Oral Medicine 1 Lecture 13 (PDF)

# Oral Medicine 1 ## Lecture 13 ## Dental Management Of Diabetic Patients ### Dental Considerations 1. **Medical History:** * Take history and assess glycemic control at the initial appointment. * **Glucose Level** * **Frequency of Hypoglycemic Episodes:** * **Medication, Dosage...

# Oral Medicine 1 ## Lecture 13 ## Dental Management Of Diabetic Patients ### Dental Considerations 1. **Medical History:** * Take history and assess glycemic control at the initial appointment. * **Glucose Level** * **Frequency of Hypoglycemic Episodes:** * **Medication, Dosage and Times:** * **Consultation** 2. **Scheduling of Visits:** Morning appointment, avoid lengthy appointment 3. **Diet:** Ensure that the patient has eaten normally and taken medication. 4. **Prophylactic Antibiotics:** * Antibiotic prophylactic prophylaxis is not required unless there is an infection or brittle diabetes. 5. **Blood Glucose: Monitoring** * **Glycated Hemoglobin Test (HbA1c):** * As glucose circulates → blood → attached to hemoglobin: * **Value of HbA1c in Diabetics:** Should be less than 7% (controlled diabetes) * **HbA1c test normally:** Is <6-6.5% * **HbA1c value of more than 8%:** Suggests that a change in patient management may be needed to improve glycemic control 6. **Blood Pressure:** Monitor blood pressure, because diabetes is associated with hypertension. 7. **During Treatment:** * **The most serious and common complication of DM in dental clinic is Hypoglycemic Shock (Hypoglycemic Coma) (Insulin Shock).** * **Hyperglycemia:** To avoid hyperglycemia, use the anxiety reduction protocol. * **Anesthesia:** Usual dose. However, in a patient with cardiac symptoms, limit the dose to 2 cartridges containing 1:100,000 epinephrine. 8. **After Treatment:** * **Infection Control and Delayed Wound Healing** * **Dietary Intake** * **Medication:** Salicylates increase insulin secretion and sensitivity, avoid aspirin and NSAIDs in patients taking sulfonylureas, because it can worsen the hypoglycemia. ### Emergency Management * **A major goal in dental treatment of diabetes is to prevent insulin shock.** * **Management of insulin shock when it occurs:** * **Leads to life-threatening consequences** * **It occurs when the concentration of blood glucose drops below 60 mg/dL.** ### Signs and Symptoms of Insulin Shock * Confusion * Restlessness * Tremors * Sweating * Tachycardia * **Severe Hypoglycemia may result in seizures or loss of consciousness.** ### Instructions to be given to a diabetic * Diabetic patients should be strongly motivated to maintain good oral hygiene by: * Brushing their teeth after every meal * Using dental floss daily. * Keeping their dentures clean. ### Diabetic Patients should be frequently recalled for: * Dental examinations * Prophylactic measures such as topical fluoride * Dental caries should be treated. * It is best to do surgery when blood sugar levels are within normal range. * **Xerostomia:** Can be relieved by providing salivary substitutes or asking the patient to suck sugar-free candy or chewing gum and frequently drink water. * After a dental appointment, the patient should keep his eating routine and medication * **Avoidance of Smoking.** * They should keep good oral hygiene and restrict to the dentist's instructions to prevent infection and impaired wound healing, dry socket, and osteomyelitis from happening. ## Dental Management of Patients with Thyroid Gland Disorders * **Thyroid Disorders classified into:** 1) Hypothyroidism 2) Hyperthyroidism ### 1) Hypothyroidism: * Is defined by a decrease in thyroid hormone production and thyroid gland function. * **Diagnostic clues to the presence of hypothyroidism include:** * Cold intolerance * **Gain in weight without increase in appetite** * **Weakness** * Fatigue * **Dry, Cold, Puffy Skin** * **Thick Tongue and Macroglossia** * **Myxedema