PROTOCOL FOR DENTAL PATIENT WITH DIABETES
MELLITUS
Introduction:
Diabetes mellitus is a clinical syndrome characterized by hyperglycemia due to
absolute or the relative deficiency of insulin. This can arise in many different ways
but is most commonly due to autoimmune type 1 diabetes or adult onset type 2
diabetes. Lack of insulin effects the metabolism of carbohydrate, protein and fat, and
can cause a significant disturbance of water and electrolyte homeostasis.[1]
A third type of diabetes mellitus, gestational diabetes, represents carbohydrate
intolerance with its onset or first recognition during pregnancy.[2] The most important
risk associated with development of diabetes is heredity. Obesity and old age are also
risk factors.[3]
There a vascular aspect to diabetes mellitus, which comprises arteriosclerosis and
microangiopathy especially of kidneys and eyes. Of all the best-known systemic
diseases, diabetes has been the one most frequently blamed as a risk agent for
periodontal disease and other oral pathogenic disorders. Therefore, every dentist
should have a basic understanding of the incidence, etiology, systemic implications
and possible oral associated findings of diabetes. [8]
It is a common disease that affects approximately 200 million people in the world.
Diabetes affects 17 people per thousand between the ages of 25 and 44 and 79 people
per thousand over the age of 65. Thus, approximately 3 to 4 % of the dentist's adult
patients will have diabetes.
The importance of diabetes care in the dental practice is only as important as the
dentist wants it to be. Practicing dental professionals must prepare themselves for the
increase in the diabetic patient population and extensive medical care that they require
to curtail the development of complications. Dentist's training in preventive healthcare
philosophy makes them apply suited to play a significant role as part of the "Diabetes
Team".[8]
TYPES OF DIABETES
Type I diabetes: It results from the body’s failure to produce insulin, the hormone
that “unlocks” the cells of the body, allowing glucose to enter and fuel them. It is
estimated that 5-10% of Americans who are diagnosed with diabetes have type1
diabetes.[6]
Type 2 diabetes: this type results from insulin resistance (a condition in which the
body fails to properly use insulin), combined with relative insulin deficiency. Most
Americans who are diagnosed with diabetes have type2 diabetes. [6]
Gestational diabetes: Gestational diabetes affects about 4% of all pregnant women –
about 135,000 cases in the United States each year. [6]
Pre-diabetes: Pre-diabetes is a condition that occurs when a person’s blood glucose
levels are higher than normal but not high enough for a diagnosis of type2 diabetes.
In incidences of pre-diabetes there are no symptoms. People may not be aware that
they have type 1 or type 2 diabetes because they have no symptoms or because the
symptoms are so mild that they go unnoticed for quite some time.[4]
AETIOLOGY AND PATHOGENESIS OF DIABETES MELLITUS:
TYPE 1 DIABETES:
Type 1 Diabetes is a slowly progressive T cell-mediated autoimmune disease.
Family studies have produce evidence that destruction of the insulin-secreting cells in
the pancreatic islets takes place over many years.
1
Genetic factors account for about one third of the susceptibility to type 1 diabetes, the
inheritance of which is polygenic.
Stress may precipitate type1 diabetes by stimulating the secretion of counterregulatory hormones and possibly by modulating immune activity.
Circumstantial evidence supports that proposition that dietary factors may influence
the development of type 1 diabetes. [5]
TYPE 2 DIABETES:
Type 2 diabetes is a more complex condition than type 1 diabetes because there is a
combination of resistance to the action of insulin in liver and muscle together with
impaired pancreatic ᵦ cell function leading to 'relative insulin deficiency'.
Type 2 diabetes is a more complex condition than type 1 diabetes because there is a
combination of resistance to the action of insulin in liver and muscle together with
impaired pancreatic ᵦ cell function leading to 'relative insulin deficiency.
In patient with type 2 diabetes excessive production of glucose in the liver and underutilization of glucose in skeletal muscle resulting from resistance to the action of
insulin. [5]
Genetic factors are important in the etiology of type 2 diabetes, many genes are
involved and the chance of developing diabetes is also influenced very powerfully by
environmental factors.
Epidemiologic studies provide evidence that type 2 diabetes is associated with
overeating, especially when combined with obesity and under-activity.
