Diabetes mellitus is a group of metabolic diseases that lead to high levels of blood glucose (hyperglycemia), which occur when the body does not produce any or enough insulin or does not use insulin well. Because diabetes is a relatively common condition, dental providers are likely to encounter it frequently. Oral manifestations of uncontrolled diabetes can include xerostomia; burning sensation in the mouth; impaired/delayed wound healing; increased incidence and severity of infections; secondary infection with candidiasis; parotid salivary gland enlargement; gingivitis; and/or periodontitis.
Types of Diabetes:
Type 1 Diabetes: a chronic autoimmune disease in which the beta cells in the pancreas create little to no insulin, and accounts for 5% to 10% of all diabetes cases.
Type 2 Diabetes: accounts for 85% to 90% or more of diabetes cases and is one of the most common chronic diseases, characterized by decreased response of target tissues to normal levels of insulin, dysregulation of insulin production, or a combination of both.
Prediabetes: when blood glucose levels are higher than normal, but not high enough for a formal diagnosis of diabetes. The person is at increased risk for developing type 2 diabetes, as well as at increased risk for heart disease and stroke. It is estimated that as many as 90% of those with prediabetes are unaware that they have prediabetes.
Gestational diabetes: a state of glucose intolerance that occurs in pregnant women who do not otherwise have diabetes. Occurring in the second half of pregnancy, gestational diabetes is caused by placental hormones and results in insulin resistance and relative insulin deficiency. Although true gestational diabetes resolves during the postpartum period, those who have had gestational diabetes are at increased risk of developing type 2 diabetes later in life.
Common Complications:
Three common complications that can occur when glucose levels are not well controlled are hypoglycemia, hyperglycemia, and diabetic ketoacidosis.
Hypoglycemia: a condition in which blood glucose levels drop below normal. For many people with diabetes, this means a blood glucose level of 70 milligrams/deciliter (mg/dL) or less. Although patients with diabetes often recognize signs and symptoms of hypoglycemia and self-intervene before changes in or loss of consciousness occur, staff should be trained to recognize the signs and treat patients accordingly.
Hyperglycemia: occurs when blood glucose levels are abnormally high. This can occur anytime there is not enough insulin in the bloodstream or the body is not using insulin properly.
Diabetic Ketoacidosis: Diabetic ketoacidosis is a serious condition that can develop when there is not enough insulin to help the body adequately use glucose.
(Refer to Table: Symptoms and Treatment for Patients with Diabetes Mellitus)
Symptoms and Treatment for Patients with Diabetes Mellitus
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Hypoglycemia
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Hyperglycemia
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Diabetic Ketoacidosis
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Mild to Moderate Symptoms
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Shakiness
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High levels of sugar in the urine
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Fruity smelling breath
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Sleepiness
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Frequent urination
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Very dry mouth
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Sweating
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Increased thirst
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High blood glucose levels
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Blurred vision
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Fatigue
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Abdominal pain
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Fast or irregular heartbeat
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Blurred vision
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Frequent urination
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Loss of coordination
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Shortness of breath
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Dizziness or lightheadedness
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Constant tired feeling
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Headaches
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Dry or flushed skin
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Trouble concentrating, confusion
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High levels of ketones in the urine
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Change in behavior or personality
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Difficulty concentrating or confusion
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Nervousness
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Nausea or vomiting
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Hunger
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Weakness
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Irritability
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Argumentative, combative
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Paleness
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Tingling/numbness of the lips or tongue
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Severe Symptoms
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Unable to eat or drink
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Seizures or convulsions
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Unconsciousness
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Treatment
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1. Provide the patient with 15-20 grams of oral carbohydrates to eat or drink
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1. Lifestyle changes, like increased exercise or eating a healthy, well-proportioned diet
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1. If ketoacidosis is suspected, the symptomatic person should be taken to the nearest emergency room
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2. Wait 15 minutes, then check blood glucose levels again.
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2. If ketones are present in urine, the patient should not exercise and should consult their physician
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2. Patient's physician should be immediately contacted
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3. Repeat these steps until blood glucose levels are above 70 mg/dL.
