Common Medical Conditions in Elderly Dental Patients. Part Two: Diabetes, Stroke, and Breathing Problems

Common Medical Conditions in Elderly Dental Patients. Part Two: Diabetes, Stroke, and Breathing Problems

Satbir Grover, B.D.S., * and Nelson L. Rhodus, D.M.D., M.P.H., F.I.C.D.**:


Introduction
In the Post World War II era from 1946 to 1964 commonly known as the “Baby Boom” years, approximately 78 million babies were born in the United States. This has had a tremendous impact  on the lifestyle and cultural trends in today’s “gray American” generation. With a total expenditure of approximately $2.3 trillion dollars, these older adults serve as the key drivers of all the major U.S. markets. 
 
In this second of a two-part series,† more common systemic conditions are presented to update dentists regarding the most common medical conditions of which they should be aware for  any elderly patient who walks into the clinic. This will help them prepare a plan to provide optimal dental treatment for this patient population. It will, as well, help them train their staffs in  either preventing or managing any emergency in the dental office.  Covered in this installment will be diabetes, stroke, and breathing problems. 


Diabetes
Diabetes mellitus has been defined as “a group of diseases characterized by high blood glucose levels that result from defects in the body’s ability to produce and/or use insulin”.31,32 
 
Diabetes mellitus (DM) is actually a group of metabolic disorders, with the most common manifestation as hyperglycemia, or elevated blood glucose level. Chronic hyperglycemia is considered  to be a contributing factor in damage to the eyes, kidneys, nerves, heart, and blood vessels. The etiology and pathophysiology of these complications related to the sustained level of  hyperglycemia, however, may be markedly different among patients suffering from DM, thus requiring customized treatment modalities depending upon the severity of the disease and the  symptoms present.33
 
Etiology
Types of Diabetes
Type 1. Diabetes mellitus formerly called Type I, IDDM, or juvenile diabetes, is an autoimmune disorder leading to beta cell destruction, thus resulting in absolute insulin deficiency. It is  estimated that 95% of patients with DM-1 develop the disease before the age of 25 years.34
 
Type 2. Diabetes mellitus formerly called Type II, NIDDM, or adult-onset diabetes, is the most common form of diabetes mellitus at approximately 80%, which is increasing at an alarming rate.  It is considered to be the result of a defect in the insulin secretory action of beta cells, and results in resistance to insulin in the peripheral tissues. It is proved to be highly associated with  family history, age (high prevalence in the elderly), lack of exercise, and obesity.34 
 
Presumably, Type 2 diabetes mellitus develops when a person begins a so-called “diabeto-genic” lifestyle. As the name suggests, this includes excessive caloric intake with inadequate caloric  expenditure, obesity, and lack of exercise, any or all with superimposition upon a susceptible genotype. As the studies indicate, women are more susceptible to developing diabetes. The body  mass index at which excess weight increases risk for diabetes varies with different racial groups. 
 
Epidemiology
Pre-diabetes, as defined by the American Diabetes Association, is that “state in which blood glucose levels are higher than normal but not high enough to be diagnosed as diabetes”. 
 
A Centers for Disease Control and Prevention (CDC) report in 2011 estimates that nearly 26 million, or 8.3%, Americans already have diabetes, with an additional 79 million estimated to be  suffering from pre-diabetes.35 Consequently, it is estimated that the cases of Type 2 diabetes will triple in the next ten years!35 
 
Signs and Symptoms
The cardinal signs for someone suffering from diabetes mellitus are: 
• Polyuria (frequent urination)
• Polydipsia (unusual thirst)
• Polyphagia (extreme hunger)
• Unusual weight loss
 
Other signs commonly associated with DM-II include but are not limited to:
• Extreme fatigue and irritability
• Frequent infections
• Blurred vision
• Cuts/bruises that are slow to heal
• Tingling/numbness in the hands/feet
• Recurring skin, gum, or bladder infections35,36
 
Dental Considerations
There is enough evidence suggesting a strong connection between oral health and systemic health. Some authors consider this pathway to be “bi-directional” — i.e., resembling “two-way  traffic” — wherein systemic metabolic disorders affect oral health and oral health problems result in multiple systemic health conditions. DM does negatively affect the mini-vasculature beds supplying the tooth and its supporting soft tissues and bones, thus giving origin to symptoms specific to dental care such as gingivitis, periodontitis, recurrent oral fungal infections, burning  mouth, and a diminished sense of taste.37 
 
In addition, patients suffering from xerostomia (dry mouth) or other salivary dysfunction, disorders of the oral mucosa such as lichen planus and recurrent aphthous stomatitis, or oral  infections such as candidiasis should also be immediately referred by the attending dentist to a medical physician.
 
