Presentation on management of gingival

1. Periodontal Treatment of
Medically Compromised Patients
( Diabetes, HTN & Pregnancy)
Presented by-
Dr. Md. Irfanur Rahman, BDS
Dhaka Dental College & Hospital

2. Contents
• Systemic diseases influencing periodontal health
• Impact of diabetes mellitus on oral health
• Diabetes mellitus & periodontal health
• Guidelines for management of a diabetic patient in dental office
• Hypertension
• Guidelines for management of a hypertensive patient in dental office
• Pregnancy & periodontal health
• Dental management during pregnancy

3. Systemic diseases influencing periodontal
health
• Endocrine disorders & hormonal changes
• Haematological disorders
• Genetic disorders
• Stress & psychosomatic disorders
• Nutritional deficiency
• Medications
• Other systemic conditions

4. Diabetes mellitus
Diabetes is a chronic, metabolic disease characterized by elevated
levels of blood glucose (or blood sugar), which leads over time to
serious damage to the heart, blood vessels, eyes, kidneys and nerves.
(WHO)
There are two major types of diabetes-
Type 1 (insulin-dependent diabetes mellitus)
Type 2 (non-insulin-dependent diabetes mellitus)

5. Diabetes mellitus
Type 1 diabetes mellitus was formerly known as insulin-dependent
diabetes mellitus, is caused by a cell-mediated autoimmune
destruction of the insulin-producing beta cells of the islets of
Langerhans in the pancreas, which results in insulin deficiency.

6. Diabetes mellitus
Type 2 diabetes mellitus was formerly known as non insulin-dependent
diabetes mellitus, is caused by-
Peripheral resistance to insulin action
Impaired insulin secretion
Increased glucose production in the liver
The insulin-producing beta cells in the pancreas are not destroyed by cell-
mediated autoimmune reaction.
It typically begins as insulin resistance, which leads to the reduced
pancreas production of insulin as the demand increases.

7. Diabetes Mellitus
Diagnostic Criteria for Diabetes Mellitus
• Fasting plasma glucose level ≥126 mg/dL (≥7.0 mmol/L).
• Two-hour postprandial glucose level ≥200 mg/dL (≥11.1 mmol/L)
during an oral glucose tolerance test.
• Glycated hemoglobin (HbA1c) value ≥6.5%
• Random plasma glucose level ≥200 mg/dL (≥11.1 mmol/L) for a
patient with classic symptoms of hyperglycemia
Reference- American Diabetes Association

8. Impact of Diabetes Mellitus on oral health
Oral Manifestations:
• Cheilosis,
• Mucosal drying and cracking,
• Burning mouth and tongue
• Diminished salivary low
• Alterations in the flora of the oral cavity, with greater
predominance of Candida albicans, hemolytic streptococci, and
staphylococci.

9. Diabetes Mellitus & Periodontal Health
Periodontal disease is considered to be the sixth complication of
diabetes.
Adults who are 45 years of age or older with poorly controlled diabetes
(i.e., with HbA1c >9%) are 2.9 times more likely to have severe
periodontitis than those without diabetes. The likelihood was even
greater (4.6 times) among smokers with poorly controlled diabetes

10. Diabetes Mellitus & Periodontal Health
Influence on periodontium:
• Tendency toward an enlarged gingiva
• Sessile or pedunculated gingival polyps
• Polypoid gingival proliferations
• Abscess formation
• Periodontitis and loosened teeth
Perhaps the most striking changes in patients with uncontrolled
diabetes are the reductions in the defense mechanisms and the
increased susceptibility to infections, which lead to destructive
periodontal disease.

11. Diabetes Mellitus & Periodontal Health
Children with type 1 diabetes tend to have more destruction around the
first molars and incisors, however this destruction becomes more
generalized at older ages
Older patients with diabetes have a greater degree of periodontal
destruction, possibly related to more disease destruction over time.
Patients who have had overt diabetes for more than 10 years have a
greater loss of periodontal support than those with a diabetic history of
less than 10 years.

12. Diabetes Mellitus & Periodontal Health
Source: British Dental Journal

13. Diabetes Mellitus & Periodontal Health
Adult with diabetes (blood glucose level
>22.2mmol/L) the gingival inflammation,
spontaneous bleeding, and edema.
Same patient after 4 days of insulin therapy
( blood glucose level <5.6 mmol/L )

14. Guidelines of managing a Diabetic patient in
Dental office
If a patient is suspected of having undiagnosed diabetes, the following
procedures should be performed:
Consult the patient’s physician.
Analyze laboratory tests, including fasting blood glucose and casual glucose
test results.
Rule out acute orofacial infection or severe dental infection; if present,
provide emergency care immediately.
Establish the best possible oral health through nonsurgical debridement of
plaque and calculus. Institute oral hygiene instruction.
Limit more advanced care until the diagnosis has been established and
good glycemic control obtained

15. Guidelines of managing a Diabetic patient in
Dental office
If the patient is known to have diabetes, then-
Patients should be asked to bring their glucometer to the dental
office at each appointment.
For a non surgical therapy, prophylactic antibiotic is not needed, but
before surgical procedure prophylactic antibiotic is given.
Before any surgical procedure, HbA1c <10% should be established.
Patients should check their blood glucose before any long procedure
to obtain a baseline level. Patients with a blood glucose level at or
below the lower end of normal before the procedure may become
hypoglycemic intraoperatively.

