This document outlines the dental management of medically compromised patients, emphasizing the significance of various endocrine conditions, particularly diabetes, thyroid disorders, adrenal disorders, and bisphosphonate-related issues. It highlights how these conditions affect dental treatment, the importance of monitoring blood glucose levels, and the need for careful planning for patients on certain medications to prevent complications such as delayed healing or emergencies. Additionally, it stresses the necessity of thorough medical histories and monitoring when treating patients with bisphosphonates to prevent osteonecrosis of the jaws.

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.
• Some 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.
• Check 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
• Stage 0 with bone pain but no exposed bone  Stage 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

23. • 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.

24. Q & A