Metabolic Syndrome and the Oral Cavity

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Metabolic Syndrome and the Oral Cavity

• M. Huber, DDS
• Oct 2007

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What is it?

• The term "metabolic syndrome" refers to a cluster
  of risk factors for cardiovascular disease and
  type 2 diabetes that occurs as a result of
  obesity and insulin resistance. Considerable
  confusion surrounding the precise use of this
  term in the clinical setting has led to
  difficulty in assessing the utility of this
  concept.

Blaha M, Elsay TA. Clinical use of the metabolic
syndrome Why the confusion? Clinical Diabetes
200624125-131.
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Whats the Value?

• Questionable value
• "By overemphasizing metabolic syndrome, there is
  a danger that physicians might overlook the
  importance of such factors as dyslipidemia,
  hypertension, etc., when they occur in isolation
  -for example, in patients who have
  abnormalities of one or more of these risk
  factors, but who don't meet the criteria for
  metabolic syndrome."

Stern MP, Williams K, Gonzalez-Villalpando C, et
al. Does the metabolic syndrome improve
identification of individuals at risk of type
2diabetes and/or cardiovascular disease? Diabetes
Care 200427 26762681.
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Whats the Value?

• Good value
• This contribution of metabolic syndrome is that
  risk is elevated when multiple subclinical risk
  factors are present.
• "While it's true that having elevated blood
  pressure or a large waist alone may not increase
  the risk for developing type 2 diabetes or CVD,
  the toll associated with metabolic syndrome
  suggests that having a combination of risk
  factors may increase risk within the population.

Carnethon MR, Loria CM, Hill JO, et al. Risk
factors for the metabolic syndrome The Coronary
Artery Risk Development in Young Adults (CARDIA)
study, 19852001. Diabetes Care 200427
27072715.
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Regardless of the Ambiguity - Metabolic Syndrome
is a Risk Factor for Cardiovascular Disease and
Diabetes Mellitus Type-2
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Cardiovascular disease

• 20,000,000 have some form of cardiovascular
  disease
• Leading cause of death in U.S.
• Over 700,000 deaths per year
• Some specific conditions
• Hypertension (HTN)
• Coronary artery disease (CAD)
• Arrhythmia
• Heart failure (HF)

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ORAL DISEASE BURDEN OF CARDIOVASCULAR DISEASE
PATIENTS
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Cardiovascular diseaseOral disease burden

• Periodontal disease
• Lichenoid stomatitis
• Xerostomia
• Gingival hyperplasia
• Hemorrhagic complications

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Cardiovascular diseaseOral disease burden

• Periodontal disease
• Cardiovascular patients with active periodontal
  disease are 1.5 - 2.7 more likely to experience a
  fatal cardiovascular event
• Increased inflammation?
• Increased bacteremia risk?

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Cardiovascular diseaseOral disease burden
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Cardiovascular diseaseOral disease burden

• Lichenoid stomatitis
• Various cardiovascular drugs may induce lichenoid
  lesions ? oral discomfort
• Diuretics
• ß1-adrenergic blockers
• ACE-inhibitors

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Cardiovascular diseaseOral disease burden

• Dry mouth
• Numerous cardiovascular drugs may reduce salivary
  function
• Diuretics
• ß1-adrenerigc blockers
• Centrally acting sympathetic agonists
• Synergistic affect with other medications to
  include OTCs

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Cardiovascular diseaseOral disease burden

• Gingival hyperplasia
• Calcium-channel blockers are commonly prescribed
• Gingival enlargement usually apparent within 1
  2 months of therapy
• Tissue usually firm and painless
• Overlying inflammation may occur

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Cardiovascular diseaseOral disease burden
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Cardiovascular diseaseOral disease burden

• Hemorrhagic complications
• Antithrombotic / anticoagulant agents increase
  the risk of
• Petechia (lt 2 mm)
• Purpura (gt2 mm - lt 1 cm)
• Ecchymosis (gt 1 cm)
• Frank hemorrhage

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Cardiovascular diseasePrinciples of dental
management

• Goals
• Develop and implement timely preventive and
  therapeutic strategies that are compatible with
  the patients physical and emotional ability to
  undergo and respond to dental care and with the
  patients social and psychological needs and
  desires

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Cardiovascular diseaseMedical history

• Assess current conditions
• Clinical predictors of increased cardiovascular
  risk in association with noncardiac procedures
• Accurate medication profile
• Functional capacity

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Cardiovascular diseaseClinical predictors of
increased cardiovascular risk in association with
noncardiac procedures

• Major predictors
• Unstable coronary syndrome
• Recent MI (7 30 days)
• Unstable angina pectoris
• Decompensated heart failure
• Severe valvular disease
• Significant arrhythmias
• Symptomatic ventricular arrhythmias in the
  presence of heart disease
• Supraventricular arrhythmias with uncontrolled
  ventricular rate
• High-grade AV block

