Risk stratification and dental management Géza T Terézhalmy DDS MA Professor and Dean Emeritus School of Dental Medicine Case Western Reserve University Cleveland Ohio The Patient With Endocrine Disorders ID: 916155
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THE PATIENT WITH ENDOCRINE DISORDERSRisk stratification and dental management
Géza T. Terézhalmy, D.D.S., M.A.
Professor and Dean Emeritus
School of Dental Medicine
Case Western Reserve University
Cleveland, Ohio
Slide2The Patient With Endocrine Disorders
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Slide3The Patient With Endocrine DisordersDIABETES MELLITUS
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Slide4The Patient With Endocrine Disorders(diabetes mellitus)Glucose homeostasis
Regulated by the ANS
Glucagon
Synthesized by pancreatic alpha-cells
Increases hepatic glycogenolysis and stimulates gluconeogenesis
A hyperglycemic hormone
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Slide5The Patient With Endocrine Disorders(diabetes mellitus)Insulin
Synthesized by pancreatic beta-cells
Stimulates cellular glucose uptake
A hypoglycemic hormone
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Slide6The Patient With Endocrine Disorders(diabetes mellitus)Glucose
Optional fuel in most tissues
Can utilize proteins and triglycerides to satisfy their energy needs
Obligate fuel in the CNS
The brain can neither synthesize nor store more than a few minutes’ supply of glucose
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Slide7The Patient With Endocrine Disorders(diabetes mellitus)Diabetes mellitus
Etiology and epidemiology
A heterogeneous group of metabolic disorders characterized by hyperglycemia
25.8 million people in the U.S. – 2010
8.3% of the population
Diagnosed: 18.8 million
Undiagnosed: 7.0 million
Prediabetes: ≈79 million
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Slide8The Patient With Endocrine Disorders(diabetes mellitus)
Type 1 DM
Absolute insulin deficiency
Beta-cell destruction
Immune-mediated (children and adolescents)
Autoantibodies
Strong HLA association
Idiopathic (patients of African and Asian origin)
Strongly inherited, but not HLA-associated
Affects <5% of people with DM
<0.5% of the population
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Slide9The Patient With Endocrine Disorders(diabetes mellitus)Type 2 DM
Relative insulin deficiency
Constellation of metabolic abnormalities
Strong genetic predilection
The incidence has doubled over the last 30 years
Represents ≈95% of all cases of DM
11.3% of those age ≥20 years the U.S. - 2010
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Slide10The Patient With Endocrine Disorders(diabetes mellitus)Diagnosis
Option 1
Symptoms of DM
(polyuria, polydipsia, and unexplained weight loss)
AND
Plasma glucose >100 mg/dL without regard to time since last meal
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Slide11The Patient With Endocrine Disorders(diabetes mellitus)Option 2
Fasting plasma glucose >126 mg/dL following no caloric intake for at least 8 hours
Option 3
2 h plasma glucose >200mg/dL during an oral glucose tolerance test
Equivalent of 75 g of anhydrous glucose dissolved in water
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Slide12The Patient With Endocrine Disorders(diabetes mellitus)
Glycohemoglobin concentration (
HbA1c)
Reflects glucose levels over the previous 6 to 12 weeks prior to the test
Expressed as a percentage of total hemoglobin
Normal range in non-diabetic adults is 4 to 8%
HbA1c
>
7% correlates well to FBG >126 mg/dL and 2 h BG >200 mg/dL
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Slide13The Patient With Endocrine Disorders(diabetes mellitus)Medical management
Lifestyle modification
Diet
(7% weight reduction if overweight)
Exercise
(ideally 150 minutes weekly)
Pharmacological strategies
Hypoglycemic agents
Insulin
Oral hypoglycemic agents
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Slide14The Patient With Endocrine Disorders(diabetes mellitus)
Hypoglycemic agents in the top 200 - 2010
Insuli
n
Lantus (long-acting insulin glargine)
Oral hypoglycemic agents
glyburide
metformin hydrochloride
Actos (pioglitazone)
Januvia (sitagliptin)
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Slide15The Patient With Endocrine DisordersMechanisms of actionInsulin
Stimulates cellular glucose uptake
Oral hypoglycemic agents
Stimulate insulin release
Decrease insulin resistance
Decrease hepatic glucose production
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Slide16The Patient With Endocrine Disorders(diabetes mellitus)
Risk assessment
Disease-related variables
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Slide17The Patient With Endocrine Disorders(diabetes mellitus)
Hyperglycemia
plasma glucose level
Glycosuria
urinary excretion of glucose
Polyuria
osmotic diuresis from cells
Nocturia
urination at night
Polydipsia
Polyuria and nocturia lead to dehydration
Reflex activation of the thirst center
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Slide18The Patient With Endocrine Disorders(diabetes mellitus)
Polyphasia
Inadequate uptake and metabolism of ingested nutrients and urinary loss of calories
To compensate for lack of nutrient and caloric uptake
Proteins amino acids glucose
glycerol glucose
Triglycerides
fatty acids ketone bodies
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Slide19The Patient With Endocrine Disorders(diabetes mellitus)
Acute, short-term consequences
Undiagnosed or undertreated patients
Hyperglycemia with or without ketoacidosis
Gradual onset (may progress to a life-threatening situation)
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Slide20The Patient With Endocrine Disorders(diabetes mellitus)
Clinical signs and symptoms
Dry, flushed skin
Thirst, hunger
Constant urination
Fatigue
Nausea, vomiting, abdominal pain
Visual disturbances
Altered mentation
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Slide21The Patient With Endocrine Disorders(diabetes mellitus)
Chronic, long-term consequences
Undiagnosed or undertreated patients
Gradual onset (may progress to life-threatening complications)
Persistent fungal and/or bacterial infection
Glycation of tissue proteins and other macromolecules and excess production of polyol compounds
Microvascular disease
Macrovascular disease
Neuropathy
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Slide22The Patient With Endocrine Disorders(diabetes mellitus)
Risk assessment
Patient-related variables
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Slide23The Patient With Endocrine Disorders(diabetes mellitus)Risk factors
Age ≥45 years
Overweight (body mass index ≥25 kg/m
2
)
Family history of DM in a first-degree relative
Habitual physical inactivity
http://www.uptodate.com/contents/screening-for-diabetes-mellitus?view=print
Screening for diabetes mellitus. Accessed March 1, 2012
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Slide24The Patient With Endocrine Disorders(diabetes mellitus)High-risk ethnic or racial group
African-American
Hispanic
Native American
Asian-American
Pacific Islanders
http://www.uptodate.com/contents/screening-for-diabetes-mellitus?view=print
Screening for diabetes mellitus. Accessed March 1, 2012
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Slide25The Patient With Endocrine Disorders(diabetes mellitus)Hypertension
BP ≥140/90 mmHg
Dyslipidemia
HDL concentration ≤35 mg/dL
Triglyceride concentration ≥250 mg/dL
http://www.uptodate.com/contents/screening-for-diabetes-mellitus?view=print
Screening for diabetes mellitus. Accessed March 1, 2012
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Slide26The Patient With Endocrine Disorders(diabetes mellitus)History of delivering a baby weighing >4.1 kg (9 lb) or of gestational DM
Previously identified HbA1c ≥5.7% or FPG ≥100 mg/dL
Polycystic ovarian syndrome
History of vascular disease
http://www.uptodate.com/contents/screening-for-diabetes-mellitus?view=print
Screening for diabetes mellitus. Accessed March 1, 2012
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Slide27The Patient With Endocrine Disorders(diabetes mellitus)Complications of hyperglycemia
Heart disease
Adults with DM have heart disease death rates about 2 to 4 times higher than adults without DM
In 2004, heart disease was noted on 68% of DM-related death certificates among people aged ≥65
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
National Diabetes Facts Sheet, 2011 . Accessed March 1, 2012
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Slide28The Patient With Endocrine Disorders(diabetes mellitus)Hypertension
In 2005-2008, adults aged 20 years or older with self-reported DM
67% had blood pressure ≥140/90 mmHg or used prescription medication for hypertension
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
National Diabetes Facts Sheet, 2011. Accessed March 1, 2012
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Slide29The Patient With Endocrine Disorders(diabetes mellitus)Stroke
Among patient with DM the risk of stroke is 2 to 4 times higher than among people without DM
In 2004, stroke was noted on 16% of DM-related death certificates among people aged ≥65
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
National Diabetes Facts Sheet, 2011 . Accessed March 1, 2012
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Slide30The Patient With Endocrine Disorders(diabetes mellitus)Diabetic retinopathy
DM is leading cause of new cases of blindness among adults aged 20 to 74 years
In 2005-2008, 4.2 million (28.5%) people with DM aged 40 years or older had diabetic retinopathy
Of these, 650,000 (4.4% of those with DM) had advanced retinopathy that could lead to severe vision loss
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
National Diabetes Facts Sheet, 2011. Accessed March 1, 2012
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Slide31The Patient With Endocrine Disorders(diabetes mellitus)Diabetic nephropathy
DM is the leading cause of renal failure, accounting for 44% of all new cases of renal failure in 2008
In 2008, 48,374 people with DM began treatment for end-stage renal disease
In 2008, 202,290 people with end-stage renal disease due to DM were living on chronic dialysis or with a renal transplant
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
National Diabetes Facts Sheet, 2011. Accessed March 1, 2012
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Slide32The Patient With Endocrine Disorders(diabetes mellitus)Diabetic neuropathy
≈60% to 70% of people with DM have mild to moderate forms of neuropathy
Somatic neuropathy
Numbness, paresthesia , anesthesia
Pruritis, burning pain
Deep ulcers at pressure points
Gangrene
Osteomyelitis
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
National Diabetes Facts Sheet, 2011. Accessed March 1, 2012
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Slide33The Patient With Endocrine Disorders(diabetes mellitus)
Autonomic neuropathy
Exercise intolerance
Resting tachycardia
Orthostatic hypotension
Silent myocardial ischemia
Hypoglycemic unawareness
Sexual dysfunction
Neurogenic bladder
Gastrointestinal dysfunction
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
National Diabetes Facts Sheet, 2011. Accessed March 1, 2012
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Slide34The Patient With Endocrine Disorders(diabetes mellitus)Amputations
More than 60% of nontraumatic lower-limb amputations occur in people with DM
In 2006, ≈65,700 nontraumatic lower-limb amputations were performed in people with DM
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
National Diabetes Facts Sheet, 2011 . Accessed March 1, 2012
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Slide35The Patient With Endocrine Disorders(diabetes mellitus)Complications of pregnancy
Poor glycemic control before conception and during the first trimester of pregnancy among women with type 1 DM
Major birth defects in 5% to 10% of pregnancies
Spontaneous abortions in 15% to 20% of pregnancies
Poor glycemic control during the second and third trimesters of pregnancy can result in excessively large babies, posing a risk to both mother and child
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
National Diabetes Facts Sheet, 2011. Accessed March 1, 2012
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Slide36The Patient With Endocrine Disorders(diabetes mellitus)
Oral complications
gingival crevicular fluid glucose concentration
