Diabetesmellitus is a common medical disorder that will be encountered by every practising dentist. Knowledge by the dentist of the general and oral signs and symptoms of undiagnosed or poorly controlled diabetes mellitus are essential, and patients displaying these signs or symptoms should receive medical referral. Patients suspected, or known to suffer from undiagnosed or uncontrolled diabetes mellitus should receive only emergency care until their health status has been properly evaluated. In the event the degree of control of a known diabetic is unknown or the patient is poorly controlled, antibiotic therapy should be administered in conjunction with any necessary surgical procedure or in the presence of oral infection. The practitioner must be prepared to manage diabetic emergencies should they occur in the dental office, and hypoglycaemic incidents are most likely.
To properly evaluate periodontal patients, the dental clinician must be aware of the general and oral signs and symptoms of diabetes mellitus.
Appropriate dental practice requires a thorough oral examination and an appropriate medical history.
The medical history format must include questions that elicit information regarding the patient’s family history of diabetes mellitus and any general symptoms that may raise the practitioner’s level of suspicion regarding this disease.
The oral examination should identify oral features suggestive of diabetes mellitus, and the presence of any such features may indicate a need for medical consultation.
On some occasions it may be preferable for the dentist to perform screening blood glucose tests prior to referring the patient for medical evaluation. Often dental patients are reluctant to seek medical evaluation and occasionally even resentful that the dentist would require medical consultation as a condition for receiving dental treatment. In these circumstances several screening tests are available for determining blood glucose levels.
Long, laborious and costly tests such as the 4- to 6-hour glucose tolerance test should be avoided. Such tests must be performed under exacting circumstances and carefully interpreted by the patient’s physician. Therefore the glucose tolerance test has little place in dental practice. Traditionally urine glucose levels have been used as a screening mechanism. For the test to be positive, however, high blood glucose levels must be present and less severe blood glucose abnormalities may go undetected.
The National Diabetes Data Group and the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus have published specific recommendations for diabetic screening, including measurement of fasting plasma glucose, glucose tolerance tests and glycated haemoglobin. The first two tests require rigid compliance with the appropriate pre-test protocol and careful interpretation of results. If the test is positive, medical referral is essential to establish the diagnosis.
The dentist should avoid telling a patient that he or she has diabetes, since plasma glucose levels may fluctuate widely even in healthy individuals due to factors such as stress and exercise. Other illnesses can also affect plasma glucose levels.
A simple screening test for dental patient evaluation is to obtain a fasting plasma lucose level (8 or more hours of fasting) alone or in combination with a 2-hour post-glucose loading plasma test to evaluate glucose utilization. Under ideal circumstances, the 2-hour post-glucose loading plasma test should include ingestion of a measured quantity of glucose. The disadvantage to the fasting plasma glucose and 2-hour post-glucose loading plasma is that the tests are costly and they require patient compliance with pre-test fasting and a controlled pre-test diet for the 2-hour post-glucose loading plasma evaluation. In addition, the tests may require two visits to the medical laboratory for completion.
Although not advocated by many diabetologists, in the dental office the glycated haemoglobin test (haemoglobin A1c) has been proposed as offering several advantages as a screening test for dentists. The test is based on the fact that glucose binds to blood haemoglobin within the circulating erythrocytes and remains attached for the life cycle of the red blood cell. It is often the preferred test for medical evaluation of diabetic control because it measures blood glucose levels over a period of 8 to 12 weeks. The test is accurate and relatively inexpensive; it requires only one medical laboratory test and patient compliance is not required as it is for a fasting and 2-hour post-glucose loading plasma test. There are variations in the reported results from one laboratory to another, however, and the practitioner must be aware of the standard observed by the laboratory to which the patient has been referred. In general, normal levels for glycated haemoglobin are 5.0–7.5%. Any patient with a higher result should be referred for medical evaluation.
Home monitoring devices (glucometers) are commonly used by diabetes mellitus patients for frequent or daily monitoring of their blood glucose levels. It is not uncommon for patients under strict metabolic control to test their blood glucose levels four to six times daily. To perform the test, a one or two-drop blood sample is obtained by finger stick, placed on a reagent strip and inserted into the reflector monitor, which determines the glucose level and displays the results. In the past this technique has been used in dental offices as a screening test for suspected diabetic individuals. The test is simple, inexpensive and reasonably accurate; however, current United States federal standards regarding regulation and inspection of medical laboratories preclude its use as a screening test for suspected diabetes mellitus patients unless the dental office has been approved as a medical laboratory.
It should be noted, however, that known diabetic patients can perform the reagent strip procedure in the dental office using their own glucometer as a means of monitoring their diabetes mellitus status prior to an extensive periodontal or oral surgical treatment procedure or prior to treatment likely to disrupt the patient’s normal dietary routine.
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