DIABETES AND DENTAL MANAGEMENT - Diabetic Dental Probl...

DIABETES AND DENTAL MANAGEMENT

DIABETES AND DENTAL MANAGEMENT
P&G Dental ResourceNet

General description. Diabetes mellitus is a disorder characterized by impairment or destruction of the pancreas' ability to produce insulin and the resultant inability of the body to metabolize carbohydrates, fats, and proteins.1 Accounting for about 40,000 deaths per year, it is the third leading cause of death in the US.2 Diabetes may occur as a result of:

a "genetic" disorder,
the primary destruction of islet cells by inflammation, cancer, or surgery,
an endocrine condition, or
iatrogenic disease due to the administration of steroids.
The present discussion will be limited to the "genetic" type of diabetes.

Epidemiology. Two to four percent (15 to 20 million persons) of the general population in the US have diabetes mellitus. The prevalence is currently about 1.89 cases per 1,000 population, but as life expectancy increases, and as persons with diabetes live longer due to better medical management, the number of cases will continue to rise.3-4 A dental practice serving an adult population of 2,000 can expect to encounter 40-80 persons with diabetes, about half of whom will be unaware of their condition.

Etiology and clinical presentation. There are two types of "genetic" diabetes: insulin-dependent diabetes mellitus (IDDM) and non-insulin-dependent diabetes mellitus (NIDDM). While both types appear to have a genetic component, the genetic role in NIDDM is much greater than in IDDM. Environmental factors such as viral infections and autoimmune reactions appear to play an important part in the etiology of IDDM; obesity plays an important but not well-understood part in the etiology of NIDDM.

Although IDDM is generally found in people under 40 years of age, it can occur at any age. It is a severe, acute condition with a sudden onset of symptoms including: polydipsia, polyuria, nocturia, polyphagia, loss of weight, loss of strength, marked irritability, recurrence of bed wetting, drowsiness, and malaise.

Its onset in children is usually preceded by a sudden growth spurt. If uncontrolled by daily injections of insulin, IDDM may result in death in a matter of days, weeks, or at the most, months. NIDDM generally occurs after the age of 40 in obese individuals; its incidence increases with age. In contrast to IDDM, the onset of symptoms in NIDDM is usually slow and can go undetected for years. Once diagnosed, however, it can be controlled by proper diet and weight reduction, usually without the need for insulin.

The primary manifestations of diabetes—hyperglycemia, ketoacidosis, and vascular wall disease—contribute to the inability of uncontrolled diabetic patients to manage infections and heal wounds.

Other signs and symptoms relating to the complications of diabetes are skin lesions, cataracts, blindness, hypertension, chest pain, and anemia.

Treatment. Although patients with IDDM require insulin to control their blood glucose level, diet control and adequate exercise can reduce the amount of insulin needed. NIDDM is frequently controlled by weight loss, diet, (rigid control of total caloric content) and physical activity. When these lifestyle changes fail to affect the blood-glucose level, hypoglycemic agents are used, sometimes in combination with insulin. These agents appear to stimulate the secretion of insulin, increase the number of cell membrane insulin receptors, and improve insulin postreceptor activity. Therapy is a highly individual process and usually continues throughout the patient's lifetime.



DENTAL MANAGEMENT

Medical considerations.

Take a thorough medical history for all patients diagnosed with diabetes.
Ascertain the identity of the physician treating the patient and the date of the last visit.
Obtain information concerning the type of diabetes, the severity and control of the diabetes, and the presence of cardiovascular or neurologic complications.
Refer any patient with the cardinal symptoms of diabetes or findings that suggest diabetes (headache, dry mouth, irritability, repeated skin infection, blurred vision, paresthesias, progressive periodontal disease, multiple periodontal abscesses) to a physician for diagnosis and treatment.
Diabetic patients who are receiving good medical management without serious complications such as renal disease, hypertension, or coronary atherosclerotic heart disease, can receive any indicated dental treatment.

Those with serious medical complications may require an altered plan of dental treatment. When the severity and degree of control of diabetes are not known, treatment should be limited to palliation.

Food intake and appointment scheduling. To preventing insulin shock from occurring:

Verify that the patient has taken medication as usual.
Verify that the patient has had adequate intake of food.
Schedule appointments in the morning, since this is a time of high glucose and low-insulin activity. Afternoon appointments are a time of low-glucose and high-insulin activity which may predispose the patient to a hypoglycemic reaction.
Instruct patients to tell the dentist if at any time during the appointment they feel symptoms of an insulin reaction occurring. A source of sugar, such as orange juice, must be available in the dental office should the symptoms of an insulin reaction occur.
Oral surgery concerns.

It is important that the total caloric content and the protein/carbohydrate/fat ratio of the patient's diet remain the same so control of the disease and proper blood glucose balance are maintained.
IDDM diabetics who are going to receive periodontal or oral surgery procedures may be placed on prophylactic antibiotic therapy during the postoperative period to avoid infection.
Consultation with a patient's physician before conducting extensive periodontal or oral surgery is advisable. The physician may, in fact, recommend that the patient be treated in a hospital environment where infection, bleeding, and dysglycemia can be better managed.
Dangers of acute oral infection. Any diabetic patient with acute dental or oral infection presents a problem in management. This problem is even more difficult for patients who take high insulin dosage and those who have IDDM. The infection will often cause loss of control of the diabetic condition, and as a result the infection is not handled by the body's defenses as well as it would be in a nondiabetic patient. The patient's physician should become a partner in treatment during this period.

Oral complications. The oral complications of uncontrolled diabetes mellitus may include:

Xerostomia,
Infection,
Poor healing,
Increased incidence and severity of periodontal disease, and
Burning mouth syndrome.
Diabetic neuropathy may lead to oral symptoms of tingling, numbness, burning, or pain in the oral region.
Oral findings in patients with uncontrolled diabetes are thought to be related to excessive loss of fluids through urination, altered response to infection, microvascular changes, and possibly increased glucose concentrations in saliva.

Early diagnosis and treatment of the diabetic state may allow for regression of these symptoms, but in long-standing cases the changes may be irreversible.

Potential Drug Interaction. While patients with well-controlled diabetes can be given general anesthetics, management with local anesthetics is preferable. General anesthetics should be used with caution because they can produce hyperglycemia.