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1. 29-09-2023 1

2. 29-09-2023 2
Impact of Periodontal Infection
on
Systemic Health
Guided by:
Dr. Monica Mahajani
Dr. Chandrahas Goud
Dr. Anup Shelke
Dr. Subodh Gaikwad
Dr. Anup Gore
Dr. Kuldeep Patil
Dr. Amrita Das
Presented by:
Dr. Chavan Sneha S.
(2nd Year PG)

3. Contents:
• Pathobiology of Periodontitis
• Focal Infection Theory
• Subgingival Environment as a Reservoir for Bacteria
• Periodontal Disease and Mortality
• Periodontal Disease, Coronary Heart Disease, and Atherosclerosis Periodontal Disease
and Stroke
• Periodontal Disease and Pregnancy Outcome
• Periodontal Disease and Chronic Obstructive Pulmonary Disease
• Periodontal Disease and Acute Respiratory Infections
• Periodontal Disease and Asthma
• Periodontal Disease and Diabetes Mellitus
• Conclusions
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4. The mechanisms by which periodontal infections may
influence systemic health have been described as follows:
• 1. Oral-hematogenous spread of periodontal pathogens and direct effects to
target organs.
• 2. Transtracheal spread of periodontal pathogens and direct effects to target
organs.
• 3. Oral-hematogenous spread of cytokines and antibodies with effects at
distant organs.
Association between periodontitis and the development of systemic diseases Igari et al. Oral Biology and
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5. 29-09-2023 5
Preterm
Low birth weight
Diabetes
Atherosclerosis,
Cardiovascular disease
Heart & Blood vessel
Endothelial injury,
Lipid deposition,
Monocyte migration,
Smooth muscle proliferation
ACUTE PHASE PROTEINS
CRP, SSA, IL-6, TNF-α, IL-6
BLOOD STREAM
SYSTEMIC INFLAMMATORY PROCESS
Inflammatory mediators
(IL-1, , INF-g, IL-6, IL-8)
Bacteria Products
(LPS, Fimbriae)
Bacteria
PERIODONTAL INFECTION
Placenta/Uterus
Contraction of uterine smooth
muscle,
Preterm rupture of membrane
Liver & Pancreas
Insulin resistance,
Glucose intolerance
Periodontal infections and systemic diseases,Anil & Al-Ghamdi , Saudi Med J 2006; Vol. 27 (6): 767-776

6. Pathobiology of Periodontitis
• Pathogenic bacteria + Susceptible host = Periodontitis
• Due to differences in host susceptibility, not all individuals are equally
vulnerable to the destructive effects of periodontal pathogens and
the immunoinflammatory response to those organisms.
• Recent evidence suggests that periodontal infection may significantly
enhance the risk for certain systemic diseases or alter the natural
course of systemic conditions.
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7. FOCAL INFECTION THEORY
• British physician William Hunter (1900) first developed the idea that
oral microorganisms were responsible for a wide range of systemic
conditions.
• He stated that the degree of systemic effect produced by oral sepsis
depended on the virulence of the oral infection and the individual's
degree of resistance.
• Oral organisms had specific actions on different tissues and that these
organisms acted by producing toxins, resulting in lowgrade
“subinfections” produced systemic effects over prolonged
periods.
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8. • 1940s and 1950s eventually this theory lost importance………..
due to lack of evidence.
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9. The Subgingival Environment As Reservoir for
Bacteria
• The subgingival microbiota in patients with periodontitis provides
a significant and persistent gram-negative bacterial challenge to
the host.
Gram-negative organisms and
their products, such as LPSs
sulcular epithelium
Periodontal tissues
Circulation
Bacteremia and
Septicemia
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10. • Bacteremias are common after mechanical periodontal therapy, and
they also occur frequently during normal daily function and oral
hygiene procedures.
• This host response may offer explanatory mechanisms for the
interactions between periodontal infection and a variety of systemic
disorders.
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11. Periodontal Disease and Mortality
• CHD-related events are a major cause of death.
• MI has been associated with acute systemic bacterial and viral
infections and is sometimes preceded by influenza-like
symptoms.
• Localized infection that results in a chronic inflammatory
reaction has been suggested as a mechanism underlying CHD
in these individuals.
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12. Effects of Periodontal Infection
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Periodontal Disease Systemic Diseases