Advanced glycosylation end-products
Stimulates vascular smooth muscle proliferation
Modifies collagen synthesis resulting in
cross-linking
degradation of recently synthesized collagen by host collagenase
concentrations of proinflammatory cytokines such as TNF, PGE
2
, and IL-1
polymorphonuclear leukocyte chemotaxis, adherence, and phagocytosis
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Slide37The Patient With Endocrine Disorders(diabetes mellitus)
Periodontal disease
Among young adults, those with DM have about twice the risk of those without DM
Adults aged 45 or older with poorly controlled DM (HbA1c >9%) were 2.9 times more likely to have severe periodontitis than those without DM
The likelihood was even greater (4.6 times) among smokers with poor glycemic control
About one-third of people with DM have severe periodontal disease consisting of loss of attachment (≥5 mm)
http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
National Diabetes Facts Sheet, 2011. Accessed March 1, 2012
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Slide38The Patient With Endocrine Disorders(diabetes mellitus)
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Slide39The Patient With Endocrine Disorders(diabetes mellitus)
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Slide40The Patient With Endocrine Disorders(diabetes mellitus)
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Slide41The Patient With Endocrine Disorders(diabetes mellitus)
Xerostomia
Association between
resting and stimulated salivary flow and
HbA1c levels
Association between
resting and stimulated salivary flow and
FPG concentrations and diabetic neuropathy
Association between
resting salivary flow, and
FPG concentrations and treatment with anticholinergic drugs
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Slide42The Patient With Endocrine Disorders(diabetes mellitus)
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Slide43The Patient With Endocrine Disorders(diabetes mellitus)
Dental caries
caries rates despite patients reporting higher levels of self-care
Tendency for more caries activity and missing teeth in older adults with DM
Association between resting salivary flow rate < 0.01 ml/min and a slightly higher prevalence of dental caries in patients with type1 DM
Normal flow rate: 0.3 to 0.5 mL per minute
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Slide44The Patient With Endocrine Disorders(diabetes mellitus)
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Slide45The Patient With Endocrine Disorders(diabetes mellitus)
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Slide46The Patient With Endocrine Disorders(diabetes mellitus)
Candidiasis
Candida
spp.
Normal inhabitants of the oral cavity
25 to 75% of the general population
Blastophores (budding yeasts) without hyphae in the absence of clinical sign and symptoms denotes a commensal status
Altered homeostasis precedes the metamorphosis from commensalism to parasitism
Candidiasis in patients with DM is ≈ 50%
Incidence
with
glycemic control
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Slide47The Patient With Endocrine Disorders(diabetes mellitus)
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Slide48The Patient With Endocrine Disorders(diabetes mellitus)
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Slide49The Patient With Endocrine Disorders(diabetes mellitus)
Bell’s palsy
Affects from 6 to 48% of patients with DM
Acute-onset unilateral weakness of the facial muscles
Often accompanied by varying degrees of taste disturbances and hyperacusis
Severity of the palsy and recovery at 1 year
The presence of hypertension, not glycemic control
Prolongation of the trigeminal “blink reflex”, which is associated with reduced compound action potential in the nasalis muscle
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Slide50The Patient With Endocrine Disorders(diabetes mellitus)
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Slide51The Patient With Endocrine Disorders(diabetes mellitus)
Glycemic control
Self-monitoring blood glucose (SMBG)
Allows patients to monitor their response to treatment on an ongoing basis
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Slide52The Patient With Endocrine Disorders(diabetes mellitus)
In the oral healthcare setting
Useful to monitor pre-, intra-, and post-operative glycemic control
Patients with a plasma glucose level of <70 mg/dL are at-risk of a hypoglycemic event
A plasma glucose level of >200 mg/dL is indicative of poor glycemic control
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Slide53The Patient With Endocrine Disorders(diabetes mellitus)
Glycohemoglobin concentration (
HbA1c)
Monitored by healthcare provider
HbA1c reflects glycemic control over the previous 6 to 12 weeks
Microvascular and macrovascular disease increases sharply when HbA1c is
>
7%
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Slide54The Patient With Endocrine Disorders(diabetes mellitus)
Hypoglycemia
insulin level
Most common undesirable acute effect of both insulin and oral hypoglycemic agent therapy
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Slide55The Patient With Endocrine Disorders(diabetes mellitus)
Signs and symptoms
Dizziness, faintness
Weakness , hunger
Headache
Diaphoresis
Tachycardia
Anxiety, tremor
Mental confusion
Loss of consciousness
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Slide56The Patient With Endocrine Disorders(diabetes mellitus)
Precipitating factors
Delayed, decreased, or missed meal
Decreased carbohydrate content of meal
Other causes
Increased rates of insulin absorption
Increased skin temperature
Heavy exercise
Anxiety
Infection
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Slide57The Patient With Endocrine Disorders(diabetes mellitus)
Functional capacity
Ability to perform a spectrum of common daily tasks expressed in terms of metabolic equivalents (METs)
1 MET is defined as
The oxygen required to meet metabolic demand by a 40-year-old, 70-kg, man in a resting state
i.e., 3.5 ml per kg per minute
Equivalent to the physiological response to 0.011 mg of epinephrine
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Slide58The Patient With Endocrine Disorders(diabetes mellitus)
Estimated energy requirements for a spectrum of common daily activities
1-4 METs
Dress, eat, or use the toilet
Walk indoor around the house
Do light work around the house, e.g., dusting, washing dishes
Walk a block on a level ground at 2-3 mph
Climb a flight of stairs or walk up hill
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Slide59The Patient With Endocrine Disorders(diabetes mellitus)
Vital signs
Blood pressure
Normal: <120/80 mm Hg
Prehypertension: 120-139/80-89 mm Hg
Stage 1 hypertension: 140-159/90-99 mm Hg
Stage 2 hypertension: ≥160/100 mm Hg
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Slide60The Patient With Endocrine Disorders(diabetes mellitus)
Pulse rate
Normal (adult): 60-100 beats per minute
Normal (children): 90-120 beats per minute
Normal (aged): 70-80 bets per minute
Rhythm
Regular or irregular
Pressure
“hammering” or “pounding”
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Slide61The Patient With Endocrine Disorders(diabetes mellitus)
Respiration: rate, rhythm, depth
Normal (adults): 16-20 breaths per minute
Normal (children): 24-28 breaths per minute
Tachypnea: increased rate and decreased depth
Hyperpnea: increased rate and depth
Kussmaul-Kien respiration: 30-40 breaths per minute
Cheney-Stokes breathing: hyperpnea with periods of apnea
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Slide62The Patient With Endocrine Disorders(diabetes mellitus)
Risk assessment
Procedure-related variables
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Slide63The Patient With Endocrine Disorders(diabetes mellitus)
Risk to glycemic control
insulin utilization
Cardiac risk
Fluid shift
Blood loss
Duration of the procedure
Physiological stress
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Slide64The Patient With Endocrine Disorders(diabetes mellitus)
Timing and length of appointments
Treat patients prior to peak insulin activity
Avoid long stressful procedures
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Slide65The Patient With Endocrine Disorders(diabetes mellitus)
Antibacterial agents
The association between uncontrolled or poorly controlled DM and increased susceptibility to oral infections is well established
However, no studies directly support the prophylactic use of antibacterial agents
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Slide66The Patient With Endocrine Disorders(diabetes mellitus)
Local anesthetic agents
Provide the greatest margin of safety when treating patients with diabetes mellitus
Absence of profound anesthesia
insulin utilization
m
yocardial ischemia
0.045 mg of epinephrine
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Slide67The Patient With Endocrine Disorders(diabetes mellitus)
Epinephrine is a hyperglycemic agent
With concentrations used in dentistry
No appreciable rise in blood glucose levels
Cardiac risk is increased in patients unable to meet a 4-MET demand for oxygen
Ensure profound local anesthesia
Use local anesthetic agents containing a vasoconstrictor congruent with the patients functional capacity
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Slide68The Patient With Endocrine Disorders(diabetes mellitus)
Post-operative glycemic control
Procedures may affect the patient’s ability to eat
Consult with patient’s physician
Ensure that target PG level is maintained
Balanced intake of food
Appropriate regimen of medications
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Slide69The Patient With Endocrine Disorders(diabetes mellitus)
Post-operative pain management
Opioid-based analgesics contribute to cardiovascular stability
Opioid w/ibuprofen
Opioid w/APAP
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Slide70The Patient With Endocrine Disorders(diabetes mellitus)
Treatment strategies
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Slide71The Patient With Endocrine Disorders(diabetes mellitus)
Risk factors
Treatment option
Consultation or referral
Dental care
AND
Local anesthesia w/ epinephrine
AND
Glycemic control (70-200 mg/dL)
AND
Minor and intermediate predictors of cardiac risk
Asymptomatic
AND
Functional capacity >4 METs
AND
Blood pressure <180/110 mm Hg
AND
Normal pulse pressure, rate, and rhythm
Comprehensive care
Routine referral for medical management and risk factor modification
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Slide72The Patient With Endocrine Disorders(diabetes mellitus)
Risk factors
Treatment option
Consultation or referral
Dental care
AND
Local anesthesia w/ epinephrine
AND
Glycemic control (70-200 mg/dL)
AND
Minor and intermediate predictors of cardiac risk
Asymptomatic
OR
Symptomatic
AND
Functional capacity <4 METs
AND/OR
Blood pressure >180/110 mm Hg
AND/OR
Abnormal pulse pressure, rate, or rhythm
Limited care
Asymptomatic:
routine referral for medical management and risk factor modification
OR
Symptomatic:
immediate referral for medical management and risk factor modification
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Slide73The Patient With Endocrine Disorders(diabetes mellitus)
Risk
factors
Treatment option
Consultation or referral
Dental care
AND
Local anesthesia w/ epinephrine
AND
Glycemic control (<70 or > 200 mg/ dL)
AND
Major predictors of cardiac risk
Establish baseline vital signs
Emergency care
Bleeding
Infection
Pain
Immediate referral for medical management and risk factor modification
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Slide74The Patient With Endocrine Disorders(diabetes mellitus)
Preventive strategies
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Slide75The Patient With Endocrine Disorders(diabetes mellitus)
Oral hygiene
Conventional vs. electromechanical toothbrushes
Antibacterial mouthwashes
Topical fluorides
Antifungal chemotherapy
Sialagogues
Pilocarpine (Salagen)
Cevimeline (Evoxac)
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Slide76The Patient With Endocrine Disorders(diabetes mellitus)
Medical emergencies
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Slide77The Patient With Endocrine Disorders(diabetes mellitus)
13,836 medical emergencies reported by 2,704 dentists occurring within a 10-year period
Malamed SF. Managing medical emergencies. JADA 1993;124(8):40-53.
