of hereditary
angioedema are primarily inuenced by the rst
two signaling pathways.
The classical pathway involves a set of
complement factors labeled C1 through C9,
along with their respective regulatory proteins.
Among these regulatory proteins is C1-INH, which
has a dual function: suppressing the activation
of complement factor C1 and broadly inhibiting
various activation processes.
The absence of C1-INH in the CS results in
excessive production of the kallikrein/HMWK
(high-molecular-weight kininogen) enzymatic
complex, which leads to an overproduction
of the protein bradykinin. Excessive levels of
bradykinin trigger systemic inammatory
responses due to the separation of cells in the
walls of small blood vessels.
This opening of intercellular junctions allows
plasma to leak into surrounding tissues, resulting
in uncomfortable swelling (edema).
Another way to activate the CS is through
the lectin pathway, specically via mannose-
binding lectins, which play a role in the
degradation of complement factor C4. Various
factors such as tissue damage caused by
accidents or surgery, stress, infections, and
autoimmunity can activate both the classical
and lectin pathways (Kaplan & Joseph, 2017;
López, 2021; Sarkar et al., 2023; Sinnathamby
et al., 2023).
The coagulation system also plays a role
in increasing bradykinin activity. The C1-INH
protein, which regulates specic aspects of the
coagulation system, prevents the conversion of
coagulation factor XII into factor XIIa, which in
turn becomes FXIIf (fragmented factor XII) and
stimulates the activation of complement factor
C1 in the absence of antibodies.
Deciency of C1-INH leads to elevated levels of
the kallikrein/HMWK complex (Kaplan & Joseph,
2017; López, 2021; Maurer et al., 2022; Sarkar et al.,
2023; Sinnathamby et al., 2023).
Furthermore, the increased presence of the
kallikrein/HMWK complex results in elevated
production of circulating plasmin, which
subsequently causes a further increase in
bradykinin levels.
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HAE Attacks
HAE attacks (HAEA) follow an unpredictable
course that can be debilitating and potentially
life-threatening for the patient. A wide variability
in symptoms has been observed, which may
differ between patients and even between
episodes in the same individual (Jean-Baptiste
et al., 2022; Longhurst & Valerieva, 2023).
Episodes can be isolated or occur in rapid
succession, leading to a reduced quality of
life, not only due to the attack itself but also
because of the constant fear and anxiety about
their next occurrence, the need to avoid triggers,
and the development of comorbidities such as
anxiety and depression (Jean-Baptiste et al.,
2022; Maurer et al., 2022).
Patients typically present with a wide range of
symptoms that may manifest in different parts
of the body. The most commonly reported
include swelling, fatigue, pain, stomach ache,
nausea, vomiting, headache, restlessness, mood
changes, and psychological issues such as
depression, sadness, and anxiety (Alfaro-Murillo
et al., 2020; Longhurst & Valerieva, 2023).
Research has focused on reducing morbidity
and preventing mortality in these patients in
an effort to improve their quality of life (Jean-
Baptiste et al., 2022).
The most frequently affected areas are the
extremities and the gastrointestinal tract.
Cutaneous attacks are not considered high-risk
for complications or death, but they do cause
signicant lifestyle disturbances in terms of work,
Complement
system
CoagulationFibrinolysis
Classical pathway
FXII Prekallikrein
+HMWK EDEMA
BRADYKININ B2 Receptor on
vascular epithelial
cells
C1-INH
Permeability
Kallikrein
+HMWK
PlasminPlasminogen
FXIIa FXIIf
C1 C1a C5-C9
MASP 1
Lectins
MASP 2
C3C2+C4
Consumption of
Figure 1. Pathophysiology of HAE
C1-INH: C1 inhibitors; HMWK: high-molecular-weight kininogen
Prepared by the authors.
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aesthetics, and function. This leads to periods of
social withdrawal (from school, work, etc.) due
to the inability to drive, walk, or embarrassment
from facial disgurement (Banerji et al., 2018;
Baptist et al., 2024; Maurer et al., 2022; Sarkar
et al., 2023), as attacks typically last between 2
to 5 days.
Laryngeal and lingual attacks are less common
but are considered medical emergencies,
requiring rapid administration of acute attack
treatments, in addition to airway management.
In some cases, intubation is necessary since
respiratory compromise can be fatal. It has
been reported that 33% of mortality in these
patients is due to edema in the upper airways
(3,4).