13. • Cardiovascular/ cerebrovascular system
Atherosclerosis
Coronary heart disease
Angina
Mycardial infraction
Cerebrovascular accident
• Endocrine system
Diabetes mellitus
• Reproductive system
Preterm low-birth-weight (LBW) infants
preeclampsia
• Respiratory system
Chronic obstructive pulmonary disease (COPD)
Acute bacterial pneumonia
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14. EFFECT OF PERIODONTAL DISEASES ON
CARDIOVASCULAR SYSTEM
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15. Ischemic Heart Disease
• Increased viscosity of blood may promote major ischemic heart
disease and stroke by increasing the thrombus formation.
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16. 29-09-2023 16

17. Factors that affect blood viscosity in health
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18. HDL cholesterol did not influence blood and plasma viscosity in healthy
normolipidemic subjects.
LDL cholesterol was marginally associated with blood viscosity.
Claudio Carallo et al.,The effect of HDL cholesterol on blood and plasma viscosity in healthy subjects, Clinical Hemorheology
and Microcirculation 55 (2013) 223–229.
HDLs interact in the bloodstream with other lipoproteins, exchange cholesterol and
triglyceride with them, ensuring the transport of excess cholesterol to the liver.
A.V. Khera, M. Cuchel, M. de la Llera-Moya, A. Rodrigues, M.F. Burke, K. Jafri, B.C. French, J.A. Phillips, M.L. Mucksavage, R.L. Wilensky, E.R.
Mohler, G.H. Rothblat and D.J. Rader, Cholesterol efflux capacity, high-density lipoprotein function, and atherosclerosis, N Engl J Med 364
(2011), 127–135.
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19. • HDLs also protect LDLs from oxidation, due to their content in
paraoxonase.
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M. Dess`ı, A. Gnasso, C. Motti, A. Pujia, C. Irace, S. Casciani, F. Staffa, G. Federici and C. Cortese, Influence of the human paraoxonase
polymorphism (PON1 192) on the carotid wall thickening in a healthy population, Coronary Artery Disease 10 (1999), 595–599.
A. Gnasso, C. Motti, C. Irace, I. Di Gennaro, A. Pujia, E. Leto, M. Ciamei, A. Crivaro, S. Bernardini, G. Federici and C. Cortese, The Arg
allele in position 192 of PON1 is associated with carotid atherosclerosis in subjects with elevated HDLs, Atherosclerosis 164 (2002),
289–295.

20. Systemic Infections
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21. Daily Activity
• An estimated 8% of all cases of infective endocarditis are associated
with periodontal or dental disease without a preceding dental
procedure.
• The periodontium, when affected by periodontitis, also acts as a
reservoir of endotoxins (LPSs) from gram-negative organisms.
• Endotoxins can pass readily into the systemic circulation during
normal daily function, thereby inducing damage to the vascular
endothelium and precipitating many negative cardiovascular effects.
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22. 29-09-2023 22
Adipokines and cardiovascular disease: a comprehensive review Ales Smekal, Jan Vaclavik, Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub. 2017; 161:XX

23. Thrombogenesis
• Platelet aggregation plays a major role in thrombogenesis.
• Oral organisms may be involved in coronary thrombogenesis
i.e. Streptococcus sanguinis, Porphyromonas gingivalis.
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24. Thromboembolism mechanism
Oral pathogens– Streptococcus sanguis and P. gingivalis
Expression of -Plalelet Aggregation Associated Protein on some
of strains
Bacterial strains enters the circulation and aggregation of platelets
Forms thromboemboli
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25. Atherosclerosis
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26. Pathogenesis of atherosclerosis
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Adhesion molecules:
intercellular adhesion molecule-1 (ICAM- 1),
endothelial leukocyte adhesion molecule-1 (ELAM-1), &
vascular cell adhesion molecule-1 (VCAM-1)
cytokines
Produces
proinflammatory
mediators

