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Dental
1. General Medicine inGeneral Medicine in
Dental PracticeDental Practice
Hossam Ghoneim, MDHossam Ghoneim, MD
A. Professor of GastroenterologyA. Professor of Gastroenterology
Cairo UniversityCairo University
Member of American Society ofMember of American Society of
Gastrointestinal Endoscopy (ASGE)Gastrointestinal Endoscopy (ASGE)
9. Diabetes MellitusDiabetes Mellitus
► Diabetes mellitus is a complex syndrome.Diabetes mellitus is a complex syndrome.
► Characterized by abnormalities in carbohydrate,Characterized by abnormalities in carbohydrate,
lipid & protein metabolism that result either fromlipid & protein metabolism that result either from
a profound or an absolute deficiency of insulin,a profound or an absolute deficiency of insulin,
related to autoimmune destruction of the insulin-related to autoimmune destruction of the insulin-
producing pancreatic beta cells (type 1, or insulin-producing pancreatic beta cells (type 1, or insulin-
dependent diabetes mellitus), ordependent diabetes mellitus), or
from target-tissue resistance to its cellular metabolicfrom target-tissue resistance to its cellular metabolic
effects,effects,
related commonly to obesity (type 2, or non–insulin-related commonly to obesity (type 2, or non–insulin-
dependent diabetes mellitus).dependent diabetes mellitus).
10. Diabetes MellitusDiabetes Mellitus
► There is no definitive cure for diabetes.There is no definitive cure for diabetes.
► It is the most common endocrine disorder andIt is the most common endocrine disorder and
affects an estimated 16 million people in USA.affects an estimated 16 million people in USA.
► Complications can be life threatningComplications can be life threatning
These include increased susceptibility to infection andThese include increased susceptibility to infection and
delayed healing; neuropathy, retinopathy anddelayed healing; neuropathy, retinopathy and
nephropathy (microvascular disease); acceleratednephropathy (microvascular disease); accelerated
atherosclerosis with associated myocardial infarctionatherosclerosis with associated myocardial infarction
and coronary artery disease; stroke; atheroscleroticand coronary artery disease; stroke; atherosclerotic
aneurysms (macrovascular disease); and amputation.aneurysms (macrovascular disease); and amputation.
Dental complicationsDental complications
11. Diabetes MellitusDiabetes Mellitus
►Hyperglycemia (elevated blood glucose) is aHyperglycemia (elevated blood glucose) is a
hallmark of diabetes mellitus—as are itshallmark of diabetes mellitus—as are its
chronic metabolic complications.chronic metabolic complications.
►These are generally more severe in theThese are generally more severe in the
patient with type 1 diabetes mellitus.patient with type 1 diabetes mellitus.
►Dentists can reduce the morbidity andDentists can reduce the morbidity and
mortality associated with diabetes bymortality associated with diabetes by
maintaining their patients’ oral health.maintaining their patients’ oral health.
13. Oral Complications Of DiabetesOral Complications Of Diabetes
► Oral complications of uncontrolled DM are devastating.Oral complications of uncontrolled DM are devastating.
► These may include, but are not necessarily limited to,These may include, but are not necessarily limited to,
gingivitis and periodontal disease;gingivitis and periodontal disease;
xerostomia and salivary gland dysfunction;xerostomia and salivary gland dysfunction;
increased susceptibility to bacterial, viral and fungal infections;increased susceptibility to bacterial, viral and fungal infections;
caries;caries;
periapical abscesses;periapical abscesses;
loss of teeth;loss of teeth;
impaired ability to wear dental prostheses (related in part to salivaryimpaired ability to wear dental prostheses (related in part to salivary
dysfunction);dysfunction);
taste impairment;taste impairment;
lichen planus;lichen planus;
burning mouth syndromeburning mouth syndrome
14. Gingivitis and periodontalGingivitis and periodontal
diseasedisease
► The susceptibility to periodontal disease—oftenThe susceptibility to periodontal disease—often
called the "sixth complication of diabetescalled the "sixth complication of diabetes
mellitus"—is the most common oral complicationmellitus"—is the most common oral complication
► The patient with poorly controlled diabetes is atThe patient with poorly controlled diabetes is at
greater risk of developing periodontal disease.greater risk of developing periodontal disease.
► It starts with gingivitis and then, with poor glycemicIt starts with gingivitis and then, with poor glycemic
control, progresses to advanced periodontalcontrol, progresses to advanced periodontal
disease.disease.
► Children with diabetes and adults with less-than-Children with diabetes and adults with less-than-
optimal metabolic control show a tendency towardoptimal metabolic control show a tendency toward
higher gingivitis scores.higher gingivitis scores.