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In severe cases, If the dental patient is not awake and/or unable to eat or drink, emergency medical help should be summoned.
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| Carbohydrate Options: |
½ cup regular (non-diet) soda |
| 4 glucose tablets or one tube of glucose gel |
½ cup of fruit juice* |
| 1 tablespoon of sugar, honey or corn syrup |
8 ounces of non-fat or 1% milk |
| Hard candies, jelly beans or gumdrops |
2 tablespoons of raisins |
*NOTE: People who have concomitant kidney disease should not drink orange juice for their 15 grams of carbohydrates because of the high potassium content. Apple, grape, or cranberry juice cocktail are good alternatives.
Monitoring Glucose Levels
Blood-glucose levels can be checked chairside using a drop of blood and a glucometer. Since they are intended for use by multiple individuals, glucometers are designed to facilitate thorough cleaning and disinfection between uses to help prevent the spread of bloodborne pathogens. After each use, the device must be cleaned and disinfected according to the manufacturer’s instructions. After blood is tested, refer to the chart below to determine the correct Treatment Considerations.
HbA1C and Estimated Average Glucose (eAG)
(28.7 x A1C) – 46.7 = eAG mg/dl
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HbA1c (%)
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eAG mg/dl
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Treatment Considerations
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4
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<70
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Provide the patient with 15-20 grams of oral carbohydrates to eat or drink.
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5
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97
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No contraindications to dental treatment.
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6
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126
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7
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154
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8
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183
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Proceed with dental treatment but monitor glucose levels if any symptoms arise.
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9
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212
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10
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240
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Delay dental treatment until diabetes is considered stable.
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A dental provider may want to ask a patient with diabetes questions such as:
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How old were you when you were diagnosed with diabetes and what type of diabetes do you have?
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What medications do you take?
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How do you monitor your blood sugar levels?
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How often do you see your doctor about your diabetes? When was your last visit to the doctor?
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What was your most recent HbA1c (A1C) result?
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Do you ever have episodes of very low (hypoglycemia) or very high blood sugar (hyperglycemia)?
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Do you ever find yourself disoriented, agitated, and anxious for no apparent reason?
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Do you have any mouth sores or discomfort?
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Does your mouth feel dry?
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Do you have any other medical conditions related to your diabetes, such as heart disease, high blood pressure, history of stroke, eye problems, limb numbness, kidney problems, delays in wound healing, or a history of gum disease? Please describe.
Scheduling Considerations
In general, morning appointments are advisable for patients with diabetes since endogenous cortisol levels are typically higher at this time; because cortisol increases blood sugar levels, the risk of hypoglycemia is less. For patients using short- and/or long-acting insulin therapy, appointments should be scheduled so they do not coincide with peak insulin activity, which increases the risk of hypoglycemia. It is important to confirm that the patient has eaten normally prior to the appointment and has taken all scheduled medications. If a procedure is planned with the expectation that the patient will alter normal eating habits ahead of time (e.g., conscious sedation), diabetes medication dosing may need to be modified in consultation with the patient’s physician. Patients with well-controlled diabetes can usually be managed conventionally for most surgical procedures. If the patient’s food consumption will be affected after oral or dental surgery, a plan to balance the patient’s diabetes medications and food intake should be established in advance.
Coordination with the patient’s physician may be necessary to determine the patient’s health status and whether planned dental treatment can be safely and effectively accomplished. Physicians should make laboratory test results available to the dentist upon request, and inform the dentist of any diabetic complications of relevance to the individual patient prior to dental procedures. The physician may need to adjust the patient’s diabetes medication to help ensure sustained metabolic control, before, during, and after surgical procedures. Patients with diabetes should obtain regular medical and dental care, including regular dental visits for a full evaluation of their dental and periodontal condition.
References:
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American Dental Association, January 2022, Diabetes, ADA.org [online], Available from: https://www.ada.org/resources/research/science-and-research-institute/oral-health-topics/diabetes .
