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Managing Type 2 Diabetes in the Dental Practice

This post was prepared by Drs. Aviv Ouanounou and Suham Alexander 

 

Diabetes occurs in approximately 6-15% of the general population and typically, in those over the age of 45 years. Up to 25-30% of the adult population over 65 years is diagnosed with some form of diabetes. Diabetes is the 6th most common cause of death and can result in blindness, end-stage renal disease, cardiac disorders as well as neuropathies.

Type I Diabetes

  • Insulin Dependent Diabetes Mellitus (IDDM)
  • Also, known as Juvenile Diabetes
  • Occurs mostly in young children and teens
  • Affects ~10% of the diabetic population
  • Destruction of beta cells via an autoimmune disorder

Type 2 Diabetes

  • Non-insulin Dependent Diabetes Mellitus (NIDDM)
  • Occurs in ~90-95% of people diagnosed with diabetes
  • Insulin is released from the pancreas but it is not used properly (insulin-resistant)

Gestational Diabetes

  • Occurs in pregnancy
  • May or may not resolve after childbirth

Diabetes induced by a virus

  • Some viruses may cause disturbances in the insulin-glucagon balance and lead to the development of diabetes (eg. cytomegalovirus, adenovirus, rubella, mumps, coxsackievirus B)

Diabetes induced by medications

  • Many drugs have been shown to cause hyperglycemia (eg. statins, ACE inhibitors, β-blockers, clozapine, estrogen supplements) diabetes

Pathophysiology

Diabetes mellitus (DM) is characterized by an absolute or relative insufficiency of insulin which results in disturbances of carbohydrate metabolism. Insulin plays an important role in regulating blood glucose levels which is the preferred fuel source of the body and the only fuel which the brain can use.

Insulin is produced by the β-cells in the pancreas and is responsible for the conversion of glucose to glycogen which is stored in the muscles and liver as well as excess glucose to fat. In this way, it prevents the breakdown of the body’s protein for use as an energy source. As glucose is converted to glycogen and blood levels decrease, insulin production is inhibited.

Glucagon is produced by the α-cells in the pancreas. The production of glucagon stimulates the breakdown of glycogen into glucose which is released into the bloodstream to maintain the homeostatic range of glucose within the body when blood glucose levels are low. Production of glucagon is inhibited when blood glucose levels are high.

In diabetes, insulin may be present but not binding appropriately to its receptors or alternatively, insulin may bind to the receptor but, a defect in signalling to Glut-4, one of the glucose transporter, hinders the uptake of glucose by muscle, liver or fat cells. As a result, glucose remains in the extracellular fluid and blood glucose levels are increased.

Clinical Manifestations

The clinical manifestations of type 2 diabetes include:

  • Non-specific symptoms such as hunger, fatigue, thirst
  • Frequent urination
  • Recurrent infections
  • Delayed wound healing

Oral Manifestations

Some common oral manifestations in this patient population include:

  • ↑periodontal disease
  • ↑salivary gland dysfunction and xerostomia
  • ↑dental caries secondary to hypoglycemic states and xerostomia
  • ↑fungal infections and other infections
  • ↑delayed wound healing after extractions and other oral surgical procedures

Management

The first steps in managing diabetes include dietary modifications as well as regular physical exercise. If diet and exercise, alone, are insufficient, an oral hypoglycemic is introduced to manage blood glucose levels. The 3 main classes of oral hypoglycemic medications are summarized in the table below.

Medication Mechanism of Action ADRs or Drug Interactions
Biguanides eg. Metformin

(very commonly prescribed)

•↑glucose uptake and utilization by  muscle cells

•↓hepatic gluconeogenesis

•↓glucose absorption from the GI

•↑insulin binding to insulin receptors

Mostly GI effects such as nausea, vomiting, abdominal cramps
Sulfonylureas eg. Glyburide

(commonly prescribed)

•↑release of endogenous insulin

•Improves insulin effectiveness in the periphery and liver

•↓serum glucagon levels

Hypoglycemia, rashes, allergic reactions
Thiazolidinediones (AZDs)

eg. Pioglitazone & Ciglitazone

•↑peripheral tissue response to insulin

•↑glucose uptake in muscle and fat tissues

•Inhibits gluconeogenesis

When used alone, hypoglycemia is rare, mild anemia

*Drug interactions with cytochrome p450 inducers

Dental Management

The most important aspect in managing these patients is taking a thorough medical history to assess the patient’s glycemic control at the first appointment. This information should include obtaining recent glucose readings, the frequency of hypoglycemic episodes as well as a complete list of medications, dosages and times these drugs are taken.

Diabetic patients should, ideally, be scheduled in the morning and when the office activity is not at its peak. Ensure the patient has eaten normally, taken his/her medication as prescribed by the physician and that the blood glucose levels are within a normal range before the appointment begins.

After treatment is rendered, patients must be advised on proper hygiene and infection control protocols. Ensure that the patient will be able to maintain an adequate diet post-procedure and give him/her the necessary dietary instructions. Clinical judgement will be required, at times, to assess whether the patient should be given prophylactic antibiotics and will involve weighing risks against benefits of taking the antibiotics in each particular instance.

Diabetic Emergencies

Hypoglycemia is a very serious complication in the diabetic patient. Hypoglycemia occurs very quickly. If the patient is conscious, an oral carbohydrate (eg. orange juice) should be administered. If the patient is unconscious, the appropriate emergency protocol including 9-1-1 and monitoring ABCs (airway, breathing, circulation) must be activated. If hypoglycemia is suspected, administer 1mg glucagon IM or 50% dextrose IV.

The signs and symptoms include:

  • Warm, sweaty skin
  • Dilated pupils
  • Confusion
  • Anxiety, tremors, aggression
  • Rapid, bounding pulse
  • Tingling sensation around the mouth
  • Loss of consciousness

Hyperglycemia is a less serious emergency and its onset is slow in comparison to hypoglycemia. Because this condition is associated with very high blood glucose levels, patients must be hospitalized and given insulin to normalize glucose levels.

The signs and symptoms include:

  • Dry mouth and skin
  • Dehydration
  • Vomiting
  • Hyperventilation
  • Acetone breath (distinct aroma)
  • Hypotension
  • Tachycardia

 

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