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My patient has diabetes! Now what do I do?
You will have patients come to your dental practice with diabetes. Some won’t know they are diabetic. Persons with diabetes may experience the following during or after dental treatment; hypoglycemia, coma, infection or delayed healing.
I. Dental management of patients with diabetes
III. What is diabetes and how many people have it?
IV. Clinical manifestations of diabetes
V. Diabetes effects on human physiology and immunity
I. Dental management of patients with diabetes
1. Know if your patients have diabetes. Have you asked or looked at their medical history?
2. Know the status of your patient’s diabetes before doing extensive oral surgeries (e.g., multiple extractions, periodontal surgery). Do you know their fasting blood glucose (FBS) or 2-hour postprandial blood glucose level (PP; blood glucose level 2 hr after meal), and hemoglobin A1c (HBA1c) levels?
- Well-controlled diabetes; FBS less than 125 mg/dL, PP less than 140 mg/dL, and HBA1c of less than 7%
- Moderately controlled diabetes; FBS 125-140 mg/dL, PP 140-200 mg/dL, and HBA1c of between 7 and 8%
- Uncontrolled diabetes; FBS greater than 140 mg/dL, PP greater than 200 mg/dL, and HBA1c of greater than 8%
3. In patients with well-controlled diabetes; no special treatment for routine prophylaxis and dental restorative care.
- Tell patients to eat normally and to follow their usual medical regimen (e.g., take medications, inject insulin). Morning appointments are the best for the patient since their cortisol levels are highest in the morning. Do not allow them to skip the morning meal before their appointment.
- Type 1 patients should NOT schedule their appointment right after an insulin injection in that it may result in hypoglycemia.
- If anesthesia is needed no more than 2 carpules of lidocaine (1:100,000), prilocaine HCL (1:200,000) or bupivacaine with 1:200,000 epinephrine.
4. In moderately controlled diabetic patients;
- If anesthesia is needed no more than 2 carpules of prilocaine or bupivacaine only.
- If a major procedure an antibiotic should be prescribed following treatment.
- Following surgeries, the patient’s food intake should include the right ratio of protein/carbohydrate/fat to maintain glucose balance.
5. In uncontrolled diabetic patients;
- Delay dental treatment in the absence of dental emergency. Encourage the patient to come back when their diabetes is under control.
- Outpatient treatments should be available only for acute dental infections.
- Anesthetics should NOT include epinephrine.
- Antibiotics should be prescribed following treatment and the patient monitored for sensitivity to the antibiotic and efficacy of the antibiotic.
- Complicated treatments require inpatient treatment; Insulin management and post-treatment care concerning infections and electrolyte balance may be needed.
- Emergency oral surgery use the anesthetic mepivacaine without epinephrine. Give antibiotics following surgery.
II. Complications associated with treating patients with diabetes. Prevention and management of their complications
The most common in-office complication during treatment is hypoglycemia. Symptoms include mood change, hunger, weakness, sweating, tachycardia, and mental disturbance. The patient may know they are becoming hypoglycemic and request a sugar source (orange juice or hard candy). Severe complications of hypoglycemia include hypotension, hypothermia, seizures, coma, and death.
Management of hypoglycemia includes:
- knowing the signs of hypoglycemia and intervening quickly.
- If a patient is becoming hypoglycemic terminate treatment and administer glucose.
- If conscious give a drink of orange juice or hard candy.
- If the patient is unconscious call an ambulance and if possible, administer glucose parenterally. Intravenous fluids useful in treatment include 25-30 ml of 50% dextrose solution or 1 mg of glycogen. One mg of glycogen may also be given by intramuscular or subcutaneous injection.
Prevention of complications includes:
- Looking at blood glucose pretreatment levels.
- Awareness of the possible complications related to co-morbid cardiovascular disease, renal failure, or stroke.
- Schedule your diabetic patients for morning appointments.
- Be aware of the symptoms of hypoglycemia and have sugar available if you need to treat their hypoglycemia.
Post-treatment problems include delayed healing and infections. In patient with uncontrolled diabetes, electrolyte imbalance can also be a problem following treatments. Realize that periodontitis is more likely and more severe as the control of the patient’s diabetes goes from well-controlled to uncontrolled. Dental professionals have an important role to play in managing diabetic patients’ oral health.
