Diabetes Mellitus and Oral Health
1. Diabetes mellitus is a metabolic condition affecting multiple organ systems. The oral cavity frequently undergoes changes, and oral infections may adversely affect metabolic control of the diabetic state
2. Human blood glucose levels normally from about 80 mg/dl to 110 mg/dl
General Dental Treatment:
Patients may present to the dental office with oral conditions that suggest an undiagnosed diabetic state. An example is severe rapidly progressing periodontitis that exceeds what would be expected given the patient’s age, habit history, oral hygiene, and level of local factors (plaque, calculus). Other findings seen in some undiagnosed diabetic patients include enlarged gingival tissues that bleed easily upon manipulation and the presence of multiple periodontal abscesses.
If the clinician suspects an undiagnosed diabetic state, the patient should be questioned to elicit a history of polydipsia, polyuria, polyphagia, or unexplained weight loss. The patient should be questioned about a family history of diabetes. If diabetes is suspected, laboratory evaluation and physician referral are indicated.
It is generally best to plan dental treatment to occur either before or after periods of peak insulin activity. This reduces the risk of perioperative hypoglycemic reactions, which occur most often during peak insulin activity. For those who take insulin, the greatest risk of hypoglycemia will thus occur about 30 to 90 minutes after injecting lispro insulin, 2 to 3 hours after regular insulin, and 4 to 10 hours after NPH or Lente insulin. For those who are taking oral sulfonylureas, peak insulin activity depends on the individual drug taken. Metformin and the thiazolidinediones rarely cause hypoglycemia
The greatest risk would occur in a patient who has taken the usual amount of insulin or oral agent but has reduced or eliminated a meal prior to dental treatment. For example, if the patient takes the usual dose of regular insulin before breakfast but then fails to eat or eats less than the usual amount, the patient will be at increased risk for hypoglycemia during a morning dental appointment
Diabetic Emergencies in the Dental Office
The most common diabetic emergency in the dental office is hypoglycemia. Signs and symptoms include confusion, sweating, tremors, agitation, anxiety, dizziness, tingling or numbness, and tachycardia. Severe hypoglycemia may result in seizures or loss of consciousness.
As soon as a patient experiences signs or symptoms of possible hypoglycemia, he or she should check the blood glucose with a glucometer. If a glucometer is unavailable, the condition should be treated presumptively as a hypoglycemic episode. The dental practitioner should give the patient approximately 15 g of oral carbohydrate in a form that will be absorbed rapidly.
If the patient is unable to take food by mouth and an intravenous line is in place, 25 to 50 mL of a 50% dextrose solution (D50) or 1 mg of glucagon can be given intravenously.
If an intravenous line is not in place, 1 mg of glucagon can be injected subcutaneously or intramuscularly at almost any body site. Glucagon injection causes rapid glycogenolysis in the liver, releasing stored glycogen and rapidly elevating blood glucose. Following treatment, the signs and symptoms of hypoglycemia should resolve in 10 to 15 minutes. The patient should be observed for 30 to 60 minutes after recovery. Evaluation by glucometer can ensure that normal blood glucose levels have been achieved before the patient is released.
In some instances, marked hyperglycemia may present with symptoms mimicking hypoglycemia. If a glucometer is not available, these symptoms must be treated as hypoglycemia. If the event was actually hyperglycemia, the small amount of extra glucose derived from treatment will generally not have a significant effect.
On the other hand, if glucose-elevating emergency treatment was withheld from a patient in a mistaken belief that the emergency was related to elevated glucose levels when hypoglycemia was in fact present, severe adverse outcomes are possible. The best means of determining the true nature of a glucose-related emergency is to check the blood glucose level with a glucometer. Because hyperglycemic emergencies develop more slowly than does hypoglycemia, they are less likely to be encountered in the dental office. In the dental office, care is limited to activating the emergency medical system, opening the airway and administering oxygen, evaluating and supporting circulation, and monitoring vital signs. The patient should be transported to a hospital as soon as possible.
Management of Hypertension in
- Hypertension is a persistently raised blood pressure resulting from increased peripheral arteriolar resistance. This condition is also known as hypertensive cardiovascular disease and hypertensive heart disease (HHD).
- The cause of hypertension is unknown in most cases and the disorder is therefore termed essential hypertension.
- Primary hypertension, and idiopathic hypertension are synonymous and interchangeable terms, meaning that no cause other than genetics can be found.
The diagnosis of hypertension is made at an arbitrary point when the blood pressure at rest exceeds 160 mm Hg systolic pressure or where diastolic pressure exceeds 95 mm Hg (World Health Organization), or where systolic is above 140 mm Hg and diastolic above 90mm Hg (American Heart Association)
A rise in diastolic blood pressure is much more significant than a rise in systolic pressure, since the higher diastolic pressure translates to a prolonged greater baseline arterial pressure, and therefore may precipitate arteriosclerosis and other end-organ pathology.
