D Oral Surgery

7/29/2019 D Oral Surgery

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DIABETES & ORAL SURGERY

BY: AMMAR HUSSAIN PABANEY


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EVERY 1 OUT OF 4 PATIENTS YOU

GET IS A KNOWN DIABETIC

EVERY 3 OUT OF 6 PATIENTSYOU GET WANTS THEIR TOOTH

REMOVED


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SOWHAT WILL I BE TALKING

ABOUT?? A brief intro to diabetes andoral surgery!

Establishing a connection

between the two phenomena!

An in-depth discussion aboutwhat one does to another!

A Diabetic patient!

Diabetic and Oral Surgeon!


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DIABETES MELLITUS!

A metabolic, endocrine,

systemic disorder.

Constant hyperglycemia.

TYPE I: Insulin-Dependent

Diabtes Mellitus (IDDM).

TYPE II: Non-Insulin-Dependent

Diabetes Mellitus (NIDDM).

Pathogenesis.


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ORAL SURGERY!

The term means injections,cutting, bleeding and messywork!

Related closely to inflammation,

infection, bleeding and healing.

Any surgery results in aconsiderable loss of healthyoral tissue as well.

A simple tooth extraction canbe easy or can make your lifehard.

Most important: Diabetics arenot healthy individualsso any

surgery can go haywire!


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HMMTWO DIFFERENTPHENOMENA CO-RELATION??


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BASIS FOR THE RELATION.

Broad axis of inflammation.

Immune cell phenotype.

Serum lipid levels.

Tissue homeostasis.

Platelet inefficiency.


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CHANGES IN IMMUNE CELL

FUNCTION..

Diabetes

Inflammatoryimmune cell

phenotype

Up-regulation of pro-inflammatory cytokines

Down-regulation of growth factors

Inflammation

Progressivetissuebreakdown

Diminishedtissuerepair

Opportunistic oral microbiota

Bacteria get a constant supply of sugar

from the blood!

Changesmanifestasdelayed

healingandwoundinfection


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ROLE OF SERUM LIPID LEVELS

DiabetesElevated LDL/ TRG Immune cell

alterationHyperlipidemiaInfections

BacteremiaElevation of IL-1

and TNF-a

Alterationsin lipid

metabolism

InsulinResistancesyndrome

Diabetesagain!!

THESYN

ERGY!


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PLATELET INEFFICIENCY.

DiabetesMegakaryocytes

dont giveplatelets

Prevents glucose transport inside

megakaryocytes

No platelets &no platelet

function.


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HENCE..

There is potential of oral surgery to exacerbate andmay be induce diabetes mellitus!

There is potential of diabetes leading to frequentvisits to oral surgeons!

DIABETESORALSURGICALPROCEDURES


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WHAT GOES IN THE CLINIC??

DOC!ITHINKIHAVE

DIABETES

OHKLETMESEE..


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HOW DOES THE CLINICIAN GO FOR

DIABETES??

ATHOROUGHHISTORY


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DIABETES??

CLASSICALSIGNS


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DIABETES??

CONSULTPATIENTSPHYSICIAN


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DIABETES??

GO FORLABTESTS!

Fasting Blood Glucose. Random Blood Glucose.

Glycosylated HemoglobinAssay (HbA1c)


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DIABETES??

RULEOUTACUTEORALINFECTIONS


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DIABETES??

ESTABLISHBESTPOSSIBLEORAL

HEALTH


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SO WHERE DOES DIABETES AND

ORAL SURGERY CLASH IN A

CLINICAL SET UP??


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IN DIABETES..

Healing is delayed.

Susceptibility to infectionsincreases due to lowered

resistance.

Platelets dont function asnormal so there is a chanceof bleeding diathesis!

Patient should not receiveany invasive procedures untilthe blood sugar level isreduced.


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IN ORAL SURGERY

Invasion of tissues Inflammation repair andregeneration.

Open surgical wounds access to bacteria infection.

Blood has sugar bacterial

feast!

Loss of tissue form andtendency to hemorrhage.


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THE CLINICAL SYNERGY!

DIABETES

Delayedhealing.

Increasedsusceptibilitytoinfections.

Bacteremia.

Progressiveinflammation.

ORAL

SURGERY

Inevitableinjury.

Greataccesstobacteriathroughsurgicalwounds.

Bacteremia.

IncreasedIL-1 andTNF-a


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EFFECT ON TREATMENT AND

HEALING

Diabetes Chronic bugger Oral surgicalprocedures(extractions, flaps etc.) Delayed healing!


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HEALING

Diabetes Alters Immune Cells Lower Immunity Exacerbate themselves as well predispose to other

infections defect in bodys homeostatic mechanisms!


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HEALINGDiabetes Decreased body immunity Beautiful access of

bacteria to blood and organs BACTEREMIA! double troubletreating infections in debilitated patients!


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HEALINGDiabetes Releases inflammatory cytokines Exaggerate

Inflammation Not Good!!


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ANY SURGERY..

STRESS.

GLUCOSE COUNTERACTS STRESS..

DIABETICS HAVE VERY LITTLE

GLUCOSE.

HYPOGLYCEMIC SHOCK!


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SOWHEN YOU ARE WORKING ON

A DIABETIC PATIENT

You shouldrememberthatthispatienthasmorebleedingtendencythannormal.

You shouldrememberthatoncehestartsbleeding,theclottingsystemisnotmucheffective adiastheticcrisis!

You shouldrememberthatthispatientcanpickupinfectionthroughouttheprocedures baseforantibioticrationale!

You shouldrememberthatthispatienthasadelayedorabnormalhealingpatternsohavetomanageyourtreatment

plansaccordingly!


