Managing Periodontal Health in Patients with Chronic Illnesses

Periodontal Treatment Of Medically Compromised Patients

Answer. There are various types of medically compromised patients for which there are various management plans which are as follows:

Cardiovascular Disease

Hypertension

Management for Hypertension

• No routine periodontal treatment should be carried out if the patient is hypertensive.
• During dental treatment stress of hypertensive patient should be minimized.
• While treating hypertensive patients, clinician should not use a local anesthetic solution containing epinephrine concentration greater than 1:100000.
• If hypertensive patient exhibit anxiety, use of conscious sedation in conjunction with periodontal procedures may be warranted.
• b-blockers are used to treat hypertension.

Ischemic Heart Disease (Angina Pectoris)

• Preoperative glyceryl trinitrate and sometimes oral sedation are advised.
• Dental care should be carried without minimal anxiety and oxygen saturation, blood pressure and pulse monitoring.
• If a patient with a history of angina experiences chest pain during dental surgery, dental treatment should be stopped. The patient should be given glyceryl trinitrate 0.3–0.6 mg sublingually and oxygen and be kept sitting upright.
• If chest pain is not relieved within about 3 min, myocardial infarction is a possible cause and medical help should be summoned.
• Pain that persists after 3 doses of nitrogen glycerin given every 5 min that lasts more than 15–20 min, or that is associated with nausea, vomiting, syncope or hypertension is highly suggestive of myocardial infarction.

Endocrine Disorders

Diabetes Mellitus

Pretreatment Assessment

Assess the patient whether the patient is prone to diabetic coma or insulin shock.

• If Tolbutamide, Chlorpropamide or small doses of insulin is taken by the patient, there will be less chances of not occurring.
• If the patient take large daily doses of insulin, then there is possibility of diabetic coma or insulin shock.
• If the patient complains of being thirsty, nauseous and shortness of breath and has warm dry skin, the patient is most likely hyperglycemic and should be immediately refer to the physician, No treatment is required by the dentist.
• Glucose drink should be available, if the patient complaints of hypoglycemia.

Preferable Appointments

• Appointment should be of short duration, especially in the morning.
• Morning appointments are ideal after breakfast because of optimum insulin levels.
• It is best to plan treatment to occur either before or after periods of peak insulin activity; this reduces the risk of perioperative hypoglycemic reactions.
• Morning appointments results in well-rested diabetic patient with maximum tolerance for potentially stressful dental procedures.
• While the patients receiving intermediate or long-acting insulin may be treated in the afternoon.

Tissue Management

• Patients with diabetes mellitus are managed in such a way as to minimize disturbances of metabolic balance.
• Tissues should be handled atraumatically as minimally as possible (Less than 2 hours).
• The physical and emotional stress, infection and surgical procedures may tend to alter patients disease.

Sedation and Antibiotic Prophylaxis

• Antibiotic prophylaxis is recommended for extensive therapy.
• For anxious diabetic patients preoperative sedation is required.
• Stress-reduction protocol may help to stabilize the patient’s insulin requirement and assists in maintenance of metabolic homeostasis.

Periodontal Procedures

• Periodontal treatment is contraindicated in uncontrolled diabetes.
• If there are periodontal conditions that require immediate care, prophylactic antibiotics should be given. Penicillin is the drug of choice.

Periodontitis

Patients with severe periodontitis, adjunctive use of the tetracyclines in conjugation with mechanical periodontal therapy may have beneficial effects on glycemic control as well as on periodontal status.

Periodontal Abscess

• In case of pain and swelling with multiple periodontal abscess antibiotic prophylaxis should be given. Relieve the abscess by incision and drainage.
• The incisions must be given parallel to the long axis of the tooth on the most dependent part of gingiva under LA without adrenaline.
• Local anesthetic without Epinephrine is to be used in dental surgical procedures, as epinephrine can elevate the blood glucose concentration.

Pocket Elimination

• Periodontal pockets can be eliminated with modified Widman flap procedures.
• Periodontal surgeries for pocket elimination must be done with strict asepsis on antibiotic coverage after consent from physician.

Maintenance Care

• Most diabetic patients can be effectively treated in the dental office on a routine outpatient basis.
• Maintenance care of all diabetic patients with periodontal problems must be done frequently at intervals of every 3 months.
• Dietary recommendations for the patient should be advised according to the insulin level.
• Postoperative oral hygiene methods could try to reduce the onslaught of periodontal breakdown.
• Recall appointments and fastidious home oral care should be stressed.

Adrenal Insufficiency

• Terminate periodontal treatment.
• Summon medical assistance.
• Give an oxygen
• Monitor vital signs
• Place the patient in supine position
• Administer 100 mg of hydrocortisone sodium succinate 4 over 30 seconds or IM.

Liver Diseases

• Consult with the physician about the current status of disease, risk for bleeding, potential drugs to be prescribed during treatment and required alterations to periodontal therapy.
• Screen for hepatitis B and C
• Check laboratory values for PT and PTT.

Leukemia

• Refer the patient for medical evaluation and treatment. Close cooperation with the physician is required.
• Before chemotherapy, a complete periodontal treatment plan should be developed.
  • Monitor hematologic laboratory values daily: bleeding time, coagulation time, prothrombin time, and platelet count.
  • Administer antibiotic coverage before any periodontal treatment because infection is a major concern.
  • Extract all hopeless, non-maintainable, or potentially infectious teeth at least l0 days before the initiation of chemotherapy, if systemic conditions allow.
  • Periodontal debridement should be performed and thorough oral hygiene instructions given if the patient’s condition allow. Twice-daily rinsing with 0.12% chlorhexidine gluconate is recommended after oral hygiene procedures. Recognize the potential for bleeding caused by thrombocytopenia. Use pressure and topical hemostatic agents as indicated.
• During the acute phases of leukemia, patients receive only emergency periodontal care. Any source of potential infection must be eliminated to prevent systemic dissemination. Antibiotic therapy is frequently the treatment of choice, combined with nonsurgical or surgical debridement as indicated.
• Oral ulcerations and mucositis are treated palliatively with agents such as viscous lidocaine. Systemic antibiotics may be indicated to prevent secondary infection.
• Oral candidiasis is common in the leukemic patient and can be treated with nystatin suspensions or clotrimazole vaginal suppositories.
• For patients with chronic leukemia and those in remission, scaling and root planing can be performed without complication, but periodontal surgery should be avoided, if possible.