|The Dental Management of Patients with Endocrine Disease|
|Tuesday, 14 February 2012 09:44|
Endocrine diseases include Diabetes mellitus (insulin dependent), Diabetes insipidus (non-insulin dependent), Addison disease, Cushing disease, Hyperthyroidism, and Hypothyroidism. The dental management of patients with endocrine disease involves assessment and treatment of oral mucosal disease and infection associated with altered endocrine function, a consideration of the necessary precautions needed during the provision of dental treatment, and the appropriate management of medical emergencies that can arise during treatment.
The well controlled diabetic patient does not require special consideration related to dental treatment. However, as a general rule it is best to provide dental treatment in the morning when the patient’s glucose levels are elevated and after breakfast and following insulin injection. Long term insulin-using diabetic patients have a very good sense of how their specific insulin works and when hypoglycemia might develop (e.g. hypoglycemia generally occurs 30 to 90 minutes after injecting Lispro insulin, 2 to 3 hours after regular insulin, and 4 to 10 hours after NPH or Lente insulin) and are not likely to neglect informing the dentist or hygienist if they are developing an insulin reaction.
However, naïve subjects or those with brittle disease may not be able to self-diagnose the signs or symptoms necessitating intervention. In these cases the treating clinician should be aware patient complaints suggesting hypoglycemia including altered mental status (e.g. confusion, disorientation, or mood alteration) sweating, pallor, or statements suggesting hunger, tingling, or other altered sensations. If the patient remains conscious, glucose should be provided by way of glucose containing drinks such as orange juice or a relevant soft drink. If hypotension renders the patient unconscious, 30-50mLs of 50% dextrose should be administered intravenously or 1mg glucagon should be administered intramuscularly. If care is rendered in the US, a 911 call should be initiated to facilitate additional emergency response and hospitalization.
Dental management of patients also includes identification of potential diabetes. For example, rampant progressive periodontal disease with tooth loosening and loss, extensive gingival erythema and bleeding, and periodontal abscesses in the absence of other likely causes for these conditions, may suggest undiagnosed diabetes. In this case a comprehensive history including questions related to level of thirst, urination, and weight loss should be initiated. A positive history suggest that additional laboratory documentation and medical assessment may be necessary.
The provision of dental treatment does not have to be altered in the controlled diabetic patient but as a general rule it is important to reduce stress that could increase the release of endogenous epinephrine and cortisone. Good pain control during anesthesia delivery and dental treatment is important. Delivery of an amide anesthetic with 1/100,000 concentration of epinephrine is not likely to elevate blood glucose levels, but care should be taken to limit the amount necessary for adequate pain control. If conscious sedation is considered, a 5% solution of dextrose in water should not significantly alter blood glucose levels but fluids without dextrose are also available. Dental management of Diabetic Patients.
Numerous studies report a significant association between diabetes and periodontal disease. (Mealey BL, Rose LF. Diabetes mellitus and inflammatory periodontal diseases. Curr Opin Endocrinol Diabetes Obes. 2008 Apr;15(2):135-41) (Iacopino AM Periodontitis and diabetes interrelationships: role of inflammation. Ann Periodontol. 2001 Dec; 6(1):125-37) (Segura-Egea JJ, Castellanos-Cosano L, Machuca G, López-López J, Martín-González J, Velasco-Ortega E, Sánchez-Domínguez B, López-Frías FJ. Diabetes mellitus, periapical inflammation and endodontic treatment outcome. Med Oral Patol Oral Cir Bucal. 2011 Dec 6. [Epub ahead of print] In the patient with poorly controlled diabetes periodontal disease may be more severe and involve greater inflammation as well as periodontal abscess.
(Kalyani Deshpande, Ashish Jain,1 RaviKant Sharma, Savita Prashar, and Rajni Jain. Diabetes and periodontitis J Indian Soc Periodontol. 2010 Oct-Dec; 14(4): 207–212). Treatment should include non-surgical scaling and root planning initially as well as dietary counseling and hygiene instruction. For the patient needing surgery, pre and post-surgical antibiotic coverage following tooth debridement may improve therapeutic outcome. Studies involving diabetic animals suggest that the topical addition of doxycycline hyclite to the post-periodontial surgical site can improve healing. (Kol R, Palattella A. The use of doxycycline in periodontology. Histologic in vivo study on mice affected by diabetes mellitus. Minerva Stomatol. 2006 Jan-Feb;55(1-2):77-86). Diabetes does not appear to effect the long term survival of dental implants. (Anner R, Grossmann Y, Anner Y, Levin L. Smoking, diabetes mellitus, periodontitis, and supportive periodontal treatment as factors associated with dental implant survival: a long-term retrospective evaluation of patients followed for up to 10 years. Implant Dent. 2010 Feb;19(1):57-64)
One important study assessed several antibiotic strategies including 1)topical water and systemic doxycycline, 100 mg for two weeks; 2)topical 0.12% chlorhexidine (CHX) and systemic doxycycline, 100 mg for two weeks; 3) topical povidone-iodine and systemic doxycycline, 100 mg for 2 weeks; and 4) topical 0.12% CHX and placebo. Compared to placebo all were found to effectively reduce multiple parameters associated with periodontal disease at three and six months post treatment. The subjects using the doxycycline preparations demonstrated the most improvement in probing depth and in the reduction in subgingival Porphyromonas gingivalis compared to placebo. (Grossi SG, Skrepcinski FB, DeCaro T, et al. Treatment of periodontal disease in diabetics reduces glycated hemoglobin. J Periodontol 1997 Aug; 68(8) :713-9). Oral infection in the diabetic also warrants prompt antibiotic therapy, typically prescription (barring allergy) of penicillin or amoxicillin prior to culture and sensitivity results.