It is well documented that accidental or surgical
trauma—such as medical procedures, dental
surgery, and other interventions—can trigger
attacks in the upper airway region. In these
cases, angioedema usually appears within the
rst 48 hours. Other factors that may induce
attacks include fatigue, psychological stress,
febrile illnesses, and hormonal changes (Forrest
et al., 2017; Maurer et al., 2022; Sarkar et al., 2023).
Some patients report prodromal symptoms
that allow them to be prepared and administer
the necessary medication before the onset
of an attack. These symptoms have not been
precisely dened, and their lack of specicity
may lead to overuse of on-demand therapy
(Maurer et al., 2022).
Despite these HAEA manifestations, it is
important to note that the life expectancy of
these patients is currently similar to that of the
general population. Modern treatments have
allowed this population to reach old age, where
the cause of death is now more commonly
related to other diseases (mainly neoplastic and
cardiovascular) rather than laryngeal edema, as
was previously reported (Perego et al., 2020).
Pharmacological Treatment of HAE
Over the past 10 to 15 years, treatment
options have changed dramatically, with the
development of therapies for both acute events
and long-term prevention.
Older adults with HAE have lived with the disease
for decades, during a time when knowledge
about the condition was limited and treatment
options were scarce. First-line treatments in the
past were different, including tranexamic acid
(an antibrinolytic) and androgens such as
danazol.
These treatments offered very limited benets
and had numerous side effects (Banerji et al.,
2018; Baptist et al., 2024; Maurer et al., 2022;
Sarkar et al., 2023).
Modern therapies have signicantly reduced
the frequency of attacks, thereby improving
patients’ quality of life (3). Agents used in
the management of HAE include C1 inhibitors
(C1-INH), ecallantide, icatibant, danazol,
lanadelumab, berotralstat, and fresh frozen
plasma (Sarkar et al., 2023). These treatments
are designed for self-administration, with prior
training provided by healthcare professionals
(Sinnathamby et al., 2023).
These medications are categorized into two
types: (i) drugs for acute attacks and (ii)
prophylactic drugs used to prevent episodes.
In the rst category, intravenous C1-INH,
ecallantide, and icatibant are commonly used
(Longhurst & Valerieva, 2023; Maurer et al., 2022;
Medications for Hereditary Angioedema, 2024;
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Sinnathamby et al., 2023); they are essential
at the onset of an attack and help reduce
the symptoms and duration of HAE episodes,
regardless of severity. It is crucial to administer
them as early as possible, since delayed
administration is less effective (Diaz-Menindez
et al., 2023; Maurer et al., 2022).
Recently, the FDA approved garadacimab,
under the commercial name Andembry, the
rst monoclonal antibody that inhibits FXIIa to
prevent HAE attacks, demonstrating a signicant
reduction in HAEA episodes (Reshef et al., 2025).
Donidalorsen, an antisense oligonucleotide
that reduces hepatic prekallikrein production, is
currently pending FDA approval.
It has shown efcacy in HAE prophylaxis, with a
favorable safety prole and good tolerability,
positioning it as a promising therapeutic option
for monthly subcutaneous administration in HAE
patients (Riedl et al., 2024). Another emerging
drug is deucrictibant, a potential treatment
currently undergoing clinical trials (HAE
Internacional (HAEi), 2025).
Medications for HAEA and Dentistry
Most of the drugs used to manage HAEA do not
interact with medications commonly used in
dentistry. Berotralstat is the only drug reported
to have interactions that dentists should be
cautious about (Diaz-Menindez et al., 2023;
European Medicines Agency, 2021; Longhurst &
Valerieva, 2023; Maurer et al., 2022).
The use of this drug in combination with
antibiotics (azithromycin, clarithromycin,
erythromycin) and antifungals (itraconazole,
ketoconazole) increases plasma levels of
berotralstat, raising the risk and severity
of side effects. When combined with
benzodiazepines (alprazolam, clonazepam,
midazolam), corticosteroids (betamethasone,
dexamethasone, prednisone), opioids (codeine,
hydrocodone, morphine, oxycodone), H1
receptor antagonists (chlorpheniramine), or
anti-inammatory and immunosuppressive
agents (deazacort), it can elevate blood levels
of these drugs, which may intensify their side
effects—such as reduced immune function,
respiratory depression, deep sedation, liver
damage, among others (Adatia & Magerl, 2024;
European Medicines Agency, 2021; Medications
for Hereditary Angioedema, 2024).
