Endocrine Disease in Dentistry PDF

Medically compromised patient in dentistry ❑ Endocrine disease ✓ Diabetic mellitus Dr. Lamia Mohammed Hail ✓ Thyroid disease BDs, MDs in oral surgery ✓ Pregnancy and implantology ✓ Steroid  Part I Diabetic mullitus: its management in oral surgery ...

Medically compromised patient in dentistry ❑ Endocrine disease ✓ Diabetic mellitus Dr. Lamia Mohammed Hail ✓ Thyroid disease BDs, MDs in oral surgery ✓ Pregnancy and implantology ✓ Steroid  Part I Diabetic mullitus: its management in oral surgery  Diabetic mellitus Diabetic mellitus is a metabolic disorder characterized by relative or absolute insufficiency of insulin, and resultant disturbances of carbohydrate metabolism. The major function of insulin is to counter the concerted action of a number of hyperglycemia generating hormones and to maintain low blood glucose levels. Dental management considerations: 1. Consultation, uncontrolled cases should be refereed for the physician 2. Stress reduction protocol 3. Dental procedures are best performed in the morning 90-180 min after breakfast. 4. In non insulin controlled patients all dental procedures could be performed. 5. Prophylactic antibiotic administration the day before & 2-3 days after surgery ( in case of massive surgery) Dental management considerations: 6. Adjustment of the insulin dose preoperatively: I. Normal postoperative feeding and minimal surgical intervention>>> do not change the dose. II. Moderate surgical intervention that may affect the postoperative feeding. III. If the diet will be completely restricted postoperatively. 7. Use smallest amount of epinephrine in LA since its effect only 1\10 in raising the blood sugar. 8. If there is any doubt of insulin shock\ diabetic coma >>> IV dextrose 9. Sugar should always be available if hypoglycemic shock occur.  Diabetic coma and Insulin shock Item Hyperglycemia Hypoglycemia diabetic coma insulin shock Consciousness Drowsiness and loss of consciousness Skin appearance Dry & flushed Moist & pale Thirst Intense …………….. Breath odor Acetone Normal vomiting common rare  Part II Thyroid dysfunction: Its management in oral surgery Introduction: Thyroid gland is composed of two elongated lobes on either side of the trachea that are joined by a thin isthmus of thyroid tissue located at or below the level of the thyroid cartilage. Secretes: ✓ thyroxin (t4) ✓Tri- iodothyronine (t3) ✓calcitonin Introduction: Thyroid hormone has: Effect on growth Effect on carbohydrate metabolism Effect on fat metabolism Effect on vitamin metabolism Effect on basal metabolic rate Effect on cardiovascular system Effect on the function of the muscle Pathophysiology Thyroid dysfunction may result due to hypo\hyper – function of thyroid gland Thyroid dysfunction is the second most common glandular disorder of the endocrine system and is increasing, predominantly among women 1. Thyrotoxicosis\ hyperthyroidism may be due to: ✓ autoimmunity ✓ Adenoma Pathophysiology 2. Hypothyroidism ✓ autoimmune ✓ thyroiditis precedes the autoimmune destruction of the thyroid gland ✓This cause progressive deterioration and finally fibrosis of the gland, with resultant diminished or absent secretion of thyroid hormone Clinical manifestation of hyperthyroidism Clinical manifestation of hyperthyroidism Clinical Manifestation Of Hypothyroidism Prevention Tow goals are essential in the management of patients with thyroid dysfunction 1. Prevention of the occurrence of the life threatening situations myedema coma & thyroid storm 2. Prevention of the exacerbation of complications associated with thyroid dysfunction, cardiovascular disease. Prevention is through 1. Medical history questionnaire 2. Dialogue history 3. Physical examination Prevention Dialogue history: An in depth dialogue history is indicated when the medical history questionnaire indicates of positive history of thyroid disease. ✓ Q. What is the nature of the thyroid dysfunction – hypo\hyperfunction? ✓ Q. How do you manage the disease? ✓ Q. Have you unexpectedly gained or lost weight recently? ✓ Q. Are you usually sensitive to old temperatures or pain relieving medications? ✓ Q. Are you usually sensitive to heat? ✓ Q. Have you become increasingly irritable or tense? Prevention Physical examination Hypothyroidism Hyperthyroidism No sweat Sweaty hand BP close to normal ( BP elevated ( systolic > diastolic slightly) diastolic) Slow hart rate Heart rate markedly Sometimes thyrotoxicosis may confused with acute anxiety Thyrotoxicosis acute anxiety Has warm, sweaty hands palms cold and clammy Prevention Dental consideration Euthyroid - Those who are receiving therapy to treat the condition, have normal levels of thyroid hormone and have no symptoms, represent euthyroid - they represent ASA II risks and may be managed normally during dental treatment - I mild manifestations of either hypo\hyper are present Elective dental treatment may proceed although certain treatment modifications should be considered They represent ASA III risk Prevention Physical status classification of thyroid gland dysfunction  Prevention Dental consideration Hypothyroid - Medical consultation considered prior to start any dental procedure - caution must be exercised when prescribing CNS depressant Sedation hypotonic Opoid analgesic Other anti anxiety drug - Administration of a normal dose may produce an overdose, leading to respiratory or cardiovascular depression or both - Dental treatment should be postponed until consultation or definitive management of the clinical manifestation is achieved Prevention Dental consideration: Hyperthyroid - Mild degree of hyper- function may show Acute anxiety, with little elevation in clinical risk However, various cardiovascular disorder, are exaggerated during dental procedure the management protocol for that special situation should be followed - Sever hyperthyroid should receiving immediate medical consultation Dental procedure should be postponed - Atropine should be avoided Cause an elevation in heart rate & may be a factor in precipitating thyroid storm. Prevention Dental consideration Hyperthyroid - Epinephrine other vasopressors should be used with caution - Vasopressor stimulate the cardiovascular system & can precipitate cardiac dysrhythmias, tachycardia, & thyroid storm in hyperthyroid patient whose cardiovascular system have already been sebsitized. - However, LA with vasoconstrictors may be used when the following precautions are taken: Used the least concentrated effective solution of epinephrine Injection the smallest effective volume of anesthetics Management of Hypothyroid - Step 1: termination of the dental procedure - Step 2: position supine position with legs elevated slightly - Step 3: A-B-C, basic life support, as needed - Step 4: definitive care - Step 4a: summoning of medical assistance Management of Hypothyroid - Step 4b: establishment of an IV line if available, an IV line of 5% dextrose& water or normal saline may be started before the arrival of medical personal - Step 4c: administration of O2 - Step 4d: definitive management of the individual to a hospital emergency department, administration of massive dose of IV doses of thyroid hormones Management of hyperthyroid - Step 1: termination of the dental procedure - Step 2 : position supine position with legs elevated slightly - Step 3: A-B-C, basic life support, as needed - Step 4: definitive care - Step 4a: summoning of medical assistance - Step 4b: establishment of an IV line if available, an IV line of 5% dextrose& water or normal saline may be started before the arrival of medical personal - Step 4c: administration of O2 Management of hyperthyroid - Step 4d: definitive management include the transport of the individual to a hospital emergency department, administration of large dose of anti-thyroid drugs ( e.g propylthiouracil) Additional includes administration of propranolol to block adrenergic- mediated effects of thyroid hormone Large doses of glucocorticoids to prevent acute adrenal insufficiency Other measures - O2 - Cold packs - Sedation careful monitoring of hydration & electrolyte balance