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Dental Management Of Diabetic Patients: A Clinical Review

Article · January 2014

DOI: 10.12816/0028742

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Revue de la littérature / Literature Review
Médecine Orale / Oral Medicine

DENTAL MANAGEMENT OF DIABETIC PATIENTS:

A CLINICAL REVIEW

Sunita Malik * | Gurdarshan Singh **

Abstract Résumé
Diabetes describes a group of metabolic diseases resulting from Le diabète est une maladie chronique du métabolisme qui appa-
impaired insulin secretion, varying degrees of insulin resistance, raît lorsque le pancréas ne produit pas suffisamment d’insuline
or both. Management of the diabetic dental patients must take ou que l’organisme n’utilise pas correctement l’insuline qu’il
into consideration the impact of dental disease and dental treat- produit. La prise en charge des patients diabétiques au cabi-
ment on the management of diabetes as well as an appreciation net dentaire doit prendre en considération l’impact des maladies
for the comorbidities that accompany long-standing diabetes. dentaires et des soins dentaires sur le contrôle du diabète, ainsi
Those comorbidities include obesity, hypertension and dyslipi- qu’une appréciation des comorbidités qui accompagnent le dia-
demia. Management of the diabetic dental patient should focus bète. Ces comorbidités sont l’obésité, l’hypertension et la dysli-
on periodontal health and the delivery of comprehensive den- pidémie. La prise en charge du patient diabétique devrait donc
tal care with minimal disruption of metabolic homeostasis and se concentrer sur la santé parodontale et la prestation des soins
recognition of diabetic comorbidities. dentaires complets sans perturber l’homéostasie métabolique.

Keywords: Diabetes mellitus - chronic hyperglycemia - reti- Mots-clés: diabéte – hyperglycémie – rétinopathie – mala-
nopathy - macrovascular disease. die macrovasculaire.

* Ass. Prof. ** Resident

M.D.S, Dpt of Maxillofacial Surgery, Dept. of Dental Surgery
Government Medical College for women, B.P.S Government Medical College for women,
Khanpur kalan, Sonepat, Haryana Khanpur Kalan, Sonepat, Haryana.
Pt. B.D Sharma Health University, Rohtak,
Haryana , India.
drsunitamalikmds@yahoo.in
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Médecine Orale / Oral Medicine

Introduction peripheral neuropathy and blurred of carious lesions, restorations, or ena-