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Cardiovascular diseaseClinical predictors of
increased cardiovascular risk in association with
noncardiac procedures

• Minor predictors
• Advanced age
• Atrial fibrillation
• History of stroke
• Low functional capacity
• Uncontrolled systemic HTN (gt180/110 mm Hg)

• Intermediate predictors
• Stable angina pectoris
• Previous MI
• Compensated HF
• Diabetes mellitus (particularly Type-1)
• Renal insufficiency

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Cardiovascular diseaseFunctional capacity

• Metabolic Equivalent (MET)
• The oxygen consumption of a 70 kg, 40-year-old
  man in a resting state is 3.5 ml / kg / minute
  1 MET
• Cardiac risks in association with noncardiac
  procedures are increased in patients unable to
  meet a 4-METs demand during normal daily
  activities

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Cardiovascular diseaseFunctional capacity

• 1-MET
• Dress, eat, use toilet walk around the house do
  light work (dusting, wash dishes) walk a block
  on level ground at 2-3 mph
• 4-METs
• Climb a flight of stairs, walk up a hill walk on
  level ground at 4 mph run a short distance do
  heavy work (scrubbing floors, move heavy
  furniture) moderate exercise (golf, bowling,
  throw a ball)
• 10-METs
• Strenuous sports (swimming, football, skiing)

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Cardiovascular diseasePhysical examination

• General assessment of physical / emotional state
• Pallor, cyanosis, peripheral edema, dyspnea,
  Cheynes-Stokes respiration, rales, obesity,
  tremor, anxiety
• BP
• Each appointment for patient with HTN,
  cardiovascular disease, diabetes mellitus,
  thyroid disorders, adrenal disease, renal
  dysfunction, and significant tobacco, alcohol,
  coffee, drug use
• Pulse rate rhythm
• Full minute to evaluate for PVCs other
  arrythmias

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Cardiovascular diseaseCardiac risk
stratification for noncardiac surgical procedures

• High Risk gt 5
• Emergent major operation in the elderly, aortic
  and other major vascular surgery, peripheral
  vascular surgery, prolonged surgery with fluid
  shifts or major bleeding
• Intermediate risk lt5
• Carotid endarterectomy, HN surgery,
  intraperitoneal / intrathoracic surgery,
  orthopedic surgery, urologic surgery
• Low risk lt1
• Endoscopic procedures, dermatologic procedures,
  cataract resection, breast surgery

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Cardiovascular diseaseDental care Local
anesthetics

• Considerable debate over the use of
  vasoconstrictor in cardiac patients
• Several studies demonstrated no significant
  affect on BP during dental treatment
• Benefit of vasoconstrictor use appears to
  outweigh risk

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Cardiovascular diseaseDental care Summing it up
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Cardiovascular diseaseDental care Summing it up
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Cardiovascular diseaseDental care Limited
office care

• Local anesthesia with vasoconstrictor (not to
  exceed 0.04 mg of epinephrine or equivalent)
• Dental prophylaxis
• Restorative
• Simple periodontics
• Simple endodontics
• Routine extractions

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Cardiovascular diseaseDental care Summing it up
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Cardiovascular diseaseDental care Summing it up
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Cardiovascular diseaseDental care Emergency
office care

• Must make a clinical judgment weighing need for
  therapeutic intervention vs risk
• Pain relief
• Treatment of infection (ID, pulpectomy)
• Induction of hemostasis (avoid epinephrine use)
• Use a local anesthesia without a vasoconstrictor

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Cardiovascular diseaseDental care Special
considerations
Patient on antithrombotic agent

• Risk of complications with routine dental care
  unlikely
• Consider pretreatment determination of bleeding
  time for invasive dental procedures
• Only the physician adjusts prescribed
  antithrombotic dosing

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Cardiovascular diseaseDental care Special
considerations
Patient on anticoagulant agent

• Must determine preoperative level of
  anticoagulation
• In general, it is safe to perform oral surgery
  with INRs lt3.5
• Meticulous technique
• Local hemostatic agents
• Primary closure
• Only the physician adjusts prescribed
  anticoagulant dosing

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Cardiovascular diseaseDental care Special
considerations
Patient with pacemaker or ICD

• Susceptible to electromagnetic interference
• Risk appears greatest with
• electro surgery units - best to avoid
• ultrasonic scalers best to avoid

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Cardiovascular diseaseDental care Preventive
strategies

• Maximize oral hygiene
• Office and home based fluoride protocol
• Salivary substitutes and sialogogues
• Carboxy methylcellulose
• Pilocarpine HCL
• Cevimeline HCL
• Monitor for adverse drug effects

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Clinical predictors of cardiovascular risk
MET assessment gt 4 METs
Pulse Normal rate rhythm
Blood pressure lt 180-110
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Diabetes mellitus