As part of an allied health team, dentists play a major role in providing oral care to patients with systemic conditions such as diabetes. With the latest reports, dentists may be the first in the  line of defense helping the diagnosis of underlying disease and thus referring patients to physicians for further evaluation.
 
In the presence of any systemic complication related to diabetes, dentists need to modify treatment plans in consultation with the patients’ physicians as well as discussing the indications  and contraindications of prescribed medications for the treatment of any oral infection. 
 
 Pursuing the goal of providing complete health care to the patient, dentists and physicians should work with the patient’s nutritionist and the attendant dental hygienist to maintain the  patient’s oral health and possibly improve the patient’s metabolic control of diabetes. Antibiotic prophylaxis can be considered for patients taking high doses of insulin who have symptoms of oral infections.1,38
 
With the advancements in medical science and technologies, dental office management of patients with DM should not surface with any major challenges. Hypoglycemia, or low blood sugar  level, is one of the most common situations faced by the dental staff, especially if patients are asked to fast before undergoing a procedure. Staff members should be trained to recognize  unusual behavior patterns and identify patients showing symptoms of hypoglycemia.37,38 High sugar content candies, juice, or gels should be placed in an easily accessible location to be  readily used in case of emergency. As well, having an accurately working glucometer in the clinic may avert many related emergencies. Along with patients’ updated medical charts, any  suspicion regarding a patient presenting diabetic signs or symptoms and/or any major fluctuation in the patient’s glucometer reading should be sufficient reason for dentists to refer the  patients to physicians for further evaluation. A well-judged and timely interruption by the dentist can go a long way in reducing the morbidity and mortality rates for patients having  diabetes.38
 
Stroke
A stroke, also known as “a brain attack”, happens due to a sudden halt of blood supply to a part of the brain. In the absence of blood supply, the affected part of the brain fails to get the  supply of blood and oxygen required for its normal functioning. As a result, brain cells can stop functioning, die, and eventually cause permanent damage in the functional capacity of the patient.
 
Etiology
There are two major types of strokes: ischemic stroke and hemorrhagic stroke. 
 
Ischemic strokes are most often caused by blocked or clogged arteries due to the thick and sticky layers of plaque formed due to accumulation of fat cells, cholesterol, and other substances inside the artery walls. According to the experts, ischemic strokes represents about 80% of all the reported cases of strokes. As the names suggests, it is caused by either decreased or complete absence of circulating blood to some parts of the brain, thus depriving the affected neurons of necessary substrates. Because the brain does not store glucose and is  unable to perform any anaerobic metabolism, the effects of ischemia are fairly rapid, leading to rapid symptomatic presentation.39  
 
Hemorrhagic stroke occurs due to the weakening and  rupturing of a blood vessel in part of the brain, causing blood to leak inside the brain. This non-traumatic intracerebral hemorrhage represents up to 15% of all strokes cases. This kind of  stroke originates from deep penetrating vessels causing localized pressure areas along with depriving the brain cells of required metabolic substrates.39 
 
Epidemiology
Stroke is estimated to be one of the prominent causes for long-term disability in the United States, as well as being the third leading cause of death, the latter encompassing approximately 140,000 individuals each year. Stroke can occur in any age group. However, three-fourths of stroke cases happen to people over the age of 65 years. Experts estimate that, on average, there is a reported case of stroke every 40 seconds in the United States.40 
 
Signs and Symptoms
As the definition describes, stroke is a sudden reduction of essential blood substitutes to different parts of the brain leading to sudden reduction in the functioning of the affected part. Considering its immediate effects, the experts recommend immediate medical attention on identification of possible symptoms of a stroke, even if they seem to fluctuate or disappear. The  signs include but are not limited to:
• Numbness or weakness of face, arm, or leg, especially on one side of the body
• Confusion; trouble speaking or understanding 
• Trouble seeing in one or both eyes 
ª Trouble walking, dizziness, loss of balance or coordination 
• Severe headache with no known cause41
 
Dental Considerations
With an ever-increasing number of patients having a history of stroke, dental clinicians should be thoroughly conversant with the possible reduced bodily functions which come as a direct or  indirect result of a stroke attack. Depending upon the part of brain where the stroke occurred, patients can present with a spectrum of varying signs, making it necessary for dentists to  perform their proposed treatment plans giving consideration to the potentially reduced cooperation from these patients. 
 