15. Gingivitis and periodontalGingivitis and periodontal
diseasedisease
► Patients with type 1 diabetes and retinopathy tendPatients with type 1 diabetes and retinopathy tend
to exhibit more loss of periodontal attachment byto exhibit more loss of periodontal attachment by
the fourth and fifth decades of life.the fourth and fifth decades of life.
► Thus, good oral hygiene and frequent checkupsThus, good oral hygiene and frequent checkups
with the dentist are extremely important for thewith the dentist are extremely important for the
patient with type 1 diabetes.patient with type 1 diabetes.
16. Gingivitis and periodontalGingivitis and periodontal
diseasedisease
► When people with diabetes smoke, they are 20When people with diabetes smoke, they are 20
times more likely to develop periodontitis with losstimes more likely to develop periodontitis with loss
of supporting bone than are those withoutof supporting bone than are those without
diabetes.diabetes.
► Although primarily related to the presence ofAlthough primarily related to the presence of
dental plaque, periodontitis appears to be relateddental plaque, periodontitis appears to be related
to several pathological events associated withto several pathological events associated with
diabetes, but the reason for the higher rates ofdiabetes, but the reason for the higher rates of
periodontal destruction in people with diabetes isperiodontal destruction in people with diabetes is
not completely understood.not completely understood.
17. Salivary gland dysfunction andSalivary gland dysfunction and
xerostomiaxerostomia
► There are reports of dry mouth complaints (xerostomia)There are reports of dry mouth complaints (xerostomia)
and salivary hypofunction in patients with diabetes, whichand salivary hypofunction in patients with diabetes, which
may be due to polyuria, or an underlying metabolic ormay be due to polyuria, or an underlying metabolic or
endocrine problem.endocrine problem.
► When the normal environment of the oral cavity is alteredWhen the normal environment of the oral cavity is altered
because of a decrease in salivary flow or alteration inbecause of a decrease in salivary flow or alteration in
salivary composition, a healthy mouth can becomesalivary composition, a healthy mouth can become
susceptible to dental caries and tooth deterioration.susceptible to dental caries and tooth deterioration.
18. Salivary gland dysfunction andSalivary gland dysfunction and
xerostomiaxerostomia
► Dry, atrophic and cracking oral mucosa is theDry, atrophic and cracking oral mucosa is the
eventual complication from insufficient salivaryeventual complication from insufficient salivary
production. Accompanying mucositis, ulcers andproduction. Accompanying mucositis, ulcers and
desquamation, as well as an inflamed,desquamation, as well as an inflamed,
depapillated tongue, are also common problems.depapillated tongue, are also common problems.
► Difficulty in lubricating, masticating, tasting andDifficulty in lubricating, masticating, tasting and
swallowing are among the most devastatingswallowing are among the most devastating
complications from salivary dysfunction and maycomplications from salivary dysfunction and may
contribute to impaired nutritional intake.contribute to impaired nutritional intake.
19. Salivary gland dysfunction andSalivary gland dysfunction and
xerostomiaxerostomia
► An increase in the rate of dental caries has beenAn increase in the rate of dental caries has been
reported in young patients with diabetes and mayreported in young patients with diabetes and may
relate to salivary dysfunction.relate to salivary dysfunction.
► Nonetheless, an association existed betweenNonetheless, an association existed between
older adults with diabetes and active caries andolder adults with diabetes and active caries and
tooth loss; this was even more significant intooth loss; this was even more significant in
patients with diabetes having poor glycemicpatients with diabetes having poor glycemic
control.control.
► The dentist can offer topical treatments such asThe dentist can offer topical treatments such as
fluoride-containing mouthrinses and salivaryfluoride-containing mouthrinses and salivary
substitutes to help prevent caries and minimizesubstitutes to help prevent caries and minimize
20. Acute oral infectionsAcute oral infections
► Representative examples of acute oral infectionsRepresentative examples of acute oral infections
—such as recurrent bouts of—such as recurrent bouts of herpes simplex virusherpes simplex virus,,
aa periodontal abscessperiodontal abscess or aor a palatal ulcer,palatal ulcer, illustrateillustrate
the severity of these conditions, particularly inthe severity of these conditions, particularly in
marginally controlled diabetes.marginally controlled diabetes.
► It is possible that the same pathogenicIt is possible that the same pathogenic
mechanisms associated with the increasedmechanisms associated with the increased
susceptibility to periodontal infections (forsusceptibility to periodontal infections (for
example, impaired wound healing, diminishedexample, impaired wound healing, diminished
chemotaxis and PMN function) may play a role inchemotaxis and PMN function) may play a role in
the greater likelihood of developing acute oralthe greater likelihood of developing acute oral
infections.infections.