27. The influence of periodontal infection on atherosclerosis
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28. The cardiovascular and periodontal consequences of the
hyperresponsive monocyte/macrophage phenotype (MØ+ )
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29. • In cardiovascular disease, the use of statins and antihypertensives
aims to control risk factors, but there are currently no available
therapies that effectively stabilize or reverse established plaques.
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Bertrand MJ, Tardif JC. Inflammation and beyond: new directions and emerging drugs
for treating atherosclerosis. Expert Opin Emerg Drugs. 2017;22(1):1–26.

30. • Anxiety and pain can enhance sympathetic activity and adrenaline
release, which increases the load on the heart and the risk of angina
or arrhythmias.
• Appointments should be short.
• Recent evidence indicates that endogenous epinephrine levels peak
during morning hours and adverse cardiac events are most likely in
the early morning, so late morning appointments are recommended.
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31. • Patients with heart disease should take their medications as usual on
the day of the dental procedure, and should bring all their
medications to the dental office for review at the time of the first
appointment.
• The most important aspect for dentists to consider is how well the
patient’s heart condition is compensated.
• Patients with stable heart disease receiving atraumatic treatment
under LA can receive treatment in the dental surgery. The dental
team should provide dental care with a stress- reduction protocol and
with good analgesia.
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32. • Pain control is crucial to minimize endogenous adrenaline release.
• Local anaesthetics must be given with aspiration and it may be
prudent to avoid epinephrine-containing LA, since
adrenaline/epinephrine in the anaesthetic entering a vessel may
theoretically raise the BP or precipitate arrhythmias.
• If a patient is taking a non-selective beta-blocker (e.g. propanolol),
use no more than two carpules of LA with epinephrine (adrenaline)
1:80,000.
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33. • The use of pulse oximetry and prophylactic sedatives should be
considered. Cardiac monitoring is desirable in some instances.
• Conscious sedation preferably with nitrous oxide can be given with
the approval of the physician.
• General anaesthesia (GA) is a matter for expert anaesthetists in
hospital.
• The combination of aspirin with other anti-platelet drugs increases
the chances for significant postoperative bleeding.
• Aspirin may cause sodium and fluid retention, which may be
contraindicated in severe hypertension or cardiac failure.
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34. • Indometacin may interfere with antihypertensive agents.
Furthermore, drugs such as erythromycin and clarithromycin
should be avoided in long QT syndrome and in patients also taking
statins (antihyperlipidemics).
• Macrolides, such as erythromycin, and azoles may cause statins to
produce increased muscle damage.
• In the case of intraoperative chest pain, include the use of
sublingual GTN (glyceryl trinitrate) spray, aspirin and oxygen.
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35. 29-09-2023 35