Recent literature suggests that the relationship between periodontal disease and diabetes may be bi-directional and that periodontal treatment may help to control glycemia in the diabetic patient. This relationship is supported by evidence from at least one literature search through March of 2009 that involved meta-analysis of RCTs of periodontal intervention lasting longer than three months. 639 research papers were identified and in all of the studies it was noted that glycemic control improved after therapy. (Teeuw W, Gerdes V, Loos B. Effect of Periodontal Treatment on Glycemic Control of Diabetic Patients Diabetes Care. 2010 February; 33(2): 421–427)
Dental management of the diabetic patient may also include two other interventions. In patients with candidiasis, which occurs frequently in uncontrolled diabetic patients, topical or systemic antifungal medications can be prescribed. Best practices suggest that anti-fungal therapy should be provided for 10-14 days in patients with severe disease. In addition, it is recommended that medication should be continued for at least 48 hours after the signs and symptoms of infection have subsided. (The clinician’s guide to treatment of common oral conditions. The American academy of oral Medicine, Spring 1997.) Patients with reduced salivary flow and dry mouth can be treated with saliva substitute and/or oral moisturizing Gels. There is also evidence that improvement in subjective symptoms may occur with OTC products such as XyliMelts (Orahealth) or Biotene rinses or gum. Systemic therapy includes EVOXAC® (cevimeline HCl) and Salagen (pilocarpine HCL), (Treatment for Dry Mouth) (Burgess J, Lee P. XyliMelts time-release adhering discs for night time oral dryness. Int J of Dent Hygiene, XyliMelts time-release adhering discs for night-time oral dryness)
The first treatment issue of concern to dentists is diagnosis of the disease, as the oral mucosal change characterized by diffuse patchy brown macular pigmentation may precede dermal discoloration. The second issue relates to the fact that the patient with Addison’s disease with adrenal insufficiency will likely be taking exogenous steroids and stress from a dental procedure or resulting pain could exacerbate this insufficiency. (Lorenzo-Calabria J, Grau D, Silvestre FJ, Hernández-Mijares A. Management of patients with adrenocortical insufficiency in the dental clinic. Med Oral. 2003 May-Jul;8(3):207-14) Historically, it has been recommended that patients at elevated risk for adrenal crisis be provided supplemental steroids. However a search of the literature from 1966 to 2000 using Medline and textbooks only identified four reports of adrenal crisis during dentistry. (Miller CS, Lettle JW, Falace DA. Supplemental corticosteroids for dental patients with adrenal insufficiency: reconsideration of the problem. J Am Dent Assoc. 2001 Nov; 132(11):1570-9). This data suggests that for the patient with controlled Addison’s disease adrenal crisis is rare in dentistry and that for routine dental care supplementation may not be necessary. Nonetheless, patients needing extensive surgical procedures or implant placement and/or have a dental infection may be at increased risk for crisis and best practices recommends prophylactic increase in steroid use prior to treatment. Guidance is available from the Resuscitation Council (UK)
(Medical Emegencies and Resuscitation) and the dental Addison’s Clinical Advisory Panel (Addison's Disease Self Help Group). These organizations suggest that there be a doubling of the patient’s steroid dose prior to dental treatment and for 24 hours after dental intervention. Regardless of the patient’s status, medical consultation is warranted pre treatment of patients with Addison’s disease (Gibson N, Ferguson JW. Steroid cover for dental patients on long-term steroid medication: proposed clinical guidelines based upon a critical review of the literature. Br Dent J. Dec, 2004; 197(11): 681-685).
These guidelines should also be considered in the management of the patient with Cushing’s disease. Additional complications associated with the disease such as hypertension, diabetes mellitus, osteoporosis, impaired healing and depression may also need to be considered in treating the patient with Cushing’s syndrome.
Patients in which the condition has been identified and medically managed do not require special consideration during dental treatment. On the other hand, uncontrolled hyper and hypothyroid disease does require special dental precautions. The uncontrolled hyperthyroid patient should not receive a local anesthetic with epinephrine and epinephrine impregnated cord should not be used during gingival retraction for crown impressions. In the untreated hypothyroid patient dental treatment can be complicated by excessive bleeding from the patient’s use of an anticoagulant coupled with levothyroxine sodium. There can also be an exaggerated response to CNS depressants, sedatives, and narcotic medications.
Managemnet of Patients of Thyroid Disease. Patients receiving radiation for thyroid cancer may have associated salivary dysfunction necessitating prescription of saliva substitutes and topical fluoride. Reports suggesting that there is increased dental caries susceptibility with thyroid disease do not appear to be well supported by the science.
Submitted by Jeff Burgess DDS MSD