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My next patient is diabetic: what are the implications for the dental treatment I provide?

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(Peer-reviewed content that will appear in the JCDA OASIS “point of care” searchable database at www.jcdaoasis.ca – which will be introduced at the beginning of 2013.

Diabetes Mellitus

Diabetes mellitus (DM) is a disease of glucose, fat, and protein metabolism characterized by hyperglycemia, which results from impaired insulin secretion or varying degrees of insulin resistance, or both.

• Types: Type 1 DM, Type 2 DM, Gestational DM

Local Anesthetic Precautions 

  • Use vasoconstrictors with caution:
    • Routine use of local anesthetic with 1:100,000 epinephrine is generally well tolerated. However, epinephrine has a pharmacologic effect that is opposite to that of insulin, so blood glucose could rise with the use of epinephrine.
    • In diabetic patients with hypertension, post-myocardial infarction, or cardiac arrhythmia caution may be indicated with epinephrine.
    • RECOMMENDATION:
      • Guidelines for diabetic patients are similar to those for patients with  cardiovascular conditions:
      • Consider limiting epinephrine to 0.04 mg (2 cartridges of 1:100,000 or 4 cartridges of 1:200,000 epinephrine) and levonordefrin to 0.2 mg.
      • AVOID  1:50,000 concentrations of epinephrine in dental anesthetic and epinephrine-impregnated retraction cord.
Drug Interactions

  • Prescribe with caution. Adverse interactions likely:
    • NSAIDs, corticosteroids with:
      • Insulin-dependent DM or noninsulin-dependent DM
        • Concurrent use may increase blood sugar.
      • Chlorpropamide (sulphonylureas)
        • Avoid large doses and long-term use as they raise blood sugar levels and have antagonistic effects (steroids, chlorpropamide).
      • Repaglinide (meglitinides)
        • Concurrent use increases risk of hypoglycemia.
        • Significant  interaction – monitor closely: Prednisone will decrease the level or effect of repaglinide by affecting hepatic / intestinal enzyme CYP3A4 metabolism.
Scheduling of Visits

  • Short, morning appointments following a regular breakfast. Always treat patient on a full stomach.
Defer Elective Care

  • Avoid elective and complex procedures until the patient’s condition is well controlled.
General Treatment

  • Advise patient to take normal insulin dosage and eat regularly on day of treatment.
  • Treat even small infections aggressively with appropriate antibiotic therapy and necessary surgical intervention, as these patients are immunosuppressed when their diabetes is poorly controlled and at an increased risk of severe infections.
  • Always provide aggressive pain management. Pain, infection, and inflammation cause epinephrine release. Epinephrine causes glycogen breakdown to glucose and this results in the precipitation of hyperglycemia.
  • Poor wound-healing following extractions may be encountered in patients with poorly controlled diabetes. Use antibiotic support as necessary.
Oral Manifestations

  • Salivary gland dysfunction (indirect result of polyuria)
  • Oral candidiasis (seen in hyperglycemia, marginally controlled or uncontrolled DM)
  • Gingivitis and periodontitis (seen in marginally controlled or uncontrolled DM)

JCDA-OASIS supports clinical decisions. However, it does not provide medical advice, diagnosis or treatment details. JCDA-OASIS is a rapidly accessible, initial clinical resource—not a complete reference.

Suggestions and feedback should be directed to jcdaoasis@cda-adc.ca

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1 Comment

  1. alison dougall April 8, 2013

    I am very intrigued by this pesudo problem with the vaso=constrictor – is a theoretical risk – rather than a clinical reality – and in my view – a sure fire way of dropping peoples blood sugar – is via anxiety and trauma induced by pain – if a local faso-constrictor is not used for a procedure and anaesthesia is not adequate.

    I think the most important factor not covered above , is to make sure that all the team can recognise a hypo – which can be induced by lost of uncontrollable things – fear, anxiety, lack of food due to waiting for emergency appointment, alcohol taken to relieve toothache etc et,
    So a patient who is sweating profusely, or acting unusually aggressively, or in a confused manner – should have a sweet drink or sugar (sometimes need to be offered (quite assertively as the patient can be argumentative if in a hypo_ – in the way of a sweet given immediately – this can prevent a collapse and the need for medical intervention.

    Reply

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