This document discusses guidelines for managing patients with hypertension, diabetes mellitus, and infective endocarditis in the dental setting. For hypertension, it recommends minimizing stress through short appointments, careful blood pressure monitoring, and consideration of medications. It provides blood pressure categories and treatment guidelines. For diabetes, it discusses assessing glycemic control, the relationship between periodontal disease and diabetes, and safety guidelines. For infective endocarditis, it outlines high risk patients, dental procedures that risk bacteremia, and antibiotic prophylaxis regimens. The goal for all conditions is reducing risk through protocol, education, and selective non-emergency dental care.

1. Periodontal management of patients with
Hypertension,
Diabetes mellitus &
Infective endocarditis
Ujwal Gautam
Roll no. 431
BDS 4th year (2009 batch)
BPKIHS

2. 20.7
12.2
67.1
Prevalence of Hypertension
in patients attending
dental OPD
diagnosed HTN
undiagnosed HTN
non HTN

3. HYPERTENSION
Our aim:
short appointments in calm, relaxing environment
MINIMIZE STRESS
Consider;
 careful history
 proper BP reading, twice 10 min apart in a minimum of two sitting; refer
to medical care if consistently found high
 Drug adjustment

4.  Recognize patient level of anxiety
 Premedicate the evening before dental appointment/medical
consultation and before dental t/t
 (Nitrous oxide is beneficial in controlling anxiety Diazepam 5mg night
before and 1 hr before procedure Or temazepam 10 mg)
 Schedule appointment in afternoon. Avoid during early morning
 Minimize patient’s waiting time
 Use adequate pain control during therapy
 Use of psychosedation
 Length of appointment short
 Follow up with postoperative pain/anxiety control
Managing Patients with Hypertension
STRESS REDUCTION PROTOCOL

5.  CATEGORIZE
BP
(mm Hg)
ASA
grade
Hypertension
stage (ASA)
JNC Class-
ification
Key consideration
<140 <90 I - Normal/Preh
ypertension
Routine dental care
140-159
90-99
II 1 Stage 1 Recheck BP before starting
Routine dental care, medical consultation
160-179
95-109
III 2 Stage 2 Recheck BP before starting
Medical advice before routine dental care
Perform selective dental care (routine
exam, prophylaxis, restorative non surgical
endodontics and periodontics)
Restrict use of epinephrine
Consider stress reduction protocol
>180 >110 IV 3 Recheck BP after 5 mins. Quiet rest
Only emergency care until BP controlled
(only alleviate pain, bleeding, infection)
Consider stress reduction protocol
Managing HypertensionManaging Patients with Hypertension

6.  NO TREATMENT to patients NOT under medication
 Only emergency care if SBP>180mmHg or DBP>110mmHg
 Xerostomia, commonly encountered side effect to all antihypertensives
requires management with topical fluoride and, possibly, systemic
medicines, such as pilocarpine or cevimeline.
 Analgesics and Antibiotics not contraindications.
• However, NSAIDS(indomethacin, ibuprofen and naproxen) can reduce
the efficacy of antihypertensives
Managing HypertensionManaging Patients with Hypertension


7.  EPINEPHRINE in Hypertension
• Not contraindicated unless SBP>200 mmHg and/or DBP>115mmHg
• < 1:100,000 concentration
 Avoid
 gingival retraction cord containing epinephrine
 Intraligamentary Injections
 Epinephrine & nonselective beta-blockers: Severe Hypertension
& reflex bradycardia.
 Epinephrine & diuretics: diuretics often produce
hypokalemia, which is exacerbated by epinephrine.
Managing HypertensionManaging Patients with Hypertension

8.  HYPERTENSIVE CRISES: URGENCIES AND EMERGENCIES
upper levels of stage II hypertension
associated with severe headache, shortness
of breath, epistaxis, or severe anxiety.
Management:
oral, short-acting agent such as
captopril, labetalol, or clonidine followed by
several hours of observation.
severe elevations in BP (>180/120 mmHg)
complicated by evidence of impending or
progressive target organ dysfunction.
Examples include hypertensive
encephalopathy, intracerebral
hemorrhage, acute MI, acute left
ventricular failure with pulmonary
edema, unstable angina pectoris, dissecting
aortic aneurysm, or eclampsia.
Management:
admitted to an intensive care unit for
continuous monitoring of BP and parenteral
administration of an appropriate agent
Hypertensive Urgency Hypertensive Emergency
Managing Patients with Hypertension