Effective communication between the dentist and the patient plays a major role in providing effective dental treatment. Among the fundamental methods would be: Face the patient; speak  slowly; use simple terms to explain the procedure; and incorporate a positive body language in support of the verbal communication. Use of drawings and frequent feedback also work in maintaining a good rapport with the patient.42-46
 
Stroke can also result in patients’ reduced motor functioning, thus directly affecting the oral habits. Reduced cleansing of teeth will result in caries, halitosis, and a very high chance of oral  infection. It has been established that the presence of any oral infection conjugated with reduced gag reflex is highly associated with aspiration pneumonia, leading to high morbidity and  possibly mortality. As well, reduced food intake or dysphasia may be present, causing changes in eating habits, nutrition, and body weight. The dentist, along with the dental hygienist,  should initiate counseling the patient and his or her caretaker in order to design a customized hygiene and recall plan, including more frequent trips to the dental clinic. This should also  include regular use of anti-microbial mouth rinses such as chlorhexidine so as provide and maintain efficient plaque control.42-46
 
Clinicians must also treat any active infections aggressively in order to prevent a subsequent stroke, since it is thought that the presence of even minor infection can alter the blood coagulation mechanism and thus trigger thrombus formation resulting in cerebral infarction.42-46 
 
Breathing Problems
People normally make new alveolar cells until 20 years of age. After that, the lungs start to lose their tissue protein — i.e., elastin — resulting in reduced elasticity. Along with the reduction  of elastin, there is a decrease in the tissue microvascular bed and lung capillaries. Subsequently, the lungs become less elastic, resulting in reduced capacity to contract and expand freely as  required during simple bodily function, thus leading to shortness of breath. These conditions may be temporary or chronic depending upon multiple factors such as age of patient and the  underlying systemic conditions. This difficulty in breathing has the potential to make even the simplest daily activities such as walking, climbing stairs, or putting on clothes tiring, even  exhausting, for the patient. This shortness of breath or other associated breathing difficulty can prove to be frightening to anyone. 
 
Etiology
The Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines define COPD as “a disease state characterized by airflow limitation that is not fully reversible, is usually  progressive, and is associated with an abnormal inflammatory response of the lungs to inhaled noxious particles or gases”.42 Thus, Chronic Obstructive Pulmonary Disease (COPD) is a group  of systemic conditions that cause difficulty breathing.
 
The two most common forms of COPD are chronic bronchitis and emphysema. As stated in the webpage of the GOLD guidelines:
• Chronic bronchitis is an inflammation of the air passages which causes mucus production, coughing, and difficulty breathing.
• Emphysema is a destruction of the alveoli and lung tissue (such as from smoking) and makes gas exchange difficult, leading to labored breathing.1,44
 
The primary cause of COPD is exposure to tobacco smoke. Overall, tobacco smoking accounts for as much as 90% of COPD risk. Secondhand smoke, or environmental tobacco smoke,  increases the risk of respiratory infections, augments asthma symptoms, and causes a measurable reduction in pulmonary function.45 
 
Epidemiology
As per some estimates, the exact percentage of COPD cases in the United States is still underestimated. This may be essentially due to the fact that they do not cause severe symptoms  until the diseases’ last stages, and thus either remain mostly undiagnosed or under treated. 
 
Consequently, The National Health Interview Survey reports the prevalence of emphysema at 18 cases per 1,000 persons, and chronic bronchitis at 34 cases per 1,000 persons.46 
 
COPD is estimated to be the fourth leading cause of death and affects approximately 32 million persons in the United States.47 
 
Signs and Symptoms
As discussed earlier, most patients with chronic obstructive pulmonary disease seek late medical attention due to the delay in presentation of the symptoms. Due to its gradual yet  progressive nature, patients often ignore the symptoms over the course of years. This even results in modification in lifestyle in order to reduce the severity of dyspnea and sputum  production. 
 
