DIABETES & ORAL SURGERY

BY: AMMAR HUSSAIN PABANEY

EVERY 1 OUT OF 4 PATIENTS YOU GET IS A KNOWN DIABETIC

EVERY 3 OUT OF 6 PATIENTS YOU GET WANTS THEIR TOOTH REMOVED

SOWHAT WILL I BE TALKING ABOUT??

A brief intro to diabetes and oral surgery! Establishing a connection between the two phenomena! An in-depth discussion about what one does to another! A Diabetic patient! Diabetic and Oral Surgeon!

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.

ORAL SURGERY!
The term means injections, cutting, bleeding and messy work! Related closely to inflammation, infection, bleeding and healing. Any surgery results in a considerable loss of healthy oral tissue as well. A simple tooth extraction can be easy or can make your life hard. Most important: Diabetics are not healthy individualsso any surgery can go haywire!

HMMTWO DIFFERENT PHENOMENA CO-RELATION??

BASIS FOR THE RELATION.

Broad axis of inflammation. Immune cell phenotype. Serum lipid levels. Tissue homeostasis. Platelet inefficiency.

CHANGES IN IMMUNE CELL FUNCTION..

Up-regulation of pro-inflammatory cytokines Down-regulation of growth factors

Diabetes

Inflammatory immune cell phenotype

Inflammation Changes manifest as delayed healing and wound infection

Opportunistic oral microbiota Bacteria get a constant supply of sugar from the blood!

Progressive tissue breakdown Diminished tissue repair

ROLE OF SERUM LIPID LEVELS

Elevated LDL/ TRG

Diabetes

Hyperlipidemia

Immune cell alteration

Infections

Insulin Resistance syndrome THE SYNERGY!

Diabetes again!!

Alterations in lipid metabolism

Elevation of IL-1 and TNF-a

Bacteremia

PLATELET INEFFICIENCY.
Diabetes
Prevents glucose transport inside megakaryocytes

Megakaryocytes dont give platelets

No platelets & no platelet function.

HENCE..
There is potential of oral surgery to exacerbate and may be induce diabetes mellitus! There is potential of diabetes leading to frequent visits to oral surgeons!

DIABETES

ORAL SURGICAL PROCEDURES

WHAT GOES IN THE CLINIC??

OHKLET ME SEE.. DOC! I THINK I HAVE DIABETES

HOW DOES THE CLINICIAN GO FOR DIABETES??

A THOROUGH HISTORY

HOW DOES THE CLINICIAN GO FOR DIABETES??

CLASSICAL SIGNS

HOW DOES THE CLINICIAN GO FOR DIABETES??

CONSULT PATIENTS PHYSICIAN

HOW DOES THE CLINICIAN GO FOR DIABETES??

GO FOR LAB TESTS!
Fasting Blood Glucose. Random Blood Glucose. Glycosylated Hemoglobin Assay (HbA1c)

YOU SHOULD ALREADY KNOW THIS.

Normal Fasting Glucose: 90-130 mg/dl. Normal Random Glucose: <180 mg/dl. HbA1c: Normal (4-6%), Good (<7%), Moderate (7-8%), You have been a bad boy (>8%)!!
-American Diabetes Association.

HOW DOES THE CLINICIAN GO FOR DIABETES??

RULE OUT ACUTE ORAL INFECTIONS

HOW DOES THE CLINICIAN GO FOR DIABETES??

ESTABLISH BEST POSSIBLE ORAL HEALTH

SO WHERE DOES DIABETES AND ORAL SURGERY CLASH IN A CLINICAL SET UP??

IN DIABETES..
Healing is delayed. Susceptibility to infections increases due to lowered resistance. Platelets dont function as normal so there is a chance of bleeding diathesis! Patient should not receive any invasive procedures until the blood sugar level is reduced.

IN ORAL SURGERY
Invasion of tissues Inflammation repair and regeneration. Open surgical wounds access to bacteria infection. Blood has sugar feast! bacterial

Loss of tissue form and tendency to hemorrhage.

THE CLINICAL SYNERGY!

DIABETES Delayed healing. Increased susceptibility to infections. Bacteremia. Progressive inflammation.

ORAL SURGERY Inevitable injury. Great access to bacteria through surgical wounds. Bacteremia. Increased IL-1 and TNF-a

EFFECT ON TREATMENT AND HEALING

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

EFFECT ON TREATMENT AND HEALING

Diabetes Alters Immune Cells Lower Immunity Exacerbate themselves as well predispose to other infections defect in bodys homeostatic mechanisms!

EFFECT ON TREATMENT AND HEALING

Diabetes Decreased body immunity Beautiful access of bacteria to blood and organs BACTEREMIA! double trouble treating infections in debilitated patients!

