Читать книгу A Practical Approach to Special Care in Dentistry - Группа авторов - Страница 217

1 Is there any connection with this patient's diagnosis of type 1 diabetes mellitus and coeliac disease?Type 1 diabetes mellitus is often associated with other autoimmune diseasesAlthough the most common coexisting organ‐specific autoimmune disease is autoimmune thyroid disease, coeliac disease may also be presentApproximately 8% of people with type 1 diabetes will also have coeliac diseaseCoeliac disease increases the risk of hypoglycaemia if a strict gluten‐free diet is not followedFigure 5.1.1 Panoramic radiography showing caries and a prior filling in tooth #54.

2  Why is a dental abscess of particular concern for this patient?Diabetes mellitus is known to be associated with increased risk of infection and impaired wound healing due to the chronic effects of hyperglycaemia:Neutrophil function (adherence, chemotaxis and phagocytosis) may be downregulated; neutrophils also produce fewer free oxygen radicals, thereby reducing their ability to make toxic metabolites for release against microbesMonocyte, macrophage and fibroblast functions are impaired, resulting in impaired tissue turnover and wound repairOral infection, pain and stress can result in alteration of blood glucose levels and lead to poor diabetic controlThe stress response elicited results in the release of hormones such as cortisol and adrenaline which work against the action of insulinAs a result, the body's production of glucose increases, which results in high blood sugar levelsAn insulin adjustment may be required

3 You decide it would be better to control the acute infection in #54 and extract the tooth at a later date. What should you consider when prescribing antibiotics?Administration of antibiotics can alter the blood glucose level and require an insulin dose adjustmentCoeliac disease may affect the absorption of antibiotics; antibiotics known to be associated with an increased risk of gastrointestinal toxicity should be avoidedAvoid azithromycin and metronidazole because they boost the action of hypoglycaemic agents

4 What factors are considered important in assessing the risk of managing this patient?SocialConsent: the parents are divorced and do not have a good relationship; their opinion regarding the proposed extraction of the #54 may differ (although there can be legal differences in the law from one country to another)Anxiety may be heightened due to the above social factorsLimited co‐operationMedicalHypoglycaemia risk: unable to eat properly due to the dental pain; fasting after dental procedures can also trigger a hypoglycaemic episodeHyperglycaemia risk: emotional and surgical stress can result in increased glucose levelsReduced co‐operation may be misinterpreted as related to generalised anxiety instead of abnormal glucose levelsEfficacy of oral medication may be impacted by poor absorption secondary to coeliac diseaseDentalIncreased susceptibility to infectionLikelihood of delayed healing after dental extractionIncreased caries risk (xerostomia; father does not assist with toothbrushing)Coeliac disease can cause enamel defects and mouth ulcers (as observed for this patient)Delayed dental development (coeliac disease and diabetes)

5 The patient injects a daily dose of fast‐acting insulin at 8 a.m. and a dose of long‐acting insulin at 10 p.m. At what time should you schedule the dental extraction?Fast‐acting insulin will have its peak effect between 9 a.m. and noonLong‐acting insulin will have its peak effect around 10 a.m.Ideally, the treatment should be performed in the morning, because the risk of hypoglycaemia is lower when the concentration of endogenous corticosteroids increases. This should be as soon as possible after breakfast (also avoids interfering with the next meal)

6 What laboratory tests are recommended before the tooth extraction?Serum glucose concentration before starting the procedureRecent HbA1c reading to determine the degree of metabolic control; postpone treatment if HbA1c >9%Figure 5.1.2 (a–c) Severe periodontal disease in a 37‐year‐old male with diabetes mellitus.