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Author: Kanchan Ganda, M.D.
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1. Endocrine Conditions

1.1. Diabetes Mellitus (DM)

This is an endocrine condition associated with elevated blood sugar levels. Diabetes is subdivided into two distinct types:

  1. Type I or insulin-dependent diabetes mellitus (IDDM).
  2. Type II, or noninsulin dependent diabetes mellitus (NIDDM).

A diabetic is unable to metabolize glucose and the blood sugar (BS) increases. Insulin is a storage hormone and it helps:

  • transfer glucose into cells of the body for utilization. Excess glucose is stored in the liver as glycogen. When there is a lack of insulin glucose isn’t stored as glycogen;
  • the transfer of amino acids across cell membranes for protein synthesis to increase muscle mass;
  • promote the storage of fats as triglycerides.

We see high levels of acetoacetic acid, beta hydrozybuteric acid and acetone in the blood (ketonemia) and urine (ketonuria) when insulin is lacking. Decreased muscle mass/weight loss occurs with lack of insulin.

1.1.1. Type I: Insulin Dependent Diabetes Mellitus (IDDM)

The beta cells of the pancreas are destroyed (due to multiple etiological factors) and the patient lacks the insulin hormone which is necessary to handle the glucose load and maintain the blood sugar levels. There-fore, the patient is treated with insulin injections, administered on a daily basis for management of the disease.

Type I which was formerly referred to as juvenile diabetes, is sudden in onset (weeks to months), and is most commonly seen in children and young adults. IDDM can manifest as early as 2-3 months of age and up to around 35-40 years of age. Occasionally patients may present with Type I DM in the sixth or seventh decade of life. This is the reason why we do not call it Juvenile DM anymore. Frequently, a type I diabetic will present with a triad of symptoms consisting of Polyuria (excessive urination), Polydypsia (excessive thirst), and Polyphagia (excessive hunger). In addition, the type I patient may also complain of fatigue, weight loss (due to the decrease in muscle mass), weakness, blurred vision, and black outs (due to the ketonemia and/or ketonuria).

Hypoglycemic and hyperglycemic reactions and coma are frequent in poorly-controlled type I patients.

1.1.2. Type II: Non-Insulin Dependent Diabetes Mellitus (NIDDM)

In type II, the beta cells of the pancreas do produce insulin, but the insulin action is inappropriate. There could be insulin resistance at the receptor sites, the insulin may not be produced at the correct time, or the insulin doesn’t mature from pro-insulin and the patient develops diabetes. These patients are treated with oral hypoglycemic agents that enhance endogenous insulin action and promote glucose utilization.

Type II was formerly referred to as maturity onset diabetes and it occurs most frequently in obese patients after the age of 40. At present, this type of diabetes is occurring in obese children and young adults due to over eating and no exercise. It is a type of diabetes that is gradual in onset.

  1. The patient may be diagnosed during routine physicals, when blood tests are done, and the blood sugar (BS) is found to be elevated. This type of patient is asymptomatic.
  2. Others may become aware of their diabetes due to frequent opportunistic infections involving the skin, mucous membranes or urinary tract. It is not uncommon for these patients to present with yeast or fungal infections at these sites.
  3. Poor wound healing following surgery or dental extractions can also signal type II diabetes.

Type II diabetics can occasionally present with the triad of symptoms mentioned above with type I, but more frequently they present with increased incidence of opportunistic infections.

1.1.3. Opportunistic Infectious Organisms

Staphylococcus, Candidia albicans, E. coli etc.—do not attack a healthy body. When the body’s defenses are down or blood sugars are elevated, these organisms take a hold and cause infections in the patient.

  • Faruncles (infected hair follicles), boils (papular lesions), and pustules occur due to staphylococcal infection involving the skin, particularly in the beard area or between the shoulder blades. These infections are chronic in nature.
  • Mucous membranes in the oral cavity frequently acquire a white coating which can be wiped off. This is a typical Candida infection.
  • Urinary tract infections (UTIs) are very common, especially in women, causing pain on urination (dysuria), burning urination, pus or blood in the urine.
  • Yeast infections—vaginitis—likewise can occur very frequently in uncontrolled diabetic women.

1.1.4. Blood Tests For Type I and Type II DM

  1. FBS (fasting blood sugar) test: The BS level is determined prior to breakfast. If a single value is above 125 mg/dl, the patient is diagnosed with diabetes.
  2. PPBS (post-prandial or post meal blood sugar) test: The BS level is determined after a meal. If a single value is above140 mg/dl, the patient is diagnosed with diabetes. We can do a PPBS 2 hours after a meal.

1.1.5. Hypoglycemic Reaction and Coma

Hypoglycemia is a common problem seen in the dental environment in diabetics, particularly the type I patient. It can also affect the normal (nondiabetic) patient who has been starving. Hypoglycemia is sudden in onset and occurs when the BS levels fluctuate between 40-50 mg/dl or below. This is a real problem because the brain only uses carbohydrates for energy. If the BS level drops, the brain will not receive enough carbohydrates and if no treatment is given within 3 minutes to the patient, the patient may die.

Three distinct stages of hypoglycemia can be outlined: mild, moderate and severe.

  1. In the mild phase, the patient becomes irritable, restless, hungry and experiences nausea as well.
  2. In the moderate phase the body is releasing large amounts of epinephrine. The patient experiences tachycardia (palpitations), a rapid bounding pulse initially and with progression to a rapid thready pulse. The patient starts sweating profusely, appears pale, flushed, shivers, and has goose bumps. In addition, the palms and soles become cold clammy, and wet. The gag reflex becomes prominent and toward the end of this phase the patient becomes very glassy-eyed, not understanding to your commands. The blood pressure starts to drop.
  3. In the severe phase, the patient throws a seizure, the BP drops further, we see a rapid, thready pulse and the patient becomes unconscious.

