Management of the diabetic dental patient

Special Peport

Management of the diabetic dental patientOsie A. May, Jr*

Diabetes mellitus is a chronic disorder affecting the metabolism of carbohydrates, fats,and proteins. Iticreasitig manbers of diabetic patients are presenting in ¡he detital office,perhaps as a result of the itnproved longevity of diabetic patients. The pathophysiology,compUeations. and oral manifestations associated with the disease, as well a.s the medi-cal and dental management of the diabetic patient are reviewed. (Quintessence Int1990:21:491-^94.)

lotroduction

The dental patient with diabetes mellitus is being seenwith increasing frequency in the dental office. Thismay be due in part to the improved survival and lon-gevity of diabetic patients in the United States. It isestimated that about 1% to 2% of the general pop-ulation may have the disease but is undiagnosed.

Diabetes mellitus is a chronic disorder affecting themetabolism of carbohydrates, fats, and proteins. It ischaracterized, in its fully developed chnical expression,hy fasting hyperglycemia, atherosclerotic and mi-croangiopathic vascular disease, and neuropathy.'

This paper will review the pathophysiology andcomphcations associated with the disease as well asthe medical and dental management of the diabeticdental patient.

Etiology

The causes of diabetes melhtus are not fully under-stood. However, three major categories of etiologicfactors may result in diabetes melhtus. These factorsinclude abnormalities in pancreatic beta cells, abnor-malities in plasma, and abnormahties in the action ofinsuhn on its target celis. Abnormahties in plasma arerarely thought to be the primary cause of diabetesmelhtus, but the abnormahties associated with betacells and target cells are believed to contribute signtf-

Associate Professor, Department of Community Dentistry. How-ard University, College of Dentistry, Wastiington, DC 20059.

icantly to the pathogenesis of the disease.̂ Althoughit is strongly beheved that heredity plays an importantrole in the development of diabetes melhtus, environ-mental factors, such as viral infections, obesity, andpregnancy, also seem to play a significant role in theexpression of diabetes meilitus. The chnical manifes-tations ofthe disease or its progression to acute emer-gency episodes may be the result of certain constitu-tional and environmental factors, affecting thosepatients who are genetically predisposed. Other pre-cipitating factors, such as trauma, hypoxia, hyper-thermia, and all forms of stress, also adversely affectthe diabetic condition. The insuhn requirements ofdiabetic patients are believed to increase significantlyduring periods of stress and especially with infection.Stress is thought to produce its effects through thereleasing of catechoiamines, which induce glycogen-olysis and lipolysis,

G lyco geno lysis further burdens the insulin-produc-ing beta cells of the pancreas, and the free fatty acidsformed through hpolysis exert an antagonistic effecton insuhn itself. Thus, although the diabetic state maybe inherited as a genetic trait, the expression of thisgenotype is conditioned by environmental influences.-

Classification and pathophysiology

The terminology used to classify diabetes in the pasthas led to some confusion and lack of uniformity inthe reporting of results by various investigators. Thiswas evident in the differing criteria on which investi-gators based their classification. Several used cliniealfeatures of the disease, some used etiology, while oth-ers used the presumed natural history of diabetes.Therefore, in an attempt to unify these differences, the

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National Diabetes Data Group of the National Insti-tutes of Healtli developed a classification incorporat-ing all the currently available information,' Under thissystem, idiopathic diabetes mellitus is divided into twomain types. Type I, also known as insulin-dependentdiabetes mellitus (IDDM). and formerly known as ju-venile diabetes, is found in about 10% of all idiopathicdiabetics. Type II, also known as noninsulin-depend-ent diabetes mellitus (NIDDM), and formerly knownas adult-onset diabetes, occurs in about 90% of theremaining idiopathic diabetics. Both type ! and typeII diabetic patients constitute the majority of all di-abetic individuals but differ from each other in theirpattern of inheritance, insulin responses, andorigins,̂ '̂ The predominant pathophysiologic effectsof diabetes are due to impaired use of glucose by cells;increased mobihzation, abnormal metabolism, anddeposition of fats; and the depletion of protein in bodytissues,*