Syncope
Mild allergic reaction
Postural hypotension
Hyperventilation
Hypoglycemia
Angina pectoris
Seizures
30.1 (o.15)
18.7 (0.09)
17.9 (0.08)
9.6 (0.04)
5.1 (0.02)
4.6 (0.02)
4.6 (0.02)
Asthma
Local anesthetic overdose
Myocardial infarction
Anaphylactic reaction
Cardiac arrest
All
o
thers
2.8 (0.01)
1.5 (0.oo7)
1.4 (0.007)
1.2 (0.006)
1.1 (0.005)
1.4 (0.007)
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Slide78The Patient With Endocrine Disorders(diabetes mellitus)
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Slide79The Patient With Endocrine Disorders(diabetes mellitus)
References
Huber MA and Terezhalmy GT. The patient with a transient bacteremia. Gen Dent 2005;53:130-143.
Kurth T, Glynn RJ, Walker AM, Chan KA, et al. Inhibition of clinical benefits on first myocardial infarction by nonsteroidal antiinflammatory drugs. Circulation 2003;108:1191-1195.
Lockhart PB, Loven B, Brennan MT, Fox PC. The evidence base for the efficacy of antibiotic prophylaxis in dental practice. JADA 2007;138(4):458-474.
Napenas JJ, Hong CHL, Brennan MT, Furney SL, et al. The frequency of bleeding complications after invasive dental treatment in patients receiving single and dual antiplatelet therapy. JADA 2009;140(6):690-695.
Malamed SF. Managing medical emergencies. JADA 1993;124(8):40-53.
Minassian C, D’Aiuto F, Hingorani AD, Smeeth L. Invasive dental treatment and risk for vascular events: a self-controlled case series. Ann Intern Med 2010;153:499-506.
Miley DD, Terezhalmy GT. The patient with diabetes mellitus: etiology, epidemiology, principles of medical management, oral disease burden, and principles of dental management.
Quintessence
Int
2005;36:779-795.
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Slide80The Patient With Endocrine Disorders(diabetes mellitus)
Picket F and Terezhalmy GT. LWW’s Dental Drug Reference with Clinical Implications. 2
nd
ed. Baltimore: Lippincott Williams & Wilkins; 2010.
Steinhauer T, Bsoul SA, and Terezhalmy GT. Risk stratification and dental management of the patient with cardiovascular disease. Part I: Etiology, epidemiology, and principles of dental management. Quintessence Int 2005;36:119-137.
Steinhauer T, Bsoul SA, and Terezhalmy GT. Risk stratification and dental management of the patient with cardiovascular disease. Part II: The oral disease burden and principles of dental management. Quintessence Int 2005;36:209-227.
Terezhalmy GT, Huber MA, Jones AC. Physical evaluation in dental practice. 1
st
ed., Wiley-Blackwell, 2009.
van Dierman DE, Aartman IHA, Baart JA, Hoogstraten J, et al. Dental management of patients using antithrombotic drugs: critical appraisal of existing guidelines. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009;107:616-624.
Circulation 2005;111:576-582
J Periodontal 1998;69:841-850
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Slide81The Patient With Endocrine Disorders
THYROID DYSFUNCTION
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Slide82The Patient With Endocrine Disorders(thyroid dysfunction)Basal metabolic rate Regulated by the HPT axis
Hypothalamus
Thyrotropin-releasing hormone
Anterior pituitary
Thyroid stimulating hormone
Thyroid gland
Tetraiodothyronine (T
4
)
Triiodothyronine (T
3
)
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Slide83The Patient With Endocrine Disorders(thyroid dysfunction)Hypothyroidism -neonate
Etiology and epidemiology
Congenital
85% is due to sporadic thyroid dysgenesis
15% due to autosomal recessive mode of inheritance
1:3,000-4,000 births
Slightly
incidence
in the Hispanic population
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Slide84The Patient With Endocrine Disorders(thyroid dysfunction)Hypothyroidism –
adult
Etiology and epidemiology
Primary
Chronic autoimmune thyroiditis
Diffuse and nodular goiter
Severe iodine deficiency
Iatrogenic (surgery,
131
I-therapy)
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Slide85The Patient With Endocrine Disorders(thyroid dysfunction)SecondaryPituitary
Tertiary
Hypothalamic
10 million in U.S. (8 million undiagnosed)
Clear female predominance (5-10:1)
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Slide86The Patient With Endocrine Disorders(thyroid dysfunction)HyperthyroidismEtiology and epidemiology
Glandular hyperfunction
Diffuse hyperthyroid goiter (Grave’s disease)
Multinodular hyperthyroid goiter (Plummer’s disease)
Autonomous nodule
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Slide87The Patient With Endocrine Disorders(thyroid dysfunction)ThyrotoxicosisExogenous thyroid hormones
4.5 million in the U.S. (600,000 undiagnosed)
Clear female predominance (5-10:1)
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Slide88The Patient With Endocrine Disorders(thyroid dysfunction)DiagnosisHypothyroidism
TSH and
free T4
Aspartate transaminase
Alanine transaminase
LDH
Creatinine
Cholesterol
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Slide89The Patient With Endocrine Disorders(thyroid dysfunction)Hyperthyroidism
TSH and
free T4
Hypercalcemia
Cholesterol
Alkaline phosphatase
Heat labile, i.e., bone
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Slide90The Patient With Endocrine Disorders(thyroid dysfunction)Specialized testing
Anti-thymoglobulin antibody (TgAb)
Anti-thyroid peroxidase antibody (TPOAb)
Anti-thyroid receptor antibody (TRAAb)
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Slide91The Patient With Endocrine Disorders(thyroid dysfunction)Medical management
Hypothyroidism
Purified or synthetic thyroid preparations (levothiroxine, liothyronine, liotrix)
Daily dosages, 0.05 to 0.15 mg, or its equivalent
5/6/2012
91
Slide92The Patient With Endocrine Disorders(thyroid dysfunction)Hyperthyroidism
Antithyroid drugs (methimazole, propylthiouracil)
Primary treatment, therapy is stopped or tapered after 12 to 18 months of therapy
Lifelong follow-up is required as spontaneous hypothyroidism may develop decades later
OR
Preparative therapy before surgery or radioiodine therapy
Permanent thyroid insufficiency
Daily replacement therapy
5/6/2012
92
Slide93The Patient With Endocrine Disorders(thyroid dysfunction)Iodine or iodide preparations
Short-term benefits
Decrease vascularity and size of the thyroid gland in preparation to surgery
Permanent thyroid insufficiency
Daily replacement therapy
5/6/2012
93
Slide94The Patient With Endocrine Disorders(thyroid dysfunction)Thyroid hormones in the top 200 - 2010levothyroxine sodium Levoxyl (levothyroxine sodium)Synthroid (levothyroxine sodium)
5/6/2012
94
Slide95The Patient With Endocrine Disorders(thyroid dysfunction)Mechanisms of action - T3Stimulates RNA polymerase
Transcription and translation
Growth and development
Carbohydrate, proteins, lipids metabolism
Thermoregulation and calorigenesis
5/6/2012
95
Slide96The Patient With Endocrine Disorders(thyroid dysfunction)Increases oxygen utilizationEnhances tissue sensitivity to catecholamines
-adrenergic receptor activation
Acts synergistically with epinephrine
glycogenolysis
glycogenolysis
5/6/2012
96
Slide97The Patient With Endocrine Disorders(thyroid dysfunction)
Risk assessment
Disease-related variables
5/6/2012
97
Slide98The Patient With Endocrine Disorders(thyroid dysfunction)Congenital hypothyroidism Puffy face
Large cranium
Flat and broad nose
Macroglossia
Thick elevated lips
Open mouth
Altered calcification of teeth
Delayed eruption of teeth
Mental retardation by the 3
rd
month of life
5/6/2012
98
Slide99The Patient With Endocrine Disorders(thyroid dysfunction)Adult hypothyroidismSlow speech
Dry hair
Cold, dry skin
Lethargy, depression
Increased sensitivity to cold
Pitting edema
Muscle weakness
Mental impairment
5/6/2012
99
Slide100The Patient With Endocrine Disorders(thyroid dysfunction) rate of respiration
CV abnormalities
Bradycardia
Hypotension
Coronary artery disease
Cardiomyopathy
Coarse facial features
