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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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HOW DOES THE CLINICIAN GO FOR
DIABETES??
CLASSICALSIGNS
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HOW DOES THE CLINICIAN GO FOR
DIABETES??
CONSULTPATIENTSPHYSICIAN
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HOW DOES THE CLINICIAN GO FOR
DIABETES??
GO FORLABTESTS!
Fasting Blood Glucose. Random Blood Glucose.
Glycosylated HemoglobinAssay (HbA1c)
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HOW DOES THE CLINICIAN GO FOR
DIABETES??
RULEOUTACUTEORALINFECTIONS
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HOW DOES THE CLINICIAN GO FOR
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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EFFECT ON TREATMENT AND
HEALING
Diabetes Alters Immune Cells Lower Immunity Exacerbate themselves as well predispose to other
infections defect in bodys homeostatic mechanisms!
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EFFECT ON TREATMENT AND
HEALINGDiabetes Decreased body immunity Beautiful access of
bacteria to blood and organs BACTEREMIA! double troubletreating infections in debilitated patients!
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EFFECT ON TREATMENT AND
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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GUIDELINES AND PROTOCOLS!
CHECKINGBLOODGLUCOSEBEFOREPROCEDURES!!
If low before hypoglycemicintra-operatively.
If high before determinepatients control proceduremay need to be postponed!
CHECK BLOODGLUCOSEDURINGANDAFTERTHEPROCEDUREAS
WELL
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GUIDELINES AND PROTOCOLS!
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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