Management of patients at risk ENDOCRINOPATHIES

Management of patients at risk ENDOCRINOPATHIES

Endocrine pathologies, whether diabetes or others, are serious pathologies that drag on over time, requiring close, slow and multidisciplinary care and whose impact is very marked both on the patient and on their environment.

Definitions:

1. Endocrinology: A medical specialty that studies the function, diseases, and treatment of endocrine glands and metabolism.
2. Endocrine glands: are those whose secretion passes directly into the blood or lymph and has a considerable influence on the body.

The main ones are: Thyroid, parathyroid, adrenal, pituitary

3. Hormone: Chemical substance secreted by an endocrine gland, acting remotely and via the bloodstream on specific receptors located on the membrane of a target cell, organ, or tissue, the development and functioning of which it excites or inhibits.
4. Endocrinopathies: These include conditions characterized by excessive hormone secretion and those characterized by insufficient hormone secretion. They can also be due to the malfunctioning of hormone receptors.

Diabetes

1. definition :

– Diabetes is the most common endocrine disorder, comprising a group of metabolic pathologies characterized by chronic hyperglycemia, which results either

of impaired insulin secretion, or insulin resistance, or both. Plasma glucose concentration > 1.26 g/l in the fasting state on several occasions.

– Insulin is a peptide hormone secreted by the β cells of the islets of

Langerhans gland of the pancreas. It plays a major role in the regulation of energy substrates, the main ones being glucose, fatty acids and ketone bodies.

The action of insulin is often summarized by its hypoglycemic effect.

2. Classification Type I Diabetes:

Insulin-dependent diabetes, represents 5-10% of cases

It can occur at any age, but is more common in children and young adults.

Often due to a genetic factor, it generally results from an autoimmune destruction or deficiency of the β cells of the islets of Langerhans of the pancreas.

It has a high incidence of severe complications.

Type II diabetes:

It replaces the term non-insulin-dependent diabetes, it represents 90-95% of cases of diabetes.

It results from the body’s inability to respond correctly to the action of insulin produced by the pancreas.

Gestational diabetes: It results from an alteration of glucose metabolism following the production of placental and maternal hormones during pregnancy, most often during the second or third trimester and regresses after childbirth.

3. Diagnosis:

Clinical diagnosis: Polyuria, weight loss, polydipsia, polyphagia.

Biological diagnosis:

– Either a fasting blood sugar level greater than or equal to 1.26g/l at least 2 times taken

– Either a 2-hour blood sugar level; after a meal; greater than or equal to 2g/l

– Glycated hemoglobin: The level of glycated hemoglobin in a blood sample represents the blood sugar level over the previous 120 days, corresponding to the lifespan of red blood cells. An HbA1c level of less than 7%, blood sugar is considered well-balanced.

4. Complications of diabetes:
   1. Acute complications:
      1. Diabetic ketoacidosis:

Is due to an absolute insulin deficiency which results in hyperglycemia and lipolysis generating ketone bodies.

It concerns patients with type 1 diabetes whose insulin is insufficient to allow peripheral tissue utilization and inhibit glucose production and tissue catabolism.

It manifests itself as cardinal syndrome associated with digestive disorders, polypnea is a sign of metabolic acidosis with an acetone odor of the breath.

2. Hyperosmolar coma:

Unlike ketoacidosis, it usually occurs in elderly patients with type 2 diabetes.

It results from hyperglycemia precipitated by infection, by large ingestion of glucose or by omission of insulin intake.

3. -Hypoglycemia

Hypoglycemia is a blood sugar concentration that is below physiological values. Severe hypoglycemia is more common when HbA1c is low (for an HbA1c below 6%, approximately one severe hypoglycemic event occurs per year).

2. Chronic complications:
   1. Microangiopathies:

The term microangiopathy refers to the set of lesions observed during diabetes on small vessels (arteries, veins, capillaries) with a diameter of less than 30 microns per meter.

It results from the glycation of capillary proteins leading to their fragility, an increase in permeability or their occlusion.

It is totally responsible for the damage to the retinal and glomerular renal capillaries.

2. Neuropathy:

Neuropathies affect more than half of diabetic patients, their prevalence increasing with age, duration of diabetes and glycemic control.

3. Macroangiopathies:

Macroangiopathy is the most important factor in mortality in diabetics.

Coronary artery disease, myocardial infarction, lower limb arteritis and high blood pressure are more common in diabetics.

