1. DENTAL CONSIDERATION IN PATIENT
WITH DAIBETES
By :
Payoj Chaudhary
1

2. INTRODUCTION
• Diabetes mellitus is a clinical syndrome characterised by
hyperglycemia caused by absolute or relative deficiency
of insulin.
• characterized by abnormally elevated blood glucose
level and dysregulation of carbohydrate , protein & lipid
metabolism.
2

3. Etiologic classification of Diabetes
Mellitus
Type 1 diabetes mellitus
• Beta cell destruction usually leading to absolute insulin deficiency
• Immune mediated
• Idiopathic
Type 2 diabetes mellitus
• Insulin resistance and relative deficiency
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4. 4

5. Other specific types
• Genetic defects of beta-cell functions
• Decrease of exocrine pancreas
• Endocrinopathies
• Drug or chemical usage
• Infections
5

6. Gestational diabetes mellitus (GDM)
• Defined as any degree of glucose intolerance with onset
or first recognition during pregnancy.
• 4% of pregnancy.
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7. Classical symptoms of DM
Delayed wound healing
Weight loss
weakness
polyuria polydipsia polyphagia
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9. Complications
• People with DM have an increased incidence of both
microvascular and macrovascular complications.
Major organs/systems showing changes Long term complications
Cardiovascular system:
heart, brain, blood vessels
Myocardial infarction; atherosclerosis;
hypertension; microangiopathy; cerebral
vascular infarcts; cerebral hemorrhage
Pancreas Islet cell loss; insulitis (Type 1); amyloid (Type 2)
Kidneys Nephrosclerosis; glomerulosclerosis;
arteriosclerosis; pyelonephritis
Eyes Retinopathy; cataracts; glaucoma
Nervous system Autonomic neuropathy; peripheral neuropathy
Peripherals Peripheral vascular atherosclerosis; infections;
gangrene
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10. Oral manifestations
• Much attention given to heart diseases, kidney diseases, nerve
diseases and eye diseases associated with diabetes.
• Oral complications are often overlooked.
• There is a strong relationship between a person's oral health
and their general health.
• In people with diabetes, the first signs and symptoms of a
medical condition can develop in the mouth.
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11. Oral manifestations
 Oral conditions include
• xerostomia,
• burning sensations,
• overgrowth of gum tissue,
• tooth decay,
• periodontal disease (6th complication)
• fungal infections,
• fruity (acetone) breath,
• increased thickness of saliva and altered taste sensation
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12. XEROSTOMIA
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13. OVERGROWTH OF GUM TISSUE 13

14. TEETH DECAY 14

15. ORAL CANDIDIASIS 15

16. Periodontitis (the 6`th complication
of DM)
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17. Diagnosis
• Random plasma glucose level of 200 mg/dL or greater.
• Fasting plasma glucose level of 126 or greater. (Normal 70-
110 mg/dL)
• Oral glucose tolerance test (OGTT) value in blood of 200 mg or
greater.
• ADA recommend >45 y/o screened every 3 years.
Diabetes Care, 2000
National Institutes of Health, Aug 2001
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18. Glucometer
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19. Monitoring
Laboratory Evaluation of Diabetes Control:
Glycosylated Hemoglobin Assay (Hb A1c)
4 – 6% Normal
<7% Good Diabetes Control
7 – 8% Moderate Diabetes Control
>8% Action suggested to improve
diabetes control
American Diabetes Association Guidelines 19

20. General Management
Considerations
20

21. Medical management
• Objective :
Maintain blood glucose levels as close to
normal as possible
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22. Medical management
 Activity and Exercise
30 minutes of moderate activity on most days of the
week
 Healthy diet:
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24. Insulin
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25. Short acting
Intermediate acting
Long acting
 Analogs
: Regular insulin
: Lente insulin
NPH insulin
: Ultralente
Short acting : Lispro, Aspart
Long acting : Glargine
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26. Dental cosiderations 26

27. Dental management considerations
To minimize the risk of an intraoperative emergency,
clinicians need to consider some issues before initiating
dental treatment.
• Medical history: Take history and assess glycemic control at
initial appointment.
• Glucose levels
• Frequency of hypoglycemic episodes
• Medication, dosage and times.
• Consultation
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28. Dental management considerations
Scheduling of visits
• Morning appointment
• Do not coincide with peak activity.
Diet
• Ensure that the patient has eaten normally and taken medications
as usual.
Prophylactic antibiotics
• Established infection
• Pre-operation contamination wound
• Major surgery
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29. Dental management considerations
Blood glucose monitoring
• Measured before beginning. (˃70 mg/dL)
During treatment
• The most complication of DM occur is hypoglycemia episode.
• Hyperglycemia
After treatment
• Infection control
• Dietary intake
• Medications : salicylates increase insulin secretion and sensitivity
avoid aspirin.
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30. Known diabetic patients
• Inquire about the medication, the type, severity and control of
diabetes, the physician treating the patient and the date of last
visit
• The dentist should be aware of the patient’s recent glycated
hemoglobin values.
• HbA1c values of less than 8% indicate relatively good
glycemic control; greater than 10% indicate poor control
• When the level of control of diabetes is not known, consult
patients physician and the treatment should be just limited to
palliation
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31. Known diabetic patients
• In patients with good glycemic control before starting any
procedure, verify that the patient has taken medication and
diet as usual
• Patients, receiving good medical management without serious
complications such as renal disease, hypertension, or coronary
atherosclerotic heart disease, can receive any indicated dental
treatment
• Local anesthesia is preferred, but such patients can even be
safely treated in general anesthesia
• Morning appointments should be preferred because this is the
time of high glucose and low insulin activity
• This reduces the risk of hypoglycemic episodes during the
dental procedures 31