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NOWYOU KNOW THE PATIENT ISDIABETIC.SO.


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ESTABLISH GLYCEMIC CONTROL

Need to know this beforeany treatment.

Lab tests providesnapshots of bloodglucose.

HbA1c reflects patientscontrol of blood sugar

over 6-8 weeks.

Poor control PoorResponse!


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WHAT ABOUT PROPHYLACTIC

ANTIBIOTICS??

Only if the surgery is the callof the hour and the patienthas horrible glycemic control!

Penicillin- safest!

Rule of thumb: BEAGGRESSIVE TO TREATINFECTIONS!


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MANAGING THE DIABETIC

PATIENT

Depends upon the type of diabetes!

Depends upon the length of the procedures!

Depends upon your as well the patients decision!


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SOME MANAGING PRINCIPLES

COMMON TO BOTH TYPEI AND II Defer surgery until diabetes is well controlled.

Schedule an early morning appointment.

Use anxiety reduction protocols.

Monitor vitals all the time.

Maintain verbal contact and reassurances all the time.

Watch for signs of hypoglycemia.

Treat infections aggresively.


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SOME SPECIFIC MANAGEMENT OFINSULIN DEPENDENT .


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INSULIN DEPENDENT!

1. IF PATIENTMUSTNOTEAT/DRINKBEFOREANDAFTERPROCEDURE:

InstructpatientNOTtotakeusualdoseofNPH/RegularInsulin.

AdministerIVDextrosewaterat150

ml/hr.


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INSULIN DEPENDENT!

2.IF PATIENTISALLOWEDTOEAT/DRINK BEFOREANDAFTERTHEPROCEDURE:

Havethepatienteatanormalbreakfast.

Takeusualdose(Regular)or

halfthedose(NPH)ofinsulin.


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INSULIN DEPENDENT!

3.ADVISEPATIENTNOTTORESUME NORMALINSULINDOSE:

Untilthecaloricintakeandactivitylevelsarebackto

normal.

4.CONSULTPHYSICIAN:

For anymodificationsintheInsulinregimen.


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SOME SPECIFIC MANAGEMENT OFNON-INSULIN DEPENDENT.


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NON-INSULIN DEPENDENT!

1. IF PATIENTMUSTNOTEAT/DRINK BEFOREANDAFTERTHEPROCDURE:

Instructpatienttoskipanyoralhypoglycemic

medicationsthatday.


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NON-INSULIN DEPENDENT!

2.IF THEPATIENTISALLOWEDTOEAT/DRINKBEFOREANDAFTERTHEPROCEDURE:

Haveanormalbreakfast.

Taketheusualdoseofhypoglycemicagent.


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SOMETHING YOU SHOULD KNOW.

REGULARINSULIN: Shortacting, 15mins. onset, 5-6 hoursduration.

NPHINSULIN:Intermediateacting, 30-60mins. onset, 4-12

hoursduration.

SULFONYLUREAS:Stimulaterapidpancreaticinsulinsecretion;haveahighriskofcausinghypoglycemia.

MEGLITINIDES,BIGUANIDES:Blocksglucoseproductionfromliver;areeuglycemics.


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THE BIGGEST PROBLEM!!


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AND SUDDENLY PATIENTGOES..HYPOGLYCEMIC!!!!!


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PATIENT WOULD HAVE..


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WHAT SHOULD YOU DO??

IF PATIENTISCONSCIOUSANDABLETOEAT/DRINK:

15gmoforalcarbohydrate(4-6 ozofjuice)or

3-4 tspofsugar.

Hardcandywith15gmofsugar.


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WHAT SHOULD YOU DO??

IF PATIENTISUNABLETOEAT/DRINK/SEDATED/

UNCONSCIOUS:

25-30mlof50%DW-IVor

1 mgGlucagonIVor

1 mgGlucagonIM (ifnoIV

access).


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GUIDELINES AND PROTOCOLS!

BRINGALONGYOURGLUCOMETER!


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CHECKINGBLOODGLUCOSEBEFOREPROCEDURES!!

If low before hypoglycemicintra-operatively.

If high before determinepatients control proceduremay need to be postponed!

CHECK BLOODGLUCOSEDURINGANDAFTERTHEPROCEDUREAS

WELL


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CHECK FORHYPOGLYCEMICSYMPTOMSTOO!!


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REMEMBER! THIS

HYPOGLYCEMIC NUISANCE

ALSO OCCURS IN NON-DIABETICS!......PERSONAL

EXPERIENCE..


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FINALLY..LET THE PATIENT GO

NOW!!


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ACKNOWLEDGEMENTS.

Beuchamp, Evers, Mattox; PRE-OPERATIVE HEALTH STATUS EVALUATION.

Textbook of Oral and Maxillofacial Surgery, 16-17.

Iacopino AM; INFLAMMATION AND DIABETES INTERRELATIONSHIPS: ROLE

OF INFLAMMATION. Ann. Periodontol. 2001 Dec.; 6(1): 125-137.

Hupp JR, Ellis E, Tucker MR; PRE-OPERATIVE HEALTH STATUS EVALUATION:

DIABETES MELLITUS. Contemporary Oral and Maxillofacial Surgery, 5th Ed., 15-

16.

Archer WH, DENTOALVEOLAR SURGERY: THE EXTRACTION OF TEETH. Oral

and Maxillofacial Surgery, Vol.

1, 5th Ed.

, 18-19.

Newman, Takei, Klokkevold, Carranza; PERIODONTAL TREATMENT OF

MEDICALLY COMPROMISED PATIENTS. Carranzas Clinical Periodontology, 10th

Ed. 657-660.


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D Oral Surgery

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