Because all diabetic patients have in common a rel-ative or absolute lack of insulin or inadequate insulinfunction, they are unable to utilize glucose adequately.The reduction in insulin also causes glycogenoiysis,which is normally inhibited by insulin. Both derange-ments lead to hyperglyeemia and glycosuria. Fattyacids mobilized from triglycérides stored within fatdepots now become the major source of energy. Indiabetes mellitus type I, and much less often in typeII, the oxidation of fatty acids to ketone bodies in theliver may exceed the rate of their utilization and mayresult in ketosis and metabolic acidosis. Since the bodytissues appear to need glucose, proteins from both thediet and tissues arc used for gluconeogenesis. Thus,anabohc processes such as the synthesis of glycogen,triglycérides, and proteins, are sacrificed to catabolicprocesses, including glycogenoiysis, gluconeogenesis.and the mobilization of fats.- As a result, the diabeticstate that begin.s as an insuhn deficiency becomes acomplex disorder of metabolic alterations.

Clinical manifestations and complications

The clinical manifestations of diabetes mellitns arerelated to the metabolic consequences of insulin de-ficiency, including vascular and organ involvement.The earliest symptoms of the disease are polyuria.polydipsia. polyphagia, loss of weight, and lack ofenergy. The polyuria is due to the osmotic diureticeffect of glucose in the kidney tubules, while the po-lydipsia results from the dehydration caused by poiy-uria. The loss of large quantities of glucose and the

semistarvation of cells causes an incicabc in hunger(poiyphagia)- Weight loss and lack of energy resultfrom widespread catabolic effects. In its fully devel-oped form, diabeies mellitus may be manifested by,symptoms of weakness, lassitude, hyperglyeemia, aci-dosis, ketosis, or protein breakdown, and secondaryabnormalities of blood vessels that may lead to renalfailure, bhndness, hypertension, congestive heart fail-ure, or combinations of any of these vascular prob-lems,'

The oral effects of diabetes mellitus include xero-stomia, cheilosis, reduced salivary flow, increased lev-els of glucose in the serous saliva of the parotid glandwith elevated blood sugar, painless swelling ofthe pa-rotid gland, and increased severity of periodontal dis-ease and dental caries, especially in poorly controlledpatients.*^ Resistence to infection also appears to hecompromised within the oral cavity,'

Hyperglyeemia and its sequelae represent one of twomajor clinical comphcations of significance associatedwith Ihe management of the diabetic patient. The oth-er important complication is hypogiycemia. Both areacute clinical complications of diabetes and are po-tentially life threatening. The signs commonly ob-served in hyperglyeemia are tachycardia, hypotension,hot dry skin, deep and rapid breathing (Kussmaul'srespiration), and acetone breath, ln hypogiycemia thecommonly observed signs are lethargy, hunger, nau-sea, cold wet skin, tachycardia, and increased anxiety.If not recognized and properly managed, hypergly-eemia and hypogiycemia may lead to diabetic comaand ultimately death,̂ '•̂ Fortunately, however, they arerarely causes of death in diabetic patients today. Themajor causes of death in diabetic patienis today aredue to the chronic comphcations associated with thedisease. In order of importance, the major causes ofdeath in diabetic patients are myoeardial infarction,renal failure, cerebrovascular disease, atheroscleroticheart disease, and infections, followed by a large num-ber of other complications more common in the dia-betic than in the nondiabetic patient (eg, gangrene ofan extremity or mesenteric thrombosis).^

Patient management

In the early days of treating diabetes, carbohydrateswere severely reduced in the diet to minimize the in-sulin requirement. Although this procedine kept bloodsugar levels near normal and prevented ]oss of glucosein the urine, it did not prevent abnormalities of fatmetabolism. Now patients are allowed an almost nor-

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Speciai Report

mal carbohydrate diet along with large quantities ofinsulin to metabolize the carbohydrate. This has beenfound to aid in depressing the rate of fat metabolismand the high level of blood cholesterol. In theory,treatment of diabetes mellitus should be the admin-istration of enough insulin to the diabetic patient toeffect carbohydrate, fat, and protein metabohsms thatare as nearly normal as possible. Optimal insulin ther-apy can prevent most acute effects of diabetes andgreatly delay the chronic efiects as well.'"

The medical management of diabetic patientsshould be tailored to meet the individual needs of eaehpatient- Generally, it should involve diet regulation,the use of insulin {type I cases), or oral hypoglycémiedrugs (some type II cases), and controlled exercise.