Age: Type 2 diabetes is principally a disease of the middle aged and elderly in the
UK, it affects 10% of the population over 65, and over 70% of all cases of diabetes
occur after the age of 50 years. [5]
OTHER SPECIFIC TYPES
 Genetic defect of B cell function
 Genetic defect of insulin action
 Pancreatic disease (e.g. pancreatitis, pancreatectomy, neoplastic disease,
cystic fibrosis, haemochromatosis, fibrocalculous, pancreatopathy)
 Excess endogenous production of hormonal antagonists to insulin (e.g.
growth hormone-acromegaly; glucocorticoids-cushing's syndrome;
glucagon-glucagonoma; catecholamines-phaeochromocytoma; thyroid
hormones-thyrotoxicosis)
 Drug -induced (e.g. corticosteroids, thiazide diuretics, phenytoin) [5]
 Viral infection s (e.g. congenital rubella, mumps, coxsackie virus B)
 Uncommon forms of immune-mediated diabetes
 Associated with genetic syndromes (e.g. Down's syndrome; Klinefelter's
syndrome; Turner's syndrome; DIDMOND (Wolfram's syndrome) diabetes insipidus, diabetes mellitus, optic atrophy, nerve deafness;
Friedreich's ataxia; myotonic dystrophy) [5]
GESTATIONAL DIABETES
The term 'Gestational Diabetes' refers to hyperglycemia occurring for the first time
during pregnancy. During normal pregnancy, insulin sensitivity is reduced through the
action of placental hormones and this affect glucose tolerance.
Repeated pregnancy may increase the likehood of developing irreversible diabetes,
particularly in obese women; 80% of women with gestational diabetes ultimately
develop permanent diabetes. [5]
2
MEDICAL EVALUATION OF THE PATIENT WITH DIABETES MELLITUS
THE DIAGNOSIS OF DIABETES:
When diabetes is suspected the diagnosis may be confirmed by a random blood
glucose concentration greater than 199 mg/dl. When random blood glucose values are
elevated but are not diagnostic of diabetes, glucose tolerance is usually assessed either
by fasting blood estimation or by the oral glucose tolerance test (OGTT) table 1.
The diagnostic criteria for diabetes mellitus (and normality) recommended by the
world Health Organization (WHO) in 2000 is shown in table 1. [5]
TABLE 1 - DIAGNOSIS OF DIABETES
1- Patient complains of symptoms suggesting diabetes
2- Laboratory evaluation:
A) Test urine for glucose and ketones
B) Measure random or fasting blood sugar, Diagnosis confirmed by*:
 Fasting plasma glucose = 126 mg/dl
 Random plasma glucose = 200 mg/dl
C) oral glucose tolerance test (OGTT)
 Unrestricted carbohydrate diet for 3 days before test
 Fasted overnight (for at least 8 hrs.).
 Rest before test (30 minutes; no smoking; seated for duration of test
 Plasma glucose measured before, and 2 hrs after, 75 g glucose load. [5]
*in asymptomatic patients two samples are required to confirm diabetes.
N.B. HbA1c is not used for diagnosis. [5]
DIAGNOSTIC CRITERIA FOR DIABETES:
American Diabetes Association (ADA) expert committee in 1997 and 1998 has
revised the diagnostic criteria for diabetes and has implemented changes in the 1979
classification as follows:
a) Use of the term type 1 and type 2 diabetes instead of insulin-dependent
(IDDM) and non insulin-dependent (NIDDM) to refer to the two major types
of diabetes mellitus.
b) Use two fasting plasma glucose (FPG) determination and
c) Lowering cutoff level for FPG 126 mg/dL (7 mmol/L) to diagnose diabetes
(this level of FPG is equivalent to the 200 mg/dL (11.1 mmol/L) value in the
oral glucose tolerance test as in table 2. [8]
Table 2 – American Diabetes Association (ADA) diagnostic criteria for diabetes and
pre-diabetes (non-pregnant adults)
Normal
1. Fasting plasma glucose <100 mg/dl.
OR
2. Oral glucose tolerance test (OGTT) 2-hr plasma glucose <140 mg/dl.
Pre-diabetes
1. A1C range of 5.7–6.4%.
OR
2. Impaired fasting glucose (IFG) = fasting plasma glucose of 100–125 mg/dl.
OR
3. Impaired glucose tolerance (IGT) = OGTT 2-hr plasma glucose of 140–199 mg/dl.
3
Diabetes
1. A1C > 6.5%. The test should be performed in a laboratory using a method that is
certified by the National Glycohemoglobin Standardization Program (NGSP) and
standardized to the Diabetes Control and Complications trial (DCCT) assay.
OR
2. Fasting plasma glucose >126 mg/dl. Fasting is defined as no caloric intake for at least eight
hours.
OR
3.
2-h plasma 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 anhydrous glucose dissolved
in water.
OR
4.
Symptoms of diabetes and a casual plasma glucose >200 mg/dl.
“Casual” is defined as any time of day, without regard to the time since the last meal. The
classic symptoms of diabetes include polyuria, polydipsia, and unexplained weight loss.