36. EFFECT OF PERIODONTAL DISEASES ON
CEREBROVASCULAR SYSTEM
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37. Periodontal Disease and Stroke
• Ischemic cerebral infarction, or stroke, is often preceded by systemic
bacterial or viral infection.
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38. • periodontal infection may stimulate a series of indirect systemic
effects, such as elevated production of fibrinogen and CRP, which
increases the risk of stroke.
• Finally, bacteremia with PAAP-positive bacterial strains from
supragingival and subgingival plaque can increase platelet
aggregation, thereby contributing to thrombus formation and
subsequent thromboembolism, which is the leading cause of stroke.
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39. • Avoid elective dental treatment for 6 months after a stroke or TIA.
• Arrange stress-free midmorning appointments with supine
positioning and raise the patient slowly to avoid orthostatic
hypotension.
• Monitor BP and heart rate preoperatively and 5 minutes after LA
injection.
• Consider bleeding tendency if patient is anticoagulated. Ensure oral
hygiene is maintained.
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40. EFFECT OF PERIODONTAL DISEASES ON
REPRODUCTIVE SYSTEM
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41. Periodontal Disease and Pregnancy Outcome
• Low-birth-weight (LBW) infants are 40 times more likely to die during
the neonatal period than normal-birth-weight (NBW) infants.
• LBW infants had significantly higher levels of Aggregatibacter
actinomycetemcomitans, Tannerella forsythia, P. gingivalis, and
Treponema denticola in their subgingival plaque than did the control
women who had NBW infants.
• Women having LBW infants also have higher levels of gingival
crevicular fluid (GCF), PGE2 , and IL-1.
Offenbacher S, Jarad HL, O'Reilly PG, et al. Potential pathogenic mechanisms of periodontitis-associated
pregnancy complications. Ann Periodontol. 1998;3:233–250.
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42. • Vogt et al. reported more cases of periodontal damage with greater
clinical attachment loss in pregnant women in trimester III Gingivitis is
the most common oral manifestation with a prevalence ranged widely
from 35 to 100%.
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Onigbinde OO, Sorunke ME, Braimoh MO, Adeniyi AO. Periodontal status and some variables among pregnant
women in a Nigeria tertiary institution. Ann. Med. Health Sci. Res 2014;4(6):852–857.

43. • Periodontal disease may also increase the risk for preeclampsia.
• The presence of periodontitis during pregnancy or a worsening of
periodontal disease during pregnancy is associated with a 2 fold to
2.5 fold increased risk for preeclampsia.
Ide M, Papapanou PN. Epidemiology of association between maternal periodontal disease and
adverse pregnancy outcomes – systematic review. J Periodontol. 2013;84(Suppl 4):S181–S194.
Boggess KA, Lieff S, Murtha AP, et al. Maternal periodontal disease is associated with an
increased risk for preeclampsia. Obstet Gynecol. 2003;101:227–231.
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44. 29-09-2023 44
Terzic, M.; Aimagambetova, G.; Terzic, S.; Radunovic, M.; Bapayeva, G.; Laganà, A.S. Periodontal Pathogens and Preterm Birth: Current Knowledge and Further Interventions. Pathogens 2021, 10, 730.
Role of periodontal infection in preterm labor

45. Mechanisms by which infection may induce preterm labor
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46. 29-09-2023 46
Hall’s Critical Decisions in Periodontology and Dental Implantology, Lisa A. Harpenau;Fifth Edition

47. • Zhu et al. reported that initial periodontal therapy combined with oral
hygiene maintenance is efficacious in treating gingival pregnancy
granuloma with normal hormone levels, which can eliminate irritants
and could potentially serve as an option to avoid surgery.
• No recurrence of gingival pregnancy tumors was noted during
subsequent follow-up. Considering the etiological factors and clinical
characteristics, they assume that initial periodontal therapy could
eliminate irritants and yield high clinical efficacy.
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Zhu YQ, Wang YQ, Tang YC, Li CZ. Initial periodontal therapy for the treatment of gingival pregnancy
tumor. Genet Mol Res 2016,15(2).

48. • When the gingival enlargement is severe or persists, despite good
plaque control and initial periodontal therapy, surgical correction is
advocated.
• It includes conventional scalpel techniques, cryotherapy,
electrocautery, sclerotherapy and laser therapy
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Tsai KY, Wang WH, Chang GH, Tsai YH. Treatment of pregnancy-associated oral pyogenic granuloma with lifethreatening
haemorrhage by transarterial embolisation. J. Laryngol. Otol 2015;129(6):607-610.
Wang SQ, Goldberg LH. Treatment of recurrent pyogenic granuloma with excision and frozen section for margin control.
Dermatol. Surg 2008;34(8):1115-1116.