MANAGEMENT IN CLINICAL DENTAL
Dentists have a unique opportunity to detect cases of hypertension since patient visits at routine intervals are encouraged. It is a professional responsibility of a dental clinician to inform the patient of their hypertensive state and to offer medical advice, including appropriate referrals.
There are no recognized oral manifestations of hypertension but antihypertensive drugs can often cause side-effects, such as:
- gingival overgrowth,
- salivary gland swelling or pain,
- lichenoid drug reactions,
- erythema multiforme,
- taste sense alteration, and
A. Local Anesthesia
Dental patients with hypertension are best treated under local anesthesia being sure that the anesthesia is complete so that no anxiety induced elevation of blood pressure occurs. The use of vasoconstrictors such as epinephrine in local anesthetic agents is known to have negligible influences on blood pressure in hypertensive patients, according to numerous clinical studies. Data in regard to epinephrine-containing local anesthetics has consistently shown that blood pressure and heart rate are minimally affected by the typically low dose and short duration of the drug use in dentistry, both in healthy and those with existing cardiovascular conditions. Nonetheless, the use of epinephrine-containing anesthetics in patients with uncontrolled hypertension, and elective dental procedures are contraindicated. According to Muzyka & Glick (JADA 1997),
“the benefits of the small doses of epinephrine used in dentistry, when administered
properly,far outweigh the cardiovascular disadvantages”
The use of aspirating syringes in local anesthetics is imperative to avoid intravenous, intrarterial, intraligamentary and intrabony injections, which could potentially precipitate further anxiety and thus rise in pressure and possible arrhythmias.
B. General Anesthesia
All antihypertensive drugs are potentiated by general anesthetic agents, especially barbiturates. General anesthesia tends to cause vasodilation. A severely reduced blood supply to vital organs can be dangerous in healthy individuals, but in the hypertensive person with vascular disease there is greater risk as the tissues have become adapted to a raised blood pressure which is needed to overcome the resistance of the vessels and maintain adequate perfusion. A fall in blood pressure below the critical level needed for adequate perfusion of vital organs such as the kidneys, can therefore be fatal. Hypokalemia as a result of diuretics may be associated with arrhythmias. Some inhalant anesthetics (halothane, enfluane, and isoflurane) are similar in action to calcium slow channel antagonists and so reduce blood pressure significantly.
2. ANXIETY CONTROL
The anxiety and stress associated with dental treatment typically causes a rise in blood pressure and may precipitate cardiac arrest or a cerebrovascular accident. Preoperative reassurance and oral sedation may help in alleviating anxiety related rise in pressure. Use of sedatives the night before a procedure may also be used.
Relative analgesia technique using nitrous oxide (N2O) can also reduce both systolic and diastolic pressure by up to 10-15mm Hg, after approximately 10 minutes of use, preoperatively. Use of oral sedation or nitrous oxide sedation may reduce blood pressure to acceptable levels, allowing initiation of local anesthesia (with or with vasoconstrictor).
3. TIMING OF DENTAL APPOINTMENTS
The increase of blood pressure in hypertensive patient is associated with the hours surrounding awakening that peaks by midmorning. This fluctuation of blood pressure tends to be less likely in the afternoon. Afternoon appointments are recommended over mornings for this reason.
4. ORTHOSTATIC HYPOTENSION
Orthostatic hypotension may be a problem in patients using antihypertensive agents that reduce sympathetic outflow or peripheral vasodilatory actions, such as centrally acting a-2-adrenergic agonists, post-ganglionic adrenergic inhibitors, a-1-adrenergic antagonists, and diuretics. Management of orthostatic hypotension includes avoiding sudden postural changes, such as return to sitting position from the supine operating position. The patient should also be instructed to stay seated for a short period until such time that adequate cerebral perfusion has occured.
5. OTHER DENTAL CONCERNS
Aspirin is now commonly taken by patients with hypertension to decrease associated coronary or cerebral vascular thrombotic disease, and aspirin may cause bleeding problems. Many patients with hypertension develop systolic heart murmurs, in which case prophylaxis for endocarditis
Algorithm for Management of Hypertensive Dental Patientdoc2
N.B.see it in this word document
* SELECTIVE DENTAL PROCEDURE may include, but not limited to;
- dental prophylaxis
- restorative procedures
- nonsurgical periodontal therapy
- nonsurgical endodontic procedures
# EMERGENT NONSTRESSFUL DENTAL PROCEDURE may include, but not limited to dental procedures that may help alleviate pain, infection or masticatory dysfunction. e.g., simple incision and drainage of intraoral fluctuant dental abscess. The medical benefits should outweigh the risk of complications secondary to the hypertensive state, in stage III and IV hypertensive patients.
Normal BP< 130< 85 High Normal BP130-139/85-89 Hypertension Stage I 140-159/90-99 Stage II 160-179/100-109 Stage III180-209/110-119 Stage IV> 210> 120
- Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. The fifth report of the Joint National Committee on Detection, Evaluation, and Treatment of High Blood Pressure. Arch Intern Med 153:154-83, 1993
- Muzyka B.C., and M. Glick. The hypertensive dental patient, JADA 128: 1109-1120, 1997
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