Clinical assessment:
Symptomatic patients with polyphagia, polydipsia, polyuria, and weight loss may
have the diagnosis of diabetes confirmed by the demonstration of a fasting blood
glucose level above 120 mg/dl. Since transient elevations in blood glucose occur after
meals, elevations of blood glucose after fasting are more diagnostic of an abnormal
state (table 3). [3]
TABLE 3 - SYMPTOMS OF HYPERGLYCEMIA
Thrist, dry mouth
Blurring of vision
Polysuria
Pruritis valuae. Balanitis (genital candidiasis)
Nocturia
Nausea; headache
Tiredness, fatigue
Hyperphagia; predilection for sweet foods
Recent change in weight
Mood change, irritability, difficulty in concentrating, apathy. [5]
MEDICAL MANAGEMENT OF DIABETES MELLITUS
Management:
The method of treatment of diabetes is:
1) Dietary / lifestyle modification
2) Oral anti-diabetic agents and
3) Insulin by injection [5]
1. DIETARY / LIFESTYLE MODIFICATION
A. Dietary management:
The aims of dietary management are to:
 Achieve good glycaemic control
 Reduce hyperglycaemia and avoid hypoglycaemia
 Assist with weight management
 Reduce the risk of micro- and macrovascular complications
 Ensure adequate nutritional intake
 Avoid 'atherogenic' diet or those that aggravate complications, e.g. high
protein intake in nephropathy.
4
B. Life style modification:
The importance of lifestyle changes such as taking regular exercise, observing a
healthy diet and reducing alcohol consumption should not be under-estimated in
improving glycaemic control, but many people, particularly the middle aged and
elderly, find them difficult to sustain. [5]
Lifestyle changes include:
 Regular exercise
 Stop smoking
 Reducing alcohol consumption
 Observing a healthy diet
People should, however, be educated about the potential risk of hypoglycaemia
and how to avoid it. [9] Patient should be encouraged to stop smoking. It is essential
that people with diabetes understand their condition and learns to handle all aspects
of their management as comprehensively and quickly as possible. [5]
Physical activity:
Regular exercise can significantly improve glycemic control. All inmates with
diabetes should be counseled on the benefits of increased physical activity, as well as
the degree of exercise best suited to them. Sedentary diabetic inmates should be
medically evaluated prior to undertaking aerobic physical activity that goes beyond the
intensity of brisk walking. [7]
Physical activity promotes weight reduction and improves insulin sensitivity, thus
lowering blood glucose levels. Together with dietary treatment, a programme of
regular physical activity and exercise should be considered for each person. Such a
programme must be tailored to the individual’s health status and fitness.
2.
Oral anti-diabetic agents and Insulin injection:
Various drugs are effective in reducing hyperglycaemia in patient with type 2
diabetes. Although their mechanism of action is different, most depend upon a supply
of endogenous insulin and they therefore have no hypoglycaemic effect in patients
with type 1 diabetes (table 4).
TABLE 4 EFFECTS OF HYPOGLYCAEMIC DRUGS USED IN THE
TREATMENT OF TYPE 2 DIABETES
Reduced basal
glycaemia
Reduced post
prandial
glycaemia
Raise plasma
insulin
Increase body
weight
Improved lipid
profile
Risk of
hypoglycaemia
Tolerability
Insulin
Sulphonylureas
Metformin
Acarbose
Thiazolinediones
Yes
Yes
Yes
Slight
Yes
Meglitimide
and aminoacid
derivitives
?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
Yes
Yes
Yes
No
No
yes
Yes
Yes
No
Slight
Slight
Variable
No
Yes
Yes
No
No
No
Yes
Good
Good
Moderate
Moderate
Good
Good
5
3. INSULIN:
Various insulin regimens are used in the treatment of diabetes. The choice of regimen
depends on the desired degree of glycaemic control, the patient lifestyle and his or her
ability to adjust the insulin dose (Table 5).
TABLE 5 DURATION OF ACTION (IN HOURS) OF INSULIN PREPARATIONS
Insulin
Onset Peak
Duration
Rapid-acting (insulin analogues, lispro, aspart, glulisine) < 0.5 0.5-2.5 3-4.5
Short-acting (soluble (regular))
0.5-1 1-4
4-8
Intermediate-acting (isophane(NPH), lente)
1-3
308
7-14
Long-acting (bovine ultralente)
2-4
6-12
12-30
Long-acting (insuli analogues-glargine, detemir)
1-2
None
18-24
COMPLICATIONS OF DIABETES:
Microvascular / neuropathic
Retinopathy, cataract
 Impaired vision
Neuropathy
 Renal failure
Peripheral neuropathy
 Sensory loss
 Motor weakness
Autonomic neuropathy
 Postural hypotension
 Gastrointestinal problems (gastroparesis; altered bowel habit)
Foot disease
 Ulceration
 Artherpathy
Macrovascular
Coronary circulation
 Myocardial ischemia/infarction
Cerebral circulation
 Transient ischemic attack
 Stroke
Peripheral circulation
 Claudication
 Ischemia
DENTAL EVALUATION OF THE PATIENT WITH DIABETES
MELLITUS
MEDICAL CONSIDERATIONS:
A carefully questions can give some indications that a patient could be at risk of being
diabetic or be an undiagnosed diabetic especially type 2 such as: do you urinate
frequently especially at night? Are you frequently thirsty? The patient should be
further questioned about personal and family history of diabetes (table 6). [12]
It is recommended that patient suspected by the dentist to be diabetic, should be
referred to a physician for proper evaluation and diagnosis (table 6).
