CHAPTER 37

Periodontal Treatment of Medically

Compromised Patients
Perry R. Klokkevold, Brian L. Mealey, and Joan Otomo-Corgel

Many patients seeking dental care have significant medical conditions that may alter both the
course of their oral disease and the therapy provided. Older periodontal patients will have a
greater likelihood of having underlying disease. Therefore the therapeutic responsibility of
the clinician includes identification of the patient’s medical problems to formulate proper
treatment plans. Thorough medical histories are paramount.1 If significant findings are
unveiled, consultation with or referral of the patient to an appropriate physician may be
indicated. This ensures correct patient management and provides medicolegal coverage to the
clinician.
This chapter covers common medical conditions and associated periodontal management.
Review of each topic area is general, and the reader is encouraged to consult other references
for more detailed coverage of specific disorders. Understanding these conditions will enable
the clinician to treat the total patient, not merely the periodontal reflection of underlying
disease.
Cardiovascular Diseases
Cardiovascular diseases are the most prevalent category of systemic disease in the United
States and many other countries, and they are more common with increasing age.2 Health
histories should be closely scrutinized for cardiovascular problems. These conditions include
hypertension, angina pectoris, myocardial infarction (MI), previous cardiac bypass surgery,
previous cerebrovascular accident (CVA), congestive heart failure (CHF), presence of cardiac
pacemakers or automatic cardioverter-defibrillators, and infective endocarditis (IE).
In most cases the patient’s physician should be consulted, especially if stressful or prolonged
treatment is anticipated. Short appointments and a calm, relaxing environment help minimize
stress and maintain hemodynamic stability.
Hypertension
Hypertension, the most common cardiovascular disease, affects more than 50 million
American adults, many of whom are undiagnosed.3 In 2003, the National Heart, Lung and
Blood Institute issued revised guidelines for evaluation and management of hypertension.4-6
The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation,
and Treatment of High Blood Pressure (JNC-7) guidelines4 simplified the classification of

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blood pressure (Table 37-1).
Compared with previous classification7,8 schemes that focused on diastolic blood pressure
(BP), the JNC-7 guidelines4 emphasize the importance of systolic BP greater than 140 mm
Hg. Systolic blood pressure greater than 140 mm Hg is considered a greater risk factor for
cardiovascular disease than elevated diastolic pressure.
JNC-7 also introduced a category known as prehypertension to replace the more innocuous
terms “high normal” and “borderline” hypertension. People with systolic BP between 120 and
139 mm Hg or diastolic BP between 80 and 89 mm Hg are classified as “prehypertensive.”
Hypertension is now classified into only two categories versus three under past classification
schemes for simplicity and because treatment for categories 2 and 3 was essentially the same.
Stage 1 hypertension is defined by systolic pressure of 140 to 159 mm Hg or diastolic
pressure of 90 to 99 mm Hg. Stage 2 hypertension is defined by a systolic pressure greater
than 160 mm Hg or diastolic pressure greater than 100 mm Hg.
Hypertension is not diagnosed on a single elevated BP recording. Rather, classification is
usually based on the average value of two or more BP readings taken at two or more
appointments. The higher value of either the systolic or diastolic pressure determines the
patient’s classification. Patients with hypertension enter the dental practice every day and are
particularly common among the older population seen in most periodontal practices.
Evidence from the Framingham Heart Study revealed that people with normal BP at age 55
still have a 90% risk of becoming hypertensive later in life.9
Hypertension is divided into primary and secondary types. Primary (essential) hypertension
occurs when no underlying pathologic abnormality can be found to explain the disease.

Endocrine Disorders
Diabetes
The diabetic patient requires special precautions before periodontal therapy. The two major
types of diabetes are type 1 (formerly known as “insulin-dependent diabetes”) and type 2
(formerly called “non–insulin-dependent diabetes”).38 Over the past decade, the medical
management of diabetes has changed significantly in an effort to minimize the debilitating
complications associated with this disease.39,40 Patients are more tightly managing their
blood glucose levels (glycemia) through diet, oral agents, and insulin therapy.41
If the clinician detects intraoral signs of undiagnosed or poorly controlled diabetes, a
thorough history is indicated.42

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The classic signs of diabetes include polydipsia (excessive thirst), polyuria (excessive
urination), and polyphagia (excessive hunger, often with unexplained concurrent weight
loss). If the patient has any of these signs or symptoms, or if the clinician’s index of suspicion
is high, further investigation with laboratory studies and physician consultation is indicated.
Periodontal therapy has limited success in the presence of undiagnosed or poorly controlled
diabetes.
If a patient is suspected of having undiagnosed diabetes, the following procedures should be
performed:
1. Consult the patient’s physician.
2. Analyze laboratory tests (Box 37-2): fasting blood glucose and casual glucose.43
3. Rule out acute orofacial infection or severe dental infection; if present, provide
emergency care immediately.