Thick lips
Puffy eyelids
Sad expression
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100
Slide101The Patient With Endocrine Disorders(thyroid dysfunction)
5/6/2012
101
Slide102The Patient With Endocrine Disorders(thyroid dysfunction)HyperthyroidismExophthalmia
Gritty sensation
Light sensitivity
Increased tearing
Double vision
Felling of retroocular pressure
Goiter
5/6/2012
102
Slide103The Patient With Endocrine Disorders(thyroid dysfunction)
5/6/2012
103
Slide104The Patient With Endocrine Disorders(thyroid dysfunction)Facial flushing Warm and moist skin
Enlarger lymph nodes
Tremor
Excitability
Increased appetite with weight loss
Emotional instability
Osteoporosis
rate of respiration
CV abnormalities
Tachycardia
Hypertension
Atrial fibrillation
Heart murmur
5/6/2012
104
Slide105The Patient With Endocrine Disorders(thyroid dysfunction)
Risk assessment
Patient-related variables
5/6/2012
105
Slide106The Patient With Endocrine Disorders(thyroid dysfunction)
Myxedema coma
The extreme life-threatening complication of hypothyroidism
5/6/2012
106
Slide107The Patient With Endocrine Disorders(thyroid dysfunction)
Signs and symptoms
Hypoventilation
Hypothermia
Bradycardia
Hypotension
Congestive heart failure
cardiac contractility
Coma
5/6/2012
107
Slide108The Patient With Endocrine Disorders(thyroid dysfunction)
Precipitating factors
Infection
Trauma
Exposure to cold
Sedative drug therapy
Stroke
Gastrointestinal bleeding
Inadequate replacement therapy for hypothyroidism
5/6/2012
108
Slide109The Patient With Endocrine Disorders(thyroid dysfunction)
Thyroid storm
The extreme life-threatening complication of hyperthyroidism
5/6/2012
109
Slide110The Patient With Endocrine Disorders(thyroid dysfunction)
Signs and symptoms
Agitation, confusion, delirium
Nausea, vomiting, diarrhea
Diaphoresis
Fever >101.3
0
F
Tachycardia
Arial fibrillation
Hypertension
Congestive heart failure
5/6/2012
110
Slide111The Patient With Endocrine Disorders(thyroid dysfunction)
Precipitating factors
Infection
Trauma
Psychosis
Parturition
Discontinuation of antithyroid drug therapy
Substantial over-treatment of hypothyroidism
5/6/2012
111
Slide112The Patient With Endocrine Disorders(thyroid dysfunction)
Functional capacity
Ability to perform a spectrum of common daily tasks expressed in terms of metabolic equivalents (METs)
1 MET is defined as
The oxygen required to meet metabolic demand by a 40-year-old, 70-kg, man in a resting state
i.e., 3.5 ml per kg per minute
Equivalent to the physiological response to 0.011 mg of epinephrine
5/6/2012
112
Slide113The Patient With Endocrine Disorders(thyroid dysfunction)
Estimated energy requirements for a spectrum of common daily activities
1-4 METs
Dress, eat, or use the toilet
Walk indoor around the house
Do light work around the house, e.g., dusting, washing dishes
Walk a block on a level ground at 2-3 mph
Climb a flight of stairs or walk up hill
5/6/2012
113
Slide114The Patient With Endocrine Disorders(thyroid dysfunction)
Vital signs
Blood pressure
Normal: <120/80 mm Hg
Prehypertension: 120-139/80-89 mm Hg
Stage 1 hypertension: 140-159/90-99 mm Hg
Stage 2 hypertension: ≥160/100 mm Hg
5/6/2012
114
Slide115The Patient With Endocrine Disorders(thyroid dysfunction)
Pulse rate
Normal (adult): 60-100 beats per minute
Normal (children): 90-120 beats per minute
Normal (aged): 70-80 bets per minute
Rhythm
Regular or irregular
Pressure
“hammering” or “pounding”
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115
Slide116The Patient With Endocrine Disorders(thyroid dysfunction)
Respiration: rate, rhythm, depth
Normal (adults): 16-20 breaths per minute
Normal (children): 24-28 breaths per minute
Tachypnea: increased rate and decreased depth
Hyperpnea: increased rate and depth
Kussmaul-Kien respiration: 30-40 breaths per minute
Cheney-Stokes breathing: hyperpnea with periods of apnea
5/6/2012
116
Slide117The Patient With Endocrine Disorders(thyroid dysfunction)
Risk assessment
Procedure-related variables
5/6/2012
117
Slide118The Patient With Endocrine Disorders(thyroid dysfunction)
Risk of myxedema coma
Risk of thyroid storm
Cardiac risk
Fluid shift
Blood loss
Duration of the procedure
Physiological stress
5/6/2012
118
Slide119The Patient With Endocrine Disorders(thyroid dysfunction)
Local anesthetic agents
The hypothyroid patient
There is no evidence to justify deferring needed surgery in patients with mild to moderate hypothyroidism
No evidence of adverse effects associated with epinephrine infusion
5/6/2012
119
Slide120The Patient With Endocrine Disorders(thyroid dysfunction)
Cardiac risk is increased in patients unable to meet a 4-MET demand for oxygen
Ensure profound local anesthesia
Use local anesthetic agents containing a vasoconstrictor congruent with the patients functional capacity
5/6/2012
120
Slide121The Patient With Endocrine Disorders(thyroid dysfunction)
The hyperthyroid patient
Increased cardiac output may limit cardiac reserve during surgery
Undiagnosed or undertreated hyperthyroidism carries a perioperative cardiac risks
Thyroid hormones act synergistically with epinephrine
5/6/2012
121
Slide122The Patient With Endocrine Disorders(thyroid dysfunction)
Cardiac risk is increased in patients unable to meet a 4-MET demand for oxygen
Ensure profound local anesthesia
Use local anesthetic agents containing a vasoconstrictor congruent with the patients functional capacity
5/6/2012
122
Slide123The Patient With Endocrine Disorders(thyroid dysfunction)
Post-operative pain management
Opioid-based analgesics may contribute to cardiovascular stability
Opioid w/ibuprofen
Opioid w/APAP
5/6/2012
123
Slide124The Patient With Endocrine Disorders(thyroid dysfunction)
Treatment strategies
5/6/2012
124
Slide125The Patient With Endocrine Disorders(thyroid dysfunction)
Risk factors
Treatment option
Consultation or referral
Dental care
AND
Local anesthesia w/ epinephrine
AND
Mild to moderate thyroid dysfunction
AND
Minor and intermediate predictors of cardiac risk
Asymptomatic
AND
Functional capacity >4 METs
AND
Blood pressure <180/110 mm Hg
AND
Normal pulse pressure, rate, and rhythm
Comprehensive care
Routine referral for medical management and risk factor modification
5/6/2012
125
Slide126The Patient With Endocrine Disorders(thyroid dysfunction)
Risk factors
Treatment option
Consultation or referral
Dental care
AND
Local anesthesia w/ epinephrine
AND
Mild to moderate thyroid dysfunction
AND
Minor and intermediate predictors of cardiac risk
Asymptomatic
OR
Symptomatic
AND
Functional capacity <4 METs
AND/OR
Blood pressure >180/110 mm Hg
AND/OR
Abnormal pulse pressure, rate, or rhythm
Limited care
Asymptomatic:
routine referral for medical management and risk factor modification
OR
Symptomatic:
immediate referral for medical management and risk factor modification
5/6/2012
126
Slide127The Patient With Endocrine Disorders(thyroid dysfunction)
Risk
factors
Treatment option
Consultation or referral
Dental care
AND
Local anesthesia w/ epinephrine
AND
Severe hypothyroidism
OR
Thyrotoxicosis
AND
Major predictors of cardiac risk
Establish baseline vital signs
Emergency care
Bleeding
Infection
Pain
Immediate referral for medical management and risk factor modification
5/6/2012
127
Slide128The Patient With Endocrine Disorders(thyroid dysfunction)
Preventive strategies
5/6/2012
128
Slide129The Patient With Endocrine Disorders(thyroid dysfunction)
Oral hygiene
Conventional vs. electromechanical toothbrushes
Antibacterial mouthwashes
Topical fluorides
Sialagogues
Pilocarpine (Salagen)
Cevimeline (Evoxac)
5/6/2012
129
Slide130The Patient With Endocrine Disorders(thyroid dysfunction)
Medical emergencies
5/6/2012
130
Slide131The Patient With Endocrine Disorders(thyroid dysfunction)
13,836 medical emergencies reported by 2,704 dentists occurring within a 10-year period
Malamed SF. Managing medical emergencies. JADA 1993;124(8):40-53.