21.
22. ManagementManagement
►The dentist plays a major role in referral ofThe dentist plays a major role in referral of
patients with diabetes to physicians forpatients with diabetes to physicians for
additional evaluation.additional evaluation.
►Any undiagnosed dental patient who hasAny undiagnosed dental patient who has
the cardinal signs and symptoms ofthe cardinal signs and symptoms of
diabetesdiabetes (polydipsia, polyuria, polyphagia,(polydipsia, polyuria, polyphagia,
weight loss, weakness),weight loss, weakness), or who presentsor who presents
with an oral manifestation (e.g.with an oral manifestation (e.g. xerostomiaxerostomia
or candidiasisor candidiasis), should be referred to a), should be referred to a
physician for diagnosis and treatment.physician for diagnosis and treatment.
23. ManagementManagement
► With respect to surgical procedures, the dentist should testWith respect to surgical procedures, the dentist should test
the patient’s blood sugar with a glucometer to avertthe patient’s blood sugar with a glucometer to avert
emergency-related events such as insulin shock (profoundemergency-related events such as insulin shock (profound
hypoglycemia) or ketoacidosis with severe hyperglycemiahypoglycemia) or ketoacidosis with severe hyperglycemia
before, during or after an invasive procedure.before, during or after an invasive procedure.
► Any patient with diabetes who is going to receive extensiveAny patient with diabetes who is going to receive extensive
periodontal or oral surgery procedures other than single,periodontal or oral surgery procedures other than single,
simple extractions should be given dietary instructions aftersimple extractions should be given dietary instructions after
surgery; these instructions should be established in concertsurgery; these instructions should be established in concert
with the patient’s physician and nutritionist.with the patient’s physician and nutritionist.
24. ManagementManagement
►In the case of an acute oral infection, notIn the case of an acute oral infection, not
only may antibiotics be indicated—only may antibiotics be indicated—
particularly in poorly controlled diabetes—particularly in poorly controlled diabetes—
but also modifications in the patient’sbut also modifications in the patient’s
medications may be needed (for example,medications may be needed (for example,
increasing the insulin dose to preventincreasing the insulin dose to prevent
hyperglycemia related to the pain and stresshyperglycemia related to the pain and stress
from infection).from infection).
25. ManagementManagement
► Finally, the dentist must play a major role inFinally, the dentist must play a major role in
modifying a patient’s destructive health habits,modifying a patient’s destructive health habits,
especially those that introduce a comorbidityespecially those that introduce a comorbidity
factor.factor.
Oral Hygiene practicesOral Hygiene practices
Smoking cessationSmoking cessation
27. HypertensionHypertension
► The diagnosis of hypertension is made at anThe diagnosis of hypertension is made at an
arbitrary point when the blood pressure at restarbitrary point when the blood pressure at rest
systolic is above 140 mm Hg and diastolic abovesystolic is above 140 mm Hg and diastolic above
90mm Hg (American Heart Association).90mm Hg (American Heart Association).
► By these criterion some 10 per cent or more of theBy these criterion some 10 per cent or more of the
population in the USA are hypertensive.population in the USA are hypertensive.
28. HypertensionHypertension
► The 1993 guideline has set 4 stages ofThe 1993 guideline has set 4 stages of
hypertension which emphasize the seriousnesshypertension which emphasize the seriousness
and severity of the condition.and severity of the condition.
► A rise in diastolic blood pressure is much moreA rise in diastolic blood pressure is much more
significant than a rise in systolic pressure, sincesignificant than a rise in systolic pressure, since
the higher diastolic pressure translates to athe higher diastolic pressure translates to a
prolonged greater baseline arterial pressure, andprolonged greater baseline arterial pressure, and
therefore may precipitate arteriosclerosis andtherefore may precipitate arteriosclerosis and
other end-organ pathology.other end-organ pathology.
29. CLASSIFICATION OF BLOOD PRESSURE IN ADULTS 18 OR OLDER
SYSTOLIC DIASTOLIC
Category Pressure (mm HG) Pressure (mm Hg)
Normal BP < 130 < 85
High Normal BP 130-139 85-89
Hypertension
Stage I 140-159 90-99
Stage II 160-179 100-109
Stage III 180-209 110-119
Stage IV > 210 > 120
From the 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
30. Management In Clinical DentalManagement In Clinical Dental
SituationSituation
►Dentists have a unique opportunity to detectDentists have a unique opportunity to detect
cases of hypertension since patient visits atcases of hypertension since patient visits at
routine intervals are encouraged.routine intervals are encouraged.
