Diabetic mellitus and dental treatment protocol

DM is a complex syndrome (chronic disease) characterized by abnormalities in carbohydrate, lipid and protein metabolism that result either from profound or an absolute deficiency of insulin, related to autoimmune destruction oft insulin producing pancreatic beta cells(Type1), or from target-tissue resistance to its cellularm effects, related to obesity(Type2).

• A carefully constructed questionnaire can give some indications that a patient could be at risk of being diabetic especially type 2

• The classical symptoms of DM include : polydipsia , polyurea and polyphagia

The following findings are also indicative of possible diabetes: recent weight loss, irritability, dry mouth, frequent infections, history of poor wound healing.

• It is recommended that a patient suspected by the dentist to be diabetic, should be referred to a physician for proper evaluation and diagnosis.

• Properly controlled type 1 and type 2 diabetic patients usually can undergo all dental treatments without special precautions.

• The dentist must know the type and dose of insulin as well as any other medications that the patient is taking.

There is no definitive cure for diabetes. It is the most common endocrine disorder and affects an estimated 16million people in the United States. An additional estimated 6 million people have diabetes but do not know it. Without a proper diagnosis, these people are at significant risk of developing life-threatening complications.

• The most severe emergent complication of diabetes mellitus is hypoglycemia i.e. Blood sugar level less than 70 mg /dl.

• The hypoglycemia has more dramatic results than hyperglycemia.

• Factors like diet, underlying systemic disease , hormones, steroids elevate blood sugar levels differential Diagnosis of Diabetic Coma

Hypoglycemia

- Coma of sudden onset.

- Too much insulin / No food.

- Moist clammy skin.

- Full pulse.

- Shallow breathing.

Hyperglycemia

- Coma of slow onset.

- Little or no insulin.

- Dry skin.

- Weak pulse.

- Acetone odour of breath

-Air hunger.

MANAGEMENT OF HYPOGLYCEMIA IN DENTAL OFFICE

• STOP THE PROCEDURE Immediately

• Initially oral Glucose 10-20 gis given ,either in liquid form or as granulated sugar (two teaspoons).

• Repeat capillary blood glucose test after 10-15minutes; if the patientis still hypoglycemic then the above can be repeated (probably upto 1-3 times).

• If hypoglycemia causes unconsciousness, or the patient Is unco-operative:Intravenous administration of 75-80 ml 20% glucose or 150-160 ml of 10% glucose (the volume will be determined by the clinical scenario).

• 50% glucose concentration is viscous and rarely used now.

• Administer Glucagon IM if IV access not possible

a. Adults 1mg

b. Children 0.5mg

c. Infants 0.25mg

• Once the patient regains consciousness, oral glucose should be administered, as above.

• Check the blood sugar with glucometer.

Do not continue the procedure after patient becomes normal.

call the patient next day.

Glucose drinks must be available in dental office for diabetic patients.

Local anesthesia without Adr is given because Adr elevate may blood glucose levels .

If hypoglycemia is not managed , it can lead to diabetic coma.

Typically, patients also should receive short morning appointments to reduce stress.

The use of tetracycline in the treatment of peri-odontal disease was associated with an improve-ment in glycemic control as assessed by HbA1c assays.

The combination of nonsurgical débridement and tetracycline antibiotics therapy in patients with diabetes mel-litus who have advanced periodontitis may have a potential positive influence on glycemic control.

Some dentists do a full mouth bridges to bind and fix mobile teeth to other non mobile teeth in diabetic patients

Systemic complications

increased susceptibility to infection and

delayed healing; neuropathy, retinopathy

and nephropathy (microvascular disease);

accelerated atherosclerosis with associ-

ated myocardial infarction and coronary

artery disease; stroke; atherosclerotic

aneurysms (macrovascular disease); and amputation.

ORAL COMPLICATIONS OF DIABETES

Gingivitis and peri-odontal disease , xerostomia and salivary gland dysfunction; increased susceptibility to bacterial,viral and fungal (that is, oral candidiasis) infec-tions; caries; periapical abscesses; loss of teeth;impaired ability to wear dental prostheses(related in part to salivary dysfunction); taste impairment lichen planus; and burning mouth syndrome. Read more on oral complications

Candidiasis. Oral candidiasis is an opportunistic fungal infection commonly associated with hyperglycemia and is thus a frequent complication of marginally controlled or uncontrolled diabetes.

Burning mouth syndrome. The etiologic factors can include salivary dysfunction, candidiasis and neurological abnormalities such as depression.

Lichen planus. Lichen planus is a relatively common, chronic mucocutaneous disease of unknown cause. It generally is considered to be an immunologically mediated process that involves hypersensitivity reaction on the micro-scopic level. Some studies provide relationship between this disease and diabetic mellitus.

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