16. Guidelines of managing a Diabetic patient in
Dental office
If the procedure lasts several hours, it is often beneficial to check the
glucose level during the procedure to ensure that the patient does
not become hypoglycemic.
After the procedure, the blood glucose can be checked again to
assess fluctuations over time.
Any time the patient feels the symptoms of hypoglycemia, the blood
glucose level should be checked immediately.

17. Cardiovascular Disorder
Common cardiovascular problems are-
• Hypertension
• Angina pectoris
• Myocardial infarction (MI)
• Cardiac bypass surgery
• Cerebrovascular accident (CVA)
• Congestive heart failure (CHF)
• Infective endocarditis (IE)
• Implanted cardiac pacemakers or automatic cardioverter-defibrillators.

18. Hypertension
Hypertension is a long term medical condition in which the blood
pressure in the arteries is persistently elevated.
It is of two types-
1. Primary Hypertension
2. Secondary Hypertension

19. Hypertension
Classification Systolic (mm Hg) Diastolic (mm Hg)
Normal <120 <80
Prehypertension 120-139 80-89
Stage I HTN 140-159 90-99
Stage II HTN ≥160 ≥100

20. Guidelines for management of a
hypertensive patient in dental office
1. Consult the physician clearly explaining the nature of periodontal
therapy.
2. Schedule the appointments preferably in the afternoon.
3. Check BP before starting the procedure.
4. No treatment is done if the systolic BP >180 mmHg or the diastolic
BP >110 mmHg.
5. Use local anesthetics with an adrenaline conc. of 1:100000 or less.
6. If the hypertensive patient exhibits anxiety, use of conscious
sedation in conjunction with periodontal procedures may be
warranted

21. Adverse effects of drugs
Some dental implications of anti-hypertensive drugs are as follows-
Drugs Dental Implications
Diuretics Dry Mouth sometimes
ACE inhibitors Burning mouth syndrome
Lichenoid reaction
ARB Taste disturbance
Dry mouth
Calcium channel blockers Gingival overgrowth
Beta blocker Dry mouth
Lichenoid reaction

22. Pregnancy & Periodontal Health
The chief oral effects of pregnancy are aggravation of gingivitis &
possible development of pregnancy epulis.
These complication usually affects those with pre-existing gingivits. &
starts around second trimester.
Occassionally, recurrent apthae is seen mostly due to iron & folate
deficiency.
During third trimester, supine hypotensive syndrome is seen among
few women.

23. Pregnancy & Periodontal Health
Pregnancy Epulis Recurent apthae

24. Guidelines for management of periodontal
disease during pregnancy
The aim of periodontal therapy for the pregnant patient is to minimize the
exaggerated inflammatory response related to pregnancy-associated
hormonal alterations.
The second trimester is the safest time to perform treatment.
Meticulous plaque control, scaling, root planning, and polishing should be
the only nonemergency periodontal procedures performed.

25. Guidelines for the management of periodontal
disease during pregnancy
In consideration of supine hypotensive syndrome long, stressful
appointments and periodontal surgical procedures should be delayed
until the postpartum period.
Ideally, no medications should be prescribed because the consideration
of potential toxic or teratogenic effects of therapy on the fetus.
The antibiotics listed as Category B include Penicillin, Amoxicillin,
Ampicillin, Cloxacillin, Flucloxacillin, Cephalexin, Cefradine, Cefuroxime,
Cefixime, Cefpodoxime, Cefotaxime, Ceftriaxone, Azithromycin,
Erythromycin, Clotrimazole, Metronidazole.

26. Guidelines for the management of periodontal
disease during pregnancy
However, analgesics, antibiotics, local anesthetics, and other drugs
may be required during pregnancy, depending on the patient’s needs.
Use of dental radiographs during pregnancy should be kept to a
minimum.
However the ADA has stated that “normal radiographic guidelines do
not need to be altered because of pregnancy.”

27. Drugs used in Pregnancy
Source: ResearchGate

28. References
1. Newman & Carranza’s Clinical Periodontology (13th Edition)
2. Cawson’s Essentials of Oral Pathology & Oral Medicine (9th Edition)
3. British Dental Journal ( Periodontology & Diabetes, 11th October,
2019)
4. ResearchGate ( Drug category based on safety during pregnancy,
September 2009)

29. Thank You