III. What is diabetes and how many people have it?
Kinds of diabetes
- Type 1
- Type 2
- Gestational diabetes (occurs in the second or third trimester)
- Diabetes secondary to other diseases
In all kinds of diabetes the person has abnormally high blood glucose levels. Their high blood glucose levels are not reduced because the pancreas does not make enough insulin (type 1) or the insulin, when made, doesn’t cause the person’s cells to take up the circulating glucose (type 2 and gestational diabetes). Patients with type 2 diabetes will initially make more insulin than normal but in time will make less than normal levels of insulin. After pregnancy, 5-10% of patients with gestational diabetes will continue to have high blood glucose levels and are usually diagnosed as having type 2 diabetes.
About 29.1 million people or 9.3% of the US population have diabetes. Most people have type 2 diabetes; 90-95%. Around 5% of people with diabetes have type 1. Twenty-one million persons have been diagnosed with diabetes. However, 8.1 million people have NOT yet been diagnosed with diabetes. Therefore, around 27.8% of people with diabetes do NOT know they have this condition.
Bottom line; You will have many patients come to your dental practice with diabetes. Some won’t know they are diabetic.
IV. Clinical manifestations of diabetes
Diabetes type 1- Signs and symptoms may develop quickly and can include the following: increased thirst, frequent urination, bedwetting in children that previously did not wet the bed at night, extreme hunger, irritability and other mood changes, fatigue, weakness, blurred vision, cuts/bruises that are slow to heal, and in females a vaginal yeast infection. A sign that is seen in type 1 but less likely to occur in type 2 is unintended weight loss.
Prediabetes or impaired glucose tolerance- This condition nearly always precedes diabetes type 2. Patients have blood glucose levels that are higher than normal but not high enough to be considered a person with diabetes. Some patients have signs and symptoms similar to patients with diabetes. Most have no signs or symptoms.
Diabetes type 2- Some people have mild symptoms and may not even know they have a problem. Signs and symptoms are the same as type 1 in that the patient has increased thirst, frequent urination, extreme hunger, irritability and other mood changes, fatigue, weakness, cuts/bruises that are slow to heal, blurred vision, and in females a vaginal yeast infection. A sign that is seen in type 2 but less likely to occur in type 1 is tingling, pain, or numbness in the hands/feet.
Gestational diabetes- Usually have NO symptoms. If they do have symptoms they are similar to the common signs and symptoms mentioned above.
V. Diabetes effects on human physiology and immunity
Diabetes can result in persons experiencing heart disease, stroke, kidney failure, blindness, and premature death. The high levels of blood glucose (hyperglycemia) has several damaging consequences. Hyperglycemia causes an increase in urine volume and excessive fluid loss by urination. This excessive fluid loss results in dehydration and electrolyte imbalance. If this fluid loss is severe the person may experience a coma.
Stress from diabetes causes the person to produce above normal amounts of cortisol. Increases in cortisol cause increases in metabolic activity. A person with diabetes can’t break down glucose in the blood with much of it being eliminated by urination. To get the energy needed to increase their metabolic activity the person will break down protein and fat stores. Break down of protein and fat results in ketone and fatty acid byproducts. This together with dehydration and electrolyte imbalance can lead to metabolic acidosis. If the ketones and fatty acid byproducts get too high a person with diabetes may develop ketoacidosis.
Hyperglycemia and ketoacidosis coupled with vascular wall damage (microangiopathy and atherosclerosis) alters the person’s ability to fight infections and to heal from trauma. Persons with poorly managed diabetes heal slowly and are more likely to get infections that are much more serious than persons without diabetes (e.g., thrush, malignant otitis externa and rhinocerebral mucormycosis).
Persons with diabetes may experience the following during or after dental treatment; hypoglycemia, coma, infection or delayed healing.
If a person has a high blood glucose level following a random (casual) blood glucose test then further testing is warranted.
1. Does the person have diabetes?
The following tests are used to determine if a patient has diabetes; fasting blood glucose (FBG), hemaglobin A1c (HBA1c), or the Oral Glucose Tolerance Test (OGTT). A second FBG, HBA1c or OGTT may be obtained on a different day to confirm.
