Dental management �for �Medically Compromised Patients 2

This part 2 lecture to discuss Dental management �for �Medically Compromised Patients for undergraduate students. Source from therapeutic guideline book.

1. Dental management for Medically Compromised Patients -2- Dr.Haydar Majeed B.D.S. SEGi Uni.

2. ENDOCRINE CONDITIONS Endocrine conditions of specific importance to dental treatment include diabetes, thyroid disorders, adrenal disorders, and bisphosphonate -treated bone and calcium disorders

3. Diabetes Type 1 diabetes accounts for 10% of all diabetes in adult populations of European origin. It is primarily caused by the immune-mediated destruction of insulin-producing beta cells. Type 2 diabetes is multifactorial in origin; risk factors include impaired glucose tolerance or impaired fasting glucose, previous gestational diabetes, age, obesity, first-degree relative with type 2 diabetes, hypertension, ethnic origin, and clinical cardiovascular disease. All patients with type I diabetes require therapy with insulin, whereas diet and regular exercise can often achieve good control of type 2 diabetes initially. If diet and exercise are not effective, therapy with one or more oral antidiabetic drugs ( eg sulfonylureas, metformin) may be prescribed. Most people with type 2 diabetes eventually require insulin, even after many years of successful oral therapy.

4. Haemoglobin Alc ( HbA1c or glycated haemoglobin ) measurement indicates the average blood glucose concentration over the previous 2 to 3 months . It has a useful role in monitoring long-term glycemic control in patients with diabetes and predicting diabetes-specific complications. A common HbAlc target in patients with diabetes is 7.0% (53 mmol / mol ) or less. If a patient's HbA1c is more than 8.0% (64 mmol / mol ), they may have delayed soft tissue healing- the dentist should liaise with the patient's medical practitioner .

5. Dental issues Dentists should ascertain how well the patient's diabetes is managed by taking a thorough medical history and assessing the patient's adherence to and understanding of their treatment. Patients with poorly controlled diabetes have an increased risk of periodontal disease. May also have impaired salivary gland function from sialadenosis . They should have regular dental care including instruction in oral hygiene and denture maintenance . Consider the possibility of undiagnosed diabetes in patients with a sudden onset of periodontal disease or delayed soft tissue healing, and a patients with recurrent or persistent bacterial or fungal oral infections.

6. Destabilization of diabetic control Most patients with diabetes have a routine of medications, diet, activity, and blood glucose monitoring that keeps them feeling well and their blood glucose concentrations within safe limits. Provided this routine is not interrupted, most general dental treatment can proceed uneventfully. S ome situations can cause instability that, particularly in a patient with unstable type I diabetes, can lead to loss of diabetic control and need for hospitalization.

7. Patients on insulin require regular blood glucose monitoring. Patients often have their own blood glucose monitor and thus are aware of their current blood glucose concentrations. In this situation: if the random blood glucose concentration is between 3.5 and 12 mmol /L, it is reasonable to proceed with the required dental treatment (a normal random blood glucose concentration range for a person without diabetes is 3 to 8 mmol /L) if the random blood glucose concentration is more than 12 mmol /L , the patient's diabetic medication needs to be adjusted by their medical practitioner if the random blood glucose concentration is less than 3.5 mmol /L or the patient exhibits symptoms or signs of hypoglycaemia , administer glucose and treat the patient as a medical emergency. if a patient on insulin presents with an oral infection and is confused , consider the possibility of diabetic ketoacidosis (DKA).

8. Problems with healing In patients with poorly controlled diabetes, healing can be delayed and the risk of infection can be increased. Although there are no detailed studies showing clear benefit from antibiotic prophylaxis, consider prophylaxis for dentoalveolar surgery in patients with poorly controlled diabetes.

9. Approach to general dental treatment for a patient with stable diabetes Initial appointment Determine the patient's usual routine and what type of activity destabilizes their diabetic control. Determine the extent and type of dental treatment required. Ask the patient to bring their glucose monitor with them. Timing of treatment appointments Make treatment appointments for midmorning or early afternoon. Remind the patient to maintain their usual meals and medications. Avoid extensive treatments and long appointments.

