8.5 Diabete s Mllitu 107
Where possible, the amount of trauma inflicted on the oral tissues during a dental extraction should be minimised – this is commonly referred to as atraumatic extraction. Extractions that do not involve the manipulation of soft tissues, avoids bone removal in favour of tooth sectioning, and minimises extraction forces transmitted to the alveolar bone may reduce the risk of development of MRONJ. Obviously, not all teeth can be removed without the use of such techniques; when surgical extraction is indicated, the surgeon must have a level of proficiency and experience sufficient to ensure that the tooth is removed with a reasonable degree of efficiency, and that the soft tissues are managed in a manner conducive to healing. This includes using smaller mucoperiosteal flaps when feasible, minimising tears or trauma to the soft tissues, using a thorough wound toilet with copious sterile saline irrigation, and making an excellent approximation of the soft tissues. For the inexperienced surgeon, difficult cases may be best managed by referral to a specialist or more experienced surgeon.
MRONJ can develop at any stage during the phase of postoperative healing. Following dentoalveolar surgery, at-risk patients require increased postoperative surveillance in the form of regular follow-up to assess for mucosal closure. A routine appointment two weeks postoperatively, followed by additional follow-up reviews at six and twelve weeks, will provide sufficient time to review healing and monitor for disease emergence.
Established MRONJ following tooth extraction requires prompt referral to a specialist oral and maxillofacial surgeon for appropriate ongoing medical and surgical management and is outside the scope of this textbook.
8.5Diabetes Mellitus
‘DM’ refers to a group of conditions characterised by poor blood glucose control. It may result from an absolute deficiency of insulin due to autoimmune pancreatic disease (type I diabetes) or a relative deficiency of insulin due to tissue insensitivity to the insulin hormone (type II diabetes).
Poorly controlled DM results in poor wound healing and increased risk of infection. As part of the preoperative workup prior to dentoalveolar surgery, the surgeon should acquire as much detail as possible about the individual circumstances regarding the patient’s management of their condition. It is recommended that the patient’s blood glucose level be tested just prior to the commencement of dentoalveolar surgery – the presence of hypoor hyperglycaemia may warrant postponement of the surgery until it is appropriately managed. For information regarding the longer-term stability of a patient’s blood sugar, a glycosylated haemoglobin (HbA1c) test can be requested from their general physician, although this is less relevant than the blood glucose level in determining whether to proceed with surgery.
Typically, patients with type I DM are managed with supplemental insulin, provided through periodic injections or with an insulin pump. These patients are most commonly susceptible to hypoglycaemic episodes, as dietary fasting without a commensurate reduction in insulin administration may result in excessively low blood sugars. Hypoglycaemia can become a medical emergency, and patients should be specifically informed not to fast prior to dentoalveolar procedures performed under local anaesthetic.
Patients with type II DM may be managed with dietary modification alone, dietary modification with oral hypoglycaemic agents, or the use of supplemental insulin. This group is more likely to develop hyperglycaemia; even in type II diabetics on insulin, hypoglycaemia is rare. Hyperglycaemia is usually asymptomatic, but when severe it may present with nausea, fatigue, diaphoresis, and weakness. In extreme cases, it can be associated with diabetic ketoacidosis, a medical emergency
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108 8 Management of the Medically Compromised Patient
of profound metabolic dysfunction, requiring hospital admission for acute management. If patients present with symptoms suggestive of hyperglycaemia, it is not advisable to proceed with surgery – referral to an appropriate medical service for assessment is recommended.
For patients undergoing extractions under general anaesthetic, specialist medical advice must be sought as to the management of the patient’s insulin regime and oral hypoglycaemic agents, as this can be incredibly complex, and varies depending on the timing of the surgery, the type of diabetes, the specific insulin regime, and other systemic factors which may affect blood sugar control. For patients undergoing dental extractions under local anaesthetic, a morning appointment should be offered, and the patient should be counselled on eating normal meals before the procedure. Additionally, oral glucose solutions should be readily available in the clinic, if required – it may be useful to provide these in anticipation of a hypoglycaemic event.
Whilst the risk of postoperative infection is higher in patients with DM, routine antibiotic prophylaxis is not recommended. However, close follow-up is advised, so that any developing or established infections may be treated promptly and aggressively. Routine oral hygiene advice and recommendations for strict blood sugar control may help to reduce the risk of infection.
8.6 Increased Bleeding Risk
Bleeding is an expected but occasionally difficult-to-control complication of any surgical intervention. Even in physiologically normal patients, obtaining haemostasis can be a significant intraoperative challenge; the presence of blood in a surgical site rapidly diminishes both access and vision, making control of a bleeding surgical site or vessel even more difficult.
For patients with an increased tendency to bleed, this is much more of a challenge, and simple methods of haemostasis may not be adequate. Recognition of increased bleeding risk in the preoperative workup is essential in order to reduce unexpected intraoperative complications, achieved through patient optimisation by their primary physician prior to the procedure, preparation of haemostatic adjuncts for use during surgery, and adequate postoperative care and instruction to manage any postoperative haemorrhage.
In general, if there is any suspicion of major or uncontrollable haemorrhage during a dentoalveolar procedure, the patient must be promptly transferred to a tertiary or specialist setting for management. Outpatient and community dental clinics are often not equipped with the staff or training to manage a critical bleed, and this risk is not justified if the surgeon is not in a setting where such complications may be managed.
For patients with increased bleeding risk, it may be wise to restrict the number of teeth to be extracted in a single procedure to three or fewer; a smaller procedure carries a proportionately lower risk. If the patient is having extractions under general anaesthetic, staging of the procedure is not indicated, as this will subject the patient to the risk of multiple general anaesthetics.
Increased bleeding risk may result either from the presence of bleeding diatheses or from the use of medications that affect the physiologic haemostatic process.
8.6.1 Bleeding Diatheses
Several conditions exist which can affect the normal process of haemostasis. These may be congenital, where there is an identifiable genetic cause, or acquired, which have developed as a result of another condition (Table 8.4). Many such conditions are uncommon in the general population, and the diagnosis often remains unknown to the patient. Surgery causing a serious and
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