Diabetes and Dental Considerations

General Dental Considerations for Diabetes

• Oral findings can be the initial manifestation of undiagnosed diabetes
• Periodontal disease is the most common oral finding, involving vascular changes, neutrophil dysfunction, and collagen metabolism deficiencies
• Presence of periodontitis impedes glycaemic control and contributes to the onset of other extraoral complications
• Susceptibility to bacterial and fungal infections, including oral candidiasis and mucormycosis in the sinuses
• Xerostomia, which can favour the onset of caries
• Chronic bilateral and asymptomatic inflammation of the parotid glands (sialosis) can develop as a compensatory mechanism

Clinical Presentation of Diabetes

• Classic symptoms of undiagnosed type 1 diabetes: polyuria, polydipsia, and polyphagia
• Fatigue, infections, slow wound healing, blurred vision, and weight loss
• Hypoglycaemia: early signs/symptoms include shakiness, dizziness, sweating, hunger, and piloerection
• Hyperglycaemia: early signs/symptoms include frequent urination, increased thirst, blurred vision, and fatigue

Dental Management of Diabetes

• The dental treatment plan is determined by the patient's previous oral health and degree of metabolic control
• The dental team should be aware of how to manage hypoglycaemic events in the dental clinic
• Risk assessment: hypoglycaemia, hyperglycaemia, fatigue, reduced tolerance for long treatment, increased risk of infection, poor wound healing, and increased risk of periodontal disease

Criteria for Referral

• If HbA1c levels are >9%, only emergency treatments should be conducted and surgical procedures should preferably be undertaken in a hospital setting
• With HbA1c readings >12%, all procedures should be postponed until glycaemic control has improved

Access/Position and Communication

• Schedule sessions for the morning to increase blood glucose levels and decrease the risk of hypoglycaemia
• Avoid scheduling appointments that coincide with the maximum insulin activity peak or when it may lead to a meal being missed
• Patients with signs/symptoms or oral findings suggestive of diabetes should be referred to their doctor for investigation

Consent/Capacity

• Patients should be informed that the dental treatment plan and its success will be determined by the degree of diabetic control
• Patients should be warned of the potential for local and systemic complications resulting from diabetes
• If diabetic control is poor, the patient may be confused, anxious, and/or agitated, reducing their capacity to give consent

Anaesthesia/Sedation

• Local anaesthesia: any local anaesthetic may be employed by following routine precautions
• Sedation: controlling the patient's stress is important, and sedation should be performed in a hospital setting for patients with poor metabolic control and comorbidities
• General anaesthesia: the use of general anaesthesia is determined by the severity of the comorbidities

Dental Treatment

• Before: confirm that the patient has eaten normally and has taken the scheduled medication, and assess the need for antibiotic prophylaxis
• During: dental implants can be placed successfully in patients with well-controlled diabetes, and the main complication is hypoglycaemia
• After: slow healing of the surgical wound is common, and consider the need for postoperative antibiotics, especially for patients with poor disease control

Drug Prescription

• Antibiotic of choice: amoxicillin
• Avoid using metronidazole, azithromycin, ciprofloxacin, and corticosteroids
• Analgesic of choice: paracetamol
• Avoid using aspirin, ibuprofen, diclofenac, and naproxen

Education/Prevention

• Patients with diabetes usually recognize the signs and symptoms of hypoglycaemia, and dentists should know how to identify and manage urgent episodes
• Maintaining optimal oral hygiene and regular reviews, with a focus on periodontal disease, should be routine for patients with diabetes
• Removing any removable prosthesis at night and renewing them periodically are essential for preventing denture-induced stomatitis

Diabetic Patients in Dental Care

General Considerations

• Oral findings can be an initial manifestation of undiagnosed diabetes
• Periodontal disease is the most common oral finding, involving vascular changes, neutrophil dysfunction, and collagen metabolism deficiencies
• Diabetes susceptibility to bacterial and fungal infections, including odontogenic abscesses and oral candidiasis
• Xerostomia can favor the onset of caries
• Chronic bilateral and asymptomatic inflammation of the parotid glands (sialosis) can develop as a compensatory mechanism
• Burning mouth syndrome, circumoral paraesthesia, glossitis, loss of filiform papillae, and dysgeusia can occur
• High prevalence of oral lichen planus, mucosal lichenoid reactions, and facial flushing as secondary effects of antidiabetic drugs
• Delayed tooth eruption is common

Dental Management

• Dental treatment plan is determined by the patient's previous oral health and degree of metabolic control
• Dental team should know how to manage hypoglycemic events in the dental clinic

Clinical Presentation of Diabetes

• Classic symptoms of undiagnosed type 1 diabetes: polyuria, polydipsia, polyphagia, fatigue, infections, slow wound healing, blurred vision, and weight loss

Hypoglycaemia

• Early signs/symptoms: shakiness, dizziness, sweating, hunger, piloerection, tachycardia, inability to concentrate, confusion, irritability, anxiety, headache
• Later signs/symptoms: clumsiness, jerky movements, muscle weakness, difficulty speaking, blurry or double vision, drowsiness, convulsions, unconsciousness, death

Hyperglycaemia

• Early signs/symptoms: frequent urination, increased thirst, blurred vision, fatigue, headache
• Later signs/symptoms: fruity-smelling breath, nausea, vomiting, shortness of breath, weakness, confusion, abdominal pain, coma

Risk Assessment

• Hypoglycaemia is the main risk and must be managed urgently
• Hyperglycaemia, fatigue, reduced tolerance for long treatment, increased risk of infection, poor wound healing, and increased risk of periodontal disease are also risks

Criteria for Referral

• If HbA1c levels are ≥9%, only emergency treatments should be conducted and surgical procedures should preferably be undertaken in a hospital setting
• If HbA1c readings >12%, all procedures should be postponed until glycaemic control has improved

Access/Positioning

• Schedule sessions in the morning to minimize risk of hypoglycaemia
• Avoid scheduling appointments during maximum insulin activity peak or when a meal may be missed

Communication

• Patients may be unaware of their diabetes diagnosis
• Patients with signs/symptoms or oral findings suggestive of diabetes should be referred to their doctor for investigation
• Impaired communication may occur due to uncontrolled blood glucose levels (slurred speech, confusion)

Consent/Capacity

• Patients should be informed that the dental treatment plan and its success will be determined by the degree of diabetic control
• Patients should be warned of potential local and systemic complications resulting from diabetes
• If diabetic control is poor, the patient may be confused, anxious, and/or agitated, reducing their capacity to give consent

Anaesthesia/Sedation

• Local anaesthesia: follow routine precautions
• Sedation: control patient's stress, and consider hospital setting for patients with poor metabolic control and comorbidities
• General anaesthesia: determined by the severity of comorbidities

Dental Treatment

• Before: confirm patient has eaten normally, taken scheduled medication, and consider antibiotic prophylaxis
• During: dental implants can be placed successfully in patients with well-controlled diabetes, but hypoglycaemia is a main complication
• After: slow healing of the surgical wound is common, and consider postoperative antibiotics, especially for patients with poor disease control

Drug Prescription

• Antibiotic of choice: amoxicillin
• Avoid metronidazole, azithromycin, ciprofloxacin, aspirin, ibuprofen, diclofenac, naproxen, and corticosteroids due to interactions with oral hypoglycaemic agents
• Analgesic of choice: paracetamol