Fasting Blood Glucose (FBG)- A FBG requires the patient not eat or drink (except water) anything for at least 8 hours before the test. This test is best done first thing in the morning. A person has diabetes if their FBG is greater than or equal to 126 mg/dl. The following table contains the level of glucose that determine if a patient has normal glucose levels, if the patient is prediabetic or has diabetes.
Result |
Fasting Plasma Glucose (FPG) |
| Normal | less than 100 mg/dl |
| Prediabetes | 100 mg/dl to 125 mg/dl |
| Diabetes | 126 mg/dl or higher |
Hemaglobin A1c (HBA1c)- The HBA1c test measures a patients average blood glucose levels for the past 2 to 3 months. This blood test does not require fasting. A person has diabetes if their HBA1c is greater than or equal to 6.5%. The following table contains the level of HBA1c that determine if a patient had normal glucose levels, if the patient is prediabetic or has diabetes.
Result |
Hemaglobin HBA1c |
| Normal | less than 5.7% |
| Prediabetes | 5.7% to 6.4% |
| Diabetes | 6.5% or higher |
Oral Glucose Tolerance Test (OGTT)- The OGTT is a two-hour test that checks the patient's blood glucose levels before and 2 hours after drinking a glucose containing drink. It demonstrates how the patient's body is processing glucose. If the patient cannot produce insulin or if the insulin produced is not effective in signaling the patient's cells to take up glucose the blood glucose levels post-drink will be high. A person has diabetes if their blood glucose at 2 hours after drinking the glucose containing drink is greater than or equal to 200 mg/dl. The following table contains the level of blood glucose that is present post-drink in a patient with normal glucose levels and if the patient is prediabetic or has diabetes.
Result |
Oral Glucose Tolerance Test (OGTT) |
| Normal | less than 140 mg/dl |
| Prediabetes | 140 mg/dl to 199 mg/dl |
| Diabetes | 200 mg/dl or higher |
2. Does the patient have type 1 or type 2 diabetes? Several tests are available.
Connecting peptide (C-peptide) test- The connecting peptide (C-peptide) test, determines the amount of insulin the patient has in their blood stream. C-peptide is a 21 amino acid peptide that holds the alpha and beta chains of insulin together before it is removed in the golgi apparatus and the two insulin chains are joined together by disulfide bonds. C-peptide levels are measured instead of insulin levels because C-peptide can determine a patient's insulin secretion even if they receive insulin injections. The liver metabolizes insulin when secreted into the portal vein but does not metabolise C-peptide. If C-peptide is low the patient does not produce much insulin and they have type 1 diabetes. Type 1 diabetic patients do not produce enough insulin whereas, type 2 diabetic patient produce a lot of insulin however the cells do not respond by taking up glucose from the blood. Type 2 diabetic patients will have normal or high levels of C-peptide.
Autoantibody tests- Several other tests exist that measure antibody levels in a patient's blood stream. These antibodies are called autoantibodies because they react with the patients' own proteins to destroy the ability of the pancreas to make insulin. If the patient has any of these antibodies they have type 1 diabetes. Several of these tests should be ordered because patients with type 1 diabetes may not be positive for all of the following tests. Autoantibodies that are used include;
- Glutamic Acid Decarboxylase Autoantibodies (GADA or Anti-GAD)-This test detects antibodies to an enzyme in the pancreatic beta cells that produce insulin.
- Insulin Autoantibodies (IAA)- This test detects antibodies to insulin.
- Insulinoma-Associated-2 Autoantibodies (IA-2A)- This test detects antibodies to an enzyme in beta cells. Both the IA-2A and GADA tests are common type 1 antibody tests.
- Zinc Transporter 8 Autoantibodies (ZnT8Ab)- This test detects antibodies to an enzyme that is specific to beta cells.
References
http://emedicine.medscape.com/article/2066164-overview
http://www.cdc.gov/diabetes/data/statistics/2014statisticsreport.html
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© 2016 Neal R. Chamberlain,Ph.D. All rights reserved.
Site Last Revised 11/2/16
A. T. Still University of Health Sciences/Missouri School of Dentistry and Oral Health/Kirksville College of Osteopathic Medicine.
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