Upon medical examination, patients typically present with an amalgamation of symptoms typical of chronic bronchitis, emphysema, and other airway restrictive conditions. These include but  are not limited to cough, continuous sputum production, progressive dyspnea, deteriorating exercise tolerance, and possibly alteration in mental status. 
 
The most common symptoms indicative of presence of any constrictive lung diseases are: 
• Productive cough or acute chest illness
• Breathlessness
• Wheezing
 
Dental Consideration
As the category’s name suggests, the patient visiting the dental clinic may be having some difficulty in normal breathing. His or her deteriorating medical condition or conditions, along with  the extensive use of inhalers and/or other medications, result in several oral symptoms; dry mouth and oropharyngeal candidiasis being the most common. Xerostomia along with poor oral  hygiene prove to be strongly associated with a high incidence of dental caries, gingivitis, and periodontitis. Consequently, patients with COPD have high chances of suffering lung infections secondary to the presence of any oral infection resulting in aspiration of oral microorganisms.45
 
These respiratory disorders demand special efforts from the dental team in order to provide appropriate care of the patient’s requirements. The conditions also have the strong potential to  limit the extent of dental treatment, considering patients’ inability to undergo extensive dental procedures, especially in a supine position. In some situations, the provider may need to work  in a standing position so as to make the patient feel both more comfortable and less threatened.28 The dentist needs to be extra cautious with the use of the rubber dam in order to avoid  worsening the symptoms. Low flow (2 to 3 L/min) supplemental oxygen can also be used to make the patient more comfortable. However, use of nitrous oxide/oxygen inhalation sedation  should be avoided in patients with severe COPD and emphysema.46  
 
References
33. Mayfield J. Diagnosis and classification of diabetes mellitus: new criteria. Am Fam Physician 1998 Oct 15;58(6):1,355-1,362.
34. Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 2009 January;32(Supplement_1):S62–S67.
35. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2011. National diabetes fact sheet: national estimates and general information on diabetes and prediabetes in the United States, 2011. 
36. http://www.diabetes.org/diabetes-basics/symptoms/
37. Kidambi S, Shailendra B, Patel. Diabetes mellitus: considerations for dentistry. JADA October 2008;139(suppl 5):85-185.
38. Vernillo AT. Dental considerations for the treatment of patients with diabetes mellitus. JADA 2003 Oct;134(Spec No:24S-33S).
39. Sid Shah. Stroke Pathophysiology. http://www.uic.edu/com/ferne/pdf/pathophys0501.pdf
40. http://www.strokecenter.org 
41. http://www.stroke.org
42. Syrjanen J, Peltola J, Valtonen V, Iivanainen M, Kaste M, Huttunen JK. Dental infections in association with cerebral infarction in young and middle-aged men. J Intern Med 1989;225(3): 179-84.
43. Ostuni E. Stroke and the dental patient. JADA 1994;125:721-7.
44. http://www.goldcopd.com 
45. Nagelmann A, Tonnov A, Laks T, Sepper R, Prikk K. Lung dysfunction of chronic smokers with no signs of COPD. COPD Apr 22, 2011.
46. Buist AS, McBurnie MA, Vollmer WM, Gillespie S, Burney P, Mannino DM et al. International variation in the prevalence of COPD (the BOLD Study): a population based prevalence study. Lancet Sep 1 2007;370(9,589):741-50.
47. Claramunt Lozano A, Gracia Sarrión Perez M, Gavaldá Esteve C. Dental considerations in patients with respiratory problems. J Clin Exp Dent 2011;3(3):e222-7.
 
 
 
*Dr. Grover is a Senior Dental Fellow, University of Minnesota School of Dentistry, and Walker Dental Clinic, Walker Methodist Health Center, Minneapolis, MN.
**Dr. Rhodus is professor and Director, Division of Oral Medicine, School of Dentistry, and adjunct professor, Department of Otolaryngology, School of Medicine, University of Minnesota,  Minneapolis, MN 55455. Email is rhodu001@umn.edu.
 
†“Common Medical Conditions in Elderly Dental Patients. Part One: Cardiovascular Implications and Management” by Satbir Grover, B.D.S., and Nelson L. Rhodus, D.M.D., M.P.H., F.I.C.D.,  Northwest Dentistry, September-October, 2012, pages 29-35.