Systemic diseases and dentistry
During everyday practice, every dentist comes in a situation to work with patients with different systemic diseases. This usually does not present a problem, especially if a dentist is well trained, educated and prepared. Adequate knowledge and following a new recommendation of relevant health organization and researchers make your dentist well informed for every health problem that can be related to dental interventions. Some systemic diseases require a different approach, special care and proper protocols in the practice.
Diabetes mellitus is an endocrine disorder that affects the metabolism of carbohydrates. There are three different types of Diabetes: Type 1 Diabetes, Type 2 Diabetes and Gestational diabetes. The Type 1 Diabetes presents a 5% while Type 2 presents a 95% of all diabetic conditions. Type 1 Diabetes has autoimmune etiology and presents a destruction of pancreatic β-cells that are responsible for insulin production and regulation of glucose level in a blood. Type 2 Diabetes is acquired the disease that develops more slowly with lighter symptoms. It is usually the consequence of disbalance in the activity of α and β pancreatic cells which leads to insufficiency in insulin regulation to peripheral tissues. Another cause for this type of diabetes may be tissue resistance known as insulin resistance. Gestational diabetes is a transitory metabolic disorder of insulin that sometimes appears during pregnancy but has no special therapeutic requirements since the glucose metabolism will normalize after the delivery.
The glucose metabolism is irregular in the way of hyperglycemia or high glucose level in a blood. General manifestations of diabetes are presented as a polydipsia or excessive thirst, polyuria or excessive production of urine, increased ketogenesis, dry skin and mucosa etc. Damage of smaller and larger vessels has a wide range of complications since it leads to metabolic disorder of lipids with microtrauma of the wall of the blood vessels called endothelium and formation of atheromatous plaque. These changes, in large and small blood vessels, leads to disorders in peripheral microcirculation with consequent and more serious systemic complications.
Xerostomia or Dry Mouth is a consequence of polydipsia. The reduction of salivation leads to change in taste, problems with speaking and eating and digestion. Besides this, saliva has an important role in the prevention of caries and periodontitis, since it “washes out” the bacteria mechanically, but also has important immune cells that prevent infections. Hyposalivation join with immunosuppression leads to oral Candida infection with diabetic patients.
Periodontal disease and decay is a common condition in diabetic patients and it is a result of damage to the level of peripheral microcirculation, lower immune response and xerostomia with abnormal bacterial growth. All of the named factors have negative impact on periodontal tissue and that is why periodontal tissue of diabetic patients needs to be under control with frequent treatments of gums and periodontal pockets.
Infection and Antibiotics in diabetic patients needs a special attention since the immune response in these patients is changed. These patients are more susceptible to infection since bacterial growth is increased while local immune response is decreased. There is often a need for antibiotic treatment with these patients which can often be unsuccessful and may require additional tests in order to determine the specific bacterial specimen and proper antibiotic treatment.
Bleeding disorder is one of major concerns in dentistry especially when it comes to surgical procedures among diabetic patients. Tooth extraction, incisions and other smaller surgical treatments can be compromised with wound healing and potential infections. Problems with surgical interventions may appear as a consequence of chronic inflammation of gums, and changes in smaller, peripheral vessels. If diabetes is under control, smaller surgical interventions can be performed safely with no additional pre-treatment. Another problem with oral surgical interventions is related to implant placement. Bone metabolism is changed in diabetic patients in the way that the osteblastic activity and metabolism of parathyroid hormones is changed which can affect the osteointegration of implants. This makes diabetes as relative contraindication for implant placement. Many researches has investigated this problem and it has been concluded that if the diabetes is stable and patients good oral habits with relatively good condition of supporting tissues, the implant placement may be performed with high success rate.
Hyper and Hypoglycaemia are critical and acute conditions in diabetes and it is very important that your dentist is well informed about your disease and how well it is controlled. Hyperglycaemia occurs when the level of glucose reach critical value and rarely affects patients in dental office. On the other hand, Hypoglycaemia can affect diabetic patients during dental treatment and can lead to serious, life threatening consequences.
It is important that your dentist discuss your health issues and consult your physician when it is necessary regard the status of your condition. Sometimes additional tests may be necessary in order to provide safest treatment without jeopardizing your health and with achieving the best outcome for your dental problems. If diabetes is uncontrolled any dental treatment is not recommended until the glucose level is under control. Diabetic patients control glucose level periodically in every 3 months, through blood test called HbA1C. This simple blood test shows the level of blood glucose and if the disease is under the control. If the glucose level is 6.0-6.4%, it is considered as prediabetes, while the exceeded value over 6.5% indicates diabetes. In the case of uncontrolled diabetes all dental interventions needs to be postponed until the blood glucose level shows that patients have proper treatment of their disease i.e. the HbA1C is lower than 6.5%. The major issue with untreated diabetes might be appearance of hyperglycaemia, but more importantly hypoglycaemia during even simplest dental procedures, such as tooth preparation.
This term includes a wide range of conditions that affects heart and blood vessels. Atherosclerosis is diseases of blood vessels that are changed in structure, since the medium and internal layer known as mesothelium and endothelium are covered with atherosclerotic plaque. The plaque consists of lipids, cholesterol and calcium, in other words- calcified collection of fat and cholesterol. These changes leads to loss of elasticity in vessels, they become more rigid. The named changes can lead to other serious conditions in other systems and organs, such as heart attack, ischemic conditions and stroke. Depending on the affected vessels, different complications may develop: coronary heart disease, angina pectoris, stroke, carotid artery disease, peripheral artery disease. Main causes for heart disease are high blood pressure, unhealthy diet (rich in fat, carbs, salt and sugar), lack of physical activity, diabetes, stress and smoking. Patients suffering from any of these conditions needs to discuss their medical history with their dentist who may contact your physician in order to collect additional information or recommendation for future dental treatments.