vision. Opportunistic infections, inclu- mel decalcification [8]. Exceptions are
Diabetes mellitus (DM) is a group ding oral and vaginal candidiasis, can the cervical caries noted in type 2 DM
of metabolic diseases characterized by be present. Adults with long-standing with high sugar diets, those that drink
hyperglycemia resulting from defects diabetes, especially those with poorly soft drinks, and those with xerostomia.
in insulin secretion, insulin action or controlled hyperglycemia, may deve- If the patient also has oral fungal infec-
both. The chronic hyperglycemia of lop microvascular and macrovascular tions, the topical antifungal medica-
diabetes is associated with long-term conditions that can produce irrever- tions have high sugar content and can
damage, dysfunction and failure of sible damage to the eyes (retinopa- promote caries.
various organs, especially the eyes, thy, cataracts), kidneys (nephropa-
kidneys, nerves, heart and blood ves- thy), nervous system (neuropathy and Candidiasis
sels [1]. paresthesias), and heart (accelerated Another manifestation of dia-
DM results when one of the fol- atherosclerosis), as well as recur- betes and an oral sign of systemic
lowing conditions occurs: insulin rent infections and impaired wound immunosuppression is the presence
released from the pancreas is impaired healing. of opportunistic infections, such as
or insulin action at peripheral tissues Gestational DM is defined as any oral candidiasis. Fungal infections
is impaired [2]. degree of glucose intolerance with of oral mucosal surfaces and remo-
A deficiency in insulin or a problem onset or first recognition during pre- vable prostheses are more commonly
with its metabolic activity can result in gnancy [5]. In the majority of cases, found in adults with diabetes. Candida
an increased blood glucose level (ie, glucose regulation will return to nor- Pseudohyphae, a cardinal sign of oral
hyperglycemia). Hyperglycemia leads mal after delivery. Candida infection, have been associa-
to an increase in the urinary volume ted significantly with cigarette smo-
of glucose and fluid loss, which then Diabetes and the oral manifestations king, use of dentures and poor glyce-
produces dehydration and electrolyte Several soft tissue abnormalities mic control in adults with diabetes
imbalance [3]. This latter problem, if have been reported to be associa- [9]. Salivary hypofunction also may
severe, may result in coma. ted with diabetes mellitus in the oral increase the oral candidal carriage
The stress of the disease also cavity. state in adults with diabetes [10].
results in an increase in cortisol secre-
tion. It is the inability of the diabetic Xerostomia and dry mouth Periodontal disease
patient to metabolize and use glucose, Dry mouth is a common complaint Large number of investigations
the subsequent metabolism of body among diabetic patients. This can be have provided the evidence that type
fat, and the fluid loss and electrolyte due to hyperglycemia, which leads to 1 and type 2 diabetes increase the risk
imbalance that causes metabolic aci- polyuria and can result in a lowering of and severity of periodontitis [11, 12],
dosis. It is the hyperglycemia and keto- fluids like saliva [6]. Xerostomia may and vice versa periodontitis has been
acidosis coupled with vascular wall also be a side effect of other medica- shown to have impact on diabetic sta-
disease (microangiopathy and athero- tions such as antihistamines. tus by using rodent studies although
sclerosis) that alters the body’s ability Xerostomia disrupts the normal the underlying mechanism has not
to manage infection and heal [3]. saliva balance in the mouth, which been discussed [13]. The association
Based on the pathogenic pro- leads to a number of oral and den- between diabetes mellitus and perio-
cesses, four types of diabetes are iden- tal disorders such changes in taste, dontal disease is therefore considered
tified [4]: speech, and the ability to eat in addi- to be bidirectional: diabetes as a risk
• Type 1 diabetes: 5% of diabetics. tion to increasing the risk of cavities factor for periodontitis and periodonti-
• Type 2 diabetes: 90% of diabetics. and infections [7]. Xerostomia also tis as a possible severity for diabetes.
• Gestational diabetes. causes mouth tissues to become infla- In fact, aggressive periodontitis is
• Other: caused by various metabo- med and sore, which in turn can make recognized as the sixth serious com-
lic disorders, drugs or surgery. chewing, tasting and swallowing dif- plication of diabetes [14].
The onset of symptoms is rapid ficult and possibly lead to difficulties Treatment of periodontal disease
in type 1 diabetes, and includes the in controlling diabetes because of a in DMs is similar to treatment in
classic triad of polyphagia, polydipsia reduced interest in eating and thus, an non-DMs. One major difference is the
and polyuria, as well as weight loss, inability to properly maintain stable strong collaboration required by the
irritability, drowsiness and fatigue [4]. blood sugar levels. dental professional with the patient’s
Symptoms of type 2 diabetes develop medical caregivers. Studies showed
more slowly, and frequently without Caries that there can be a temporary increase
the classic triad; rather, these patients Due to the low sugar diets followed in the control of DM when periodon-
may be obese and may have pruritus, by most DMs, many do not have a lot tal disease is controlled. Proper oral
28