Oral considerations

Dental therapy for the diabetic patient should be per-formed in conjunction with prudent medical manage-ment. Whether a diabetic dental patient has been pre-viously diagnosed or is suspected of having diabetes,a thorough medical and dental history must be ob-tained. The dental practitioner, therefore, should beon the alert when a patient complains of frequentlyhaving a dry mouth. Xerostomia is a commonly re-ported oral symptom in the diabetic patient."•'-

Rapid alveolar bone loss and acute or multiple peri-odontal abscess could also signal the presence of un-suspected diabetes or reflect a change in metaboliccontrol of a known diabetic person.'^ Such patientsshould he referred to a physician for medical evalua-tion.

Prompt recognition of diabetes-related complica-tions by office staff is essential, should a medicalemergency arise in the dental office. Differentiationbetween hypoglycemia and hyperglycemia is key in thesuccessful management of these potentially life-threat-ening complications. Should there be difficulty ascer-taining which condition is present, the patient shouldbe managed for hypoglycemia until a more definitivediagnosis can be obtained. This would include theadministration of an oral carbohydrate (coia, candy,orange juice) to the conscious patient, along with sup-portive care until additional medical assistance isavailable. Dental office management of the conscioushyperglycémie patient shotild also be of the supportivetype. If, however, the diabetic patient loses conscious-ness, basic life support steps should be instituted toensure adequate cerebral blood flow, until furthermedical assistance becomes available.

When planning treatment for diabetic dental pa-tients, the dentist should obtain a medical evaluationof the patient's current health status. No elective den-tal procedures should be performed on an uncon-trolled diabetic patient. Only extreme emergency den-tal treatment should be rendered to relieve discomfort;the patient should then be referred for medical eval-uation immediately For the controlled diabetic dentalpatient, office visits should be coordinated in a waythat will not interfere with the patient's daily regimenof meals and hypoglycémie therapy If this is not pos-sible, the patient's physician should be consulted be-fore any modifications to dietary arrangements or di-abetic therapy are made. When adequate schedulingis possible, dental appointments should be short andpreferably early in the morning when the patient ismore likely to be well rested.

Local anestheties containing epinephrine may beused for minor oral surgery and routine restorativeprocedures, provided that the concentration of epi-nephnne is reasonable (1:100,000) and multiple injec-tions are not required.''•* If general anesthesia is nec-essary for a dental procedure, a medical consultationshould be requested, and the procedure should be per-formed in a hospital.

The well-eon trolled diabetic patient without acuteoral infection is not required to be prophylactieallytreated with antibiotics when undergoing routine den-tal treatment, such as minor periodontal proceduresand uncomplicated extraction of one or two teeth.Prophylactic administration of antibiotics becomesnecessary for diabetic dental patients when active oralinfection such as pericoronitis, dental abcess, or cel-lulitis is present-Summary

The diabetie dental patient can be successfully man-aged in the office setting after the patient's healthstatus has been established and controlled. Then thedental practitioner can proceed with a well-coordi-nated treatment plan that does not interfere with thepatient's normal diet and hypoglycémie therapy. Theimportance of maintaining good oral hygiene as wellas having frequent dental checkups should be empha-sized as part of an overall preventive program to re-duee oral infection- By frequently reviewing and up-dating the medical histories of diabetic patients, thedentist will maintain an awareness of their specialneeds and will be prepared to respond adequately todiabetic medical emergencies.

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Special Report

References

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2. Bennett PH: The diagnosis of diabetes: new international clas-si Heat ion and diagnostic criteria. Ann Rer Med 1983;34:295-309.

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9. Munioe CO: Tbe dental patient and diabetes mellitus. Dem ClinNorth Am 1983;27:329-340.

lU. Giiytoii AC; Textbook of Medicat Fhysiology, ed 7. Philadelphia,WB Saunders Co, 1986, pp 933-936.

11 Conner S, Iranpour B, Mills 3: Alteration in parotid salivaryflow in diabetes mellitus. Oral Surg Oral Med Oral Patkol197O;30:55-59.

12. Russoto S: A symptomatic parotid gland enlargement in dia.betes mellitus. Oral Surg Oral Med Oral Pathol I981;52:594-598.

13. Sheridan P: Diabetes and oral health / Am Dent ASKCl987;115:741-742

14. Zoelter GN, Kadis B: The diabetic dental patient. Gen Deal19S1;29:58-61. •

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