6
Any dental patient whose condition remains undiagnosed but who has the cardinal
symptoms of diabetes (i.e., polydipsia, polyuria, polyphagia, recent weight loss, and
weakness) should be referred to a physician for diagnosis and treatment. [12]
Patients with findings that may suggest diabetes (headache, dry mouth, marked
irritability, repeated skin infection, history of poor wound healing, blurred vision,
paresthesias, progressive periodontal disease, multiple periodontal abscesses,
persistent candidiasis, loss of sensation) should be referred to a clinical laboratory or a
physician for screening tests. [12]
The following findings are also indicative of possible diabetes; if a woman has given
birth to an unusually heavy baby (>5 kg) or has had several spontaneous abortion and
obese patients over 40 years of age also should be properly questioned. [8]
TABLE 6 DETECTION OF THE PATIENT WITH DIABETES
KNOWN DIABETIC PERSON
1. Detection by history:
a. Are you diabetic?
b. What medications are you taking?
c. Are you being treated by a physician?
2. Establishment of severity of disease and degree of “control”
a. When you were first diagnosed as diabetic?
b. What was the level of the last measurement of your blood glucose?
c. What is the usual level of blood glucose for you?
d. How are you being treated for your diabetes?
e. How often do you have insulin reactions?
f. How much insulin do you take with each injection, and how often do
you receive injections?
g. Do you test your urine for glucose?
h. When did you last visit your physician?
i. Do you have any symptoms of diabetes at the present time?
UNDIAGNOSED DIABETIC PERSON
1. History of signs or symptoms of diabetes or its complications
2. High risk for developing diabetes
a. Parents who are diabetic
b. Gave birth to one or more large babies
c. History of spontaneous abortions or stillbirths
d. Obese.
e. Over 40 years of age
3. Referral or screening test for diabetes
DENTAL CONSIDERATIONS:
Based upon the information gathered, generally we have two groups of patient:
1. Patients not known to have diabetes mellitus:
These are patients with sign and symptoms suggesting the possible diagnosis of
diabetes. Patients with positive family history of diabetes, and Patients documented to
have evaluated of blood glucose level. All of them should be referred for medical
evaluation and blood glucose level determination prior to the initiation of
comprehensive dental treatment. [8]
2. Patient known to have diabetes mellitus:
For this group, time of onset of diabetes, type of required therapy (control of diet, oral
hypoglycemic agents, insulin therapy), adequacy of control (fasting blood sugar,
7
hemoglobin A1c level, history of hypoglycemia, history of ketoacidosis),
complication of diabetes (vascular, neurological, renal, infections) must be taken in
consideration. [8]
RISK CATEGORIES FOR THE PATIENT WITH DIABETES MELLITUS
REGARDING DENTAL TREATMENT:
Patients at Low risk: Patients with good metabolic control on a stable medical regimen are at low risk. These patients are asymptomatic and have no neurologic, vascular, or infectious complications.
 Fasting blood sugar < 200 mg/dl
 Hemoglobin A1c level < 7%
Patients at Medium risk: These patients have occasional symptoms but are in
reasonable metabolic balance. There is no recent history of hypoglycemia or
ketoacidosis, and few of the complications of diabetes are present.
 Fasting blood sugar < 250 mg/dl
 Hemoglobin A1c level < 7% to 9%
Patients at High risk: These patients have multiple complications of the disease
and are under poor metabolic control. There is a history of frequent hypoglycemia or
ketoacidosis, and there is often a constant need to adjust insulin dosages.
 Fasting blood sugar > 250 mg/dl
 Hemoglobin A1c level > 9%
These risk categories should suggest some specific guidelines for management. [8]
DENTAL MANAGEMENT OF THE PATIENT WITH DIABETES
MELLITUS
GENERAL GUIDELINES
The dentist should know if the patient has a history of hypoglycemic attacks and the
accompanying signs and symptoms. The chances of having a hypoglycemic attack are
increased if there have been previous attack. [8]
It should be stressed that the dentist should take all the necessary precautions in order
to avoid the occurrence of hypoglycemic attack while the patient is undergoing dental
treatment.
The primary goal should be to avoid untoward metabolic imbalances during the period of dental therapy. Patients should be carefully instructed about their diet and their
medications during the course of therapy so as to minimize problems related to either
hyperglycemia or hypoglycemia.[3]
1. DIET:
A major goal in the dental management of patients with diabetes who are being
treated with insulin is to prevent insulin shock during the dental appointment.
Patients should be told to take their usual insulin dosage and to eat normal meals
before their dental appointment, which is usually best scheduled in the morning.
When such a patient comes for the appointment, the dentist should confirm that
the patient has taken insulin and has eaten breakfast. In addition, patients should
be instructed to tell the dentist whether at any time during the appointment, they
feel symptoms of an insulin reaction. [12]
It is advisable to have in the dental office orange juice or any other form of sugar.