Revue de la Littérature | Litrature Review

IAJD Vol. 5 – Issue 1

hygiene care may arrest periodontal For glycemic control, it is recom- and required changes in medication
disease if treatment is aimed at daily mended that the HbA1c level (moni- regimens. Another diet change occurs
plaque removal and timely calculus tored every three months) be main- when patients are placed on orders to
removal [15]. tained at less than 7 percent. If daily take nothing by mouth (NPO) before
blood glucose monitoring is perfor- dental treatment, a common recom-
Taste disturbances med, fasting blood plasma levels mendation before conscious sedation.
Taste is a critical component of should be less than 120 mg/dl and Consultation with the patient’s physi-
oral health that is affected adversely in blood glucose levels two hours post- cian may be needed to adjust the dose
patients with diabetes [16]. One study prandial should be less than 150 mg/ of insulin or oral agents in this situa-
reported that more than one-third of dl. For every 1 percent HbA1c level, tion [5]. Physicians often recommend
adults with diabetes had hypogeusia there is an associated increase in com- reducing the insulin dose that imme-
or diminished taste perception, which plication rates for both microvascular diately precedes lengthy or extensive
could result in hyperphagia and obe- and macrovascular diseases. dental procedures.
sity [17]. This sensory dysfunction can Also, elective procedures should
inhibit the ability to maintain a pro- be postponed if the fasting glucose is Scheduling considerations for
per diet and can lead to poor glycemic either less than 70 mg/dl. It has been diabetic dental patients
regulation. emphasized that when blood glucose Morning appointments are recom-
Other oral manifestations include level is less than 70 mg/dl, there is risk mended, preferably 11/2 hours after
oral lichen planus, trigeminal neu- of hypoglycemia [18]. breakfast and morning meds to avoid
ralgia, traumatic ulcers and irritation the peak action time for those who take
fibromas. Antibiotic coverage insulin injections and since the endo-
Patients with poorly controlled genous cortisol levels are generally
Dental management considerations diabetes are at risk of developing oral higher at this time. Do not schedule
Diabetes mellitus is not a curable complications because of their sus- appointments during lunch breaks
disease. Any patient who has cardi- ceptibility to infection and sequelae, or as the last appointment of the day
nal symptoms of diabetes (polydyp- and likely will require supplemental before dinner since blood sugar levels
sia, polyuria, polyphagia, weight loss, antibiotic therapy [19]. Anticipation can be low and oral health care pro-
weakness) but has not been diagnosed, of dentoalveolar surgery (involving cedures can interfere with eating. In
should be referred to a physician for mucosa and bone) with antibiotic the case of type 1, ask the patient to
diagnosis and treatment. coverage may help prevent impaired bring their own monitoring device to
To minimize the risk of intraope- and delayed wound healing. Orofacial the appointment to monitor their glu-
rative emergency, clinicians need to infections require close monitoring. cose if there is any question as to their
consider a number of issues before Cultures should be performed for acute control.
initiating the dental treatment [Lalla]. oral infections, antibiotic therapy ini- For patients who take insulin, the
tiated and surgical therapies contem- greatest risk of hypoglycemia will thus
Medical history plated if appropriate (for example, occur about 30 to 90 minutes after
It’s important for clinicians to take incision and drainage, extraction, pul- injecting lispro insulin, 2 to 3 hours
a good medical history at the first pectomy). In cases of poor response to after regular insulin, and 4 to 10 hours
appointment. They should ask patients the first antibiotic administered, den- after NPH or Lente insulin. For those
about recent blood glucose levels and tists can select a more effective anti- who are taking oral sulfonylureas,
frequency of hypoglycemic episodes, biotic based on the patient’s sensiti- peak insulin activity depends on the
as well as the antidiabetic medica- vity test results. individual drug taken. Metformin and
tions, their dosage and their times of the thiazolidinediones rarely cause
administration [5]. Diet hypoglycemia.
Dental treatment can result in pos- For the above mentioned reasons,
Blood glucose monitoring toperative discomfort. This may neces- it‘s advised to avoid dental appoint-
Depending on the patient’s medi- sitate changes in the diet, especially in ments when the patient:
cal history, medication regimen and cases of extensive dental therapy [5]. • Has not had meds or eaten
procedure to be performed, dentists Because diet is a major component • Has cold, or flu, or tiredness
may need to measure the blood glu- of diabetes management, diet altera- • Has not recently seen their
cose level before beginning any pro- tions that are made because of dental physician
cedure, especially to prevent the risk of treatment may have a major impact on • Has levels <70 mg/dl or >150 mg/
a hypoglycemic event [5]. the patient. The clinician may need to dl
consult the patient’s physician prior to • Has had a recent emergency.
therapy, to discuss diet modifications
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Médecine Orale / Oral Medicine

