Medically Compromised Patients in Dentistry

Medically Compromised Patients in Dentistry

• Endocrine diseases, diabetic mellitus, thyroid disease, pregnancy, and steroid use are medically compromised conditions.
• Dr. Lamia Mohammed Hail, BDS, MDs, specializes in oral surgery and implantology.

Diabetic Mellitus

• Diabetic mellitus is a metabolic disorder characterized by insufficient or no insulin and resulting carbohydrate metabolism disturbance.
• Insulin's primary function is to counteract hyperglycemia-generating hormones and maintain low blood glucose.
• Two main types of diabetes mellitus are:
  • Type 1 (insulin-dependent) or juvenile-onset diabetes (IDDM)
  • Type 2 (non-insulin-dependent) or adult-onset diabetes (NIDDM)
• Other specific types include genetic defects of beta-cell function, decrease of pancreatic exocrine function, endocrine pathologies, drug or chemical usage, and infections.
• Gestational diabetes mellitus (GDM) is any degree of glucose intolerance that develops during pregnancy. Approximately 4% of pregnancies in the US involve gestational diabetes.
• Blood sugar levels are categorized as:
  • Normal fasting: 70-100 mg/dL, 2 hours post-meal <140 mg/dL, 4-6 mmol/l.
  • Pre-diabetes fasting: 101-125 mg/dL, 2 hours post-meal 140-200 mg/dL, 6.1-6.9 mmol/l.
  • Diabetes fasting: >126 mg/dL, 2 hours post-meal >200 mg/dL, >7 mmol/l.

Pathophysiology of Diabetes

• Healthy individuals maintain blood glucose levels between 60 and 150 mg/dL.
• Insulin is synthesized in beta cells of the pancreas and rapidly secreted into the bloodstream in response to blood sugar elevation.
• Insulin promotes glucose uptake from the blood into cells and its storage as glycogen.
• Fatty acids and amino acids are converted to triglycerides and protein stores.
• Lack of insulin or insulin resistance results in an inability of insulin-dependent cells to utilize glucose.
• Triglycerides break down into fatty acids, leading to increased blood ketones and diabetic ketoacidosis.
• Elevated blood sugar (hyperglycemia) leads to glucose excretion in the urine (polyuria) and increased thirst (polydipsia) due to osmotic diuresis.
• This also causes dehydration.
• Cells starved of glucose cause increased hunger (polyphagia).
• Paradoxically, diabetic patients can lose weight.

Diagnosis of Diabetes

• A casual plasma glucose level of 200 mg/dL or higher along with symptoms is considered a diagnostic marker for diabetes.
• Fasting plasma glucose of 126 mg/dL or higher is a diagnostic marker for diabetes (normal fasting glucose < 110 mg/dL).
• An oral glucose tolerance test (OGTT) with a blood glucose reading of 200 mg/dL or higher is also diagnostic.
• ADA recommends that individuals over 45 have diabetes screening every 3 years.

Oral Manifestations and Complications of Diabetes

• No specific oral lesions are associated with diabetes. However, hyperglycemia causes several problems, including:
  • Periodontal disease: Microangiopathy alters antigenic challenge. Impaired immune response and neutrophil chemotaxis increase plaque formation. Increased collagen breakdown leads to periodontal disease.
  • Salivary glands: Xerostomia (dry mouth) is common. Tenderness, pain, and burning of the tongue may indicate, along with parotid gland enlargement with sialosis.
  • Dental caries: Increase prevalence in adults due to xerostomia, increase saliva glucose, and hyperglycemia.
  • Increased risk of infection: Macrophage metabolism is altered with inhibition of phagocytosis. Poor peripheral circulation and immunological deficiency increase infection risk.
  • Delayed healing of wounds: Microangiopathy and protein utilization for energy impair tissue repair increases prevalence of dry socket.
  • Miscellaneous conditions: Degeneration of vascular systems (Pulpitis), neuropathies, drug side effects (lichenoid reaction from sulphonylurea, like chlorpropamide), oral ulcers.