9.  POSTURAL HYPOTENSION
supine-to-standing BP decrease >20 mmHg systolic or >10 mmHg diastolic.
Management:
i. Assessment of consciousness
ii. Position patient in supine with feet slightly elevated
iii. Assess ABC
iv. Initiate definitive care
• Administration of O2
• Monitor vital signs
v. Subsequent management after consciousness/medical consultation on
delayed recovery
vi. Discharge
Managing HypertensionManaging Patients with Hypertension

10. 
• Depression
• Nausea
• Sedation
• Xerostomia
• Altered taste
• Angioedema
• Lichenoid Drug reaction
• Gingival overgrowth
• Orthostatic hypotension
DRUGS
Interaction
Side effects
Indomethacin/ibuprofen/naproxen
+ Β-blockers/ACEI/thiazide:
reduced antihypertensive effect.
Managing HypertensionManaging Patients with Hypertension

11. DIABETES MELLITUS
o A leading cause of death and disability
o Periodontal disease, 6th complication of Diabetes

12. Undiagnosed…
Suspect if;
 Any of Polydipsia, Polyuria, Polyphagia or
 presence of
• oral infection(dentoalveolar abscess with fascial plane involvement in
seemingly healthy patients);
• dry mouth;
• glossitis or burning mouth sensation in absent of apparent physical
changes
Confirm through;
 Random glucose >= 200 mg/dl
 Fasting glucose >= 126 mg/dl
 Post prandial blood glucose >= 200 mg/dl 2 hrs. after OGTT
ONLY nonsurgical oral hygiene procedures until diagnosis
has been established
Managing Patients with Diabetes Mellitus

13. Diagnosed…
Assess glycaemic control.
HbA1c < 10% for surgery; < 8% responds as non-diabetic
Prophylactic antibiotics in poor glycemic control:
Sub antimicrobial dosage of doxycycline
Tetracycline in combination with Scaling & root planing
Managing Patients with Diabetes Mellitus

14. Gram-negative
Periodontal
infection
Increased
Insulin
resistance
Worsened
Glycemic
control
Improved
Glycemic
control
Increased
Insulin
sensitivity
Periodontal
treatment
Potential effects of periodontal infection and periodontal therapy on
glycemia in patients with diabetes
Decreased
inflammation
Managing Patients with Diabetes Mellitus

15. Guidelines …
How to Ensure Safety of Patients with Diabetes
 Identification
 Location:
only be held where there is immediate access to health care
professionals
 Access to diabetes medication and food:
Post treatment adjustment of insulin dosage as the periodontal
therapy may render the patient unable to eat. However,
ensure treatment does not interfere with eating
 Sugar
 Emergencies
Managing Patients with Diabetes Mellitus

16.  Mid-morning appointments after a normal breakfast and normal
diabetic treatment.
 Conscious sedation can be safely used
 LA can be safely used. Epinephrine has no significant effect on blood
sugar
 Patient should raise gently from the chair after the treatment.
Chances of orthostatic hypotension due to autonomic neuropathy.
 Avoid aspirin and steroids
 Establish the medication patient is taking to identify the onset, peak
and duration of activity.
AVOID PEAK INSULIN ACTIVITY
Guidelines …
contd
Managing Patients with Diabetes Mellitus

17. Diabetic emergency
tremors
Disorientation
Agitation and anxiety
Sweating
Tachycardia
Deepening drowsiness
Unconsciousness
Managing Patients with Diabetes Mellitus

18.  Lay patient flat
 if conscious, give at least 4 sugar lumps equivalent to 15 gm
carbohydrate, 150 ml glucose drink or Hypostop. Reassure the
patient
 if unconscious, administer 25-30 ml of 20-50% dextrose iv
 if iv access not established, administer 1 mg glucagon im
 seek medical help
 defer immediate treatment until another day
Incidence has recently risen with the intensified use of Diabetic medication
Diabetic emergency
 HYPOGLYCEMIA
Managing Patients with Diabetes Mellitus

19. INFECTIVE ENDOCARDITIS
In a survey of 5000 cases of IE attributable to dental treatment, dental
extractions were performed in 95% of them
AHA recommends,
“All dental procedures that involve manipulation of gingival tissue
or the periapical region of teeth or perforation of the oral
mucosa” require antibiotic prophylaxis

20. …from dental procedures:
o tooth extraction (10-100 %)
o periodontal surgery (36-88 %)
o scaling and root planing (8-80 %)
o teeth cleaning (up to 40 %)
o rubber dam matrix/wedge
placement (9-32 %)
o endodontic procedures (up to 20
%)
…during routine daily activities:
o tooth brushing and flossing
(20- 68 %)
o use of wooden toothpicks (20-
40 %)
o use of water irrigation devices
(7-50 %)
o chewing food (7-51 %)
Incidence of transient bacteremia...
Managing Patients with Infective Endocarditis