49. • Excisional surgery remains the most common therapy for pyogenic
granuloma.
• However, the surgical approach may produce unwanted mucogingival
defects and severe gingival injury, especially when the pregnancy
tumor is located in the anterior region.
29-09-2023 49
Esmeili T, Lozada-Nur F, Epstein J. Common benign oral soft tissue masses. Dent. Clin. North Am 2005;49(1):223240, x.
Joda T. Esthetic management of mucogingival defects after total excision in a case of pyogenic granuloma. Eur. J. Esthet.
Dent 2012;7(2):110-119.

50. • So, the regular supportive periodontal therapy is effective in resolving
the inflammation and the gingival overgrowth and in eliminating the
need for surgical treatment.
• Partial or complete regression after parturition is one of the clinical
features of pregnancy granuloma.
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Zhu YQ, Wang YQ, Tang YC, Li CZ. Initial periodontal therapy for the treatment of gingival
pregnancy tumor. Genet Mol Res 2016,15(2).
Seymour RA. The sex hormones. In: Seymour RA, Heasman PA, (eds). Drugs, diseases, and the
periodontium. Oxford University Press: New York 1992,135-138p.

51. • It has been proposed that, in the absence of vascular endothelial
growth factor (VEGF), angiopoietin-2 (Ang-2) causes blood vessels to
regress.
• Periodontal surgery is relatively contraindicated during pregnancy.
29-09-2023 51
Yuan K, Lin MT. The roles of vascular endothelial growth factor and angiopoietin-2 in the
regression of pregnancy pyogenic granuloma. Oral Dis 2004;10(3):179-85.
Little JW. Pregnancy and breast-feeding. In: Little JW, Falace DA, eds. Dental management of
the medically compromised patient, 3rd edn. The CV Mosby Company: St Louis 1988,325-331p

52. Drugs to avoid in pregnant mothers:
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53. 29-09-2023 53

54. Drug use in pregnancy:
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55. 29-09-2023 55

56. EFFECT OF PERIODONTAL DISEASES ON
RESPIRATORY SYSTEM
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57. Periodontal Disease and Chronic Obstructive
Pulmonary Disease
• COPD shares similar pathogenic mechanisms with periodontal
disease.
• Individuals with poor oral hygiene have also been found to be at
increased risk for chronic respiratory diseases such as bronchitis and
emphysema.
Scannapieco FA, Papandonatos GD, Dunford RG. Associations between oral conditions and respiratory disease in
a national sample survey population. Ann Periodontol. 1998;3:251–265
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58. How oral bacteria can participate in the pathogenesis of
respiratory infections:
• 1. Oral pathogens (such as P. gingivalis, A. actinomycetemcomitans)
may be aspirated into the lung to cause infection.
• 2. Periodontal disease – associated enzymes in saliva may modify
mucosal surfaces to promote adhesion and colonization by
respiratory pathogens.
• 3. Cytokines originating from periodontal tissues may alter respiratory
epithelium to promote infection by respiratory pathogen.
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59. • In untreated periodontal disease, oral pathogens continuously
stimulate the cells of the periodontium to release a wide variety of
cytokines and other biologically active molecules.
• Cytokines produced by epithelial and connective tissue cells in
response to these bacteria are interleukin IL - 1α, IL - 1β, IL - 6, IL - 8,
and TNF - α.
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60. • Oral bacteria can also stimulate the peripheral mononuclear cells to
release cytokines (IL1α and TNF - α). Thus, resulting neutrophil influx
leads to release of oxidative and hydrolytic enzymes that cause tissue
destruction directly.
• Recruitment of monocytes and macrophages leads to further release
of proinflammatory mediators.
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61. • A longitudinal study of >1100 men showed that more severe bone
loss found during the baseline dental examination was associated
with an increased risk of subsequently developing COPD as compared
with less bone loss, independent of age, smoking status, and other
known risk factors for COPD.
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62. Periodontal Disease and Acute Respiratory
Infections
• Community-acquired bacterial pneumonia is caused primarily by the
inhalation of infectious aerosols or the aspiration of oropharyngeal
organisms.
• Streptococcus pneumoniae and Haemophilus influenzae are the most
common, although numerous other species may be found, including
anaerobic bacteria.
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Ostergaard L, Anderson PL. Etiology of communityacquired pneumonia: evaluation by transtracheal aspiration, blood culture, or serology. Chest.
1993;104:1400– 1407.