BOX 37-2 Diagnostic Criteria for Diabetes Mellitus

Diabetes mellitus may be diagnosed by any one of three different laboratory methods.
Whichever method is used, it must be confirmed on a subsequent day by using any one of the
following three methods.
1. Symptoms of diabetes plus casual (nonfasting) plasma glucose ≥200 mg/dL. Casual
glucose may be drawn at any time of day without regard to time since the last meal.
Classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight
loss.
2. Fasting plasma glucose ≥126 mg/dL. “Fasting” is defined as no caloric intake for at
least 8 hours. (Normal fasting glucose is 70-100 mg/dL.)
3. Two-hour postprandial glucose ≥200 mg/dL during an oral glucose tolerance test.*
The test should be performed using a glucose load containing the equivalent of 75 g
of anhydrous glucose dissolved in water. (Normal 2-hour postprandial glucose is <140
mg/dL.)

37-3 Laboratory Evaluation of Diabetes Control: Glycosylated Hemoglobin (HbA1c) Assay*

4%-6% Normal
<7% Good diabetes control
7%-8% Moderate diabetes control
>8% Action suggested to improve diabetes control
*American Diabetes Association guidelines.

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4. Establish best possible oral health through nonsurgical debridement of plaque and
calculus; institute oral hygiene instruction. Limit more advanced care until diagnosis
has been established and good glycemic control obtained. If a patient is known to
have diabetes, it is critical that the level of glycemic control be established before
initiating periodontal treatment. The fasting glucose and casual glucose tests provide
“snapshots” of the blood glucose concentration at the time the blood was drawn; these
tests reveal nothing about long-term glycemic control. The primary test used to assess
glycemic control in a known diabetic individual is the glycosylated (or glycated)
hemoglobin (Hb) assay (Box 37-3). Two different tests are available, the HbA1 and
the HbA1c assay; the HbA1c is used more often.41
This assay has been shown by a large international study to provide an accurate
measure of the average blood glucose concentrations over the preceding 2 to 3
months.44 Table 37-4 lists the average blood glucose concentrations for HbA1c
values from that study, and Figure 37-2 is a simplified graphic representation of the
data. The therapeutic goal for many patients is to achieve and maintain an HbA1c
below 8%. Patients with relatively well-controlled diabetes (HbA1c < 8%) usually
respond to therapy in a manner similar to nondiabetic individuals.45-47 Poorly
controlled patients (HbA1c > 10%) often have a poor response to treatment, with
more postoperative complications and less favorable long-term results38,46 (see
Figure 11-3). Improvements in HBA1c values after periodontal therapy may provide
an indication of the potential response. As discussed in Chapter 11, periodontal
infection may worsen glycemic control and should be managed aggressively. Diabetic
patients with periodontitis should receive oral hygiene instructions, mechanical
debridement to remove local factors, and regular maintenance. When possible, an
HbA1c of less than 10% should be

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 TABLE 37-4

HbA1c, glycosylated hemoglobin A1c.

Figure 37-2 Graphic representation of glycosylated hemoglobin (Hb) A1c values and
estimated average blood glucose.

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established before surgical treatment is performed. Systemic antibiotics are not needed
routinely, although recent evidence indicates that tetracycline antibiotics in combination with
scaling and root planing may positively influence glycemic control. If the patient has poor
glycemic control and surgery is absolutely needed, prophylactic antibiotics may be given;
penicillins are most often used for this purpose. Frequent reevaluation after active therapy is
needed to assess treatment response and prevent recurrence of periodontitis.
Almost all diabetic patients use glucometers for immediate blood glucose self-monitoring.
These devices use capillary blood from a simple fingerstick to provide blood glucose
readings in seconds. Diabetic patients should be asked whether they have glucometers and
how often they use them. Because these devices provide instantaneous assessment of blood
glucose, they are highly beneficial in the dental office environment. The following guidelines
should be observed:
1. Patients should be asked to bring their glucometer to the dental office at each
appointment.
2. Patients should check their blood glucose before any long procedure to obtain a
baseline level. Patients with blood glucose levels at or below the lower end of normal
before the procedure may become hypoglycemic intraoperatively. It is advisable to
have such a patient consume some carbohydrate before starting treatment. For
example, if a 2-hour procedure is planned and the pretreatment glucose level is 70
mg/dL (lower end of normal range), providing 4 oz of juice preoperatively may help
prevent hypoglycemia during treatment. If pretreatment glucose levels are excessively
high, the clinician should determine whether or not the patient’s glycemic control has
been poor recently. This can be done by thorough patient questioning and by
determining the most recent HbA1c values. If glycemic control has been poor over the
preceding few months, the procedure may need to be postponed until better glycemic
control is established. If glycemic control has been good, and the currently high
glucometer reading is a fairly isolated event, the surgical procedure may proceed.
3. If the procedure lasts several hours, it is often beneficial to check the glucose level
during the procedure to ensure that the patient does not become hypoglycemic.
4. After the procedure, the blood glucose can be checked again to assess fluctuations
over time.
5. Any time the patient feels symptoms of hypoglycemia, blood glucose should be
checked immediately. This may prevent onset of severe hypoglycemia, a medical
emergency.

