Diabetes Mellitus Management in Dentistry

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Questions and Answers

Which thyroid hormone is primarily secreted by the thyroid gland that regulates metabolism?

Parathyroid hormone

Tri-iodothyronine (T3)

Calcitonin

Thyroxin (T4) (correct)

What is a common cause of hyperthyroidism?

Thyroiditis

Fibrosis of the gland

Hypothyroidism

Adenoma (correct)

Which of the following is NOT a clinical manifestation of hypothyroidism?

Fatigue

Cold intolerance

Depression

Weight loss (correct)

What is one of the main goals in the management of thyroid dysfunction?

Preventing life-threatening situations Signup and view all the answers

Which question is relevant during a dialogue history for assessing thyroid dysfunction?

Are you sensitive to old temperatures? Signup and view all the answers

Which of the following is NOT a precaution when using local anesthetics (LA) with vasoconstrictors?

Administering the largest volume of anesthetics possible Signup and view all the answers

What is the first step in the management of a hypothyroid emergency during a dental procedure?

Terminate the dental procedure Signup and view all the answers

When managing a patient with hyperthyroid emergency, which medication is administered to block adrenergic-mediated effects of thyroid hormone?

Propranolol Signup and view all the answers

What should be established as part of the definitive care in a hyperthyroid crisis?

An IV line of 5% dextrose and water Signup and view all the answers

In the management of both hypothyroid and hyperthyroid emergencies, what position should the patient be placed in?

Supine with legs elevated slightly Signup and view all the answers

What is the major function of insulin in the body?

To counteract hyperglycemia generating hormones Signup and view all the answers

When should dental procedures be ideally performed for diabetic patients?

90-180 minutes after breakfast in the morning Signup and view all the answers

What should be done in case of doubt regarding insulin shock or diabetic coma during a procedure?

Provide IV dextrose Signup and view all the answers

Which adjustment is necessary to insulin administration for patients undergoing moderate surgical intervention?

Adjustments depend on postoperative feeding capacity Signup and view all the answers

What is a common characteristic of hyperglycemia in diabetic coma?

Flushed, dry skin Signup and view all the answers

What is the term for the condition where there is an absolute insufficiency of insulin?

Diabetic mellitus Signup and view all the answers

What is one key dental management consideration for diabetic patients undergoing surgery?

Use the smallest amount of epinephrine in local anesthesia Signup and view all the answers

In case of massive surgery, when should prophylactic antibiotic administration take place?

The day before and 2-3 days after surgery Signup and view all the answers

What is a key characteristic that differentiates hypothyroidism from hyperthyroidism in physical examination?

Slow heart rate Signup and view all the answers

Which ASA risk category represents patients who are euthyroid during dental treatment?

ASA II Signup and view all the answers

Which condition may present with symptoms that are confused with thyrotoxicosis?

Acute anxiety Signup and view all the answers

What precaution should be taken when prescribing sedation for a patient with hypothyroidism?

Avoid CNS depressants Signup and view all the answers

What action should be taken for a patient with severe hyperthyroidism before performing dental procedures?

Postpone the procedure and consult medically Signup and view all the answers

What effect does atropine have that may be detrimental to a hyperthyroid patient during dental treatment?

Elevates heart rate Signup and view all the answers

Which of the following is a correct consideration when treating a patient with mild hyperthyroidism during dental procedures?

Cardiovascular disorders must be carefully managed Signup and view all the answers

Which of the following medications should be used with caution in a hyperthyroid patient?

Epinephrine and other vasopressors Signup and view all the answers

Signup and view all the answers

Study Notes

Medically Compromised Patients in Dentistry

Endocrine diseases are a concern for dental procedures
Diabetic Mellitus, Thyroid Disease, Pregnancy, and Steroid use are examples of endocrine diseases
Dr. Lamia Mohammed Hail is an expert in oral surgery and implantology
Diabetes Mellitus is a metabolic disorder characterized by insufficient insulin leading to metabolic disturbances

Part I: Diabetic Mellitus Management in Oral Surgery

This section focuses on managing diabetes patients during oral surgery

Introduction to Diabetes Mellitus

Diabetes mellitus is a metabolic condition
Insulin's role is to regulate blood sugar levels and counter other hormones that increase blood sugar
Insufficient insulin or resistance to insulin results in high blood sugar levels

Etiologic Classification of Diabetes Mellitus (DM)

Two main types of DM:
- Type 1 (insulin-dependent or juvenile-onset diabetes)
- Type 2 (non-insulin-dependent or adult-onset diabetes)
Other types include genetic defects impacting beta cells or pancreatic exocrine function deficiencies, endocrine pathologies, and drug/chemical usage or infections.

