Managing the patient with diabetes: Important considerations

This summary is based on information found in Diabetes Mellitus and Oral Health: An Interprofessional Approach, First Edition (Wiley Publishing, 2014)

• Dental management of patients with diabetes can be challenging.
• Working closely with the physician and understanding the patient’s daily diabetes management regimen leads to developing appropriate pathways of care and minimizes risk for in-office emergencies.

Results of periodontal therapy

• There is much less research examining the outcomes of periodontal therapy in periodontitis patients with diabetes compared to those without diabetes.

The patient with undiagnosed diabetes

• Dentists and dental hygienists may be the first to recognize signs and symptoms, such as advanced periodontal diseases or other infections, burning mouth, xerostomia, or parotid enlargement.
• The medical history must be reviewed thoroughly to determine if the patient has been previously diagnosed with diabetes or if the patient has risk factors for diabetes such as prediabetes, overweight/obesity, racial risk factors, family history of diabetes, history of gestational diabetes, or others.
• Interaction between the dentist and physician is a critical component of care.
• Initial oral evaluation should include the assessment of the periodontium for:
  • Signs of potential undiagnosed or poorly controlled diabetes such as extensive gingival bleeding,
  • Presence of multiple simultaneously occurring periodontal abscesses,
  • Localized or generalized gingival swelling that may be accompanied by tissue that appears to proliferate out of the periodontal pocket,
  • Rapid progression of bone loss and attachment loss that is inconsistent with the level of plaque and calculus, or
  • A poor wound healing response after periodontal therapy.
• If such signs are present, the dentist should thoroughly review the medical history again.
• In the presence of intraoral signs and symptoms of possible undiagnosed diabetes, patients with one or more risk factors for diabetes should receive further evaluation.
• Ask the patient about these common signs and symptoms of undiagnosed diabetes:
  • A history of polyuria (frequent urination),
  • Polydipsia (excessive sense of thirst) and polyphagia (excessive sense of hunger or inability to remain satiated after a meal),
  • Recent vision changes, or
  • Rapid weight loss.
• If in doubt, consultation with the patient’s physician.

The patient with a diagnosis of diabetes

• For patient previously diagnosed with diabetes, the dentist must first determine which type of diabetes the patient has in order to preliminarily assess the patient’s own understanding of his or her diabetes.
• The clinician should ask the patient to describe the level of glycemic control to assess the patient’s knowledge of his own condition before s/he begins a course of therapy that may require communication with the physician and alterations in the diabetes management plan, or may involve dental treatment with outcomes that depend on the patient’s ability to maintain good glycemic control.
• The clinician must obtain an accurate and detailed understanding of the patient’s medical management regimen.
• Because some diabetes medications are associated with a significant risk for hypoglycemic emergency, it is critical that the dentist determine exactly which medications the patient takes (21, 26).

Treatment plan and therapy

• The dentist performs a thorough oral examination and develops a list of diagnoses.
• If any acute lesions or conditions are found, they should be treated on an emergent basis. The treatment done at this time is limited to managing the acute problem.
• For routine dental treatment, there is little indication for routine use of prophylactic antibiotics in patients with diabetes. However, if an infection is present, antibiotics are generally indicated, especially if the patient’s glycemic control is poor.
• The next step is to accurately determine the patient’s level of glycemic control over an extended period of time and this should be done before any definitive dental treatment. This is done by using the glycated hemoglobin test (HbA1c test) (24).
• The dentist should consult the patient’s physician with a detailed request for information about the patient’s glycemic control, specifically asking for the results of the HbA1c tests for at least the past two years.
• This consult demonstrates that:
  • The dentist has evaluated the patient’s diabetes history,
  • Examined the patient and found significant oral disease, and
  • Needs the physician’s assistance in determining an appropriate plan of care.
• As routine dental therapy, the dentist must consider the impact of diabetes on the treatment plan itself.
• It is important to continue to monitor glycemic control throughout the course of therapy.
• If the patient’s glycemic control is determined to be relatively good and dental treatment is required, that treatment should be provided:
  • If the patient’s glycemic control is determined to be poor, the dentist should proceed cautiously with elective care. Treat any inflammatory periodontal disease via scaling and root planing to reduce the bacterial bioburden and resultant inflammation.
  • In the periodontal re-evaluation, include an assessment of oral hygiene, changes in periodontal tissue health, and alterations in glycemic control.
  • Assess changes in HbA1c three months after scaling and root planing may provide valuable information.
  • After scaling and root planing followed by re-evaluation, if the patient’s glycemic control remains poor the dentist should generally postpone elective periodontal therapy.