Syncope
Mild allergic reaction
Postural hypotension
Hyperventilation
Hypoglycemia
Angina pectoris
Seizures
30.1 (o.15)
18.7 (0.09)
17.9 (0.08)
9.6 (0.04)
5.1 (0.02)
4.6 (0.02)
4.6 (0.02)
Asthma
Local anesthetic overdose
Myocardial infarction
Anaphylactic reaction
Cardiac arrest
All
o
thers
2.8 (0.01)
1.5 (0.oo7)
1.4 (0.007)
1.2 (0.006)
1.1 (0.005)
1.4 (0.007)
5/6/2012
131
Slide132The Patient With Endocrine Disorders(thyroid dysfunction)
5/6/2012
132
Slide133The Patient With Endocrine Disorders(thyroid dysfunction)
References
Huber MA, Terezhalmy GT. Risk stratification and dental management of the patient with thyroid dysfunction.
Quintessence Int
2008;39:139-150.
Malamed SF. Managing medical emergencies. JADA 1993;124(8):40-53.
Picket F and Terezhalmy GT. LWW’s Dental Drug Reference with Clinical Implications. 2
nd
ed. Baltimore: Lippincott Williams & Wilkins; 2010.
Terezhalmy GT, Huber MA, Jones AC. Physical evaluation in dental practice. 1
st
ed., Wiley-Blackwell, 2009
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:171-181
Med Clin North Am 2003;87:175-192
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:42-46
Arch Intern Med 2001;161:1509-1512
ADA 2001;132:1570-1579
5/6/2012
133
Slide134The Patient With Endocrine DisordersADRENAL DYSFUNCTION
5/6/2012
134
Slide135The Patient With Endocrine Disorders(adrenal dysfunction)Adaptive stress response
Regulated by the hypothalamic-pituitary-adrenal (HPA) axis
Hypothalamus
Corticotropin-releasing hormone (CRH)
Pituitary
ACTH
Adrenal cortex
Cortisol
(10-13 mg daily)
5/6/2012
135
Slide136The Patient With Endocrine Disorders(adrenal dysfunction)
Hypoadrenocorticism -
Addison’s disease
Etiology
Autoimmune adrenal disease
Autoimmune thyroid disease
Type 1 and 2 diabetes mellitus
Pituitary abnormalities
Tuberculosis and HIV infection
5/6/2012
136
Slide137The Patient With Endocrine Disorders(adrenal dysfunction)Hyperadrenocorticism -
Cushing’s syndrome
Etiology
Hypothalamic abnormalities
Pituitary tumors
Adrenal adenoma
Adrenal carcinoma
Small cell lung carcinoma
5/6/2012
137
Slide138The Patient With Endocrine Disorders(adrenal dysfunction)
Diagnosis
Plasma cortisol level
Following injection of synthetic ACTH-Cosyntropin (Cortrosyn
)
Provocative physiologic testing
Insulin tolerance test
5/6/2012
138
Slide139The Patient With Endocrine Disorders(adrenal dysfunction)
Medical management
Addison’s disease
Daily replacement therapy
Hydrocortisone, 30 mg
OR
Prednisone, 5 mg
OR
Dexamethasone, 0.75 mg
AND
Fludrocortisone, 0.05-0.20 mg
5/6/2012
139
Slide140The Patient With Endocrine Disorders(adrenal dysfunction)
Cushing’s syndrome
Surgical resection or radiotherapy
Permanent adrenal insufficiency
i.e., Addison’s disease
Daily replacement therapy
5/6/2012
140
Slide141The Patient With Endocrine Disorders(adrenal dysfunction)
Glucocorticoids in the top 200 - 2010
prednisone
methylprednisolone
Advair Diskus (fluticasone propionate w/ salmeterol)
Flovent HFA (fluticasone propionate)
fluticasone propionate
Nasonex (mometasone furoate)
5/6/2012
141
Slide142The Patient With Endocrine Disorders(adrenal dysfunction)
Mechanisms of action
Regulate cell metabolism
Peripheral fat and protein catabolism
Synergism with epinephrine
5/6/2012
142
Slide143The Patient With Endocrine Disorders(adrenal dysfunction)
Suppress inflammation and the immune system
leukocyte migration
cytokine production
T cell proliferation
Suppress the HPA axis
Chronic use of supraphysiological doses
5/6/2012
143
Slide144The Patient With Endocrine Disorders(adrenal dysfunction)Risk assessmentDisease-related variables
5/6/2012
144
Slide145The Patient With Endocrine Disorders(adrenal dysfunction)Addison’s disease
Nausea, vomiting, anorexia
Abdominal pain, diarrhea
Salt craving
Weight loss
Lethargy
Reduced libido
Amenorrhea
Muscle weakness
5/6/2012
145
Slide146The Patient With Endocrine Disorders(adrenal dysfunction)Hypoglycemia
gluconeogenesis
Cardiovascular
Decreased cardiac output
Hypotension
Arrhythmias
Hyperpigmentation of skin and oral mucosa
ACTH and
-MSH
5/6/2012
146
Slide147The Patient With Endocrine Disorders(adrenal dysfunction)
5/6/2012
147
Slide148The Patient With Endocrine Disorders(adrenal dysfunction)
5/6/2012
148
Slide149The Patient With Endocrine Disorders(adrenal dysfunction)
5/6/2012
149
Slide150The Patient With Endocrine Disorders(adrenal dysfunction)Cushing's syndrome
Facial fullness (moon facies)
Facial plethora
Acne
Hirsutism
Buffalo hump
Truncal obesity with violaceous striae of the skin
Easy bruising, gastrointestinal bleeding
5/6/2012
150
Slide151The Patient With Endocrine Disorders(adrenal dysfunction)Muscle wasting and myopathy
Psychological symptoms
Impaired cognitive and memory function
Psychoses
Cardiovascular
Fluid retention
Hypertension
Arrhythmias
5/6/2012
151
Slide152The Patient With Endocrine Disorders(adrenal dysfunction)Hyperglycemia
gluconeogenesis
Increased risk of infection
Impaired wound healing
Hyperpigmentation of skin and oral mucosa
ACTH and
-MSH
Stunted linear growth in children
Delayed eruption of teeth
5/6/2012
152
Slide153The Patient With Endocrine Disorders(adrenal dysfunction)
5/6/2012
153
Slide154The Patient With Endocrine Disorders(adrenal dysfunction)
5/6/2012
154
Slide155The Patient With Endocrine Disorders(adrenal dysfunction)
5/6/2012
155
Slide156The Patient With Endocrine Disorders(adrenal dysfunction)Risk assessmentPatient-related variables
5/6/2012
156
Slide157The Patient With Endocrine Disorders(adrenal dysfunction)
Adrenal insufficiency
Patients with Addison's disease are inherently unable to produce cortisol to meet physiologic demand
Following surgical resection or radiotherapy, patients with Cushing’s syndrome develop permanent adrenal insufficiency
Patients on supraphysiological doses of exogenous glucocorticoids may experience HPA axis suppression
5/6/2012
157
Slide158The Patient With Endocrine Disorders(adrenal dysfunction)
Wide variability in HPA axis suppression
Topical and inhaled corticosteroids can suppress the HPA axis but rarely cause clinical adrenal insufficiency
The persistence of HPA axis suppression after cessation of systemic glucocorticoid therapy is equivocal
5/6/2012
158
Slide159The Patient With Endocrine Disorders(adrenal dysfunction)
No HPA axis suppression
Less than 5 mg of prednisone or equivalent per day for any duration
Alternate-day single morning dose of short-acting glucocorticoid, such as hydrocortisone, of any dose or duration
Any dose of glucocorticoids for less than 3 weeks
5/6/2012
159
Slide160The Patient With Endocrine Disorders(adrenal dysfunction)
HPA axis suppression uncertain
5-20 mg of prednisone or equivalent for more than 3 weeks within the past year
Low-dose ACTH stimulatory test to determine HPA axis suppression
5/6/2012
160
Slide161The Patient With Endocrine Disorders(adrenal dysfunction)
HPA axis suppression presumed or documented
More than 20 mg of prednisone or equivalent for more than 3 weeks within the past year
Stigmata of Cushing’s syndrome
Adrenal insufficiency documented by low-dose ACTH stimulation test
5/6/2012
161
Slide162The Patient With Endocrine Disorders(adrenal dysfunction)
Addisonian crisis
The extreme life-threatening complication of adrenal insufficiency
Hypotension
Cardiogenic shock
5/6/2012
162
