Medically Compromised Patients (Part II) Ra ed Salma BDS, MSc, JBOMFS, MFDRCSI
Endocrine Disorders
I. Diabetes Mellitus (DM) Definition (WHO): - Chronic disease due to absolute or relative lack of insulin that leads to failure of glucose to enter the body cells (Relative lack = insulin resistance) - DM can be Primary or Secondary (v. rare) - DM is a leading cause of death
Types of Primary DM: Type Old Names % Pathogenesis Contributing Factors 1 IDDM (Insulin Dependent), Juvenile Onset 5-10 % Insulin deficiency 90% Islet cell autoantibodies, Genetics, Viruses, Race 2 NIDDM (Noninsulin Dependent), Maturity Onset 90-95 % Insulin resistance Family history, Overweight, Inactivity, Age, Stress 3?? Gestational* DM Rare Pregnancy Hormones cause Insulin Resistance Family history, Race (Africans) * Affects 5% of pregnant ladies. Risk of type 2 DM later
Early (acute) signs & symptoms of DM Glucose Unable to Enter the Cells Hyperglycemia Lethargy (fatigue) Metabolism of proteins & fat to get energy Glycosuria Polyuria Weight loss, wasting, polyphagia Type 1 only Ketonemia & Ketonuria Thirst The most common symptom Metabolic Ketoacidosis Polydipsia Respiratory Alkalosis (Hyperventilation)
Acute complications of DM Hypoglycemia: very dangerous & quick Hyperglycemia: less dangerous & slow Ketoacidosis (only type 1) --------------------------- LOC (loss of consciousness) is common in hypoglycemia & very rare in hyperglycemia
Chronic effects (complications) of DM Same signs & symptoms + Retinopathy visual deterioration Nephropathy renal failure Peripheral Neuropathy numbness in limbs Immunopathy (PMNs dysfunction) recurrent infections, candidiasis & delayed healing Atherosclerosis IHD & CVA (stroke) Peripheral vascular disease gangrene Deep mycosis (rare) Autonomic neuropathy postural hypotension Oral effects xerostomia, sialosis & periodontitis
Diagnosis of DM WHO 2006, a patient is diabetic if: 1. FPG (8-h fasting plasma glucose) 126 mg/dl OR 2. 2h Plasma Glucose (after 75g glucose drink) 200 mg/dl (test called OGTT) In two repeated tests on different days or in one test if symptomatic patient
ADA 2010 (American Diabetes Assoc.): - A patient is diabetic if: 1. Same WHO 2006 OR 2. RPG (random plasma glucose) 200 mg/dl AND Symptoms of DM or Crisis OR 3. HbA1C (glycosylated hemoglobin) 6.5% on repeated testing or one test if symptomatic, the test should be standardized
Dental management of diabetics In all diabetics you should take the following precautions: 1. Check if the patient is controlled, HOW? 2. Early morning appointment (Why?). Short visit 3. Be sure patient took his drug & his breakfast 4. Work within 2 hours of breakfast 5. Work with stress reduction
6. Measure blood sugar before (esp. extraction or surgery (GlucoCheck), keep < 180 & >90, if < 90 give oral glucose before start 7. If patient can t eat after procedure, recheck glucose after you finish 8. Beware of the risk of hypoglycemic coma 9. Acute infection of fascial space refer to OMFS for hospitalization
Type 1 DM type 1 Controlled Uncontrolled Simple procedure up to single extraction Multiple extractions or Surgery Elective Treatment Dental Emergency Treat normally Take mentioned precautions Hospitalize (refer to OMFS) Defer till control Non surgical Single Extraction Ok but Take the precautions Ok but precautions + Prophylaxis AB
Type 2 DM Type 2 Controlled Uncontrolled Treat as normal patient but Take mentioned precautions Treat as Type 1 uncontrolled
II. Adrenal Gland & Steroids 1. Patients on Systemic Steroids Therapy Suspected patients to be on systemic steroids: - Asthma - Autoimmune disease: SLE, RA, Pemphigus - Organ transplant - ITP (idiopathic thrombocytopenic purpura), - Leukemia, Lymphoma - IBD (inflammatory bowel disease) - Addison disease - Post adrenalectomy - Hypopituitarism