1.1.5.1. Management of Patients with Hypoglycemia

  1. In the conscious patient: The first thing we want to do is to see if we can communicate with the patient. We place the patient in a semi-sitting position and administer quick, simple sugars such as cake icing squirted on the gums or popsicle stick. This reverses the hypoglycemia. We can also give liquids, but be careful when giving orange juice (OJ) to these patients because we often see kidney disease with diabetes which can be worsened due to the potassium in the OJ. Also, the excess K+ will result in hyperkalemia. Therefore, I personally recommend giving apple juice if you give a liquid.. Once the patient is feeling better, give peanut butter and crackers or cheese and crackers to the patient because they are complex carbohydrates and will stay in the body longer.
  2. If you cannot communicate with the patient due to a very low BS or because the patient is having a seizure, you should wait until the seizure is completed (about 30 seconds). You must prevent the patient from falling. After the seizure, the patient is placed in a horizontal position with elevated feet, the vital signs are monitored, and 50 ml of 50% dextrose is given intravenously (IV) slowly at the rate of 5ml/min. The patient should respond immediately. The 50 % dextrose is not given rapidly because it can cause the patient to collapse. If the patient cannot be given dextrose, you can give 1 mg glucagon IM (intramuscular) in the deltoid muscle. The patient should respond within 3-15 minutes. These forms of treatment are also the treatments of choice in the conscious but non-communicative patient.

Early diagnosis will facilitate treatment and a successful outcome. In the early stages, let the patient take a position that is most comfortable. Liquids can sometimes be cumbersome to give because of the prominent gag reflex during the moderate to severe stage.

1.1.5.2. Hyperglycemic Reaction and Coma

The patient has ketones in the blood, an elevated BS, high levels of fat and protein in the blood, glucosuria, ketonuria, ketonemia, and deep acidotic breathing. The patient will also have a fruity smell due to the ketones in the blood and urine. The patient is slow to react to your communication, their skin is warm, and they have a rapid, irregular pulse.

1.2. Thyroid Dysfunction

The thyroid gland maintains the basal metabolic rate (BMR) of the body via the thyroid hormone thyroxine. If the thyroid gland is enlarged, it is referred to as a goiter. The enlarged gland may be a hypofunctioning gland (hypothyroidism) producing low levels of thyroxine, a hyperfunctioning gland (hyperthyroidism) producing high levels of thyroxine, or a normal functioning gland (euthyroid gland). Thyroid dysfunction occurs most commonly in females and the condition runs in families.

1.2.1. Hypothyroidism

Hypothyroidism results from poor functioning of the thyroid gland. Thyroxine replacement brings the gland to the euthyroid or normal functioning level.

Hypothyroidism is frequently associated with tiredness, weakness, fatigue, cold intolerance where the patient has a preference for very warm clothing and many blankets even when the surroundings are pleasant. Additionally decreased sweating, dry cold skin, thick coarse hair, decreased appetite, a history of weight gain, hoarseness, constipation, poor memory, depression, disinterest in surroundings, hands and feet being cold, white, and painful (Raynaud’s phenomenon) due to vasoconstriction, puffiness under the eyes (myxedema), thickened skin, hair loss, loss of the lateral third of the eyebrows are the other symptoms experienced.

  • Signs seen are slow pulse (bradycardia), decreased systolic blood pressure (SBP) because of lowered BMR, and increased diastolic blood pressure (DBP) because of peripheral vasoconstriction.
  • Uncontrolled patients have bradycardia and a narrowed pulse pressure (PP).
    • PP is the difference of the SBP(systolic BP) and DBP (diastolic BP).
    • So the PP = SBP minus DBP. The normal PP is 40 mmHg.
    • In uncontrolled hypothyroid patients the PP is less than 40 mmHg.

1.2.2. Hyperthyroidism

Hyperthyroidism is associated with heat intolerance, excessive sweating, warm moist skin, increased appetite, feeling hot all of the time, weight loss (the patient is very lean because of this weight loss), tremors of the hands, diarrhea, short attention span, hyperactivity, irregular pulse, occasionally missed beats, and increased heart rate (tachycardia). In addition, these patients have a “resting tachycardia.” Resting tachycardia means that the patient has an increased pulse rate, even when in deep sleep. Normally, the pulse slows down when one sleeps.

The hyperthyroid patient has an elevated SBP ( as the BMR is increased), lowered DBP due to vasodilation, and consequently an elevated PP (PP more than 40 mmHg). You may hear a functional heart murmur with many of these patients. The functional heart murmur is caused by a hyperdynamic circulation as the BMR is increased. This functional murmur does not need premedication.

1.3. Adrenal Dysfunction

The adrenal cortex can hyperfunction (Cushing’s syndrome) or hypofunction (Addison’s disease).

1.3.1. Cushing’s Syndrome

Obesity, fatigue, weakness, ankle edema, easy bruising, absent or decreased menstrual bleeding is suggestive of Cushing’s syndrome. The obesity particularly affects the face (referred to as moon face), the interscapular region (referred to as a buffalo hump), and the trunk. The limbs are spared. Acne is very common and these patients become hirsute (excessive facial hair growth).

1.3.2. Addison’s Disease

Addison’s disease patients frequently present with weakness, weight loss, nausea, vomiting, light headedness, and dizziness experienced when getting up from a lying-down position (due to postural hypotension), excessive skin pigmentation particularly around the mouth, lethargy, anorexia, and fatigue.