Slide163The Patient With Endocrine Disorders(adrenal dysfunction)
Risk factors that
may precipitate
an Addisonian crisis
Cold
Fever
Trauma
Burns
Exercise
Emotional stress
Pain
Hypotension
Infection
Cytokines
IL-1
, IL-6, TNF-
Hemorrhage
5/6/2012
163
Slide164The Patient With Endocrine Disorders(adrenal dysfunction)
Functional capacity
Ability to perform a spectrum of common daily tasks expressed in terms of metabolic equivalents (METs)
1 MET is defined as
The oxygen required to meet metabolic demand by a 40-year-old, 70-kg, man in a resting state
i.e., 3.5 ml per kg per minute
Equivalent to the physiological response to 0.011 mg of epinephrine
5/6/2012
164
Slide165The Patient With Endocrine Disorders(adrenal dysfunction)
Estimated energy requirements for a spectrum of common daily activities
1-4 METs
Dress, eat, or use the toilet
Walk indoor around the house
Do light work around the house, e.g., dusting, washing dishes
Walk a block on a level ground at 2-3 mph
Climb a flight of stairs or walk up hill
5/6/2012
165
Slide166The Patient With Endocrine Disorders(adrenal dysfunction)
Vital signs
Blood pressure
Normal: <120/80 mm Hg
Prehypertension: 120-139/80-89 mm Hg
Stage 1 hypertension: 140-159/90-99 mm Hg
Stage 2 hypertension: ≥160/100 mm Hg
5/6/2012
166
Slide167The Patient With Endocrine Disorders(adrenal dysfunction)
Pulse rate
Normal (adult): 60-100 beats per minute
Normal (children): 90-120 beats per minute
Normal (aged): 70-80 bets per minute
Rhythm
Regular or irregular
Pressure
“hammering” or “pounding”
5/6/2012
167
Slide168The Patient With Endocrine Disorders(adrenal dysfunction)Risk assessmentProcedure-related variables
5/6/2012
168
Slide169The Patient With Endocrine Disorders(adrenal dysfunction)
Risk of an Addisonian crisis
Cardiac risk
Fluid shift
Blood loss
Duration of the procedure
Physiological stress
5/6/2012
169
Slide170The Patient With Endocrine Disorders(adrenal dysfunction)
Supplemental glucocorticoid regimens
Only in the amount equivalent to the anticipated physiological response to surgical stress
“Stress dose”
5/6/2012
170
Slide171The Patient With Endocrine Disorders(adrenal dysfunction)
Major surgical stress
e.g., cardiac surgery involving cardiopulmonary bypass
Recommended prophylaxis
100 to 150 mg of hydrocortisone or equivalent for 2 to 3 days
OR
100 mg IV hydrocortisone prior to induction of anesthesia
AND
50 mg hydrocortisone q8h for 48-72 h
5/6/2012
171
Slide172The Patient With Endocrine Disorders(adrenal dysfunction)
Moderate surgical stress
e.g., segmental colon resection or abdominal hysterectomy
Recommended prophylaxis
50 to 75 mg of hydrocortisone or equivalent for 1 to 2 days
OR
50 mg IV hydrocortisone prior to induction of anesthesia
AND
25 mg hydrocortisone q8h for 24-48 h
5/6/2012
172
Slide173The Patient With Endocrine Disorders(adrenal dysfunction)
Minor surgical stress
e.g., inguinal herniography under local anesthesia
Usual daily glucocorticoid dose during perioperative period
Dental procedure under local anesthesia
Recommended prophylaxis
Usual daily glucocorticoid dose during perioperative period
5/6/2012
173
Slide174The Patient With Endocrine Disorders(adrenal dysfunction)
Local anesthetic agents
Provide the greatest margin of safety when treating patients with adrenal dysfunction
Absence of profound anesthesia
m
yocardial ischemia
5/6/2012
174
Slide175The Patient With Endocrine Disorders(adrenal dysfunction)
Cortisol plays a permissive role for epinephrine
Cardiac risk is increased in patients unable to meet a 4-MET demand for oxygen
Ensure profound local anesthesia
Use local anesthetic agents containing a vasoconstrictor congruent with the patients functional capacity
5/6/2012
175
Slide176The Patient With Endocrine Disorders(adrenal dysfunction)
Antibacterial prophylaxis
The association between hyperadrenocorticism, increased risk of infection, and impaired wound healing is well established
No studies directly support the prophylactic use of antibacterial agents
5/6/2012
176
Slide177The Patient With Endocrine Disorders(adrenal dysfunction)
Post-operative pain management
Opioid-based analgesics contribute to cardiovascular stability
Opioid w/ibuprofen
Opioid w/APAP
5/6/2012
177
Slide178The Patient With Endocrine Disorders(adrenal dysfunction)
Treatment strategies
5/6/2012
178
Slide179The Patient With Endocrine Disorders(adrenal dysfunction)
Risk factors
Treatment option
Consultation or referral
Dental care
AND
Local anesthesia w/ epinephrine
AND
Mild to moderate adrenal
dysfunction
AND
Minor and intermediate predictors of cardiac risk
Asymptomatic
AND
Functional capacity >4 METs
AND
Blood pressure
<180/110 mm Hg
AND
Normal pulse pressure, rate, and rhythm
Comprehensive care
Routine referral for medical management and risk factor modification
5/6/2012
179
Slide180The Patient With Endocrine Disorders(adrenal dysfunction)
Risk factors
Treatment option
Consultation or referral
Dental care
AND
Local anesthesia w/ epinephrine
AND
Mild to moderate adrenal
dysfunction
AND
Minor and intermediate predictors
Asymptomatic
OR
Symptomatic
AND
Functional capacity <4 METs
AND/OR
Blood pressure
>180/110 mm Hg
AND/OR
Abnormal pulse pressure, rate, or rhythm
Limited care
Asymptomatic:
routine referral for medical management and risk factor modification
OR
Symptomatic:
immediate referral for medical management and risk factor modification
5/6/2012
180
Slide181The Patient With Endocrine Disorders(adrenal dysfunction)
Risk
factors
Treatment option
Consultation or referral
Dental care
AND
Local anesthesia w/ epinephrine
AND
Severe adrenal dysfunction
AND
Major predictors of cardiac risk
Establish baseline vital signs
Emergency care
Bleeding
Infection
Pain
Immediate referral for medical management and risk factor modification
5/6/2012
181
Slide182The Patient With Endocrine Disorders(adrenal dysfunction)Preventive strategies
5/6/2012
182
Slide183The Patient With Endocrine Disorders(adrenal dysfunction)
Oral hygiene
Conventional vs. electromechanical toothbrushes
Antibacterial mouthwashes
Topical fluorides
Sialagogues
Pilocarpine (Salagen)
Cevimeline (Evoxac)
5/6/2012
183
Slide184The Patient With Endocrine Disorders(adrenal dysfunction)Medical emergencies
5/6/2012
184
Slide185The Patient With Endocrine Disorders(adrenal dysfunction)
13,836 medical emergencies reported by 2,704 dentists occurring within a 10-year period
Malamed SF. Managing medical emergencies. JADA 1993;124(8):40-53.
Syncope
Mild allergic reaction
Postural hypotension
Hyperventilation
Hypoglycemia
Angina pectoris
Seizures
30.1 (o.15)
18.7 (0.09)
17.9 (0.08)
9.6 (0.04)
5.1 (0.02)
4.6 (0.02)
4.6 (0.02)
Asthma
Local anesthetic overdose
Myocardial infarction
Anaphylactic reaction
Cardiac arrest
All
o
thers
2.8 (0.01)
1.5 (0.oo7)
1.4 (0.007)
1.2 (0.006)
1.1 (0.005)
1.4 (0.007)
5/6/2012
185
Slide186The Patient With Endocrine Disorders(adrenal dysfunction)
5/6/2012
186
Slide187The Patient With Endocrine Disorders(adrenal dysfunction)
References
Huber MA, Terezhalmy GT. Risk stratification and dental management of patients with adrenal dysfunction. Quintessence Int 2007 Apr;38(4):325-338.
Malamed SF. Managing medical emergencies. JADA 1993;124(8):40-53.
Picket F and Terezhalmy GT. LWW’s Dental Drug Reference with Clinical Implications. 2
nd
ed. Baltimore: Lippincott Williams & Wilkins; 2010.