10. Treatment When the patient attends for treatment, check that they have followed their normal medication regimen. If they have missed a meal, either reschedule the appointment, or send them to eat and commence treatment 30 minutes later. Do not give the patient glucose or a sweetened drink 'just in case' ; this routine is usually ineffective and destabilizes the patient's diabetes management. If the patient feels ill during treatment, cease treatment. Assess the patient's blood glucose concentration if a blood glucose monitor is available. Do not allow the patient to leave your care if they are unwell or confused.

11. Thyroid disorders Hypothyroidism: Hypothyroidism is a common condition-particularly in females over 55 years, in whom the prevalence may approach 2%. It is generally managed with oral thyroxine. Hyperthyroidism Important symptoms of hyperthyroidism include weight loss, heat intolerance, tremor , muscle weakness and palpitations . The diagnosis may be obvious if there is associated tachycardia and goitre , but presentations of hyperthyroidism are often atypical, particularly in elderly people. Treatment includes drug therapy, radioactive iodine and surgery.

12. Dental issues Patients with a stable medication-controlled thyroid disorder do not usually have difficulties with dental treatment. Patients with an unstable thyroid disorder must have dental treatment deferred until their thyroid condition has been stabilized. Adrenaline-containing local anaesthetics are not contraindicated in patients with stable thyroid disorder, but they should be avoided in patients with unstable hyperthyroidism as there is a risk of thyroid storm (crisis).

13. Adrenal disorders The adrenal glands produce steroid hormones from the cortex and catecholamines from the medulla. When both adrenal glands have been destroyed or removed (primary adrenal insufficiency), replacement of steroid hormones, particularly the glucocorticoids, is essential. Replacement of catecholamines is not needed. Removal of one adrenal gland does not usually require steroid replacement therapy. The therapeutic use of corticosteroids is the most common cause of adrenal suppression. Corticosteroids are used in the management of some inflammatory and immune disorders ( eg rheumatoid arthritis , severe dermatological conditions , severe asthma ). Treatment with prednisolone or prednisone at doses greater than 10 mg daily for more than 3 weeks can be sufficient to cause adrenal suppression.

14. Dental issues It is important to ascertain if a patient is taking corticosteroids and, if so, their underlying condition and current drug regimen. C heck if they are taking bisphosphonates to treat steroid-induced osteoporosis If a patient requires long-term treatment with corticosteroids, they generally have a serious underlying condition. Dental treatment may be physiologically stressful, particularly tooth extractions, root planing and extended restorative treatment. If a patient with adrenal insufficiency or suppression cannot produce sufficient steroid hormones following such stress, Addisonian (adrenal) crisis may occur. This presents as a progressive hypotension occurring 6 to 12 hours after the dental treatment. The patient may initially feel faint, become confused and collapse.

15. If a patient has adrenal insufficiency and is taking replacement therapy, their dose of replacement steroid should be increased on the day before and the day of dental treatment to simulate the normal increase in glucocorticoid secretion that occurs in response to stress. lf a patient has been taking corticosteroids sufficient to cause adrenal suppression, the dose may need to be doubled. If the treatment is more extensive ( eg full dental clearance), or if the patient has been fasting or vomiting, the dose may need to be trebled or quadrupled. Stressful dental treatment should be performed in the morning so that if an Addisonian crisis occurs, symptoms present while the patient is awake. If treatment is performed in the afternoon, the condition may manifest at night and progress while the patient is asleep; this can result in death. After dental treatment, the patient should remain in the presence of a responsible adult for the rest of the day. If symptoms occur, the patient's medical practitioner must be contacted.

16. Bisphosphonate-related osteonecrosis of the jaws Bisphosphonate-related osteonecrosis of the jaws (BRONJ) is an area of exposed bone in the jaws persisting for more than 8 weeks in a patient treated with a bisphosphonate. It is usually painful, and sometimes there is a draining sinus with extensive undermining of the surrounding mucosa overlying the necrotic bone. The most common complication of BRONJ is soft tissue infection, which may be extensive. Other pathologies should be excluded, particularly malignancy at the site and a history of head and neck radiotherapy where the condition is correctly described as osteoradionecrosis of the jaws.

17. BRONJ is thought to be caused by bisphosphonate inhibition of osteoclastic bone resorption, leading to reduced bone turnover. The severity of BRONJ can be classified in stages, ranging from S tage with bone pain but no exposed bone  S tage III with full thickness bone involvement, pathologic fracture, and extensive soft tissue infection and fistulae. BRONJ most commonly follows tooth extractions, but may be associated with poorly fitting dentures. There have also been cases of BRONJ without evident bone-invasive procedures; these commonly occurred over exostoses, such as tori or mylohyoid ridges.