63. • To date, no associations have been found between oral hygiene or
periodontal disease and the risk for acute respiratory conditions such
as pneumonia in community-dwelling individuals.
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Scannapieco FA, Papandonatos GD, Dunford RG. Associations between oral conditions and respiratory disease
in a national sample survey population. Ann Periodontol. 1998;3:251–265

64. 29-09-2023 64
Zhang D, Wang Z (2018) The Association between Chronic Periodontitis and Chronic Obstructive Pulmonary Disease - A Review. Int J Oral
How periodontitis could contribute to the development of COPD ?

65. • Best treated in an upright position at midmorning or early
afternoon, since they may become increasingly dyspnoeic if laid
supine.
• LA is preferred for dental treatment, but bilateral mandibular or
palatal injections should be avoided.
• Conscious sedation with diazepam and midazolam should not be
used.
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66. • Patients should be given GA only if absolutely necessary;
postoperative respiratory complications are more prevalent.
• Interactions of theophylline with drugs, such as epinephrine,
erythromycin, clindamycin, clarithromycin or ciprofloxacin, may result
in dangerously high levels of theophylline.
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67. RENAL DISEASE
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68. • The most common causes of renal failure are glomerulonephritis,
pyelonephritis, kidney cystic disease, renovascular disease, drug
nephropathy, obstructive uropathy, and hypertension.
• The dental management of patients with renal disease may need
to be drastically altered, physician consultation is necessary to
determine the stage of renal disease, regimen for medical
management, and alterations in periodontal therapy.
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69. • The following treatment modifications should be made:
Consult the patient's physician.
Monitor BP; patients in end-stage renal failure are usually hypertensive.
Eliminate areas of oral infection to prevent systemic infection.
• Good oral hygiene should be established.
• Periodontal treatment should aim at eliminating inflammation or
infection and providing easy maintenance.
Questionable teeth should be extracted if medical parameters permit.
• Frequent recall appointments should be scheduled.
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70. • Drugs that are nephrotoxic or metabolized by the kidney should not
be given (e.g., phenacetin, tetracycline, aminoglycoside antibiotics).
• Acetaminophen may be used for analgesia and diazepam for
sedation. Local anesthetics such as lidocaine are usually safe.
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71. Bleeding tendency:
• Excessive bleeding can occur during or after periodontal treatment
because of drug-induced thrombocytopenia or anticoagulation, or
both.
• Minor surgery can be performed with an INR of up to 2.5.
• Complex surgery or multiple extraction may require an INR < 1.5.
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72. • the patient who is receiving dialysis requires modifications in
treatment planning.
• Only hemodialysis patients require special precautions.
• They have a high incidence of viral hepatitis, anemia, and prolonged
hemorrhage. The risk of hemorrhage is related to anticoagulation
during dialysis, platelet trauma from dialysis, and the uremia that
develops with renal failure.
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73. • Patients receive heparin anticoagulation on the day of
hemodialysis.
• Periodontal treatment should be provided on the day after
dialysis, when the effects of heparinization have subsided.
Hemodialysis treatments are usually performed three or four
times per week.
• If an emergency dental treatment needs to be performed on the
day of dialysis, protamine sulfate can be administered.
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74. Hypertension:
• The patient with ESRD are usually hypertensive.
• The blood pressure should be controlled with antihypertensive drug.
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75. Anemia:
• Decrease in synthesis of erythropoietin in kidney disorders may
results in anemia.
• The patient may complain of tiredness & inability to tolerate long
dental procedures.
• The physician should be consulted for the needful treatment & then
dental treatment should be carried out.
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76. Drug intolerance:
• Penicillin & its derivatives (such as amoxicillin), clindamycin &
cephalosporins are the preferred antibiotics.
• Paracetamol is the drug of choice in NSAIDs.
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77. Susceptibility to infection :
• Transplant recipients take immunosuppressive drugs that greatly
reduce resistance to infection.
• Individuals with permanent kidney dialysis shunts should be placed
on prophylactic antibodies.
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78. Gingival overgrowth:
• A patient with gingival overgrowth should be asked to maintain
good oral hygiene.
• A change in immunosuppressive therapy is an alternative to
surgical treatment, but it is not always possible.
• In case of severe gingival overgrowth, gingivectomy should be
performed.
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79. • In addition to the recommendations for patients with chronic renal
failure, the following should be considered for the renal transplant
recipient:
1. Hepatitis B and C screening
2. Determination of the level of immune system compromise
resulting from antirejection drug therapy
3. Prophylactic antibiotics using AHA recommendations or a specific
regimen based on physician consultation; not all transplant
recipients require antibiotic coverage, and physician consultation
is warranted before prescribing.
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80. 29-09-2023 80
Yasuyoshi Miyata et al.Review Periodontal Disease in Patients Receiving Dialysis, Int. J. Mol. Sci. 2019, 20, 3805
Figure :Pathological roles played by periodontal disease in patients on hemodialysis