Terezhalmy GT, Huber MA, Jones AC. Physical evaluation in dental practice. 1
st
ed., Wiley-Blackwell, 2009
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;90:171-181
Med Clin North Am 2003;87:175-192
Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:42-46
Arch Intern Med 2001;161:1509-1512
ADA 2001;132:1570-1579
5/6/2012
187
Slide188The Patient With Endocrine DisordersOSTEOPENIA AND OSTEOPOROSIS
5/6/2012
188
Slide189The Patient With Endocrine Disorders(osteopenia and osteoporosis)Bone homeostasisMediated by hormones
5/6/2012
189
Slide190The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Parathyroid hormone
GI tract
Ca
2+
absorption via vitamin D action
[Ca
2
]
[PO
4
]
Kidney
Ca
2+
reabsorption
PO
4
reabsorption
Bone
Osteoclastic activity
(continuous PTH)
Osteoblastic activity
(once-daily PTH)
Bone mass
Bone mass
5/6/2012
190
Slide191The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Vitamin D
Parathyroid hormone
PTH synthesis
[Ca
2+
]
[PO
4
]
GI tract
Ca
2+
,
PO
4
absorption
Kidney
Ca
2
,
PO
4
reabsorption
Bone
Number and activity of osteoclasts
5/6/2012
191
Slide192The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Calcitonin
Bone
Osteoclastic activity
[Ca
2+
]
[PO
4
]
Steroids
GI tract
Ca
2+
absorption leading to
PTH
Osteopenia
Kidney
Ca
2+
,
PO
4
reabsorption
Osteoporosis
Bone
Osteoblastic activity and
apoptosis
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Slide193The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Thyroid hormone
Bone
Bone resorption
Osteopenia
Reproductive hormones
Bone
Osteoclastic activity
Osteoclastic apoptosis
Osteoblastic apoptosis
Bone formation
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Slide194The Patient With Endocrine Disorders(osteopenia and osteoporosis)Bone modelingDetermines length and width of developing bone, i.e., size and shape
Driven by mechanical forces
Directed by chondrocytes
Endochondral bone formation
Osteoblasts form new bone
Periosteal appositional growth
Osteoblastic and osteoclastic activity not coupled
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Slide195The Patient With Endocrine Disorders(osteopenia and osteoporosis)Bone remodelingMaintains bone mass and strength
Responds adaptively to shear stress
Bone is continually resorbed and reformed
Cortical bone: 3% per year
Trabecular bone: 25% per year
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Slide196The Patient With Endocrine Disorders(osteopenia and osteoporosis)Directed by osteocytes (mechanoreceptors) Identify sites for remodeling in response to prevailing physical loads
Coordinated activity of osteoclasts and osteoblasts
Basic multicellular units (BMUs)
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Slide197The Patient With Endocrine Disorders(osteopenia and osteoporosis)
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Slide198The Patient With Endocrine Disorders(osteopenia and osteoporosis)Osteopenia and osteoporosis
Etiology and epidemiology
Bone resorption exceeds bone formation
Compromised bone strength (i.e., bone density, bone quality) predisposing to an increased risk of factures
≈ 34 million Americans are estimated to have low bone mass (osteopenia) and are at increased risk of osteoporosis
≈ 44 million Americans (55% of people 50 years of age or order) have osteoporosis
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Slide199The Patient With Endocrine Disorders(osteopenia and osteoporosis)DiagnosisLow bone density
Gold standard
Dual x-ray absorptiometry (DXA) of the femoral neck
Scored as standard deviations (SDs) from a young healthy norm and reported as T-scores
Other laboratory testing dictated by clinical judgment
To exclude possible secondary causes of bone loss
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Slide200The Patient With Endocrine Disorders(osteopenia and osteoporosis)
WHO Diagnostic Categories of Bone Mineral Density
Diagnostic Category
Criterion
Normal
BMD within 1.0 SD of the reference mean for young adults
Osteopenia
BMD that is more than 1.0 but less than 2.5 SD below the mean for young adults
Osteoporosis
BMD that is 2.5 SD or more below the mean for young adults
Severe osteoporosis
BMD that is 2.5 SD or more below the mean for young adults in combination with one or more fragility (low-trauma) fractures
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Slide201The Patient With Endocrine Disorders(osteopenia and osteoporosis)Medical management Lifestyle measures
Adequate weight-bearing exercise
Smoking cessation
Avoidance of excessive alcohol intake
Calcium supplementation
Vitamin D supplementation
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Slide202The Patient With Endocrine Disorders(osteopenia and osteoporosis)Pharmacological strategiesAntiresorptive agents
Estrogen
Bisphosphonates
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Slide203The Patient With Endocrine Disorders(osteopenia and osteoporosis)Antiresorptive agents in the top 200 - 2010Premarin (conjugated estrogen)alendronate sodium
Actonel (risendronate)
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Slide204The Patient With Endocrine Disorders(osteopenia and osteoporosis)Estrogen Mechanisms of actionBinds to estrogen receptors (ER
and ER
)
Dimerization of two estrogen receptors
The dimer is transported into nucleus
Binds to the estrogen receptor elements of DNA
Co-activators or co-repressors enhance or inhibit the transcription of estrogen-dependent genes
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Slide205The Patient With Endocrine Disorders(osteopenia and osteoporosis)Conserves calcium and phosphorus and encourages bone formation
Osteoclastic activity
Osteoclastic apoptosis
Osteoblastic apoptosis
vertebral,
nonvertebral, and
hip fractures
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Slide206The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Risks/benefits of hormone therapy
ADEs
Estrogen
Estrogen/progestin
Osteoporosis
Colorectal Ca
≈
Coronary artery disease
≈
Venous thrombosis
Cholecystitis
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Slide207The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Risks/benefits of hormone therapy
ADEs
Estrogen
Combination
Dementia
Stroke
Endometrial Ca
≈
Breast Ca
Quality of life
≈
Unknown
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Slide208The Patient With Endocrine Disorders(osteopenia and osteoporosis)Oral bisphosphonates (alendronate, risendronate)
Mechanisms of action
Analogues to pyrophosphates
Incorporate into the mineral matrix
Remain in bone until remodeling (≈ 10.5 years)
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Slide209The Patient With Endocrine Disorders(osteopenia and osteoporosis)At the time of remodeling, some BP molecules are internalized by osteoclasts
Inhibit a step in the mevalonate pathway essential for the synthesis of certain signaling proteins
o
steoclastic activity
osteoclastic apoptosis
osteoblastic activity
vertebral,
nonvertebral, and
hip fractures
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Slide210The Patient With Endocrine Disorders(osteopenia and osteoporosis)ADEsMild upper GI events, e.g., nausea
Esophageal ulcerations, perforations, and bleeding events
Bisphosphonate-associated osteonecrosis (BON) of the jaw
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Slide211The Patient With Endocrine Disorders(osteopenia and osteoporosis)Case definition of BONCurrent or previous treatment with a BP
Exposed, necrotic bone in the maxillofacial region that has persisted for more than 8 weeks
No history of radiation therapy to the jaws
J Oral Maxillofac Surg 2007;65:369-376.
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Slide212The Patient With Endocrine Disorders(osteopenia and osteoporosis)Risk assessmentDisease-related variables
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Slide213The Patient With Endocrine Disorders(osteopenia and osteoporosis)Increased risk of fractures Hip, spine, and wrist
Lifetime risk of osteoporotic fractures even among 50-year-old women and men at average risk
40 % in women
13 % in men
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Slide214The Patient With Endocrine Disorders(osteopenia and osteoporosis)Oral stigmata
Decreased bone density
Thinning of trabeculae
Thinning of cortical bone
Mandibular alveolar bone resorption
Increased tooth loss in postmenopausal women
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Slide215The Patient With Endocrine Disorders(osteopenia and osteoporosis)
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Slide216The Patient With Endocrine Disorders(osteopenia and osteoporosis)
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Slide217The Patient With Endocrine Disorders(osteopenia and osteoporosis)
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Slide218The Patient With Endocrine Disorders(osteopenia and osteoporosis)Risk assessmentPatient-related variables
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Slide219The Patient With Endocrine Disorders(osteopenia and osteoporosis)Major risk factorsPersonal history of fractures as an adult
History of fragility fracture in a first degree relative
Low body weight, i.e., < 127 lb (58 kg)
Current smoking
Systemic corticosteroid therapy
Daily dose equivalent of ≥ 5 mg of prednisone for more than 3 months
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Slide220The Patient With Endocrine Disorders(osteopenia and osteoporosis)Additional risk factorsEstrogen deficiency at an early age, i.e., before 45 years
Dementia
Poor health or frailty
Low calcium intake
Low physical activity
Alcohol in amounts greater than two per day
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Slide221The Patient With Endocrine Disorders(osteoporosis)
Functional capacity
Ability to perform a spectrum of common daily tasks expressed in terms of metabolic equivalents (METs)
1 MET is defined as
The oxygen required to meet metabolic demand by a 40-year-old, 70-kg, man in a resting state
i.e., 3.5 ml per kg per minute
Equivalent to the physiological response to 0.011 mg of epinephrine
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Slide222The Patient With Endocrine Disorders(osteoporosis)
Estimated energy requirements for a spectrum of common daily activities
1-4 METs
Dress, eat, or use the toilet
Walk indoor around the house
Do light work around the house, e.g., dusting, washing dishes
Walk a block on a level ground at 2-3 mph
Climb a flight of stairs or walk up hill
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Slide223The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Vital signs
Blood pressure
Normal: <120/80 mm Hg
Prehypertension: 120-139/80-89 mm Hg
Stage 1 hypertension: 140-159/90-99 mm Hg
Stage 2 hypertension: ≥160/100 mm Hg
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Slide224The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Pulse rate
Normal (adult): 60-100 beats per minute
Normal (children): 90-120 beats per minute
Normal (aged): 70-80 bets per minute
Rhythm
Regular or irregular
Pressure
“hammering” or “pounding”
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Slide225The Patient With Endocrine Disorders(osteopenia and osteoporosis)Risk assessmentProcedure-related variables
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Slide226The Patient With Endocrine Disorders(osteopenia and osteoporosis)Risk of “fragility” fracturesLow trauma fractures
e.g., extraction-related
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Slide227The Patient With Endocrine Disorders(osteopenia and osteoporosis)Increased risk of fallsBenzodiazepines
Age-related changes in GABA
A
-receptors are responsible for high sensitivity of elderly to benzodiazepines
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Slide228The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Inappropriate drugs in older adults: independent of medical diagnosis or condition
flurazepam (Dalmane)
diazepam (Valium)
quazepam (Doral)
halazepam (Paxipam)
Long half-life in elderly patients (often several days):
Prolonged sedation
Increased risk of syncope
Increased risk of falls
4/1/2010
Terezhalmy
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Slide229The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Potentially inappropriate drugs in older adults: independent of medical diagnosis or condition
lorazepam (Ativan), 3 mg
oxazepam (Serax), 60 mg
alprazolam (Xanax), 2 mg
temazepam (Restoril),15 mg
triazolam (Halcion), 0.25 mg
Smaller doses may be effective as well as safer:
Daily doses should rarely exceed the suggested maximums
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Terezhalmy
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Slide230The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Potentially inappropriate drugs in older adults: considering medical diagnoses or conditions
All benzodiazepines
Stress incontinence
Incontinence
Depression
Depression
COPD
Respiration
Syncope/falls
Ataxia
syncope/falls
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230
Slide231Managing Medical Emergencies(postural hypotension)Postural hypotension
Sudden postural change usually from a supine to an upright position
Followed by cerebral hypo-perfusion
Increased risk of syncope
Increased risk of falls
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Slide232Managing Medical Emergencies(postural hypotension)
Signs and symptoms
No prodromal signs and symptoms
Following postural change from a supine to an upright position
of ≥20 mm Hg in systolic BP
OR
of ≥10 mm Hg in diastolic BP
OR
in pulse rate of ≥20 beats per minute
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Slide233Managing Medical Emergencies(postural hypotension)
Precipitating actors
Impaired homeostatic mechanisms of blood pressure regulation
Age-related changes
Disease-related changes
Antihypertensive medications
Recent food intake
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Slide234The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Risk of BON
Risk category A patients
Patients who have been treated with oral BPs
No apparent exposed/necrotic bone
Incidence of BON
0 to 0.4 percent
JADA 2008;139:1674-1677
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Slide235The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Risk category B patients
Patients who have been treated with IV BPs
No apparent exposed/necrotic bone
Incidence of BON
≈ 20 percent
JADA 2008;139:1674-1677
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Slide236The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Rationale for BON
Osteoclasts dissolve mineral matrix releasing BPs
Some BP molecules are internalized by osteoclasts
Inhibit a step in the mevalonate pathway essential for the synthesis of certain signaling proteins
Loss of osteoclastic activity and ultimately osteoclast apoptosis
Reduced synthesis of matrix-derived cytokines, TGF-
β
, IGF-1, and other factors
Failure to activate osteoblast precursors
BPs are also cytotoxic and antiangiogenic
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Slide237The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Treatment strategies
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Slide238The Patient With Endocrine Disorders(osteopenia and osteoporosis)Patient educationThe actual incidence of BON is unknown
Estimates ranging from 0 to 1 in 2,260 cases
There are no validated diagnostic tests available to determine if a patient is at increased risk
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Slide239The Patient With Endocrine Disorders(osteopenia and osteoporosis)There is no rationale for a drug holiday to eliminate or reduce the risk of BON
JAMA 2006;296:2927-2938.