Dental Management Considerations (Diabetes)

• Medical History: Take a detailed medical history and assess glycemic control at the initial appointment, including glucose levels, frequency of hypoglycemic episodes, medication (dosage and times), and consultation.
• Scheduling Visits: Avoid scheduling during peak endogenous cortisol levels in the morning. Patients should eat normally and take medications as usual.
• Blood Glucose Monitoring: Monitor blood glucose before starting procedures and frequently (<70 mg/dL).
• Prophylactic Antibiotics: Use for established infections, pre-operative contamination, and major surgery.
• During Treatment: The most common complication is hypoglycemia. Be prepared, and have glucose available.
• After Treatment: Infection control and dietary intake are crucial. Salicylates increase insulin sensitivity— avoid aspirin.
• Referral (if needed): Uncontrolled cases should be referred to a physician.
• Stress reduction protocols (if needed): Stress protocols should be implemented with procedures and management.
• Specific management (hypoglycemia): 15 grams of fast-acting oral carbohydrate, intravenous dextrose (25-30 ml of 50%), and glucagon (1 mg). Call 911 or emergency services when necessary.
• Specific management (hyperglycemia): Medication intervention and insulin administration. Administer glucose first.
• Post-Operative Management: Adjust insulin dose pre-operatively. Normal postoperative feeding minimal surgical intervention (no dose changes), Moderate surgical intervention may affect postoperative feedings, and in cases where postoperative feeding is restricted, smallest dose of epinephrine in local anaesthetics).
• Diabetic Coma and Insulin Shock: Distinguishing symptoms (see table).
• Emergency Management: Following protocol in case of diabetic coma or insulin shock, including blood glucose monitoring and supportive care.

Thyroid Dysfunction

• The thyroid gland is composed of two lobes on either side of the trachea, connected by a thin isthmus.
• It secretes thyroxine (T4), triiodothyronine (T3), and calcitonin.
• Thyroid hormone affects growth, carbohydrate and fat metabolism, vitamin metabolism, basal metabolic rate, cardiovascular system, and muscle function.
• Thyroid dysfunction (hypothyroidism or hyperthyroidism) can result from autoimmune disorders or tumors.

Clinical Manifestations (Hyperthyroidism)

• Symptoms: Weight loss, palpitation, nervousness, tremors, chest pain, dyspnea, edema, disorientation, diarrhea, abdominal pain.
• Signs: Fever (above 103° F, 57-70%), tachycardia (100-139 bpm,170-200bpm 14%), sinus tachycardia, dysrhythmias, wide pulse pressure, thyrotoxic state, eyelid retraction, hyperkinesis, heart failure, weakness, coma, enlarged thyroid, tender liver, infiltrated ophthalmopathy, somnolence or obtundence, psychosis, jaundice.

Clinical Manifestations (Hypothyroidism)

• Symptoms: Paresthesia, loss of energy, intolerance to cold, muscular weakness, pain in muscle and joints, inability to concentrate, drowsiness, constipation, forgetfulness, depressed auditory acuity, emotional instability, headaches, dysarthria.
• Signs: "Pseudomyotonic" reflexes, change in menstrual pattern, hypothermia, dry scaly skin, puffy eyelids, hoarse voice, weight gain, dependent edema, sparse axillary and pubic hair, pallor, thinning eyebrows, yellow skin, loss of scalp hair, abdominal distention, goiter, decreased sweating.

Prevention of Thyroid Dysfunction

• Thorough medical history, physical examination, and dialogue history are essential, focusing on the nature of dysfunction (hypo or hyper), management methods, recent weight changes, sensitivity to temperature/pain medications, sensitivity to heat, and irritability/tension.
• Euthyroid patients generally do not require specific dental procedures or precautions.
• ASA II risk classification.
• Mild hyper/hypothyroidism - Elective dental treatment is usually possible.
• Severe hyperthyroidism - Postpone dental procedures if necessary.

Management of Hypothyroidism

• Step 1: Terminate the dental procedure.
• Step 2: Position the patient supine with slightly elevated legs.
• Step 3: Perform basic life support (ABCs).
• Step 4: Provide definitive care.
• Step 4a: Summon medical assistance.
• Step 4b: Establish an IV line with 5% dextrose/water or normal saline, if available.
• Step 4c: Administer O2.
• Step 4d: Definitive management in an emergency department (administration of massive dose of IV thyroid hormone).

Management of Hyperthyroidism

• Step 1: Terminate the dental procedure.
• Step 2: Position the patient supine with slightly elevated legs.
• Step 3: Perform basic life support (ABCs).
• Step 4: Provide definitive care.
• Step 4a: Summon medical assistance.
• Step 4b: Establish an IV line with 5% dextrose/water or normal saline, if available.
• Step 4c: Administer O2.
• Step 4d: Definitive management in an emergency department (Include transport and administration of large doses of anti-thyroid drugs (e.g., propylthiouracil), propranolol to block adrenergic effects, glucocorticoids to prevent acute adrenal insufficiency, cold packs, and careful hydration and electrolyte monitoring).