81. 29-09-2023 81

82. EFFECT OF PERIODONTAL DISEASES ON
ENDOCRINE SYSTEM
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83. Diabetes mellitus:
• The mechanisms by which adjunctive antibiotics may induce
positive changes in glycemic control when they are combined
with mechanical debridement are unknown at this time.
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84. Criteria for the diagnosis of diabetes:
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85. Periodontal Infection Associated With
Glycemic Control in Diabetes
• Systemic inflammation plays a major role in insulin sensitivity and
glucose dynamics.
• Periodontal diseases can induce or perpetuate an elevated systemic
chronic inflammatory state, which is reflected in increased serum CRP,
IL-6, and fibrinogen levels seen in many people with periodontitis.
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86. Two way relationship between periodontal
disease and diabetes mellitus
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87. Potential effects of periodontal infection and periodontal
therapy on glycemia in patients with diabetes
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88. 29-09-2023 88
Hall’s Critical Decisions in Periodontology and Dental Implantology, Lisa A. Harpenau;Fifth Edition

89. Periodontal therapy
• The patient should be asked about recent blood glucose levels
& frequency of hypoglycemic episodes.
• The drug interactions with various anti-diabetic drugs may alter
blood glucose levels.
• If patient is scheduled for any surgical procedure, the insulin or
any the antidiabetic drug dosage may be adjusted with the
counsultation of the physician.
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90. • Periodontal surgery be scheduled in the morning after breakfast and
medication administration.
• If the patient is taking insulin, the visits should be arranged in such a
way that the treatment time does not coincide with the peak activity
of insulin.
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91. • Treatment procedures should be short (2 hours or less), as atraumatic
as possible.
• Patient anxiety should be managed to minimize endogenous
epinephrine release.
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92. • Diabetes mellitus–related xerostomia should be managed on a case-
by-case basis, but in general patients should be encouraged to adhere
to strict diabetes mellitus metabolic control and to avoid smoking or
the use of alcohol and caffeine-containing beverages.
• Artificial saliva substitutes and frequent ingestion of water may be of
benefit.
• A pilocarpine-containing drug (Salagen) has recently been approved
by the Food and Drug Administration for management of xerostomia
resulting from therapeutic radiation exposure and Sjogren’s
syndrome.
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The Medical Letter. Treatment of xerostomia. Med Lett 1988: 30: 74–76.
Gage TW, Pickett FA, ed. Dental drug reference. 4th edn. St. Louis: Mosby Publishing, 1998: 534–535

93. • Patients should be encouraged to stimulate salivary flow by the use of
sugarless gum or natural salivary stimulants such as chewing raw
carrots and celery.
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Haverman CW, Redding SW. Dental management and treatment of xerostomic patients. Tex Dent J 1998: June: 43–56.