EFFECT ON TREATMENT AND HEALING

Diabetes Releases inflammatory cytokines Inflammation Not Good!! Exaggerate

ANY SURGERY.. STRESS. GLUCOSE COUNTERACTS STRESS.. DIABETICS HAVE VERY LITTLE GLUCOSE. HYPOGLYCEMIC SHOCK!

SOWHEN YOU ARE WORKING ON A DIABETIC PATIENT

You should remember that this patient has more bleeding tendency than normal. You should remember that once he starts bleeding, the clotting system is not much effective a diasthetic crisis! You should remember that this patient can pick up infection throughout the procedures base for antibiotic rationale! You should remember that this patient has a delayed or abnormal healing pattern so have to manage your treatment plans accordingly!

NOWYOU KNOW THE PATIENT IS DIABETIC.SO.

ESTABLISH GLYCEMIC CONTROL

Need to know this before any treatment. Lab tests provide snapshots of blood glucose. HbA1c reflects patients control of blood sugar over 6-8 weeks. Poor control Response! Poor

WHAT ABOUT PROPHYLACTIC ANTIBIOTICS??

Only if the surgery is the call of the hour and the patient has horrible glycemic control! Penicillin- safest! Rule of thumb: BE AGGRESSIVE TO TREAT INFECTIONS!

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!

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.

SOME SPECIFIC MANAGEMENT OF INSULIN DEPENDENT .

INSULIN DEPENDENT!
1. IF PATIENT MUST NOT EAT/DRINK BEFORE AND AFTER PROCEDURE: Instruct patient NOT to take usual dose of NPH/Regular Insulin. Administer IV Dextrose water at 150 ml/hr.

INSULIN DEPENDENT!
2. IF PATIENT IS ALLOWED TO EAT/DRINK BEFORE AND AFTER THE PROCEDURE: Have the patient eat a normal breakfast. Take usual dose (Regular) or half the dose (NPH) of insulin.

INSULIN DEPENDENT!
3. ADVISE PATIENT NOT TO RESUME NORMAL INSULIN DOSE: Until the caloric intake and activity levels are back to normal. 4. CONSULT PHYSICIAN: For any modifications in the Insulin regimen.

SOME SPECIFIC MANAGEMENT OF NON-INSULIN DEPENDENT.

NON-INSULIN DEPENDENT!
1. IF PATIENT MUST NOT EAT/ DRINK BEFORE AND AFTER THE PROCDURE: Instruct patient to skip any oral hypoglycemic medications that day.

NON-INSULIN DEPENDENT!
2. IF THE PATIENT IS ALLOWED TO EAT/DRINK BEFORE AND AFTER THE PROCEDURE: Have a normal breakfast. Take the usual dose of hypoglycemic agent.

SOMETHING YOU SHOULD KNOW.

REGULAR INSULIN: Short acting, 15 mins. onset, 5-6 hours duration. NPH INSULIN: Intermediate acting, 30-60 mins. onset, 4-12 hours duration. SULFONYLUREAS: Stimulate rapid pancreatic insulin secretion; have a high risk of causing hypoglycemia. MEGLITINIDES, BIGUANIDES: Blocks glucose production from liver; are euglycemics.

THE BIGGEST PROBLEM!!

AND SUDDENLY PATIENT GOES..HYPOGLYCEMIC!!!!!

PATIENT WOULD HAVE..

WHAT SHOULD YOU DO??

IF PATIENT IS CONSCIOUS AND ABLE TO EAT/DRINK: 15 gm of oral carbohydrate (4-6 oz of juice) or 3-4 tsp of sugar. Hard candy with 15 gm of sugar.

WHAT SHOULD YOU DO??

IF PATIENT IS UNABLE TO EAT/DRINK/SEDATED/ UNCONSCIOUS: 25-30 ml of 50% DW-IV or 1 mg Glucagon IV or 1 mg Glucagon IM (if no IV access).

GUIDELINES AND PROTOCOLS!

BRING ALONG YOUR GLUCOMETER!

GUIDELINES AND PROTOCOLS!

CHECKING BLOOD GLUCOSE BEFORE PROCEDURES!!
If low before hypoglycemic intra-operatively. If high before determine patients control procedure may need to be postponed!

CHECK BLOOD GLUCOSE DURING AND AFTER THE PROCEDURE AS WELL

GUIDELINES AND PROTOCOLS!

CHECK FOR HYPOGLYCEMIC SYMPTOMS TOO!!

REMEMBER! THIS HYPOGLYCEMIC NUISANCE ALSO OCCURS IN NONDIABETICS!......PERSONAL EXPERIENCE..

FINALLY..LET THE PATIENT GO NOW!!

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., 1516. 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.