Other Specific Types of Diabetes Mellitus

Genetic defects in beta cells' functions
Decrease in exocrine pancreas functions
Endocrine pathologies
Drug or chemical usage
Infections

Gestational Diabetes Mellitus (GDM)

Glucose intolerance during pregnancy
Affects approximately 4% of pregnancies in the US

Blood Sugar Levels Chart

mg/dL and mmol/l tables show normal, pre-diabetes, and diabetes ranges for fasting and post-meal blood sugar levels

Pathophysiology of Diabetes Mellitus

Normal blood glucose levels are maintained between 60-150 mg/dL
Insulin is released by pancreas in response to elevated blood sugar to keep blood sugar low
Glucose is absorbed and stored as glycogen
Fatty acids and amino acids are converted into triglycerides and protein stores
Lack of insulin or resistance to insulin results in glucose not being used by cells
Triglycerides break down into fatty acids causing increased blood ketones leading to ketoacidosis
High blood sugar results in glucose in urine due to osmotic diuresis causing dehydration and increased thirst (polyuria and polydipsia).
Cells not receiving glucose causes increased hunger (polyphagia)
Patients may experience weight loss

Diagnosis of Diabetes Mellitus

Casual plasma glucose level ≥200 mg/dL accompanied by symptoms (indicates diagnosis)
Fasting plasma glucose ≥126mg/dL
Oral glucose tolerance test (OGTT) with blood sugar ≥200mg/dL.
ADA recommends screening for patients over 45 years old every 3 years.

Oral Manifestations and Complications of Diabetes Mellitus

No specific oral lesions are associated with diabetes. However, hyperglycemia leads to issues like:
- Increased risk of periodontal disease due to altered immune response/ impaired neutrophil chemotaxis, increased collagen breakdown, plaque formation
- Salivary gland dysfunction: xerostomia, tenderness, pain, burning sensation, and enlarged salivary glands
- Increased risk of dental caries due to decreased saliva production/ oral hygiene
- Increased risk of infection because of impaired macrophage function and deficient immune system
- Delayed healing
- Increase in dry socket
Miscellaneous conditions like pulpitis, neuropathies (facial nerves), and drug-induced effects (e.g., sulphonylureas like chlorpropamide) and ulcers can occur

Dental Management Considerations for Medically Compromised Patients

Thorough patient history and evaluation of glycemic control (Glucose levels, hypoglycemic episodes frequency, medication dosages and times) by a dentist
Scheduling visits for dental procedures in optimal times (avoiding peak hormone/glucose levels)
Ensuring patients have eaten normally before procedures and have taken necessary medications
Blood glucose monitoring before starting procedures and keeping glucose levels within acceptable ranges
- Recommended level being <70 mg/dL.
Prophylactic antibiotics for established infection or during high-risk procedures (e.g., major surgery, pre-op contamination)
During treatment, hypoglycemia is a major complication and must be monitored
Post-treatment monitoring for infection control and dietary intake.
Medications like salicylates increase insulin sensitivity - avoid administering Aspirin to DM patients
Referrals to physicians are often necessary for complex cases
Adjust insulin dosages before surgeries
Use of smallest amount of epinephrine during local anesthesia
- Minimizes the risk of raising blood glucose
Maintaining proper hydration of patients.

