- Brian L. Mealey, DDS, MS
General Dental Treatment
Overall, diabetic patients respond to most dental treatments similarly to the way nondiabetic patients respond. Responses to therapy depend on many factors that are specific to each individual, including oral hygiene, diet, habits such as tobacco use, proper dental care and follow-up, overall oral health, and metabolic control of diabetes. For example, the diabetic patient with poor oral hygiene, a history of smoking, infrequent dental visits, and a high fermentable-carbohydrate intake is more likely to experience oral diseases such as caries and periodontitis and to respond poorly to dental treatment than a diabetic patient without these factors.
Glycemic control appears to play an important role in the response to periodontal therapy. Well-controlled diabetic patients with periodontitis have positive responses to nonsurgical therapy, periodontal surgery, and maintenance that are similar to those of people without diabetes. However, poorly controlled diabetic patients respond much less favorably, and short-term improvements in periodontal health are frequently followed by regression and by recurrence of disease. It is imperative that the dental practitioner have a clear understanding of each diabetic patient's level of glycemic control prior to initiating treatment.
Patients may present to the dental office with oral conditions that suggest an undiagnosed diabetic state. An example is severe rapidly progressing periodontitis that exceeds what would be expected given the patient's age, habit history, oral hygiene, and level of local factors (plaque, calculus). Other findings seen in some undiagnosed diabetic patients include enlarged gingival tissues that bleed easily upon manipulation and the presence of multiple periodontal abscesses.
If the clinician suspects an undiagnosed diabetic state, the patient should be questioned to elicit a history of polydipsia, polyuria, polyphagia, or unexplained weight loss. The patient should be questioned about a family history of diabetes. If diabetes is suspected, laboratory evaluation and physician referral are indicated. A patient with previously diagnosed but poorly controlled diabetes may present with oral findings similar to those of the undiagnosed diabetic individual. The dental practitioner must establish the level of glycemic control early in the treatment process; this can be done by physician referral or by a review of the patient's medical records. Patients who perform SBGM may be asked to bring their glucose log to the dental office for review by the dental team.
The clinician should determine the patient's recent glycated hemoglobin values since this test provides a measure of glycemic control over the preceding 2 to 3 months. HbA1c values of less than 8% indicate relatively good glycemic control; values greater than 10% indicate poor control. Physician referral is appropriate any time glycemic control is in question. The issue of glycemic control should be addressed often by the dental team since dental treatment outcomes may be dependent partly on good metabolic control of the underlying diabetic state. Other key dental treatment considerations for diabetic patients include stress reduction, treatment setting, the use of antibiotics, diet modification, appointment timing, changes in medication regimens, and the management of emergencies.
Endogenous production of epinephrine and cortisol increase during stressful situations. These hormones elevate blood glucose levels and interfere with glycemic control. Adequate pain control and stress reduction are therefore important in treating diabetic patients. Profound anesthesia reduces pain and minimizes endogenous epinephrine release. The small amounts of epinephrine in dental local anesthetics at 1/100,000 concentration have no significant effect on blood glucose. Conscious sedation should be considered for extremely anxious patients. Most practitioners who use intravenous sedation elect to use fluids without dextrose, such as normal saline. However, fluids such as D5W (a 5% solution of dextrose in water) in small amounts should not produce wide fluctuations in glycemia in most patients.
Most diabetic patients can easily be managed on an outpatient basis in the dental office. Patients with very poor glycemic control, severe head and neck infections, other systemic diseases or complications, and dental-treatment needs that will require long-term alteration of medication regimens or diet may be considered for treatment in a more controlled medical environment.
The use of systemic antibiotics for routine dental treatment is not necessary for most diabetic patients. Antibiotics may be considered in the presence of acute infection. Some clinicians prefer to prescribe prophylactic antibiotic coverage prior to surgical therapy if the diabetic patient's glycemic control is poor. This usually applies to emergency situations since elective procedures are generally deferred until glycemic control improves. In patients with severe periodontitis, adjunctive use of tetracycline antibiotics in conjunction with mechanical periodontal therapy may have beneficial effects on glycemic control as well as on periodontal status.
Dental treatment can result in postoperative discomfort. This may necessitate changes in the diet, especially in cases of extensive dental therapy. Because diet is a major component of diabetes management, diet alterations that are made because of dental treatment may have a major impact on the patient. Whereas some patients are very knowledgeable about their diabetic condition and can adjust for changes in diet, this may not be the case with others. The clinician may need to consult the patient's physician prior to therapy, to discuss diet modifications and required changes in medication regimens. Another diet change occurs when patients are placed on orders to take nothing by mouth (NPO) before dental treatment, a common recommendation before conscious sedation. Consultation with the patient's physician may be needed to adjust the dose of insulin or oral agents in this situation; however, some patients are able to make these adjustments themselves. Physicians often recommend reducing the insulin dose that immediately precedes lengthy or extensive dental procedures.
Appointment timing for the diabetic patient is often determined by the individual's medication regimen. Conventional wisdom holds that diabetic patients, like other medically compromised individuals, should receive dental treatment in the morning. While this may be true for some patients, it is not true for others. It is generally best to plan dental treatment to occur either before or after periods of peak insulin activity. This reduces the risk of perioperative hypoglycemic reactions, which occur most often during peak insulin activity. For those who take insulin, the greatest risk of hypoglycemia will thus occur about 30 to 90 minutes after injecting lispro insulin, 2 to 3 hours after regular insulin, and 4 to 10 hours after NPH or Lente insulin. For those who are taking oral sulfonylureas, peak insulin activity depends on the individual drug taken. Metformin and the thiazolidinediones rarely cause hypoglycemia.
The main factor to consider in determining appointment times is the peak action of insulin and the amount of glucose being absorbed from the gut following the last food intake. The greatest risk would occur in a patient who has taken the usual amount of insulin or oral agent but has reduced or eliminated a meal prior to dental treatment. For example, if the patient takes the usual dose of regular insulin before breakfast but then fails to eat or eats less than the usual amount, the patient will be at increased risk for hypoglycemia during a morning dental appointment. Patients with good long-term glycemic control and patients with a previous history of severe hypoglycemic episodes are at greater risk for future hypoglycemia.
Often, it is not possible to plan dental treatment so as to avoid peak insulin activity. This is particularly true for patients who take frequent insulin injections. In these instances, the clinician must be aware that the patient is at risk for perioperative hypoglycemia. It is helpful to check the pretreatment blood glucose level (using the patient's glucometer) and to have a source of carbohydrates readily available. When treating patients with a history of asthma or angina, dentists usually have the patients bring their inhaler or nitroglycerine with them to dental appointments. In the same way, diabetic patients should be encouraged to bring their glucometer with them to the dental office. Before dental treatment begins, the patient may check his or her blood glucose. If the level is near the lower end of the normal range, a small amount of pretreatment carbohydrate may prevent hypoglycemia during the appointment. Having the glucometer available also allows rapid determination of blood glucose levels should the patient experience signs and symptoms of hypoglycemia.