Dental Care for Older Adults with HAE
Aging is the process through which individuals
undergo morphological and physiological
changes over time, accompanied by the
accumulation of various cellular and molecular
damage that gradually and individually leads
to a decline in physical and psychological
capacities, with an increased risk of developing
multiple diseases (Envejecimiento y salud, 2022).
Patients who have lived with HAE now face the
challenges of aging alongside the condition
they have suffered from for decades. A lack
of awareness about HAE during early life led
many to receive treatments and therapies that
resulted in adverse effects on their physical and
emotional health (Baptist et al., 2024).
It is well documented that physical trauma,
such as dental surgery, can trigger HAEA
(Maurer et al., 2022), and for this reason, invasive
treatments should be avoided. In some cases,
however, such procedures are unavoidable
and must be approached with several
precautions. It is essential to work within a
multidisciplinary framework, where the geriatric
dentist communicates with the primary care
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physician—through consultation—regarding
the necessity, complexity, and severity of any
planned invasive procedures. This allows for the
joint development of an action plan, including
prophylactic therapy before, during, and after
treatment.
More than one-third of patients undergoing
tooth extractions without prior prophylaxis
develop HAEAs, which may begin within 10 to 24
hours after the procedure (Maurer et al., 2022;
Morimoto et al., 2020).
Due to comorbidities, patients often struggle
to determine whether the symptoms they
experience are related to HAE or to another
condition, which can lead to overmedication
(Sarkar et al., 2023).
With the emergence of new illnesses,
polypharmacy becomes a concern, increasing
the risk of adverse health effects, drug
interactions, and medical costs. A higher
number of medications raises the likelihood of
unpredictable physiological responses in older
adult patients (OAPs) (Canio, 2022).
Many drugs commonly used to treat diseases
in the elderly have oral side effects, the most
common being hyposalivation and xerostomia,
which increase the risk of oral infections, dental
caries, and periodontal disease.
Vomiting is a frequent side effect of HAEA
medications and, depending on its severity and
frequency, may cause damage to both hard
and soft oral tissues, such as dental erosion.
Another signicant side effect is coagulation
alteration, which can complicate unavoidable
invasive dental procedures (Longhurst &
Valerieva, 2023).
It is also important to recognize that aging
is often accompanied by reduced access to
healthcare services due to economic issues
(such as loss of employment), decreased
physical capacities, or the HAEA itself, which may
cause lower limb edema, impairing mobility and
the ability to travel.
HAEAs have emotional consequences, including
anxiety, depression, and stress, which in turn can
trigger further HAEAs.
Many of these emotional issues are tied to past
experiences of receiving unnecessary medical
treatments due to a lack of awareness among
healthcare professionals about HAE and the
delayed diagnosis of the disease (Sarkar et al.,
2023). Many patients fear medical and dental
procedures because, throughout their lives,
they were misdiagnosed, and their pain and
inammation were improperly treated.
It is necessary to create a comfortable
environment for the patient, where they
feel at ease with the professional team
and the procedure itself, ensuring that
both pain and anxiety are controlled.
Multiple non-pharmacological techniques
can assist in managing patient behavior,
including desensitization, modeling, positive
reinforcement, music therapy, aromatherapy,
and clinical hypnosis, among others (Burghardt
et al., 2018).
In dental care, the professional who should
lead the treatment of OAPs is the geriatric
dentist, who is trained to manage age-
related conditions and knowledgeable in the
pathophysiology of diseases such as HAE.
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Prevention and Promotion of Oral
Health in Older Adult Patients with HAE
Once invasive dental treatments have been
completed, it is necessary to develop a
preventive care plan to follow in the subsequent
years. Literature shows that patients with chronic
illnesses often neglect the needs of their oral
cavity, which again calls for an interdisciplinary
approach to promote the importance of
maintaining adequate oral health.
In cases of HAEAs affecting the hands,
performing oral hygiene maneuvers can
become difcult.
Providing alternatives such as modied
toothbrush handles (thicker grips), electric
toothbrushes, mouth rinses, waterpicks, among
others, offers patients the tools to continue
preventing oral diseases. When these options
are not feasible, a caregiver or responsible
party—previously trained in oral hygiene
therapies—can be designated to perform these
tasks during acute HAE episodes.
Proper oral care reduces the need for surgical
interventions (such as extractions) and the
development of acute or chronic intraoral
infections, thereby lowering the risk of HAEA, the
high nancial burden of procedures (Baptist
et al., 2024), and disease-related sequelae.