• 8 million cases of DM are undiagnosed
• Polyuria, nocturia, polydipsia, polyphagia,
  weakness, obesity, weight loss, pruritus
• Co-morbidities
• Hypertension
• Dyslipidemia
• Microvascular disease
• Retinopathy
• Renal dysfunction

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ORAL DISEASE BURDEN OF DIABETES MELLITUS PATIENTS
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Diabetes mellitusOral disease burden

• Periodontal disease
• Xerostomia
• Dental caries
• Candidiasis
• Other
• Burning mouth syndrome
• Altered taste
• Lichen planus
• Bells palsy
• Trigeminal neuralgia

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Diabetes mellitusOral disease burden

• Periodontal disease
• Uncontrolled or poorly controlled DM

J Periodontol 199970935-949
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Diabetes mellitusOral disease burden

• Dry mouth
• Lower resting and stimulated saliva
• Elevated HbA1c
• Elevated plasma glucose concentrations

Diabetes Care 199215900-904 Oral Surg Oral
Med Oral Pathol Oral Radiol Endod 200192281-291
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Diabetes mellitusOral disease burden

• Dental caries
• Slightly higher incidence resting
• Salivary flow rates lt 0.01 mL/min
• Normal 0.3 - 0.5 mL/min

Oral Surg Oral Med Oral Pathol Oral Radiol
Endod 200192281-291
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Diabetes mellitusOral disease burden

• Candidiasis
• Incidence inversely related to glycemic control
• Reported frequency as high as 51 and its

J Oral Pathol 198716282-284
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Diabetes mellitusPrinciples of dental management

• Goals
• Develop and implement timely preventive and
  therapeutic strategies that are compatible with
  the patients physical and emotional ability to
  undergo and respond to dental care and with the
  patients social and psychological needs and
  desires

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Diabetes mellitusMedical history

• Assess current condition
• Macrovascular disease
• Coronary artery disease
• Cerebrovascular disease
• Peripheral vascular disease
• Neuropathy
• Peripheral sensory neuropathy
• Peripheral autonomic neuropathy
• Tachycardia
• Exercise intolerance
• Silent myocardial ischemia
• Glycemic control
• SMBG
• HbA1c

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Diabetes mellitusMedical history

• Accurate medication profile
• Vital signs
• Blood pressure
• lt180/110 mm Hg
• Not an independent risk factor for cardiovascular
  risk in association with non-cardiac procedures
• gt180/110 mm Hg
• Constitutes a medical emergency
• Pulse pressure, rate, and rhythm
• Pulse pressure correlates closely with systolic
  BP
• Reliable cofactor to either rule out or confirm
  significant CVD
• Pulse rate lt50 or gt120 beats/min
• Constitutes a medical emergency
• PVCs
• Significant finding
• Functional capacity

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Diabetes mellitusTreatment issues

• The physiological events associated with the
  stress of a procedure
• Affect cardiac function - Myocardial ischemia
• Affect diabetic control - Hypoglycemia
• Timing and length of appointments
• Treat patients prior to peak insulin activity
• Avoid long stressful procedures

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Diabetes mellitusTreatment issues

• Local anesthetic agents
• Provide the greatest margin of safety
• Absence of profound anesthesia
• ? Myocardial ischemia
• Epinephrine has an action opposite of that of
  insulin
• No appreciable rise in blood glucose levels
• Cardiac risk is increased in patients unable to
  meet a 4-MET demand for oxygen
• Hemodynamic effect of 4 METs is equivalent to the
  effect of 0.045 mg of epinephrine

Oral Surg Oral Med Oral Pathol Oral Radiol Endod
00090171-181
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Diabetes mellitusTreatment issues

• Antibacterial agents
• The association between uncontrolled or poorly
  controlled DM and increased susceptibility to
  oral infections is well established
• However, no studies directly support the use of
  antibacterial prophylaxis

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Diabetes mellitusTreatment issues

• Pain management
• Opioids contribute to cardiovascular stability
• ASA to prevent thromboembolic events
• Opioid/ASA vs opioid/ibuprofen
• ASA vs. oral hypoglycemic agents (sulfonyurea)

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Diabetes mellitusDental care Summing it up
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Diabetes mellitusDental care Summing it up
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Diabetes mellitusDental care Summing it up
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Diabetes mellitusDental care Summing it up
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Diabetes mellitusTreatment issues

• Postoperative glycemic control
• Procedures may affect the patients ability to
  eat
• Consult with patients physician
• Ensure that targeted BG levels are maintained
• Balanced intake and appropriate regimen of
  medications

• Preventive strategies
• Oral hygiene
• Conventional vs. electromechanical toothbrushes
• Antibacterial mouthwashes
• Topical fluorides
• Sialagogues
• Pilocarpine (Salagen)
• Cevimeline (Evoxac)

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