When the dental practitioner is called upon to provide dental treatment for a previously diagnosed diabetes mellitus patient, a certain amount of detailed information should be gathered. The patient should be questioned regarding the type of diabetes, the age at onset and duration of the disease; any current medications and their method of administration. The patient’s degree of compliance and monitoring technique should be discussed.
The practitioner should review any previous history of diabetic complications, determine the most recent laboratory results and record the name and address of the patient’s physician(s). By gathering this information the clinician can best relate the patient’s oral condition to his or her systemic status and determine whether or not medical consultation is required. Under most circumstances it would be prudent to obtain medical clearance prior to performing any extensive dental therapy, especially if surgery is indicated.
1. In most instances the well-controlled type 1 or type 2 patient can be managed in a manner consistent with a healthy non-diabetic individual.
2. Periodontal surgical procedures can be performed, although it must be assured that the patient can maintain a normal diet post-surgically. In the event that the treatment procedure modifies the patient’s dietary habits, dietary supplements should be recommended.
3. Supportive therapy such as scaling and root planning should be provided at relatively close intervals (2 to 3 months) since some studies indicate a slight but persistent tendency to progressive periodontal destruction despite effective metabolic diabetes mellitus control.
The uncontrolled or poorly controlled diabetic patient or the diabetes mellitus patient who does not know his or her control status should not receive elective dental treatment until the condition is stabilized or medical clearance obtained.
1. Prophylactic antibiotic therapy should be used for performance of emergency oral or surgical procedures to minimize the potential for postoperative infections and delayed wound healing.
2. Any therapy other than emergency treatment may be contraindicated in the poorly controlled diabetes mellitus patient until appropriate metabolic controlled is achieved.
3. In many instances this may require short- or long-term prescription of insulin or oral medications by the physician.
For many years, type 2 diabetes mellitus has been treated by diet control and various hypoglycaemic agents, usually a first- or second-generation sulfonylurea (acetohexamide, chlorpropamide, tolazamide, tolbutamide, glimepiride, glipizide or glyburide).
Sulfonylurea promotes insulin secretion, and importantly, they are all capable of inducing hypoglycaemia. Non-sulfonylurea drugs may be used as monotherapy or in combination with other oral hypoglycaemic agents or insulin.
1. Troglitazone is a thiazolidinedione agent which improves insulin sensitivity and decreases insulin resistance. When used as monotherapy it does not induce hypoglycaemia. It is active only in the presence of insulin.
2. Repaglinide is a new antidiabetic agent that potentiates glucose-stimulated insulin secretion. It can produce hypoglycaemia, and serious cardiovascular events have been reported.
3. The biguanide, metformin, is often used as a monotherapy. When combined with sulfonylurea or insulin, however, it may also induce hypoglycaemia.
4. The alpha-glycosidase inhibitors, acarbose and meglitol do not cause hypoglycaemia unless given in combination with sulfonylurea.
Insulin is classified as rapid, short, intermediate or long-acting. Each category induces variable onset of peak activity and duration. Insulin injections are timed so that peak plasma levels coincide with peak postprandial glucose levels. It is important for the practitioner to know the medication regimen being used by the patient, and any surgical therapy should be timed to avoid peak insulin activity and possible hypoglycaemic crisis
Dental practitioners must remain alert for possible complications and/or emergencies associated with diabetes mellitus.
Hyperglycemia may lead to shock (diabetic coma), although the condition develops relatively slowly and abrupt onset is unlikely. The hyperglycaemic patient may become disoriented, breathing may become rapid and deep (Kussmaul’s respiration), the skin may be hot and dry and ‘‘acetone’’ breath may be evident.
Severe hypotension and coma may follow. Coma is usually associated with plasma glucose levels of between 300 and 600 mg/dl. Patients experiencing this condition will usually remain conscious but should be transferred immediately to a hospital emergency room for evaluation.
If the patient becomes unconscious, basic life support procedures should be initiated (open airway, administration of 100% oxygen) and the emergency medical alert system activated. If circumstances allow, non-glucose-containing intravenous fluids should be administered to prevent vascular collapse. Patient recovery from diabetic coma may be slower than from hypoglycaemic shock.
In contrast, hypoglycaemic shock is associated with relatively sudden onset when plasma glucose levels drop below 40 mg/dl. It may be precipitated by exercise, diabetes mellitus drug overdose, stress or failure by the patient to properly control his or her dietary intake.
In many instances hyperglycaemic or hypoglycaemic shock may be difficult to differentiate based on signs and symptoms. In both circumstances the patient may experience mood changes, mental confusion, lethargy and increasingly bizarre behaviour. Although careful analysis may indicate the true nature of the patient’s condition, it is usually more prudent to treat unknown reactions by diabetes mellitus patients in the dental office as though they were experiencing hypoglycaemia.
Treatment should be initiated as quickly as possible since hypoglycaemia may lead to tachycardia, hypotension, hypothermia, loss of consciousness, seizures and even death. Early treatment includes the administration of oral carbohydrates such as orange juice, soft drinks, candy or glucola. Such agents administered during hyperglycaemic states will have little additional detrimental effects, while they may reverse hypoglycaemic status. Dextrose can be administered intravenously to the conscious or unconscious patient, while glucagon may be administered subcutaneously, intramuscularly, or intravenously (1 mg), followed by epinephrine (0.5 mg of 1:1000 concentration). Glucagon may be less useful in type 2 diabetes mellitus, since its function is to stimulate insulin secretion rather than decrease resistance.
If the patient remains unresponsive, the emergency alert system should be activated and the patient transferred to a hospital emergency room. In most instances, patients will become alert in response to therapy within five to ten minutes. In this event careful observation is necessary until the patient is fully stabilized. If possible the patient’s own glucometer should be used to evaluate his or her status. In any event the patient’s physician should be notified.
Ongoing multi centre studies of diabetic patients indicate that strict control of blood glucose levels in both type 1 and type 2 patients close to the range of normal for non-diabetic individual’s results in fewer medical complications. Consequently, increased emphasis is being placed on home monitoring and rigorous efforts by patients to maintain strict blood sugar control. Although, on balance these efforts may greatly benefit the diabetes mellitus patient, there is also strong evidence to suggest that maintenance of blood glucose levels close to the range of normal can lead to an increased incidence of hypoglycaemia.
Elderly diabetes mellitus patients are prone to develop insidious hypoglycaemia and any diabetes mellitus patient may develop hypoglycaemia without displaying or sensing the common signs and symptoms.
The dental practitioner must remain constantly alert for evidence of the condition during therapy and take steps to prevent its occurrence.
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