Forgetting
medications
Polypharmacy Comorbidities
Anxiety
Depression
Stress
Drug
interactions
Side effects
Physical
consequences
Hand
Inflammation
Xerostomia
Difficulty Oral
Hygiene Dental caries
PD
Infections
Foot
inflammation Difficulty
accessing
medical care
Dentistry
Emotional
aftermath
Social
consequences
HAE
attacks
Job
Economic
problems
Invasive
treatments
Aging
Figure 2. Hereditary angioedema attacks, their social consequences, and physical sequelae. (PD: periodontal disease)
Prepared by the author.
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After eliminating infectious foci, it is important
to encourage older adult patients (OAPs)
with HAE to schedule periodic visits with
the geriatric dentist, in addition to routine
radiographic evaluations such as panoramic
radiographs, which allow for a quick, painless,
and comprehensive assessment of the maxillary
and mandibular structures (Fuentes et al., 2021;
Tirado Lr et al., 2015).
The geriatric dentist (GD) must educate patients
with HAE about the necessity of regular care and
evaluation—even if their dental history includes
HAEA triggered by minor oral trauma or dental
surgeries (Singh et al., 2020).
Communication Between Healthcare
Professionals and Patients
Effective communication with patients is
essential to obtain a complete medical history,
including a thorough investigation of the
triggering factors for their HAE episodes, previous
dental treatment history, and a subsequent
discussion of necessary and elective treatments,
with realistic expectations. Older adult patients
(OAPs) may present with various comorbidities
and polypharmacy, which must be carefully
analyzed before considering certain treatments.
Close communication with the healthcare
professionals involved in the care of OAPs—not
only in medicine but also in nutrition, psychology,
physical therapy, and other disciplines—is
crucial. Understanding their adherence to both
pharmacological and non-pharmacological
treatments serves as a foundation for achieving
successful recovery from dental procedures.
Raising Awareness Among Dental and
General Healthcare Professionals
The GD differs from other dental professionals
in that they must be familiar with and work
closely with the support networks of OAPs) These
networks are composed of their families and the
various healthcare professionals involved in their
care. The GD should promote the idea that older
adult patients with additional physical, mental,
or medical complications should be treated by
specialists in geriatric dentistry, just as pediatric
dentists treat younger patients.
The dental profession as a whole must increase
awareness of complex medical conditions
such as HAE, ensuring that all dental personnel
working with these patients possess the
necessary knowledge to provide appropriate
care and promote patient comfort and
satisfaction.
To achieve this, effective pain management
and patient reassurance are essential, along
with a multidisciplinary approach to managing
potential complications that may arise during
treatments required by OAPs with HAE.
It is also necessary to conduct analyses
and studies on the risks that specic dental
procedures may pose in triggering HAEA,
enabling professionals to be better prepared
and more condent regarding the effects of
certain treatments.
At the same time, this provides patients with
reassurance that specialists are well-informed
and that nothing is left to chance. This process
can begin with inferential analyses, which will
open the door to gradually offering better
evidence-based care for these patients.
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Conclusions
In older adult patients with HAE, it is essential to
be meticulous about factors such as the history
of HAE attacks, their triggers and consequences,
comorbidities, polypharmacy and its side
effects, drug interactions, the loss of physical
and cognitive function, and the nancial
investment in the patient’s healthcare.
Dental treatment for patients with HAE requires
a comprehensive and multidisciplinary
approach that addresses both specic dental
needs and the underlying medical conditions.
A thorough assessment of the patient’s
medical and dental history is essential, as
well as effective communication with other
healthcare professionals involved in their care.
Emphasis should be placed on prevention and
on selecting non-invasive dental treatments
whenever possible. Patient education is a key
component in promoting long-term oral health
and improving the patient’s quality of life.
Each patient with HAE is unique and requires an
individualized approach to dental care. Geriatric
dentists must take the lead in managing these
patients, always striving for comprehensive,
high-quality care to achieve optimal health
outcomes within the challenging context of
aging and chronic disease.
Author contribution statement:
Conceptualization and design: CL, SC
Literature review: CL
Methodology and Validation: SC
Formal analysis: CL, SC
Investigation and data collection: CL, SC
Resources: CL, SC
Data analysis and interpretation: CL, SC
Writing-original draft preparation: CL, SC
Writing-review & editing: CL, SC
Supervision: SC
Project administration: CL, SC
Conict of Interest:
The authors declare that there are no conicts
of interest, no nancial relationships, no personal
relationships, and no external inuences that
could have affected the development of this
work.
Funding:
This work did not receive funding, nancial
support, materials, services, or resources
from any public, commercial, or non-prot
organization.
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