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The most common dental office complication seen in diabetic patients taking insulin is
symptomatic low blood glucose, or hypoglycemia (Box 37-4). Hypoglycemia is also
associated with the use of numerous oral agents (Table 37-5). In patients receiving conscious
sedation, the warning signs of an impending hypoglycemic episode may be masked, making
the patient’s glucometer one of the best diagnostic aids. Hypoglycemia does not usually occur
until blood glucose levels fall below 60 mg/dL. However, in patients with poor glycemic
control who have prolonged hyperglycemia (high blood glucose levels), a rapid drop in
glucose can precipitate signs and symptoms of hypoglycemia at levels well above 60 mg/dL.
As medical management of diabetes has intensified over the last decade, the incidence of
severe hypoglycemia has risen.48 The clinician should question diabetic patients about past
episodes of hypoglycemia. Hypoglycemia is more common in patients with better glycemic
control. When planning dental treatment, it is best to schedule appointments before or after
periods of peak insulin activity. This requires knowledge of the pharmacodynamics of the
drugs being taken by the diabetic patient. Patients taking insulin are at greatest risk, followed
by those taking sulfonylurea agents.

BOX 37-4 Signs and Symptoms of Hypoglycemia

Shakiness or tremors
Confusion
Agitation and anxiety
Sweating
Tachycardia
Dizziness
Feeling of “impending doom”
Unconsciousness
Seizures

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Metformin and thiazolidinediones generally do not cause hypoglycemia (see Table 37-5).
Insulins are classified as rapid-acting, short-acting, intermediateacting,or long-acting agents
(Table 37-6). The categories vary in their onset, peak, and duration of activity. It is important
that the clinician establish exactly which insulins the diabetic patient takes, the amount, the
number of times per day, and the time of the last dose. Periodontal treatment often can be
timed to avoid peak insulin activity. Many diabetic patients take multiple injections each day,
in which case it is difficult, if not impossible, to avoid peak insulin activity. Checking the
pretreatment glucose with the patient’s glucometer, checking again during long procedures,
and checking again at the end of the procedure provides a better understanding of the
patient’s insulin pharmacodynamics and help prevent hypoglycemia.
If hypoglycemia occurs during dental treatment, therapy should be immediately terminated. If
a glucometer is available, the blood glucose level should be checked. Treatment guidelines
include the following41:
1. Provide approximately 15 g of oral carbohydrate to the patient:
• 4 to 6 oz of juice or soda
• 3 or 4 tsp of table sugar
• Hard candy with 15 g of sugar
2. If the patient is unable to take food or drink by mouth, or if the patient is sedated:

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• Give 25 to 30 mL of 50% dextrose intravenous (IV), which provides 12.5 to 15.0 g of
dextrose, or
• Give 1 mg of glucagon IV (glucagon results in rapid release of stored glucose from the
liver), or
• Give 1 mg of glucagon intramuscularly or subcutaneously (if no IV access).
Emergencies resulting from hyperglycemia are rare in the dental office. They generally take
days to weeks to develop. However, the glucometer may be used to rule out hyperglycemic
emergencies such as diabetic ketoacidosis, a life-threatening event. Because periodontal
therapy may render the patient unable to eat for some time, adjustment in insulin or oral agent
dosages may be required. It is absolutely critical that patients eat their normal meal before
dental treatment. Taking insulin without eating is the primary cause of hypoglycemia. If the
patient is restricted from eating before treatment (e.g., for conscious sedation), normal insulin
doses will need to be reduced. As a general guideline, wellcontrolled diabetic patients having
routine periodontal treatment may take their normal insulin doses as long as they also eat
their normal meal. If the procedures are going to be particularly long, the insulin dose before
treatment may need to be reduced. Likewise, if the patient will have dietary restrictions after
treatment, insulin or sulfonylurea dosages may need to be reduced.
Consultation with the patient’s physician is prudent and allows both practitioners to review
the proposed treatment plan and determine any modifications needed. When periodontal
surgery is indicated, it is usually best to limit the size of the surgical fields so that the patient
will be comfortable enough to resume a normal diet immediately.