94. • Consider giving oral glucose just before treatment, and ensure
patients inform the clinician if they feel a hypoglycaemic episode
starting.
• Autonomic neuropathy in diabetes can cause orthostatic
hypotension; therefore the supine patient should be slowly raised
upright in the dental chair.
• Otherwise, guidelines for diabetics are similar to those for patients
with cardiovascular issues.
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95. • Poorly controlled diabetics (whether Type 1 or 2), should be referred
for improved control of their blood sugar before non-emergency
surgery is performed.
• If emergency surgery is needed, prophylactic antibiotics are prudent.
Treat even small infections aggressively with appropriate antibiotic
therapy and necessary surgical intervention.
• Severe dentoalveolar abscess with fascial space involvement in a
seemingly healthy individual may signify diabetes.
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96. • Severe diabetics with ketoacidosis are predisposed to fungal
infections such as paranasal sinus mucormycosis.
• Drugs that can disturb diabetic control – aspirin and steroids – must
be avoided.
• Drugs should be sugar-free.
• Doxycycline and other tetracyclines may enhance insulin
hypoglycaemia.
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97. Treatment of hypoglycemia:
• Conscious patient:
Administer 15 gm of simple carbohydrates.
Repeat finger-stick glucose test after 15 minutes:
Blood glucose level > 60 mg/dl: patient should be asked to eat or drink
(for example, a sugar-sweetened beverage).
Blood glucose level < 60 mg/dl: repeat treatment 15 gm of simple
carbohydrates and check blood glucose after 15 minutes. Continue
until achieving a blood glucose level > 60 mg/dl.
Ask the patient to notify his/her physician.
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98. • Unconscious patient- With intravenous access:
Administer 25-30 ml of 50% dextrose immediately.
Notify the patient's physician.
Without intravenous access:
Apply glucose gel inside the mouth in a semi obtunded patient or treat
with 1 mg of glucagon intramuscularly or subcutaneously .
Repeat the blood glucose test after 15 minutes.
Establish intravenous access and notify the patient’s physician.
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99. Preoperative management in type 1 diabetes
mellitus – fasted patient
• The patient should be first on the list of patients
• All long-acting insulin should be stopped the night before surgery
• Intravenous access should be obtained at an early stage
• If surgery is in the morning, all subcutaneous morning insulin should
be stopped
• If surgery is in the afternoon, the usual short-acting insulin should be
given in the morning at breakfast but no medium or long-acting insulin
Medical emergencies in the dental practice; Periodontology 2000, Vol. 46, 2008, 27–4
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100. Preoperative management in type 2 diabetes
mellitus – fasted patient
• These patients may be managed by attention to diet or, more
commonly, use of oral hypoglycemics.
A fasting blood glucose of >10 mmol ⁄ l may require management
along the lines of a type 1 diabetic
• Patients taking a long-acting sulfonylurea should have the dose
halved the day before surgery and the tablet should be omitted
altogether on the day of surgery.
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101. • The fasting blood glucose level should be checked on the
morning of surgery and treatment is only needed if the level is
more than 15 mmol. The blood glucose level should be
monitored in any event using a finger-prick blood sample
• If the blood glucose level is more than 15 mmol, insulin should
be used
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102. Classification of oral agents used to treat type
2 diabetes:
From American Diabetes Association: Type 2 diabetes in children and adolescents, Pediatrics 105:671–680, 2000.
102
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103. Currently available insulin preparations:
From Grady R, editor: Diabetes forecast, 2006,Alexandria, VA, American Diabetes Association, 2006.
103
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104. Conclusion :
• Periodontitis tends to be a “silent” disease.
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105. 29-09-2023 105

106. • 1.Hayes C, Sparrow D, Cohen M, et al. The association between
alveolar bone loss and pulmonary function: the VA Dental
Longitudinal Study. Ann Periodontol. 1998;3:257– 261.
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