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

Periodontal management of patients with Hypertension,

Diabetes mellitus &Infective endocarditis

Ujwal GautamRoll no. 431

BDS 4th year (2009 batch)BPKIHS

20.7

12.2

67.1

Prevalence of Hypertensionin patients attending

dental OPD

diagnosed HTNundiagnosed HTNnon HTN

HYPERTENSION

Our aim: short appointments in calm, relaxing environmentMINIMIZE 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

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

CATEGORIZE

BP(mm Hg)

ASA grade

Hypertension stage (ASA)

JNC Class-ification

Key consideration

<140/ <90 I - Normal/Prehypertension

Routine dental care

140-159/ 90-99

II 1 Stage 1 Recheck BP before startingRoutine dental care, medical consultation

160-179/ 95-109

III 2 Stage 2 Recheck BP before startingMedical advice before routine dental carePerform selective dental care (routine exam, prophylaxis, restorative non surgical endodontics and periodontics)Restrict use of epinephrineConsider stress reduction protocol

>180/ >110 IV 3 Recheck BP after 5 mins. Quiet restOnly emergency care until BP controlled (only alleviate pain, bleeding, infection)Consider stress reduction protocol

Managing HypertensionManaging Patients with Hypertension

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


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.


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

POSTURAL HYPOTENSION

supine-to-standing BP decrease >20 mmHg systolic or >10 mmHg diastolic.

Management:i. Assessment of consciousnessii. Position patient in supine with feet slightly elevatediii. Assess ABCiv. Initiate definitive care

• Administration of O2• Monitor vital signs

v. Subsequent management after consciousness/medical consultation on delayed recovery

vi. Discharge


• Depression• Nausea• Sedation• Xerostomia• Altered taste• Angioedema• Lichenoid Drug reaction• Gingival overgrowth• Orthostatic hypotension

DRUGSInteraction

Side effects

Indomethacin/ibuprofen/naproxen + Β-blockers/ACEI/thiazide: reduced antihypertensive effect.


DIABETES MELLITUS

o A leading cause of death and disability

o Periodontal disease, 6th complication of Diabetes

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

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


Gram-negativePeriodontal

infection

IncreasedInsulin

resistance

WorsenedGlycemiccontrol

ImprovedGlycemiccontrol

IncreasedInsulin

sensitivity

Periodontaltreatment

Potential effects of periodontal infection and periodontal therapy on glycemia in patients with diabetes

Decreasedinflammation


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


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


Diabetic emergency

tremorsDisorientationAgitation and anxietySweatingTachycardiaDeepening drowsinessUnconsciousness


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


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

…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

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


Antibiotic prophylaxis recommended for

o Prosthetic cardiac valve or prosthetic material used for cardiac valve repair

o Previous infective endocarditiso Congenital heart disease (CHD)

Unrepaired cyanotic CHD, including palliative shunts and conduitsCompletely repaired congenital heart defect with prosthetic material or device, whether placed by surgery or by catheter intervention, during the first six months after the procedureRepaired 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


Regimen Antibiotics Dosage

Standard oral regimen Amoxicillin 2 gm 1 hr before procedure

Patient allergic to amoxicillin\penicillin

Clindamycin orAzithromycin or

Clarithromycin orCephalexin or cefadroxil

600 mg 1 hr before procedure500 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 procedure1gm i.m or i.v within 30 min before procedure


IE associated with Actinobacillus actinomycetemcomitans

Found in periodontal pocket and implicated as probable causative agent for IE

Aa responsible for aggressive periodontitisResistant to penicillin

Prophylaxis; > tetracycline 250 mg qid x 14 days > followed by conventional prophylaxis at the time of dental

treatment


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.


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

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


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)

Education

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