Dental Management

Hyperthyroidism

excessive activity of the thyroid gland

Concerns with hyperthyroidism:

adverse interaction with Epinephrine

life threatening arrhythmias

congestive heart failure, hypertension, angina, MI

thyrotoxic crisis

Dental management of hyperthyroidism:

avoid surgery

avoid epinephrine

monitor BP

treat infections with Ab

___ may be associated with hyperthyroidism, which would complicate dental procedures... this is rare though

Thrombocytopenia (excessive bleeding)

Thyrotoxic crisis, also called thyroid storm, has a ___

high mortality rate

What are some signs and symptoms of thyrotoxic crisis?

◦ Restlessness

◦ Very high fever

◦ Severe tachycardia

◦ Pulmonary edema

◦ Tremor, sweating, stupor

◦ Coma and death

What should you do if patient is going through a thyrotoxic crisis?

seek medical assistance ASAP

monitor vital signs

wet, ice packs

CPR, if needed

Generally speaking, if hyperthyroidism is well controlled, what can you do in dental office?

routine dental care

What are some oral manifestations of hyperthyroidism?

osteoporosis

periodontal disease

caries

premature loss of baby teeth; early eruption of permanent teeth

early jaw development

Hypothyroidism

underactivity of the thyroid gland

Concerns with hypothyroidism:

avoid surgery

treat infections aggressively

avoid/limit sedatives, depress, narcotics

myxedematous coma is a feared (rare) AE

Myxedematous Coma

life-threatening complication of long-term hypothyroidism; hypothermia, hypotension, lactic acidosis, dehydration, epileptic seizures, bradycardia

What should you do if patient has myxedematous coma?

seek medical aid

cover patient to conserve heat

CPR

Generally speaking, if hypothyroidism is well controlled, can you conduct routine dental treatment in office?

yes

What is congenital hypothyroidism syndrome called?

cretinism

= severe intellectual disability

= may need assistance with personal hygiene

Cretinism: Oral Manifestations in Kids

thick lips

enlarged tongue

delayed eruption of teeth

malocclusion

hoarse cry

Cretinism: Oral Manifestations in Adults

enlarged tongue

hoarse speech

puffy face

dry skin

coarse hair

Adrenal Insufficiency

condition in which the adrenal glands underproduce necessary hormones

(Addison's)

If a patient has Addison's, how should dental treatments be managed?

dental routine treatment should be deferred until patient is stabilized with corticosteroid therapy

Why do you need steroids, again?

Patients with Addison's disease lack the ability to naturally produce cortisol, the hormone the body relies on to manage physical and emotional stress. Because dental appointments induce stress, patients often need a temporary, pre-appointment "stress dose" of corticosteroids to prevent a life-threatening medical emergency known as an adrenal crisis.

Addison's Disease: Oral Manifestations

abnormal pigmentation

delayed healing

infection

Hyperadrenalism

excessive activity of one or more adrenal glands

(Cushing's)

Cushing's Syndrome: Dental Problems/Concerns

no specific ones!

just may need to modify due to possible symptoms of Cushing's, such as hypertension, diabetes, ulcers, etc.

Diabetes Mellitus

insulin is not secreted adequately or tissues are resistant to its effects

What test screens diabetic patients?

A1C

What are some common symptoms of diabetes mellitus?

polydipsia, polyuria, polyphagia, weakness

What A1C determines that you have diabetes?

over or equal to 6.5

A1C (HbA1c) measures what, in particular? Hint: beyond blood glucose levels

nonenzymatic glycosylation of hemoglobin - IRREVERSIBLE

Irreversible??

yes! once RBC has sugar attached to it, it will always have it.. until it dies/is replaced

Therefore, A1C reflects glucose levels in the blood over ___

the preceding 2-3 months (RBC lifespan)

not current, necessarily!

In health, patients should have A1C levels less than ___

5.7%

In well controlled diabetes, the level should stay below ___

7%

If diabetes is UNCONTROLLED UNCONTROLLED, A1C levels hit as high as ___ in some cases

20%

ABSURD

Glucometer

device for measuring blood glucose levels from a drop of blood obtained by a fingerstick

need to do ahead of dental appointment

Under ___ mg/dL means hypoglycemic, maybe due to taking too much insulin

70

under 70 = sweat, tremble

under 40 = convulsions, coma

under 20 = brain damage, death

What do you do in dental office?

defer elective tx or give carbs then proceed

Over ___ mg/dL means patient must take their insulin... blood glucose levels are spiking

200

What should you do in dental office?

defer tx, maybe give hypoglycemic

if very high, refer to physician

What are some potential issues with dental care of uncontrolled diabetic patients?

infection

poor wound healing

What are some complications of chronic diabetes?

CV issues

eyes — blindness

kidneys — renal failure

nervous system — peripheral neuropathy

What if diabetes is well controlled, what can dentist do?

all procedures can be performed without special precautions

One form of dental tx that should definitely be delayed if diabetes is not contemporarily controlled is ___ care

prosthodontic

Which appointments are best for diabetics?

morning

patient should take Insulin dosage and eat a normal meal before appointment

A dentist should always have ___ available in office, just in case

sugar

If extensive oral surgery is needed for a diabetic, a dentist should ___

consult MD

Do diabetics need antibiotic prophylaxis when undergoing extensive oral surgery?

maybe, if their diabetes is 'brittle'

What is insulin shock?

hypoglycemic reaction caused by taking excess of insulin —> too much glucose out of blooddstream

Signs of mild insulin shock:

◦ Hunger

◦ Weakness

◦ Tachycardia

◦ Pallor

◦ Sweating, skin wet and cold

◦ Paresthesias occasionally

Signs of moderate insulin shock:

◦ Incoherence

◦ Uncooperative

◦ Belligerence

◦ Lack of judgment

◦ Poor orientation

Signs of severe insulin shock:

◦ Unconsciousness

◦ Tonic/clonic movements (seizures)

◦ Hypotension

◦ Hypothermia

◦ Rapid thready pulse

If insulin shock occurs ...

terminate dental tx

place patient in comfy position upright

assess basic life support & monitor vitals

if conscious, give sugar

if unconscious, place patient in supine position with legs up — give glucose paste to buccal mucosa, no liquids!!! — and call 911

What is a popular drug that can cause hyperglycemia?

corticosteroids

Diabetes: Oral Manifestations

accelerated periodontitis

xerostomia = increased dental caries

poor healing, infection

traumatic ulcers

oral candidiasis

neuropathies

mucormycosis

Mucormycosis

type of fungal infection

associated with diabetes and HIV

feelings of numbness, but not pain

treated with amphotericin B

30-50% chance of mortality... very severe iinfection — fungus eats at bone and invades system