Coma due to Untreated Hypothyroidism** * **>>> Myxedema Coma <<<** ### Manifestation of Myxedema Coma 1. Hypothermia 2. Hypotension 3. Arrhythmias 4. Bradycardia followed by death * **Treatment of this emergency in a dental office is doing basic life support until the arrival of an ambulance** ### Complications of Hypothyroidism * Infection * Psychological problem * Bleeding * Narcotic, Barbiturate, Tranquilizes * Cardiovascular disease. * Susceptibility to infection. * Metabolic activity of fibroblast. * Delayed wound healing. * **Bleeding Potency:** Subcutaneous mucopolysaccharide decrease ability of small blood vessel constriction. * **Cardiovascular Disease:** Arteriosclerosis due to Lipoproteins (LDL) accumulation ### Hypothyroidism Patients are Treated with L-Thyroxine * **Patients are sensitive to the following drugs:** * Normal dose may prove to be an overdose, leading to respiratory or CVS depression, or both. * 1. Sedatives (e.g., barbiturates) * 2. Narcotics (e.g., codeine) * 3. Antianxiety (diazepam) * **Drug interaction of L-Thyroxine:** * Increase the effect of warfarin * Tricyclic antidepressants: Elevate L-thyroxine level. ### 2) Hyperthyroidism * Hyperthyroidism is a condition caused by unregulated production of thyroid hormones. * **Thyrotoxicosis:** Is a serious sequela of hyperthyroidism that corresponds to an overt tissue exposure to excess circulating thyroid hormone. * **Diagnostic Clues** * Sweating * Heat intolerance * **Tachycardia** * Warm, thin, soft, moist skin * Exophthalmos * Tremors ### Dental Management of Hyperthyroidism * **The risk of development of Thyrotoxicosis (Thyroid Storm)**, which includes the following symptoms: * 1. Extreme irritability * 2. Hypotension * 3. Vomiting * 4. Diarrhea * 5. It can be triggered by surgery, sepsis, and trauma; emergency medical treatment is required. * 6. Epinephrine is contraindicated and elective dental care is recommended. * 7. Stress management and short appointments. * 8. **Infection:** Antithyroid agents can cause agranulocytosis or leukopenia. * 9. **Bleeding:** Antithyroid drugs have anti-vitamin K. * 10. **Propylthiouracil:** Can cause sialolith formation and can increase the anticoagulant effects of warfarin. * 11. **Aspirin and NSAIDs:** May cause increase levels of circulating T4 leading to thyrotoxicosis; NSAIDs can also decrease the effect of beta-blockers. ### Thyroid Crisis (Thyroid Storm) * **Thyroid storm is a life-threatening health condition that is associated with untreated or undertreated hyperthyroidism.** * **Heart rate, blood pressure, and body temperature can soar to dangerously high levels** ### Management of Thyroid Crisis in Dental Office 1. **Patient cooled with cold towels and ice packs** 2. **I/V Hydrocortisone (100-300 mg)** 3. **I/V Infusion of hypertonic glucose** 4. **CPR Initiated if necessary** 5. **Monitor vital signs** 6. **Call medical assistance** ## Dental Management of Liver Diseases #### Types of liver disease 1. Hepatitis - infectious and non-infectious 2. Alcoholic liver disease 3. Non-alcoholic fatty liver disease 4. Hepatocellular carcinoma 5. Liver cirrhosis ### Dental Management of Liver Patients' Protection for the Practitioner 1. **Difficult or impossible to identify carriers of HBV, HCV, HDV.** Most carriers are unaware that they have had hepatitis. 2. **Standard precautions:** HBV Vaccination, Post exposure prophylaxis 3. Consult a physician. 4. Lab investigation (Prothrombin - bleeding time) 5. **Protective barriers (infection control measures)** 6. **Disposable instruments** 7. **Minimize aerosol production.** 8. **Wipe the dental chair with hypochlorite and disposable coverage.** 9. **Proper dispose for all disposable items after gathering, bagging, and labeling.** 10. **Rinse with oral antiseptic 30 minutes prior to the procedure.** 11. **Should be the last session.**