18. Dental procedures in patients treated with bisphosphonates Before commencing long- term oral or intravenous bispbosphonates in any patient, the medical practitioner should refer the patient to a dentist to undet1ake a comprehensive oral examination, including pulp tests and radiographs, to ensure that they are dentally fit and unlikely to require extractions in the foreseeable future . The dentist should eliminate caries ( eg extractions, restorations) , establish a healthy periodontium ( eg scaling , extractions), and advise the medical practitioner when the patient is dentally fit. Patients should be informed of the potential benefits and harms of bisphosphonate therapy, including the risk of developing BRONJ.

19. After commencement of a bisphosphonate, the dentist should monitor the patient's oral health regularly ( eg clinical dental examinations, radiographs), undertake dental treatment as required and, if worn, ensure dentures fit well . Patients with dental implants need to have their implants monitored as loss of osseointegration and BRONJ may occur. Do not undertake extractions or bone surgery in any patient until it is known if they are being treated with a bisphosphonate and, if so, until their risk of BRONJ has been assessed The risk of BRONJ is related to the potency of the bisphosphonate (nitrogen-containing bisphosphonates are more potent than non-nitrogen-containing bisphosphonates), the total dose, and the duration of bisphosphonate therapy . The patient's underlying bone condition, age and comorbidities are also factors. Bisphosphonates enter the bone matrix where they remain for at least l year, and possibly up to 10 years. Clinically , however, the risk of BRONJ decreases 1 year after therapy is ceased.

20. C-terminal telopeptide (CTX) is a breakdown product of bone resorption and therefore its serum concentration provides an estimate of bone turnover. The normal serum CTX concentration is between 400 and 500 pg / mL. Measurement of the fasted morning serum CTX concentration may be considered to assess the risk of BRONJ. If the CTX concentration is 150 pg /mL or more , bone invasive procedures can safely proceed. If the CTX concentration is less than 150 pg /mL , patients are at risk of developing BRONJ and consideration should be given to a 'drug holiday ', where the bisphosphonate is ceased temporarily. The CTX concentration usually increases by 25 pg /mL each month after the bisphosphonate is ceased. This can be used to estimate when bone invasive procedures can be safely undertaken and the length of the drug holiday . A repeat CTX test should be performed to confirm the concentration before undertaking any bone invasive procedures. Generally , bisphosphonate therapy can be restarted 10 days after an extraction.

21. History -taking relating to bisphosphonates It is highly recommended that dentists check the following points with their patients or in the patient's medical history: 1. Have you received treatment for any bone or calcium disorders? Conditions that may be treated with a bisphosphonate include : Osteoprosis Paget's disease of bone cancer with spread to bone ( eg breast, prostate, liver, lung, kidney) • multiple myeloma. 2. Are you taking any bisphosphonate medications? Bisphosphonates are usually taken orally, either daily or once weekly. However, they are sometimes administered intravenously and given less frequently ( eg once yearly ). Bisphosphonates available in: nitrogen-containing bisphosphonates (alendronate, risedronate , pamidronate , zoledronic acid, ibandronate ) non-nitrogen-containing bisphosphonates (et idronate , clod ronate , tiludronate ). If the answer to either of the questions is 'yes', the patient is at risk of bisphosphonate-related osteonecrosis-do not proceed with extractions or bone surgery without careful establishment of the facts regarding the bone or calcium disorder and the medication history. Specialist advice may be needed

22. All procedures involving bone ( eg implant placement, orthodontic tooth movement, periapical or radicular surgery, periodontal flap surgery) require careful consideration and informed consent from the patient before proceeding . If an extraction is unavoidable, it should be performed with the minimum of trauma and with closure of the socket by suturing. Medically well patients can usually be managed in a general dental practice. Severely medically compromised patients on intravenous bisphosphonates for malignancy are best managed by a dental specialist associated with the oncology team. If the patient is medically compromised (particularly if they have diabetes or are taking corticosteroids), consider antibiotic prophylaxis. Monitor the extraction wound until it heals. Healing may be slow. If bone is still clinically visible at 8 weeks, BRONJ has occurred and urgent specialist referral is required. Do not curette non-healing sockets.

23. Q & A