Diabetic Coma and Insulin Shock

Diagnostic Table showing differences between hyperglycemia coma and hypoglycemia shock, including symptoms such as consciousness level, skin appearance, thirst, breath odor, and vomiting

Emergency Management

Hypoglycemia treatment:
- 15g fast-acting oral carbohydrates
- Measuring blood sugar for confirmation
- Intravenous (IV) administration of 50% dextrose solution (25-30 ml) over a 3-minute period
Glucagon 1mg
- Necessary for severe cases
Notify emergency services (911, 119) for serious conditions
Severe hyperglycemia (long-term):
- Ketoacidosis may occur with nausea, vomiting, abdominal pain, noticeable acetone breath odor
- Difficult to quickly distinguish between hypoglycemia vs. hyperglycemia in emergency situations
Medications and insulin administration needed for hyperglycemia
Glucose should be administered when in emergency situations

Conclusion & Preventive Measures

Emphasize the importance of thorough patient history, routine dental checkups, and minimizing complications.
- Detailed medical history including questions about the nature of thyroid dysfunction (hypo/hyper), how it's managed, recent weight changes, sensitivity to temperature/pain relievers, heat sensitivity, and irritability
- Monitoring of blood glucose levels, dietary intake, preventing peak activity periods of insulin
- Evaluating for complications of plaque control and periodontal disease.
- Providing oral hydration and managing oral dryness
- Avoidance of smoking, caffeine, and alcohol

Thyroid Dysfunction in Dentistry

Thyroid gland, located near the trachea, produces hormones such as thyroxine (T4), triiodothyronine (T3), and calcitonin.
These hormones have numerous functions impacting metabolism

Introduction

Thyroid gland is composed of 2 lobes on either side of the trachea, joined by an isthmus
Secretes hormones: thyroxine (T4), triiodothyronine (T3), and calcitonin
Thyroid hormones affect growth, carbohydrate and fat metabolism, vitamin metabolism, basal metabolic rate, cardiovascular system function, and muscle function.

Pathophysiology

Thyroid dysfunction, due to either hypo- or hyper-function, is a concern
Thyrotoxicosis (hyperthyroidism): results from factors like autoimmune issues, or tumors (adenomas).
Hypothyroidism (underactive thyroid): typically autoimmune destruction of the thyroid gland causing progressive deterioration leading to absence of thyroid hormone secretion

Clinical Manifestations (Hyperthyroidism)

Symptoms vary but include intolerance to heat, fine/straight hair, bulging eyes, facial flushing, enlarged thyroid, tachycardia, increased systolic blood pressure, possibly weight loss, muscle wasting
Diagnostic Table of common and less common symptoms of hyperthyroidism

Clinical Manifestations (Hypothyroidism)

Symptoms include paresthesia, fatigue, intolerance to cold, muscle weakness, pain in muscles and joints, difficulty concentrating, drowsiness, constipation, forgetfulness
Diagnostic Table of common and less common symptoms of hypothyroidism.

Prevention

Thorough medical history including questions about thyroid disease, how it's managed, recent weight changes, sensitivity to temperature/pain relievers, heat sensitivity and irritability.
Physical exams to check for features like a palpable thyroid, BP, and heart rate

Dental Considerations (Euthyroid Patients)

Dental procedures can proceed if the patient has normal thyroid levels
Patients with mild hyper or hypothyroidism can typically have dental treatment with careful monitoring - if they are on medication, consult with the physician about their medications
Those with more severe cases may require modifications

Physical Status Classification

Physical status classification based on thyroid function is needed when determining appropriate dental care - ASA II: usual dental care considerations
ASA III : need more considerations when it comes to dental care (possibly including avoiding vasopressors/CNS depressants for those with hyperthyroidism and taking precautions when prescribing vasopressors and CNS depressants for those with hypothyroidism, monitoring,etc)

Hypothyroidism Management

Dental procedure termination
supine position with legs elevated slightly
basic life support
definitive care
summoning medical assistance
establishment of IV line (normal saline/5% dextrose)
Oxygen administration
hospitalization for emergency treatment, massive thyroid hormone administration given intravenously

Hyperthyroidism Management

Termination of dental procedure
supine position with legs elevated slightly
basic life support
summoning medical assistance
establishment of IV line (normal saline/5% dextrose)
Oxygen administration
hospitalization for emergency treatment, possible administration of anti-thyroid drugs and/or propranolol, additional large glucocorticoid doses to prevent adrenal insufficiency

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Description

Explore the implications of managing medically compromised patients, particularly those with Diabetes Mellitus, in dental procedures. This quiz covers the effects of endocrine diseases and the necessary precautions for providing oral care to diabetic patients during surgery. Enhance your understanding of insulin's role and the classifications of diabetes in a dental context.