Preparedness should include availability of different forms of orally administered
rapidly absorbed carbohydrates such as fruit juice, sodas, cake icing, plain sugar,
ice cream, candies, etc. patients with hypoglycemia will recover from the attack
within 10 to 20 minutes after orally administering 15 g of carbohydrate, this is
8
equivalent to 4 to 6 ounces of fruit juice or soda, the same result will be achieved
with 4 teaspoons of plain sugar. [8]
2. MEDICATION
The dentist must know the type and dose of insulin as well as any other
medications that the patient is taking. [8]
The patient must be advised not to change the insulin dose and time of application
as well as not to change his/her diet. [8]
Patients should be instructed to take their normal dosage of oral hypoglycemic
agents for all patient dental procedures. [3]
In order to avoid an episode of hypoglycemia while undergoing dental treatment it
is advisable to schedule the patient based on the time of highest insulin activity
which varies from 30 minutes to 8 hours after injection depending on the type of
insulin. Therefore, the appointment does not need to be necessarily in the
morning. [8]
3. MINIMIZATION OF STRESS
The dentist should attempt to minimize stress to the diabetic patient. Whenever
feasible, lengthy procedures should be spread over several shorter appointments.
Appropriate sedation should be considered. [3]
Emotional and physical stress increases the amount of secreted cortisol and
epinephrine, which induce hypoglycemia. Therefore, if the patient is very
apprehensive pre-treatment sedation should be contemplated. [8]
4. MINIMIZING THE RISK OF INFECTION:
Host immune defenses are altered in the patient through several mechanisms.
High glucose concentrations in blood and body fluids promote the overgrowth of
certain fungal pathogens, particularly the Candida species. Infections, whether
from the mouth or other sites, will sometimes cause an increase in blood glucose
levels. Treatment of infection in a patient with diabetes requires aggressive
antibiotic therapy. [8]
Instruct the patient to leave dentures out at night and to soak denture in a 1%
sodium hypochlorite solution for 15 minutes with thorough rinsing under running
water for at least 2 minutes, before bedtime. [8]
Antibiotic should be prescribed for patients who have a difficult to control
diabetes or is under high insulin dosage in order to prevent secondary infections or
complication of the pre-existing infection and to facilitate wound healing.
The basic aim of treatment is to simultaneously cure the oral infection and
respond to the need to regain control of the diabetic condition. Patients who are
receiving insulin usually require additional insulin, which should be prescribed by
their physician; non–insulin-controlled patients may need more aggressive
medical management of their diabetes, which may include insulin, during this
period. The dentist must treat the infection very aggressively by incision and
drainage, extraction, pulpotomy, warm rinses, and antibiotics. [12]
5. MEDICAL CONSULTATION:
The physician should be consulted on specific management issues in order to
ascertain the severity of the patient's disease and the degree of control over it. The
physician should also be involved in decisions about insulin coverage during
dental treatment. [3]
9
6. TREATMENT PLANNING MODIFICATIONS:
The patient with diabetes who is receiving good medical management and is
under good glycemic control without serious complications such as renal disease,
hypertension, or coronary atherosclerotic heart disease can undergo any indicated
dental treatment. If diabetes is under good control, even cardiac transplantation
can be safely performed.
However, in patients with diabetes who have serious medical complications,
the plan of dental treatment may need to be altered. Studies have indicated that
many dental patients with diabetes are not under good glycemic control. Elevated
fasting blood glucose levels render the dental patient more susceptible to
complications. [12]
SPECIFIC GUIDELINES:
Patients at Low risk:
Properly controlled type 1 and type 2 diabetes patients usually can undergo all
treatment without special precautions. Patients with diabetes who have no evidence of
complications and whose disease is under good medical control, as determined by
consultation with the patient's physician, require little or no special attention when
receiving dental treatment, unless they develop a significant dental or oral infection
that is possibly accompanied by swelling or fever. [12]
Patients at Medium risk:
General guidelines regarding diet control, minimization of stress, and risk of infection
are increasingly important for patients at medium risk. Patient advised to take usual
insulin dosage and normal meals on day of dental appointment; information
confirmed when patient comes for appointment. Advise patient to inform dentist or
staff if symptoms of insulin reaction occur during dental visit.