►It is a professional responsibility of a dentalIt is a professional responsibility of a dental
clinician to inform the patient of theirclinician to inform the patient of their
hypertensive state and to offer medicalhypertensive state and to offer medical
advice, including appropriate referrals.advice, including appropriate referrals.
31. ANESTHESIAANESTHESIA
► Local AnesthesiaLocal Anesthesia
Dental patients with hypertension are best treated under localDental patients with hypertension are best treated under local
anesthesia being sure that the anesthesia is complete so that noanesthesia being sure that the anesthesia is complete so that no
anxiety induced elevation of blood pressure occurs.anxiety induced elevation of blood pressure occurs.
Data in regard to epinephrine-containing local anesthetics hasData in regard to epinephrine-containing local anesthetics has
consistently shown that blood pressure and heart rate are minimallyconsistently shown that blood pressure and heart rate are minimally
affected by the typically low dose and short duration of the drug useaffected by the typically low dose and short duration of the drug use
in dentistry, both in healthy and those with existing cardiovascularin dentistry, both in healthy and those with existing cardiovascular
conditions.conditions.
Nonetheless, the use of epinephrine-containing anesthetics inNonetheless, the use of epinephrine-containing anesthetics in
patients with uncontrolled hypertension, and elective dentalpatients with uncontrolled hypertension, and elective dental
procedures are contraindicated.procedures are contraindicated.
32. TIMING OF DENTALTIMING OF DENTAL
APPOINTMENTSAPPOINTMENTS
►The increase of blood pressure inThe increase of blood pressure in
hypertensive patient is associated with thehypertensive patient is associated with the
hours surrounding awakening that peaks byhours surrounding awakening that peaks by
midmorning.midmorning.
►This fluctuation of blood pressure tends toThis fluctuation of blood pressure tends to
be less likely in the afternoon.be less likely in the afternoon.
►Afternoon appointments are recommendedAfternoon appointments are recommended
over mornings for this reason.over mornings for this reason.
33. ORTHOSTATIC HYPOTENSIONORTHOSTATIC HYPOTENSION
► Orthostatic hypotension may be a problem inOrthostatic hypotension may be a problem in
patients using antihypertensive agents that reducepatients using antihypertensive agents that reduce
sympathetic outflow or peripheral vasodilatorysympathetic outflow or peripheral vasodilatory
actionsactions
► Management of orthostatic hypotension includesManagement of orthostatic hypotension includes
avoiding sudden postural changes, such as returnavoiding sudden postural changes, such as return
to sitting position from the supine operatingto sitting position from the supine operating
position.position.
► The patient should also be instructed to stayThe patient should also be instructed to stay
seated for a short period until such time thatseated for a short period until such time that
adequate cerebral perfusion has occurred.adequate cerebral perfusion has occurred.
34. OTHER DENTAL CONCERNSOTHER DENTAL CONCERNS
►Aspirin is now commonly taken by patientsAspirin is now commonly taken by patients
with hypertension to decrease associatedwith hypertension to decrease associated
coronary or cerebral vascular thromboticcoronary or cerebral vascular thrombotic
disease, and aspirin may cause bleedingdisease, and aspirin may cause bleeding
problems.problems.
►Many patients with hypertension developMany patients with hypertension develop
systolic heart murmurs, in which casesystolic heart murmurs, in which case
prophylaxis for endocarditis.prophylaxis for endocarditis.
Antibiotic inj. 1hr prior to procedureAntibiotic inj. 1hr prior to procedure
35.
36. HypertensionHypertension
► Undetected and insufficiently treated hypertensionUndetected and insufficiently treated hypertension
is a problem in a dental environment. Elevated BP,is a problem in a dental environment. Elevated BP,
especially markedly elevated BP, increases aespecially markedly elevated BP, increases a
patient’s risk of experiencing cardiovascularpatient’s risk of experiencing cardiovascular
conditions such as angina, myocardial infarctionconditions such as angina, myocardial infarction
and cerebrovascular accident while undergoingand cerebrovascular accident while undergoing
dental care.dental care.
► The JNC 7 urges all health care professionals,The JNC 7 urges all health care professionals,
including dentists, to become actively involved inincluding dentists, to become actively involved in
diagnosing HTN by simple sphignomanomiter.diagnosing HTN by simple sphignomanomiter.
37. HypertensionHypertension
► Any dental patients whose BP is higher thanAny dental patients whose BP is higher than
210/120 mm Hg should be referred for immediate210/120 mm Hg should be referred for immediate
medical evaluation.medical evaluation.
