permits, an alternative analgesic, such as acetaminophen, should be used. Patients with diabetes who use the glinide and sulfonylurea oral hypoglycemic medications should be educated about their potential adverse interaction with NSAIDs. The use of the broad-spectrum antibiotic cephalexin may increase the hypoglycemic effect of the biguanide hypoglycemic agent metformin, as the plasma concentration of metformin is increased as its renal clearance is decrease (Wynn, 2019).) Cephalexin is employed occasionally in the treatment of odontogenic infections. However, dental clinicians should avoid the use of cephalexin for patients with type 2 diabetes who are using metformin; instead, they should consider other antibiotics for the treatment of infections of odontogenic origin. intramuscularly or subcutaneously (Miller & Ouanounou, 2020). The dental office should have this medication available as a component of a commercially available dental emergency kit. On resolution of the hypoglycemic reaction, the patient’s physician should be advised of the occurrence. Dental treatment should not be resumed until the patient’s glycemic issues have been resolved. It is essential that the contents of a dental emergency kit be monitored regularly to ensure that the medications within these kits have not passed their expiration dates. The occurrence of a hypoglycemic reaction is not the time to discover that the emergency medication kit does not have any glucagon or that the glucagon within the kit may have lost its potency. Also, periodic mock emergency drills for the entire dental staff must be a part of staff training, and each staff member must have an assigned role in the event of any medical emergency that occurs during dental treatment. Hyperglycemia Hyperglycemia is a condition indicating an abnormally high blood glucose level. Unlike the symptoms of hypoglycemia, those of hyperglycemia can take days to develop, with the final phases culminating in ketoacidosis and coma. Symptoms of hyperglycemia include warm and dry skin, a loss of mental acuity, a weak and rapid pulse, and dyspnea (labored breathing). Due to metabolic acidosis, acetone breath, also described as fruity or sweet breath, is evident. Without proper treatment, severe hypotension and loss of consciousness develop. The unconscious hyperglycemic patient must be transported to the hospital. Management by emergency personnel involves basic life support, including airway maintenance with administration of 100% oxygen. Intravenous fluids may also be given to prevent vascular collapse. Patients suffering from hyperglycemia should not be given insulin before serum electrolyte and glucose values have been obtained at the hospital emergency department. is escorted to the operatory. Dr. Milford enters the operatory a few minutes later and discovers that Thomas is mumbling incoherently; has cold, clammy skin; is sweating; and has a rapid heartbeat (tachycardia). He remains conscious at this point. Question What is the underlying cause of Thomas’s current condition? What should Dr. Milford and the dental staff do to help Thomas? Discussion Thomas is experiencing insulin shock, or a hypoglycemic reaction. As noted, he is a type 1 diabetic who has taken his normal dose of insulin before his dental appointment but has opted to skip breakfast. This combination leads to a rapid drop in the blood glucose levels and is manifested as insulin shock. Dr. Milford and the staff must act immediately to prevent more dire consequences from developing. Because he is conscious,
interactions between these medications and those that are used adjunctive to dental treatment have been noted. Many patients think that OTC medications have no potential for adverse side effects or adverse interactions with other medications. However, this is not always true. The use of large doses of nonsteroidal anti-inflammatory drugs (NSAIDs), which are used for analgesic purposes, can potentiate the hypoglycemic effect of insulin or oral hypoglycemic agents (Patton & Glick, 2016). The most common NSAIDs that are available OTC are ibuprofen and naproxen, and can be used on a long-term basis for conditions such as osteoarthritis and rheumatoid arthritis. Patients who have been prescribed the glinide and sulfonylurea oral hypoglycemic agents should not use these analgesic medications. When the medical history
Emergency management of the dental patient with diabetes Often the patient with diabetes is the person most knowledgeable about the control of his or her blood glucose levels. Dentists should briefly discuss with patients their most recent history of blood glucose control.
Auxiliary personnel should encourage patients to bring their self-monitoring blood glucose devices with them to dental appointments and demonstrate their use to the dentist in case glucose administration becomes necessary during a procedure. Hypoglycemia During a dental appointment, the emergency most likely to result from a patient’s diabetes is hypoglycemia, or insulin shock, a condition of severely low blood glucose level. Although the most common hypoglycemic reactions occur due to an excessive dose of insulin or the failure to maintain a normal diet while taking insulin, a hypoglycemic reaction can also follow an excessive dose of an oral hypoglycemic medication, particularly a medication in the sulfonylurea class of oral hypoglycemic medications (ADA, 2019). The signs and symptoms of insulin shock at onset include mental confusion, tremors, anxiety, mood changes, incoherence, sweating, cold and clammy skin, hunger, and tachycardia. This reaction can progress to hypotension, tonic or clonic movements, unconsciousness, coma, and death. The onset of these symptoms can occur rapidly, and they can progress quickly to life- threatening issues if immediate treatment is not initiated. If a patient with diabetes begins to demonstrate any of these signs and symptoms, the clinician should check the patient’s blood glucose level with a glucometer. If a glucometer is not available and the patient is known to have diabetes type 1 or 2, the clinician should treat the event as a hypoglycemic reaction and stop dental treatment immediately. If the patient is conscious, a fast- acting carbohydrate such as regular soda or fruit juice can be given. It should be available in the office, and the soda must be regular, with sugar (ADA, 2019). If the patient is not conscious, emergency medical services must be activated immediately. A 1-mg dose of glucagon can be administered Case scenario 1 Thomas has been a patient of Dr. Milford for several years. He has had type 1 (insulin-dependent) diabetes since childhood and has no other issues with his medical history. He is a 30-year-old male who is compliant with his insulin regimen and reasonably compliant with the dietary restrictions of type 1 diabetes. Thomas recently fractured a molar that had a long-standing large amalgam restoration. Dr. Milford has recommended a crown to restore this tooth, and Thomas has agreed to the treatment plan. Thomas knows that Dr. Milford will need to take an impression of the prepared tooth so that the dental laboratory can fabricate a crown. Thomas also knows that he has a very strong gag reflex and is concerned that the oozing of the impression material could stimulate this protective reflex and cause him to vomit. He has taken his normal dose of insulin but skipped breakfast to minimize the contents in his stomach in the event that he becomes nauseated during the procedure. On arrival at the practice, Thomas appears to be in good health and spirits and
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