Dental interventions are usually stressful for everyone. Stress in dental office needs close attention in patients with any form of cardiovascular disease, especially those with unstable angina pectoris. In these patients, stress can be a trigger for worsening their condition. Therefore, in order to reduce stress during the procedure, patients may be advised to take oral sedatives prior to the intervention. Earlier considerations suggested that anaesthetic solutions with adrenalin should be avoided in patients with cardiovascular diseases since they may negatively affect patients’ health. Nowadays, attitudes towards anaesthetics with adrenalin indorse their application in patients with cardiovascular conditions, but with caution regarding the dosage that should not exceed 0.04 mg of adrenalin.
Many patients suffering from cardiovascular diseases are taking anticoagulant medications that are preventing clot formation. The problem with these patients may appear during surgical treatments since the clotting time is increased and bleeding is longer than normal. Oral surgical interventions are usually less invasive, with small wounds and healing is possible without interrupting medication therapy. If anticoagulant therapy would be stopped prior to surgical treatment, that could negatively affect primer health condition and lead to complication of cardiovascular disease with fatal outcome. With these patients, important thing is to be familiar with INR value on the day of surgical intervention. INR value is clotting time in patients taking anticoagulants. This factor should be in the range of 2.0-4.0 in order to conduct a safe surgical procedure. As a part of a regular protocol, local hemostasis should be provided for these patients. Whether it is an absorbable gelatin sponge that could be placed into the wound in order to help hemostasis, hemostatic gauze impregnated with iodoform or simply surgical suturing of a wound, your dental surgeon will know which is the right additional treatment to prevent any prolonged bleeding after the procedure.
If patients have implanted a pacemaker, that should be seriously considered since dentist often use electronic devices in everyday practice for additional diagnoses. There are many different pacemakers nowadays, and its interferential with dental electronic devices is not uniform. Usually, the manufacturer in their instruction for use will suggest how to handle patients with a pacemaker. The safest procedure is your dentist consulting your cardiologist since he will know the exact type of pacemaker implanted and how your dentist can proceed in order to avoid interaction between these two appliances.
Infective endocarditis is an infection of the inner layer of the heart known as the endothelium. The causes of this infection are bacteria known as Streptococcus and Staphylococcus. This condition, if it is not treated, has manifestations similar to any fever, with high body temperature, chills, general fatigue, sweating, aching of muscles and joints etc. Complication of infective endocarditis can have a fatal outcome. Thanks to antibiotics, this condition can be easily treated. Many other heart conditions can be accompanied with infective endocarditis, such as rheumatic heart disease, different congenital heart diseases, mitral valve prolapse, artificial valves.
High blood pressure- Hypertension
Hypertension is a common disease of a modern world. Depending on the sources and statistical analyses, percentages of patients suffering from hypertension may vary. In Europe, the prevalence of this disease is around 35-40% of general population. The etiology of hypertension leads to the classification of this disease in the two groups: Primary or Essential has the unknown cause and is usually diagnosed accidentally, while the Secondary Hypertension is a consequence of other, primary disease related to renal pathology, endocrine neurological etc. Primary hypertension is actually developed as a result of the synergy of numerous factors, such as genetics, age, bad habits (smoking and alcohol consumption), diet and physical activity. In 2017 ACC (American College of Cardiology) and AHA (American Heart Association) presented a new classification of hypertension:
- Normal: <120 mmHg Systolic BP; <80 mmHg Diastolic BP
- Elevated: 120-129 mmHg Systolic BP;
Stage 1 130-139 mmHg Systolic BP; 80-89 mmHg Diastolic BP
Stage 2 ≥140 mmHg Systolic BP; ≥90 mmHg Diastolic BP
- Hypertensive Crisis: >180 mmHg Systolic BP; >120 Diastolic BP
There is a great number of complication and consequential health problems caused by high blood pressure. Persistent hypertension leads to pathological changes in the blood vessels of heart, brain and kidney leading to serious chronic conditions of these organs. Since it is mainly diagnosed when complication on named organs occurs and many people are not aware of the problem with high blood pressure, this disease has its fully valid name- “Silent Killer”. This is why in many countries worldwide, preventive protocols suggest measurement of blood pressure in the dental offices. However, it should be pointed out that another form of hypertension may be present in the dental office, known as WCH (White Coat Hypertension). It appears only among the patients that experience anxiety and fear in the office prior to and during the medical/dental treatment, while blood pressure rate is completely normal outside of the dental office.
Therapy of Hypertension consists of changing lifestyle habits by increasing physical activities, changing diet and quitting smoking and alcohol consumption. When this conservative approach is not enough, medication can be included. Depending on the stage of the disease and associated factors physician will ordinate the most appropriate medications. These medications can lead to oral manifestation like Xerostomia or “Dry mouth”, or Gingival Hyperplasia.
If you are familiar with your blood pressure and you control hypertension with proper medications, you must inform your dentist. Since anaesthetics used for dental procedures usually contains adrenalin that can increase your blood pressure. Your dentist can apply anaesthetics without adrenalin and that way avoids any complications due to potential adrenalin injection into vessels with the consequential increase of blood pressure. However, when long and extensive dental procedures are planned, anaesthetics with no adrenalin are considered as less effective since the absorption of anaesthetic is faster and its durability shorter. In these cases your dentist may consult your cardiologist in order to adjust therapy for Hypertension in order to enable safe injection of anaesthetics with adrenalin that will allow enough time for planned surgical procedure.
It is important that your dentist is familiar with your health condition, medication therapy and stages of any diseases you might have, so they can prevent any other complication of present health status and provide you with best possible care.