These patients can undergo restorative dentistry utilizing normal protocol. [3]
Aggressive soft tissue management, periodontal scaling, root planning and
periodontal surgery are indicated depending on the level of periodontal disease
involvement. The patient's level of disease control should be reassessed on a regular
basis and related to any oral health problems they may have.[8]
If is lengthy, especially surgical procedure is to be undertaken; the patient's physician
should be consulted. [8] Consultation with the patient's physician is a must when the
patient has systemic complications of diabetes such as heart or renal disease.[8]
Some patients with type 1 diabetes who are being treated with large doses of insulin
have periods of extreme hyperglycemia and hypoglycemia (brittle diabetes), even
when given the best of medical management. For these patients, antibiotic
prophylaxis can be considered and close consultation with the physician is required
before any dental treatment is started. [12]
Patients who have not seen their physician for a long time, who have had frequent
episodes of insulin shock, or who report signs and symptoms of diabetes may have
disease that is unstable. These patients should be referred to their physician for
evaluation, or the physician should be consulted to establish the patient's current
status. [12]
The patient's physician should be consulted about dietary recommendations for the
postoperative period. One suggestion is to have the patient use a blender to prepare
his or her usual diet so that it can be ingested with minimum discomfort; alternatively,
special food supplements in a liquid form may be used. The physician also may alter
the patient's insulin regimen according to his or her ability to eat properly, and
according to the extent of the surgery to be performed. [12]
10
Patients at High risk:
These patients can undergo oral examination after appropriate measures are taken to
minimize stress.
All other procedures should be deferred until the medical status is stabilized. [3]
DENTAL MANAGEMENT OF THE PATIENT WITH DIABETES AND
ACUTE ORAL INFECTION
Host immune defenses are altered in the diabetic patient through several mechanisms.
High glucose concentrations in blood and body fluids promote the overgrowth of
certain fungal pathogens, particularly the Candida species. Infection, whether from
the mouth or other sites, will sometimes cause an increase in blood glucose levels. [8]
Treatment of infection in a patient with diabetes requires aggressive antibiotic therapy
as follow:
1. Non–insulin-controlled patients may require insulin; consultation with
physician required
2. Insulin-controlled patients usually require increased dosage of insulin;
consultation with physician required
3. Patient with brittle diabetes or receiving high insulin dosage should have
culture(s) taken from the infected area for antibiotic sensitivity testing
a. Culture sent for testing
b. Antibiotic therapy initiated
c. In cases of poor clinical responses to the first antibiotic, a more
effective antibiotic is selected according to sensitivity test results
d. These patients may require hospitalization during management of an
infection. The patient's physician should be consulted and should
become a partner during this period. [12]
4. Infection should be treated with the use of standard methods
a. Warm intraoral rinses
b. Incision and drainage
c. Pulpotomy, pulpectomy, extractions, etc.
d. Antibiotics
MEDICAL MANAGEMENT OF DIABETIC EMERGENCIES
Dental practitioners should encourage diabetic patients who self-monitor blood
glucose levels to bring their glucometer to the dental office at each visit.
If glucose levels are at or below the lower end of the normal fasting range (80 to 120
mg/dL), then it may be necessary for the patient to consume a fast acting
carbohydrate.
The most common causes of hypoglycemia include injection of excess insulin,
delaying or missing meals or snacks with the usual dose of insulin, and increasing
exercise without adjusting the insulin dose (exercise reduces the requirement for
insulin).
The signs and symptoms include confusion, shakiness (tremors), agitation,
belligerence, sweating (diaphoresis), and tachycardia.
The dentist must know the time, dose, and type of insulin the patient took that day and
the time, amount, and type of carbohydrate (simple vs complex) the patient consumed
before the dental visit. In this way, the dentist can match the patient’s plasma insulin
levels with the food intake, thus determining the likelihood of hypoglycemia.[10]
11
How to manage Hypoglycemia:
If a glucometer determination shows hypoglycemia, then the administration of sugar
under the tongue usually rapidly reverses the hypoglycemia. The glucose can be
rapidly absorbed from the sublingual site. Patients can usually be treated with rapid
acting oral carbohydrates, e.g. fruit juice, packets of granulated sugar, glucose powder
neat or dissolved in water. After ten minutes this short acting carbohydrate should be
followed up with food which contains longer acting carbohydrate. It is important that
the patient is not left alone until all danger of hypoglycaemia has passed.
If the patient is sedated or unable to take food or drink by mouth, then 25 to 30 mL of
50% dextrose or 1 mg of glucagon can be administered intravenously,
intramuscularly, or subcutaneously. A glucagon injection causes glycogenolysis in the
liver. It will rapidly reverse hypoglycemia, usually within 15 minutes.
How to manage Hyperglycemia:
The dentist must be aware of the signs and symptoms of hyperglycemia and be
prepared to manage it.
If a glucometer determination shows hyperglycemia, then the dentist must contact the
patient’s physician and refer the patient for immediate medical evaluation, or the
patient can administer a loading dose regular insulin at 0.1 units/kg body weight to a
maximum of 10 units followed by an infusion of regular insulin at 0.1 units/kg body
weight/hour, to a maximum of 10 units/hour to treat the hyperglycemia. [11]
In some cases, hyperglycemia can present with symptoms similar to those of
hypoglycemia (eg, confusion and disorientation). If a glucometer is not available to
determine blood glucose levels accurately and the conscious patient has symptoms
suggestive of hypoglycemia, then the dentist must administer glucose or fruit juice.