4. Infectious complications:

Disruption of leukocyte functions (impairment of chemotaxis, bactericidality and phagocytosis of polymorphonuclear cells)

3. Oral repercussions:

Dry mouth (xerostomia), cheilitis, hypertrophy of the filiform papillae, median glossitis and periodontal disease are present. There is also the presence of numerous cavities and delayed healing with a tendency to postoperative infections.

5 – Conduct to be adopted

• The interrogation:

The collection of certain information revealing the imbalance of diabetes or the suspicion of complications encourages the dental practitioner to contact the treating physician.

A correspondence will thus be established in order to know precisely the state of health of the patient, the nature of the treatment, the medication in progress and any possible complications.

This correspondence makes it possible to define a treatment plan and precautions adapted to each type of diabetic.

• Assess and monitor glycemic balance:

In well-controlled patients: HbA1c less than 7%

• No associated complications: all oral care can be performed
• With associated complications (renal, cardiac): depending on the nature of the care envisaged, specific precautions are necessary

In unbalanced patients (glycated hemoglobin >7%):

Treatment should be avoided. The patient will be referred to their primary care provider for reassessment. There are two exceptions to this rule:

-when the dental home is solely responsible for the diabetes imbalance

– when dental lesions are urgent (cellulitis, pulpitis)

• Sedative premedication:

Stress stimulates the production of adrenaline and corticosteroids. These substances are hyperglycemic. Therefore, a change in insulin dosage should be considered, especially in cases of significant stress.

The use of diazepines is perfectly indicated in diabetics.

Nitrous oxide sedation is a possible option for better management of particularly stressed diabetic patients.

In some situations, stress can interfere with diabetes. At this point, non-urgent care is postponed until the diabetes is controlled and stable.

• Anesthesia:

It has been established that the rate of vasoconstrictors per cartridge does not particularly increase blood sugar (adrenaline is hyperglycemic). It is even considered that the discharge of adrenaline secreted during pain during care due to shallow anesthesia (case of anesthesia without vasoconstrictor), is much greater and more harmful than that produced by the anesthetic solution with vasoconstrictor. Consequently, local anesthesia with vasoconstrictor is indicated for the balanced diabetic subject.

However, the multiplicity of anesthesia cartridges with vasoconstrictor injected during the same treatment represents a danger for the patient

• Antibiotic prophylaxis and surgical procedures:

Antibiotic prophylaxis is not systematic. It varies depending on the diabetic subject (balance, complications), oral health and the importance of the therapeutic act.

Antibiotic prophylaxis is not indicated in well-controlled patients with acceptable oral hygiene.

Antibiotic prophylaxis will be started the day before the procedure and ATB intake will be continued until healing.

The molecules of choice are penicillins; ß-lactams. In case of allergy to penicillin, prescribe pristinamycin or clindamycin.

  For complex surgeries , hospitalization may be considered and an adjustment of the insulin dosage is recommended, in agreement with the attending physician.

No intervention will be performed until the diabetes is stabilized.

Two circumstances are exceptions to this rule:

• When the dental home is solely responsible for the diabetes imbalance,
• When dental lesions are urgent (pulpitis, cellulitis, etc.).

At this point, it is a question of intervening in a hospital environment after readjustment of insulin and antibiotic prophylaxis.

Precautions to take when prescribing

Systemic miconazole or oral gel is contraindicated in patients treated with sulfonylureas.

NB: Please note:

• Diabetes control is not achieved by a single correct fasting blood sugar level, but by assessing the glycemic cycle in the health record.
• Properly controlling diabetes during and after dental care reduces healing time and decreases the frequency of complications.
• In case of hypoglycemia:
  • Give three pieces of sugar to relieve the discomfort, otherwise give an intramuscular injection of 1 mg of glucagon (active in 30 seconds)
  • In case of profound hypoglycemia; inject 20 cm3 of 30% hypertonic glucose serum.

2- Thyroid disorders: 2-1 Hypothyroidism:

Hypothyroidism is a thyroid disorder resulting from either insufficient production of thyroid hormones or resistance to the action of thyroid hormones.

Oral manifestations of hypothyroidism

-macroglossia

-delays in dental eruption in cases of prepubertal deficiency

-malocclusions

-gingival and labial edema and hypertrophy

-bone demineralization Hormonal Assessment:

Action to take:

T3 and T4 are collapsed. TSH: is high

Caution against anxiety and stress

Sedatives and narcotic analgesics are not recommended in hypothyroid patients.

Precautions against the risk of infection

Due to the risk of myxedema coma, the practitioner must be very vigilant regarding infection. Aggressive antibiotic therapy will be prescribed in case of infection and antibiotic prophylaxis will be carried out during surgical procedures.

