Periodontal management of pt. with diabetes mellitus, hypertension, iinfective endocarditis


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periodontal mangement of patients with diabetes mellitus, hypertension, iinfective endocarditis

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  • peak endogenous epinephrine release during early morning hours;Endogenous epinephrine release during painPsychosedation = Vocal sedation + Relaxation techniques
  • No surgery as postop increased sympathetic tone and vascular resistance might lead to HTNiv infusion of sodium nitroprusside, nicardipine, labetalol
  • Epinephrine used in the smallest possible dosage; use outweighs potential for haemodyanamic compromise
  • Diuretics, nitratesCare with older HTNive patients, diabetics
  • Keep in mind the sideeffects of antiHTNive drugs and possible interaction of those drugs with the drugs that are to be prescribed1> salt-retention mechanism of hypertension associated with the loss of natriuretic prostaglandins such as PGE2.2> inhibition of cyclooxygenase pathway; reduced vasodilatory PGs; reduced renal blood flow; salt-water retention; reduced antihypertensive effect of drugs
  • Incidence???
  • BMI > 25
  • HbA1c reflects past 6 – 8 wks status20mg/day for 14 daysFor host modulation; decreasing the destruction of bone due to periodontitis
  • patient should be asked to bring their glucometer to the dental office at each appointment.obtain baseline level of blood glucose before treatmentcheck the glucose level in between if procedure lasts longafter the procedure the blood glucose can be checked again to assess fluctuation over time
  • Dosage of insulin or sulfonylurea may need to be reduced if procedures are going to be long or may involve dietary restrictionsLispro: 30-90 minRegular: 2-3 hrsNPH: 4-10 hrsLente: 4-12 hrsUltralente: 12- 16 hrsGlargine:Peakless
  • Check pulse to confirmUnless certain that the cause is hyperglycaemia (Diabetic Ketoacidosis); ruled out by glucometerConfirm Rather diabetic collapse than fainting
  • Dental treatment exposes the patient to significant risk should proper prophylactic measures not under taken
  • Although the infective dose required to cause IE in humans is unknownHowever, no data show that visible bleeding during a dental procedure is a reliable predictor for bacteremia.
  • (even probing requires antibiotic prophylaxis!!)Topical antiseptic rinses do not penetrate beyond 3 mm into the periodontal pocket and, therefore, do not reach areas of ulcerated tissue where bacteria most often gain entrance to the circulation. On the basis of these data, it is unlikely that topical antiseptics are effective to significantly reduce the frequency, magnitude and duration of bacteremia associated with a dental procedure.
  • The Council on Scientific Affairs of the American Dental Association has approved these guidelines as they relate todentistry.
  • At every appointments. Appointments better kept at least 7 days apart; if not administer alternative regimenPt under ab therapy; alternate regimenInfective endocarditis (IE) is much more likely to result from frequent exposure to random bacteremias associated with daily activities than from bacteremia caused by a dental, gastrointestinal (GI) tract or genitourinary (GU) tract. Procedured Prophylaxis may prevent an exceedingly small number of cases of IE, if any, in people who undergo a dental, GI tract or GU tract procedure. The risk of antibiotic-associated adverse events exceeds the benefit, if any, from prophylactic antibiotic therapy. Maintenance of optimal oral health and hygiene may reduce the incidence of bacteremia from daily activities and is more important than prophylactic antibiotics for a dental procedure to reduce the risk of IE
  • inconsistent to recommend prophylaxis of IE for dental procedures but not for these same patients during routine daily activities. Such a recommendation for prophylaxis for routine daily activities would be impractical and unwarranted.scientific proof is lacking to support these assumptions. No prospectiverandomised placebo controlled trials till date; all based on retrospective studies
  • Periodontal management of pt. with diabetes mellitus, hypertension, iinfective endocarditis

    1. 1. Periodontal management of patients with Hypertension, Diabetes mellitus & Infective endocarditis Ujwal Gautam Roll no. 431 BDS 4th year (2009 batch) BPKIHS
    2. 2. 20.7 12.2 67.1 Prevalence of Hypertension in patients attending dental OPD diagnosed HTN undiagnosed HTN non HTN
    3. 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. 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. 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. 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. 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. 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. 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. 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. 11. DIABETES MELLITUS o A leading cause of death and disability o Periodontal disease, 6th complication of Diabetes
    12. 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. 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. 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. 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. 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. 17. Diabetic emergency tremors Disorientation Agitation and anxiety Sweating Tachycardia Deepening drowsiness Unconsciousness Managing Patients with Diabetes Mellitus
    18. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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)