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Slide240The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Bone resorption
FLEX baseline ↑ 55.6%
FIT baseline ↓ 7%
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Slide241The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Bone formation
FLEX baseline ↑ 59.5%
FIT baseline ↓ 24%
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Slide242The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Bone formation
FLEX baseline ↑ 28.1%
FIT baseline ↓ 7%
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Slide243The Patient With Endocrine Disorders(osteopenia and osteoporosis)Sound oral hygiene practices and regular dental careComprehensive oral examination before or during the early stages of therapy
If any problem develops during or subsequent to BP therapy, the patient should promptly consult a dentist
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Slide244The Patient With Endocrine Disorders(osteopenia and osteoporosis)General considerationsRoutine dental treatment generally should not be modified
It may be prudent to proceed conservatively
Allowing time for healing before putting multiple quadrants at risk
Limit the possibility of extensive or multifocal involvement
Conditions that already involve medullary bone should be treated immediately even if multiple quadrants are involved
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Slide245The Patient With Endocrine Disorders(osteopenia and osteoporosis)Periodontal diseaseAppropriate forms of non-surgical therapy
Reevaluate every 4-6 weeks
Conservative surgical treatment
Obtain access to root surfaces
Modest bone-recontouring
Primary soft-tissue closure is desirable
No evidence of risk
Guided tissue regeneration
Bone replacement grafts
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Slide246The Patient With Endocrine Disorders(osteopenia and osteoporosis)Implant placementPatient may be at increased risk of BON
Extensive preparation of the osteotomy site
Guided bone regeneration required to augment a deficient alveolar ridge
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Slide247The Patient With Endocrine Disorders(osteopenia and osteoporosis)Maintenance of implantAccepted mechanical and pharmacological methods to prevent peri-implantitis
Regular monitoring
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Slide248The Patient With Endocrine Disorders(osteopenia and osteoporosis)Peri-implantitisAppropriate form of nonsurgical treatment
Surgical revision of soft tissue
Modest bone recontouring
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Slide249The Patient With Endocrine Disorders(osteopenia and osteoporosis)Oral and maxillofacial surgeryConsider alternative treatment plans
Endodontics followed by removal of clinical crown
Allowing roots to exfoliate instead of extraction
FPD and RPD instead of implants
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Slide250The Patient With Endocrine Disorders(osteopenia and osteoporosis)If extraction or bone surgery are necessaryConservative surgical techniques with primary closure
Chlorhexidine-containing rinses
Pre-op and post-op
Antibiotic use should be based on the risk of an infection and not history of BP use
There is no evidence that the use of antibiotics is effective in preventing BON
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Slide251The Patient With Endocrine Disorders(osteopenia and osteoporosis)EndodonticsPreferable to surgical manipulation
Routine endodontic technique
Manipulation beyond the apex not recommended
Consider endodontic treatment of nonrestorable teeth followed by removal of clinical crown
Passive exfoliation of the root tip
Endodontic surgical procedures should be guided by the same principles as OMFS procedures
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Slide252The Patient With Endocrine Disorders(osteopenia and osteoporosis)Restorative dentistry and prosthodonticsRoutine restorative procedures generally should not be modified
There is no evidence that malocclusion or masticatory forces increase the risk of BON
Crowns, FPDs, RPDs, complete dentures preferable to implant placement
Removable prostheses should be adjusted for fit promptly to prevent ulceration and possible bone exposure
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Slide253The Patient With Endocrine Disorders(osteopenia and osteoporosis)OrthodonticsCase reports of inhibited tooth movement
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Slide254The Patient With Endocrine Disorders(osteopenia and osteoporosis)Stage 1 BONExposed/necrotic bone in patients who are asymptomatic
No evidence of infection
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Slide255The Patient With Endocrine Disorders(osteopenia and osteoporosis)Treatment strategiesAntimicrobial mouth rinse
Removal of mobile segments of bony sequestrum
Clinical follow-up on a quarterly basis
Patient education
J Oral Maxillofac Surg 2007;65:369-376.
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Slide256The Patient With Endocrine Disorders(osteopenia and osteoporosis)Stage 2 BONExposed/necrotic bone associated with infection
Pain and erythema in the region of the exposed bone with or without purulent drainage
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Slide257The Patient With Endocrine Disorders(osteopenia and osteoporosis)Treatment strategiesSymptomatic treatment with a broad-spectrum oral antibacterial agent
Antimicrobial mouth rinse
Pain control
Superficial debridement to relieve soft tissue irritation
J Oral Maxillofac Surg 2007;65:369-376.
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Slide258The Patient With Endocrine Disorders(osteopenia and osteoporosis)Stage 3 BONExposed/necrotic bone associated with infection, pain, and one or more of the following
Extraoral sinus tract
Osteolysis extending to the inferior border
Pathologic fracture
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Slide259The Patient With Endocrine Disorders(osteopenia and osteoporosis)Treatment strategiesAs in Stage 2 BON
Surgical debridement/resection for longer term palliation of infection and pain
J Oral Maxillofac Surg 2007;65:369-376.
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Slide260The Patient With Endocrine Disorders(osteopenia and osteoporosis)Preventive strategies
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Slide261The Patient With Endocrine Disorders(osteopenia and osteoporosis)
Oral hygiene
Conventional vs. electromechanical toothbrushes
Antibacterial mouthwashes
Topical fluorides
Sialagogues
Pilocarpine (Salagen)
Cevimeline (Evoxac)
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Slide262The Patient With Endocrine Disorders(osteopenia and osteoporosis)Medical emergencies
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Slide263The Patient With Endocrine Disorders(osteopenia and osteoporosis)
13,836 medical emergencies reported by 2,704 dentists occurring within a 10-year period
Malamed SF. Managing medical emergencies. JADA 1993;124(8):40-53.
Syncope
Mild allergic reaction
Postural hypotension
Hyperventilation
Hypoglycemia
Angina pectoris
Seizures
30.1 (o.15)
18.7 (0.09)
17.9 (0.08)
9.6 (0.04)
5.1 (0.02)
4.6 (0.02)
4.6 (0.02)
Asthma
Local anesthetic overdose
Myocardial infarction
Anaphylactic reaction
Cardiac arrest
All
o
thers
2.8 (0.01)
1.5 (0.oo7)
1.4 (0.007)
1.2 (0.006)
1.1 (0.005)
1.4 (0.007)
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Slide264The Patient With Endocrine Disorders(osteopenia and osteoporosis)
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Slide265The Patient With Endocrine Disorders(osteopenia and osteoporosis)References
American Association of Oral and Maxillofacial Surgeons Position Paper on Bisphosphonate-Related Osteonecrosis of the Jaws. J Oral Maxillofac Surg 2007;65:369-376.
Edwards BJ, Hellstein JW, Jacobsen PL, Kaltman S, et al. Updated recommendations for managing the care of patients receiving oral bisphosphonate therapy. An advisory statement from the American Dental Association Council on Scientific Affairs. JADA 2008;139:1674-1677.
Qaseem A, Snow V, Shekelle P, Hopkins R, et al. Pharmacological treatment of low bone density or osteoporosis to prevent fractures: a clinical practice guideline from the American College of Physicians. Ann Intern Med 2008;149:404415.
Woo S.B, Hellstein J.W. Systematic review: Bisphosphonates and osteonecrosis of the jaws. Ann Intern Med 2006;144:753-761,
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