Precaution in the context of prescription

Narcotic analgesics and sedatives should be avoided in patients with severe hypothyroidism; their dosage should be reduced in cases of moderate hypothyroidism because their

effects may be potentiated. NSAIDs should be used with caution in these same patients. The use of aspirin should be avoided.

2-2 Hyperthyroidism

Hyperthyroidism is characterized by an excess of T3 and T4, resulting from thyroid hyperfunction.

Oral manifestations

It is about:

-Early exfoliation of temporary teeth associated with eruption of permanent teeth due to excess production of thyroid hormones during dental eruption.

-Maxillary or mandibular osteoporosis;

-A susceptibility to periodontal diseases which can be aggressive and to dental caries which can be more extensive;

• early growth of the jaws

-Lingual burns; Hormonal assessment:

T3 and T4 are very increased, while TSH is very low.

Action to take:

Caution against anxiety and stress

Due to the precipitating role of stress and/or anxiety, as in the case of other endocrine disorders, sedation is strongly recommended during treatment, particularly in hyperthyroid patients.

As a general rule, interventions, if possible short, will preferably be scheduled in the morning.

Precautions during anesthesia

Due to the cardiostimulatory effects of adrenaline, anesthesia with vasoconstrictors should be avoided in hyperthyroid patients who are not treated or are poorly treated.

Precautions against the risk of infection

Due to the incidence of infection, particularly in hyperthyroid patients due to its precipitating role in thyrotoxic crisis, aggressive antibiotic therapy will be prescribed in the event of infection and antibiotic prophylaxis will be carried out during surgical procedures, including in well-controlled patients.

3 Secretion disorders affecting the parathyroid:

• Hyperparathyroidism : this is the abnormal increase in parathyroid hormone which affects the phosphocalcic balance.

Assessment: This increase causes:

– Bone demineralization – Subperiosteal resorption – Microgeodes – A significant decrease in bone mass leading to alveolysis and tooth loss. We can also find:

-High blood pressure –Heart rhythm disorders –Duodenal ulcers.

• patients present risks linked to complications of the disease.

Action to take:

– Advice from a cardiologist is essential (hypertension; rhythm disorder).

-Surgical procedures will be atraumatic and appropriate due to the risk of bone fracture.

4- Adrenal disorders

They are very sensitive patients from a psychological and organic point of view with a tendency to diabetes, high blood pressure and heart disease.

Adrenal insufficiency

Stress intolerance Delayed healing

Susceptibility to infection

Adrenal Hyperfunction

Delayed healing + susceptibility to infection Risk of hypertension

Risk of osteoporosis Risk of ulcer

Action to take

In case of adrenal insufficiency in relation to stress intolerance:

The patient’s attending physician will be consulted in order to define, based on the nature of the care and the associated stress, the most appropriate attitude to compensate for the patient’s potential insufficiency.

NB:

The presence of complications associated with corticosteroid therapy, which are part of the treatment of other pathologies, must be taken into account because they expose the patient to other potential problems and require specific precautions:

Cardiovascular: hypertension, ischemia Metabolic: glucose intolerance, diabetes Gastrointestinal: ulcer

In the case of adrenal hyperfunction

Any treatment requires a prior assessment of the circulating corticosteroid level ; when this is controlled, routine care can be considered.

Surgical and non-surgical care can be considered without special precautions in patients who have had unilateral adrenalectomy.

On the other hand, patients who have had bilateral surgery and are being treated with chronic steroid therapy should be treated with the same precautions as patients with adrenal hypofunction.

Regarding susceptibility to infection:

Universal hygiene and asepsis measures must be observed to minimize the risk of cross-transmission of bacterial and/or viral infectious diseases.

Anti-infectious prophylaxis is recommended for patients taking corticosteroids. In view of the risk of hypertension:

The use of adrenaline in anesthesia is not contraindicated provided the usual doses are respected.

Regarding the risk of ulcers: NSAIDs should be avoided.

Management of patients at risk ENDOCRINOPATHIES

  Deep cavities may require root canal treatment to save the tooth.
Dental veneers can correct stained or malformed teeth.
Misaligned teeth can cause speech problems.
Dental implants prevent bone loss in the jaw.
Antiseptic mouthwashes reduce bacteria that cause infections.
Decayed baby teeth must be treated to avoid complications.
An electric toothbrush cleans more effectively than a manual one.
 

Management of patients at risk ENDOCRINOPATHIES