Evaluation and management of diabetes emergencies

• Diabetic ketoacidosis or DKA, a life-threatening emergency, generally does not occur in the dental office because it is not a condition that develops in minutes or hours.
• Unlike hyperglycemic emergencies, hypoglycemia is a much more likely cause of dental office emergency.
• Assessment of risk for an in-office hypoglycemic event should be part of the initial work-up for any dental patient with diabetes, because severe hypoglycemia may result in seizures or loss of consciousness (26).
• Intensive management regimens have reduced diabetes complications such as neuropathy, nephropathy, retinopathy, and cardiovascular diseases.
• Patients with type 1 diabetes now come to the dental office on insulin regimens that involve three or four injections of insulin daily, or use of an insulin pump, instead of the single daily injection regimens of 20 years ago.
• Patients with type 2 diabetes are often taking multiple oral medications, sometimes in combination with insulin injections. However, the risk for hypoglycemia must be recognized by dentists and dental hygienists as they treat patients with diabetes, especially those who are taking insulin.
• Some people with diabetes develop a phenomenon known as hypoglycemia unawareness (37).
• Individuals with hypoglycemia unawareness often show none of the usual early symptoms of hypoglycemia such as tachycardia, sweating, dizziness, or anxiety before severe symptoms occur, including seizures or unconsciousness. The patient may be acting normally one moment and the next moment begin to experience severe symptoms of hypoglycemia including seizures or unconsciousness.
• The dentist should ask patients with diabetes if they have hypoglycemia unawareness and be prepared for sudden onset of severe hypoglycemia in any individual with diabetes.
• The dentist should ensure that the patient has taken the usual medications and eaten the usual meals on the day of dental treatment.
• Have all patients with diabetes bring their glucometer with them to the dental office. Patients often appreciate the dentist’s concern about their well-being during dental treatment.
• The dentist must consider the length of the procedure, the type and timing of the patient’s medications, and recent meals or snacks.
• For longer appointments it may be useful to take another glucometer reading an hour or so after treatment begins to ensure the patient remains at relatively low risk for hypoglycemia.
• If hypoglycemia occurs during dental treatment, that treatment should be terminated and all attention focused on managing the hypoglycemic event:
  • If the patient is conscious and can take food by mouth, the dentist should provide approximately 15 grams of simple carbohydrates such as 4–6 ounces of fruit juice by mouth. Another glucometer reading should be done in 10–15 minutes. If symptoms do not resolve and the glucose level does not rise significantly within 10–15 minutes, another 15 grams of carbohydrate should be given and the glucose level rechecked in another 10–15 minutes.
  • For hypoglycemic patients who cannot take food by mouth, perhaps due to loss of consciousness or onset of seizures, the dentist has two options:
    • If an intravenous line (IV) has already been established, the dentist should rapidly give approximately 30 ml of 50% dextrose IV (15 grams of dextrose).
    • If an IV line has not been established, the drug of choice is glucagon, which is rapidly absorbed, causing immediate glucose release from the liver and thereby raising blood glucose levels promptly. Nausea and vomiting may occur after administration of glucagon, so an unconscious patient should be placed in a position to avoid aspiration.

Timing of dental appointments

• Appointment timing for patients with diabetes is important. The early morning hours may or may not be appropriate for people with diabetes, depending primarily on the patient’s medication regimen.
• Ideally, dental treatment occurs at a time of day when blood glucose levels are higher rather than lower to reduce the risk of in-office hypoglycemia.

List of References (PDF)