Treat patients presumptively for hypoglycemia if they experience tremors,
diaphoresis, tachycardia, or disorientation and agitation. If the symptoms were from
hyperglycemia rather than hypoglycemia, then the additional amount of carbohydrate
will generally cause no harm.
The best way to determine the true nature of a diabetic emergency quickly is to
measure blood glucose levels with a glucometer. The accuracy of the glucometer
readings is generally within an error range of 5%.
LOCAL ANESTHETICS AND EPINEPHRINE
For most patients with diabetes, routine use of local anesthetic with 1:100,000
Epinephrine should be tolerated well. However, epinephrine has a pharmacologic
effect that is opposite that of insulin, so blood glucose could rise with the use of
epinephrine. In diabetic patients with hypertension, post myocardial similar to those
for patients with cardiovascular conditions and may be even more strict for those with
diabetes and cardiovascular conditions, as along with determination of functional
capacity via metabolic equivalent levels METs. [12]
Diabetic patients with more than 4 METs are usually more stable, and when other
indicators of physical status are also present (e.g., glycemic control), they are able to
tolerate most dental procedures. Conversely, patients with METs values lower than 4
may be more likely to encounter complications and should be approached with
caution. Obviously, diabetic patients may fluctuate between these states from time to
time and from appointment to appointment. [12]
12
SUMMERY TABLE 1
DIABETES MELLITUS: GENERAL INFORMATION
DEFINITION:
Diabetes mellitus is a clinical syndrome characterized by hyperglycemia due to
absolute or the relative deficiency of insulin.
INCIDENCE
Approximately 3 to 4 % of the dentist's patients
TYPES OF DIABETES MELLITIS

PRE-DIABETES: Occurs when a person’s blood glucose levels are higher
than normal but not high enough for a diagnosis of type 2 diabetes.
 TYPE 1 DIABETES: Results from the body’s failure to produce insulin,
 TYPE 2 DIABETES: Results from insulin resistance, combined with relative
insulin deficiency.
 GESTATIONAL DIABETES: Represents carbohydrate intolerance with its
onset or first recognition during pregnancy.
SYMPTOMS
 Polydipsia
 Polyuria
 Polyphagia
 Weight loss
Signs:
 Glycosuria
SUMMERY TABLE 2
AETIOLOGIC CLASSIFICATION OF DIABETES
TYPE 1 DIABETES:
 Immune-mediated
 Idiopathic
TYPE 2 DIABETES:
 Combination of resistance to the action of insulin in liver and muscle together with
impaired pancreatic ᵦ cell function.
 Many genes are involved and also influenced by environmental factors.
 Evidence that type 2 diabetes is associated with overeating, especially when
combined with obesity and under-activity.
OTHER CAUSES OF DIABETES MELLITUS INCLUDE:
 Genetic defects of islet cell function
 Genetic defects in insulin action
 Endocrinopathies such as Cushing’s disease or syndrome
 Drug- or chemical-induced hyperglycemia
 Infections
 Insults to the pancreas from a variety of causes such as:
 Pancreatic Cancer
 Cystic Fibrosis
 Trauma
 Pancreatitis
GESTATIONAL DIABETES: During normal pregnancy, insulin sensitivity is reduced
through the action of placental hormones and this affect glucose tolerance.
13
SUMMERY TABLE 3
MEDICAL EVALUATION OF THE PATIENT WITH DIABETES MELLITUS
CLINICAL ASSESSMENT
Patient complains of symptoms suggesting diabetes
LABORATORY EVALUATION: (non- pregnant adults)
NORMAL
1. Fasting plasma glucose <100 mg/dl.
OR
2. 2. Oral glucose tolerance test (OGTT) <140 mg/dl.
PRE-DIABETES
1. A1C range of 5.7–6.4%.
OR
2. Fasting plasma glucose of 100–125 mg/dl.
OR
3. Impaired glucose tolerance (IGT) = 140–199 mg/dl.
DIABETES
A1C > 6.5%.
OR
2. Fasting plasma glucose >126 mg/dl.
OR
3. 2-h plasma glucose >200 mg/dl during an oral glucose tolerance test.
OR
4. Symptoms of diabetes and a casual plasma glucose >200 mg/dl.
SUMMERY TABLE 4
MEDICAL MANAGEMENT OF DIABETES MELLITUS
GOALS:
 Optimal metabolic control.
 Prevent Ketoacidosis
 Prevent hypoglycemia.
METHOD OF TREATMENT:
 Dietary / lifestyle modification.
 Oral anti-diabetics.
 Insulin.