Management of potential drome of burning mouth syndrome Conclusion

complications (BMS). Radiation therapy, some sys- Managing the care of patients
Certain patients may need a medi- temic diseases, and a variety of phar- with DM in the dental office should
cal consult before elective dental treat- macologic agents [22], known to be not pose a significant challenge.
ment [20]. Many of them may have capable of inducing a decrease in sali- Hypoglycemia is the major issue that
complications such as cardiovascular vary flow rate [23] have reportedly been usually confronts dental practitioners
disease, renal disease, blindness, or associated with increased incidence of when they are treating patients with
side effects from related medications. BMS [24]. DM, especially if patients are asked to
It is vital for the dental professional BMS may represent a complex of fast before undergoing a procedure.
to always be prepared for emergency multiple diseases with overlapping Finally, having well-controlled
situations and immediately control symptoms [25]. Consequently, dealing blood glucose levels is important
any serious oral infections. with a syndrome which is poorly defi- for infection prevention and proper
ned by symptom(s) without regard healing. At the same time, patients
Hypoglycaemia to etiology actually causes more are needed to be made aware of regu-
The most common complication problems relative to diagnosis and lar periodontal maintenance schedule
of diabetic mellitus that can occur in management. and oral hygiene.
the dental office is a hypoglycemic However, maintaining an adequate
episode [21]. If insulin or oral antidia- oral hydration (saliva substitutes,
betic drug levels exceed physiological sugarless gums, water, ice chips) and
needs, the patient may experience a the restriction of caffeine and alcohol
severe decline in his or her blood sugar intake can help reduce the symptoms
level. The maximal risk of developing [26].
hypoglycemia generally occurs during
peak insulin activity. Initial signs and Infection and delayed wound healing
symptoms include mood changes, Wound infection is a major com-
decreased spontaneity, hunger and plication in diabetic patients [27].
weakness. These may be followed Factors such as age, obesity, malnu-
by sweating, incoherence and tachy- trition, and macrovascular and micro-
cardia. If untreated, possible conse- vascular diseases may contribute to
quences include unconsciousness, wound infection and delayed wound
hypotension, hypothermia, seizures, healing especially in the type II diabe-
coma and death. tic patient. In addition, hyperglycemia
Preventing such complication caused by decreased insulin availabi-
requires: lity and increased resistance to insulin
•Thorough medical history and can affect the cellular response to tis-
consultation with physician to sue injury.
assess glycemic control, disease At the cellular level, an increase
severity and medications with in the number of acute inflammatory
hypoglycemic potential. cells, absence of cellular growth, and
•Monitoring of the blood glucose migration of the epidermis have been
level and the dietary intake before observed [28]. Patients with diabetes
treatment. have impaired leukocyte function, and
•Avoidance of peak activity periods the metabolic abnormalities of dia-
of insulin or oral antidiabetic betes lead to inadequate migration of
medications. neutrophils and macrophages to the
•Recognition of signs and symp- wound, along with reduced chemotaxis
toms of low blood glucose level [29, 30]. Such cellular changes would
and timely administration of car- predispose individuals to an increased
bohydrate source (oral, intramus- risk of wound infection.
cular, intravenous) In order to prevent such complica-
tion, frequent dental visits may help to
 alivary gland dysfunction and oral
S control plaque formation and to iden-
burning tify risk factors for periodontal disease,
Salivary gland dysfunction might caries and oral candidiasis.
play a role in the onset of the syn-
30

Revue de la Littérature | Litrature Review

IAJD Vol. 5 – Issue 1

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