21.  Identify the susceptible patients…
 Always start with gentle procedures to improve gingival health… gradually
turn to aggressive procedures…
…MINIMIZE THE CHANCES OF BACTEREMIA
 Pre-procedural application of 10% povidone-iodine or 0.5% chlorhexidine
gel to gingival crevice or 0.2% chlorhexidine mouth rinse 5 min before
 Antibiotic prophylaxis to high risk patients
Managing Patients with Infective Endocarditis

22. Antibiotic prophylaxis recommended for
o Prosthetic cardiac valve or prosthetic material used for cardiac valve
repair
o Previous infective endocarditis
o Congenital heart disease (CHD)
Unrepaired cyanotic CHD, including palliative shunts and conduits
Completely repaired congenital heart defect with prosthetic material or
device, whether placed by surgery or by catheter intervention, during the first
six months after the procedure
Repaired CHD with residual defects at the site or adjacent to the site of a
prosthetic patch or prosthetic device (which inhibit endothelialization)
o Cardiac transplantation recipients who develop cardiac valvulopathy
American Heart Association guidelines
Managing Patients with Infective Endocarditis

23. Regimen Antibiotics Dosage
Standard oral regimen Amoxicillin 2 gm 1 hr before procedure
Patient allergic to
amoxicillinpenicillin
Clindamycin or
Azithromycin or
Clarithromycin or
Cephalexin or cefadroxil
600 mg 1 hr before procedure
500 mg 1 hr before procedure
2 gm 1 hr before procedure
Patient unable to take
oral medication
Ampicillin 2 gm i.m or i.v within 30 min
before procedure
Patient unable to take
oral medication and
allergic to penicillin
Clindamycin
or
Cefazolin
600 mg i.v within 30 min
before procedure
1gm i.m or i.v within 30 min
before procedure
Managing Patients with Infective Endocarditis

24. IE associated with Actinobacillus actinomycetemcomitans
Found in periodontal pocket and implicated as probable causative agent
for IE
Aa responsible for aggressive periodontitis
Resistant to penicillin
Prophylaxis;
> tetracycline 250 mg qid x 14 days
> followed by conventional prophylaxis at the time of dental
treatment
Managing Patients with Infective Endocarditis

25. Antibiotic prophylaxis: The Good, The Bad & The Ugly
o Deaths from anaphylaxis to antibiotics estimated to be possibly
five to six times more likely than that from Infective Endocarditis
o Proof of efficacy is lacking. Only an extremely small number of IE
cases might be prevented with antibiotic prophylaxis, even if
prophylactic therapy were 100% effective.
Managing Patients with Infective Endocarditis
Maintenance of good oral hygiene and access to routine dental
care, more important in reducing the lifetime risk of IE than is the
administration of antibiotic prophylaxis for a dental procedure

26. Due to medicolegal implications, it is mandatory to give the
prophylaxis but one should act on the side of caution and fully inform
and discuss the risks with the patients.... it is the American Dental
Association’s recommendation that a dentist exercise independent
professional judgment in applying these or any other guidelines as
necessary in any clinical situation
-American Dental Association Division of Legal Affairs
Managing Patients with Infective Endocarditis

27. References:
• Newman, et al.; Carranza’s Clinical Periodontology; Elsevier; 10/e; 2006
• Lindhe; Clinical Periodontology and Implant Dentistry; Blackwell Munksgaard; 4/e; 2003
• Scully C., Cawson R. A.; Medical problems in Dentistry; Churchill Livingstone; 5/e; 2005
• Wilson W., et al.; Prevention of infective endocarditis: Guidelines from the American
Heart Association; JADA, Vol. 139; January 2008
• American Diabetes Association. Standards of medical care in diabetes – 2011. Diabetes
Care 2011;34(suppl 1):S11-12.
• The Seventh Report of the Joint National Committee on
Prevention, Detection, Evaluation, and Treatment of High Blood Pressure; U.S.
Department Of Health And Human Services; NIH Publication; August 2004
• Nunn P; Medical emergencies in the oral health care setting; Journal of Dental Hygiene
2000;74(II):136-151.
• Shobha, Ramesh; Study on Prevalence of Hypertension in Dental Out-Patient Population;
Journal of Indian Academy of Oral Medicine and radiology; April-June 2010; 22(2)