HPA axis suppression will occur if: 1. Patient is currently on daily steroid of > 5 mg/day prednisolone 1. Patient took steroid in the last month regularly 2. Patient took steroids > 1 month in the last year HPA suppression In case of stress (trauma, infection, surgery, anxiety), Risk of Adrenal Crisis (Addisonian Crisis/Shock) Adrenal crisis is not common in dental practice
Dental management of patients with history of systemic steroids Stress reduction Early morning visit, short visit Check associated diseases: HTN, DM If HPA axis suppression Steroid Cover If extraction or surgery & patient currently on steroid Antibiotic Prophylaxis for wound infection If currently on steroid avoid NSAIDs Monitor BP if risk of adrenal crisis
Steroid cover regimens Procedure Currently on Steroids Steroids in the Last Year Dental procedure* up to single extraction Multiple extractions or Minor surgery Major surgery or Trauma Double the usual dose in morning OR Hydrocortisone 25-50 mg IV Preoperative** Double the usual dose in morning + Hydrocortisone 25-50 mg IV Preoperative** Double the usual dose in morning + Hydrocortisone 25-50 mg IV Preoperative** + IM Postoperative 6-hourly for 24-72 h Take the usual dose in morning OR Hydrocortisone 25-50 mg IV Preoperative** Take the usual dose in morning + Hydrocortisone 25-50 mg IV Preoperative** Take the usual dose in morning + Hydrocortisone 25-50 mg IV Preoperative** + IM Postoperative 6-hourly for 24-72 h * Exclude simple procedures ** Immediately before you start
III. Thyroid Gland 1. Hyperthyroidism - Thyroid function test (TFT) High T3, T4 & Low TSH Most common causes: Graves, toxic nodule Clinical Features: - Tachycardia, palpitations - Sweating - Exophthalmos (few cases) - Increased appetite - Tremor - Heart failure - Irritability - Oral changes - Weight loss - Heat intolerance - Diarrhea - Risk of thyroid crisis (How?)
2. Hypothyroidism Definition: - Low T3, T4 (but TSH level according to cause) Most common causes: Post thyroidectomy Clinical features: reverse of hyperthyroidism Treated by Thyroxine Not relevant for dental work except if GA or sedation (correct hypothyroidism first) Risk of myxedema coma (rare): hypotension, bradycardia, collapse mainly in sedation or GA
Dental management of hyperthyroidism I. Controlled: Controlled means: asymptomatic, hormone levels are normal on last test & visits the physician at least once/year - Treat as normal patient but: * Stress reduction, short visit, took his medicine * Check associated diseases (e.g. HF, HTN) * Drug history: - If on anti-thyroid drugs may have leukopenia or anemia. Do CBC first. - If on beta blockers minimize adrenaline LA
II. Uncontrolled: If unknown, do thyroid function test & decide: If Hyper Defer non-emergency treatment & consult physician to control first If emergency treatment and hyper or unknown * Measure BP and manage accordingly * Avoid adrenaline LA (ADA 2002) * Minimize NSAIDs & avoid aspirin * Very short visit then send to physician
Gastrointestinal Disorders
I. Peptic Ulcer Disease (PUD) Risk Factors: - H. Pylori: most common contributing factor - NSAIDs: most common cause if H. Pylori -ve - Stress - Smoking & alcohol - Diet (high fat) - Genetics
Dental management of Peptic Ulcer patient 1. NSAIDs are contraindicated esp. if active disease (not healed), if old ulcer best avoid NSAIDs or short course or cover with H2 Blocker if NSAIDs given (selective COX-2 inhibitors group of NSAIDs are relatively safer) 2. Avoid steroids
II. Inflammatory Bowel Disease (IBD) 1. Crohn s Disease 2. Ulcerative Colitis * Dental management of IBD patients: - Check anemia - Check if taking steroids - Check if taking immunosuppressants - Avoid NSAIDs - Avoid antibiotics that may cause diarrhea (e.g. augmentin, clindamycin, erythromycin)
Thank You