DENTAL TREATMENT CONSIDERATIONS FOR PATIENTS WITH DIABETES
alveolar bone (Zhang et al., 2019). Initial periodontal treatment will be determined by a composite of the clinical examination findings, radiograph results, and the patient’s willingness to maintain optimal oral hygiene at home and to remain on a regular dental recall schedule. Some studies have shown that nonsurgical periodontal therapy can improve glycemic control, as evidenced by decreased HbA1c levels following this therapy (Son & Lee, 2018). Restorative dentistry must achieve functional goals with restorations that are conducive to maintaining optimal periodontal health. Any restoration that is placed, such as a basic composite restoration, single or multiple units of crowns, and even crowns or prostheses retained by implants, must be easily cleansable and maintainable by the patient. Implants are not contraindicated in patients with good glycemic control (Wang et al., 2020). Margins of restorations should be placed supragingivally whenever possible. Subgingival margins present a more difficult oral hygiene challenge for the patient and can be a chronic source of gingival inflammation. Margins that impinge on the biological width of the periodontium present an extremely difficult if not impossible oral hygiene challenge for the patient. The emergence profile of a restoration should not impinge on the free gingival tissues. Contact points between restored teeth must be closed enough to prevent food impaction but placed so that the patient can floss easily. The ability to attain a profound level of anesthesia is essential for restorative and surgical procedures. Vasoconstrictors are included in local anesthetics to potentiate the depth of anesthesia, prolong its duration, and promote hemostasis via localized vasoconstriction. Epinephrine in concentrations of 1:100,000 and 1:200,000 is the most common among the current array of local anesthetics. Use of a local anesthetic containing epinephrine must be judicious in patients with diabetes, as the pharmacological effect of epinephrine is contrary to that of insulin (Nazir et al., 2018). Some local anesthetic formulations do not contain epinephrine and are ideal for procedures of short duration. It is essential that patients who require oral surgery, periodontal surgery, implant placement, or root planing and curettage have adequate glycemic control before any of these procedures are initiated. The stress of surgical procedures can promote hyperglycemia via the secretions of hormones and inflammatory cytokines, which can predispose the patient to protracted healing of surgical sites and postsurgical infections, both of which can be exacerbated by a pattern of poor glycemic control (Bera et al., 2020). Elective surgery should be postponed if a patient exhibits poor glycemic control. Surgical procedures must be completed as expeditiously and atraumatically as possible. Clinicians must make an honest self-assessment to determine whether their surgical skills are conducive to meeting this requirement. If not, they should refer the patient to a specialist, such as an oral surgeon or a periodontist. Antibiotic premedication before invasive dental treatment is not mandatory for all diabetic patients; however, the need for this regimen should be evaluated on a patient-by-patient basis (Miller & Ouanounou, 2020).
Dental treatment for every patient must begin with a thorough review of the patient’s medical history at the initial appointment and each subsequent appointment. This entails determining whether the patient has type 1 or 2 diabetes and, if so, how well it is controlled. The dentist should consult with the patient’s physician if the patient has problems with glycemic control, especially if the patient has type 1 diabetes and is considered to have “brittle diabetes.” Most patients with well-controlled type 1 or type 2 diabetes can proceed with dental treatment (ADA, 2019; Bera et al., 2020). However, if there is any doubt about the patient’s ability to tolerate dental treatment, especially when invasive procedures are planned, treatment should be deferred until the physician has been consulted and has cleared the patient for dental treatment. Early morning appointments are ideal for patients with diabetes, as levels of endogenous cortisol, a hormone that raises blood glucose levels, are usually higher at this time (Miller & Ouanounou, 2020). A patient with a higher level of blood glucose will be less likely to develop a hypoglycemic crisis (insulin shock) after using insulin or an oral hypoglycemic medication before the appointment. Some patients with diabetes may be reluctant to eat before a dental appointment because they are afraid that they will experience nausea and vomiting during a dental appointment. However, they must be advised to eat, as a hypoglycemic crisis can occur if the patient takes his or her normal dose of insulin or an oral hypoglycemic medication and does not maintain a normal diet. The patient’s physician must be consulted when extensive oral surgery procedures – such as multiple or full-mouth extractions (with or without the immediate placement of dentures), the simultaneous extraction of all four wisdom teeth, or periodontal surgery with the placement of surgical packs – interfere with the patient’s ability to eat normally. The concern is that the normal dosage of insulin or hypoglycemic agent taken by a patient who has difficulty eating can precipitate a hypoglycemic crisis. Pureed foods or liquid nutritional supplements may be employed to meet the patient’s nutritional requirements. The patient’s physician may temporarily adjust the insulin or oral hypoglycemic agent dosage to compensate for the decreased consumption of solid food (Bera et al., 2020). Because the relationship between periodontal disease and diabetes mellitus is bidirectional, periodontal disease can impact diabetes by increasing glucose resistance and glucose dysregulation, and diabetes can compromise immune function and wound healing (Shutoff & Boyd, 2018). An initial comprehensive examination must also include a complete analysis of the patient’s periodontal health. A full-mouth series of radiographs, full-mouth periodontal probing, and an assessment of the level of attached tissue will establish a baseline of the patient’s periodontal health. The level of oral hygiene and habits, such as smoking, also must be considered in the patient’s periodontal treatment plan. Smoking, as a separate entity, has been estimated to increase the risk of the development of periodontal disease as it reduces the immune response within the periodontal tissues, exacerbates the inflammatory response of the periodontal tissues, and decreases the metabolism of
ADVERSE INTERACTIONS BETWEEN HYPOGLYCEMIC MEDICATIONS AND ADJUNCTIVE DENTAL TREATMENT MEDICATIONS
insulin. Minimizing or refraining from the use of local anesthetics with epinephrine can decrease or alleviate this potential hyperglycemic effect. Oral hypoglycemic medications are generally employed for patients with type 2 diabetes. There are several classes of medications within the general category of oral hypoglycemic medications. Fortunately, only a few potential adverse
Each year a vast number of prescription medications for various systemic diseases are introduced into the U.S. market, and globally. The use of any medication has its benefits and risks, including the potential for adverse interactions with other prescribed or over-the-counter (OTC) medications. The medications that are used to treat diabetes types 1 and 2 are no exception. As noted, however, the epinephrine within local anesthetics has an effect on glucose that is opposite that of
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