SUMMERY TABLE 5
DENTAL EVALUATION OF THE PATIENT WITH DIABETES MELLITUS
MEDICAL CONSIDERATIONS:
Known Diabetic Person:
3. Detection by history:
4. Establishment of severity of disease and degree of “control”
Undiagnosed Diabetic Person:
4. History of signs or symptoms of diabetes or its complications
5. High risk for developing diabetes
6. Referral or screening test for diabetes
14
DENTAL CONSIDERATIONS:
Risk Categories for Dental Patient with Diabetes Mellitus:
1. Patients at Low risk
 Fasting blood sugar < 200 mg/dl
 Hemoglobin A1c level < 7%
2. Patients at Medium risk
 Fasting blood sugar < 250 mg/dl
 Hemoglobin A1c level < 7% to 9%
3. Patients at High risk
 Fasting blood sugar > 250 mg/dl
 Hemoglobin A1c level > 9%
SUMMERY TABLE 6
DENTAL MANAGEMENT OF THE PATIENT WITH DIABETES MELLITUS
GENERAL GUIDELINES
1. DIET: patient:
 patient should eat normal meals before dental appointment
 Any form of sugar should be available in the dental office
2. MEDICATION:
 Patients should take their usual insulin dosage
3. MINIMIZATION OF STRESS
4. MINIMIZING THE RISK OF INFECTION:
5. MEDICAL CONSULTATION
6. TREATMENT PLANNING MODIFICATIONS:
 Dental treatment plan may need to be altered with diabetic patients
have serious medical complications.
SPECIFIC GUIDELINES
Patients at Low risk: Properly controlled diabetes patients usually can undergo all
treatment without special precautions
Patients at Medium risk:
 Restorative dentistry utilizing normal protocol
 Surgical procedures:
 Extractions, aggressive soft tissue management, periodontal scaling,
root planning and periodontal surgery are indicated depending on the
level of periodontal disease involvement
 lengthy, especially surgical procedure is to be undertaken; the patient's
physician should be consulted
 Patient with brittle diabetes or receiving high insulin dosage should
have culture(s) taken from the infected area for antibiotic sensitivity
testing
Patients at High risk:
 Undergo oral examination after minimize stress.
 All other procedures should be deferred until the medical status is stabilized
15
SUMMERY Table 7
MEDICAL MANAGEMENT OF DIABETIC EMERGENCIES
Fasting blood sugar (Glucometer) reading
Hypoglycemia
Hyperglycemia
< 70 mg/dl
>200 mg/dl
Defer elective treatment
Defer elective treatment
Or
Or
Give Carbohydrates
Give hypoglycemic (insulin)
Or
Refer to physician
REFERENCES
1. B.M.FRIER, M. FIHIER. Davidson's Principles and Practice of Medicine 20ed.
Pages 805-808.
2. Little JW, Falace DA, Miller CS, Rhodus NL. Diabetes. In: Dental management of
the medically compromised patient. 5th ed. St Louis: Mosby; 1997. p. 387-409.
3. Stephen T. Sonis, Robert C. Fazio, Leslie Fang, Principles And Practice Of Oral
Medicine
4. AHA American Heart Association D:\systemic diseases ‫\مواضيع طبية‬diabetes
mellitis\DIABETES MELLITIS new\Diabetes\Symptoms, Diagnosis & Monitoring
of Diabetes.mht
5. B.M.FRIER, M. FIHIER. Davidson's Principles and Practice of Medicine 20ed.
Pages 810-815, pages 817-819 and page 829
6. D:\systemic diseases ‫\مواضيع طبية‬diabetes mellitis\DIABETES MELLITIS
new\Weld Diabetes Project.mht Copyright 2010 Weld County Govenment |
Disclaimer
7. Management of Diabetes - Federal Bureau of Prisons Clinical Practice Guidelines November 2010
8. Dan wollner, Pacific Health Dialog Vol. 10 No.1.2003, view point and perspactives.
9. Dr A.A.S. Alwan, Regional Adviser, Noncommunicable Diseases. Management Of
Diabetes Mellitus Standards Of Care And Clinical Practice Guidelines. WHO
Regional Office for the Eastern Mediterranean.
10.
Mealey B. Impact of advances in diabetes care on dental treatment of the
diabetic patient. Comp Dent Ed 1998;19:41-58. Little JW, Falace DA, Miller CS,
Rhodus NL. Diabetes. In: Dental management of the medically compromised
patient. 5th ed. St Louis: Mosby; 1997. p. 387-409
11.
Kitabchi AE, Umpierrez GE, Miles JM, Fisher JN: Hyperglycemic crises in
adult patients with diabetes. Diabetes Care 32:1335–1343, 2009
12.
James W. Little, DMD, MS, Donald A. Falace, DMD, Craig S. Miller, DMD,
MS, Nelson L. Rhodus, DMD, MPH, Dental Management of the Medically
Compromised Patient, 7th ed. Part Six – Endocrine And Metabolic Disease, Chapter
15 – Diabetes Mellitus Copyright © 2007 Mosby, An Imprint of Elsevier
‫مع تحيات قسم صحة الفم واألسنان في دائرة األمور الفنية‬
dentalhealthmoh@yahoo.com
16