► It is not uncommon for patients seeking urgentIt is not uncommon for patients seeking urgent
dental care to have elevated BP. The possibledental care to have elevated BP. The possible
causes of this are multiple and include undetectedcauses of this are multiple and include undetected
hypertension, inadequate treatment, poor patienthypertension, inadequate treatment, poor patient
compliance with physicians’ recommendations, orcompliance with physicians’ recommendations, or
simply the associated painsimply the associated pain
38. HypertensionHypertension
► From a dental treatment perspective, there is no simpleFrom a dental treatment perspective, there is no simple
answer to the problem posed by people with elevated BPanswer to the problem posed by people with elevated BP
needing urgent dental care, such as an extraction.needing urgent dental care, such as an extraction.
► There are no professionally recognized criteria based onThere are no professionally recognized criteria based on
BP values to indicate when it is safe to proceed.BP values to indicate when it is safe to proceed.
44. Liver DiseaseLiver Disease
►Wide spectrum of disease amongst whichWide spectrum of disease amongst which
the chronic viral hepatitis is the mostthe chronic viral hepatitis is the most
common in Egypt.common in Egypt.
►Estimated 12 million patients with HCV (1 inEstimated 12 million patients with HCV (1 in
6 of the population) and about 2.5 million6 of the population) and about 2.5 million
with HBVwith HBV
►Estimated new cases of HCV about 100,000Estimated new cases of HCV about 100,000
per yearper year
►National campaign treated 26000 patients inNational campaign treated 26000 patients in
three yearsthree years
45. HBVHBV
► Preventable diseasePreventable disease
Efficient vaccineEfficient vaccine
►Transmitted sexually, Perinatally and byTransmitted sexually, Perinatally and by
bloodblood
►Long term oral treatment with no definitiveLong term oral treatment with no definitive
cure pointcure point
►More chance to develop HCCMore chance to develop HCC
►Leads to chronic liver disease and LCFLeads to chronic liver disease and LCF
46. HCVHCV
► No VaccineNo Vaccine
Integrated community efforts are indispensableIntegrated community efforts are indispensable
► Transmitted ONLY by blood, even vertical orTransmitted ONLY by blood, even vertical or
intrafamilial transmission is below 3%intrafamilial transmission is below 3%
► Defenitive cure is possible with a success rate ofDefenitive cure is possible with a success rate of
60% in the early stages of the disease, using60% in the early stages of the disease, using
INTERFERON (The ONLY treatment)INTERFERON (The ONLY treatment)
► Less chance to develop HCCLess chance to develop HCC
► Leads to more aggressive liver disease & LCFLeads to more aggressive liver disease & LCF
47. Chronic Liver Disease & LCFChronic Liver Disease & LCF
► Chronic HepatitisChronic Hepatitis
► Liver CirrhosisLiver Cirrhosis
Compensated – fatigue & malaiseCompensated – fatigue & malaise
Decompensated – one or more of LCF complicationsDecompensated – one or more of LCF complications
► Liver Cell Failure (LCF)Liver Cell Failure (LCF)
Heamatemesis & Bleeding tendencyHeamatemesis & Bleeding tendency
Jaundice (under surface of tongue)Jaundice (under surface of tongue)
Ascites & LL oedemaAscites & LL oedema
Hepatic encephalopathy & coma, where fetor hepaticusHepatic encephalopathy & coma, where fetor hepaticus
is one of the early signsis one of the early signs
48. Liver patient in the Dental clinicLiver patient in the Dental clinic
► Infection controlInfection control
CidexCidex
Personalized setsPersonalized sets
Professional riskProfessional risk
► Bleeding tendenciesBleeding tendencies
P.T & P.C.P.T & P.C.
► EncephalopathyEncephalopathy
Foetor hepaticusFoetor hepaticus
NervousnessNervousness
► MedicationsMedications
AntibioticsAntibiotics
NSAIDsNSAIDs
55. CRFCRF
►ON Dialysis or on medication?ON Dialysis or on medication?
NO DOSE ADJUSTMENTS IF ON DIALYSISNO DOSE ADJUSTMENTS IF ON DIALYSIS
►UremiaUremia
Urea & creatinine levelsUrea & creatinine levels
56. Take Home MessageTake Home Message
► Dentists are reputed doctors dealing with humanDentists are reputed doctors dealing with human
beings (patients)beings (patients)
► History takingHistory taking
► Prescription pitfallsPrescription pitfalls
► Diagnosing medical problemsDiagnosing medical problems
► Integrated efforts for disease preventionIntegrated efforts for disease prevention
Infection controlInfection control
Patient educationPatient education