32. Known diabetic patients
• Appointments should be of short duration
• a source of glucose such as an orange juice must be
available in the dental office to avoid hypoglycemic
attacks
• Prophylactic antibiotics for patients taking high doses of
insulin to prevent post-operative infection are
recommended
• It's best to do surgery when blood sugar levels are within
normal range
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33. Known diabetic patients
To avoid hyperglycemia use anxiety reduction
protocol
Emotional stresses and painful conditions
increase the amount of cortisol and epinephrine
secretion which induce hyperglycemia so
• pre-treatment anxiety should be reduced by sedation
• pain during procedures can be avoided by a potent
anesthesia
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34. Management of Diabetic emergency
• If the dental needs are urgent and blood sugar is poorly
controlled, treatment should be provided in a hospital or
other setting where more medical professionals can
monitor patient
• The most common diabetic emergency which a dentist
encounters is hypoglycemia
• it can lead to life-threatening consequences
• it occurs when the concentration of blood glucose drops
below 60 mg/dL
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35. Management of Insulin Shock
 Insulin shock is a hypoglycemic reaction to over dosage
of insulin, a skipped meal, a strenous exercise by an
insulin dependent diabetic( type I).
Features
• confusion, sweating, tremors, agitation,
• anxiety, dizziness, tingling or numbness, tachycardia.
• Severe hypoglycemia may result in seizures or
loss of consciousness , convulsions and coma.
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36. Management of Insulin Shock
• As soon as such signs or symptoms are present the dentist
should check the blood glucose with a glucometer.
• Establish adequate airway, breathing & circulation by
loosening dress near the neck, switching on the fan/air
conditioners
• place the patient in the head-low-feet-up position
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37. Management of Insulin Shock
If patient is conscious and able to take food by
mouth, give 15g of oral carbohydrate in one of
the following forms;
• 4-6 ounce fruit juice or soda,
• 3-4 teaspoon sugar,
• a hard candy.
• Small amount of honey/sweet syrup can also be placed in
the buccal fold
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38. Management of Insulin Shock
• In unconscious patients, give 50ml of dextrose in 50%
concentration or 1mg glucagon intravenously, or give
1ml glucagon intramuscularly at almost any body site.
• Following treatment, the signs and symptoms of
hypoglycemia should resolve in 10 to 15 minutes
• The patient should be observed for 30 to 60 minutes
after recovery.
• Normal blood glucose level is confirmed by a
glucometer before the patient is allowed to leave
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40. As soon as such signs or symptoms are present the dentist
should check the blood glucose with a glucometer,, the
“Golden Rule” is that manage the patients as if they are
hypoglycemic until proven otherwise
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41. Hyperglycemia
Clinical symptoms
• thirst, increased urine output and dehydration.
• progressive reduction in conscious level and
hypotension, with coma and cessation of urine output
in severe cases.
Management
• Primary assessment and resuscitation securing the
airway, breathing and circulation.
• Transport to a hospital facility.
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42. Post-operative Period
Eating the right diet is a critical part of diabetes therapy,
If the patient is expected to have difficulty in eating solid
food after dental procedure;
Diet should be modified to soft solids or liquids
Even the use of blender to blend food before eating is
recommended
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43. Post-operative Period
 Consult the patient’s physician for post-operative period
diet plan
It is necessary that the total caloric content and
proteins/carbohydrates/fats ratio of the diet remain same
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44. Instructions to be given to a diabetic
diabetic patients should be strongly motivated to
maintain a good oral hygiene by
• brushing after every meal
• using floss daily
• keeping their dentures clean
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45. Instructions to be given to a diabetic
patients should be frequently recalled for
• dental examinations
• prophylactic measures, such as topical fluorides should
be applied
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46. Instructions to be given to a diabetic
 Cavities should be treated as quickly as possible.
 The dryness of mouth can be relieved by providing
salivary substitutes or
 Asking the patient to suck sugar-free candy or gums and
frequently drink water
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47. Instructions to be given to a diabetic
Because their good oral health can help in maintaining
good glycemic control,
They should be taught that if there is a problem like a
bleeding, swollen or tender gums, continuous bad taste or
white patches,
 They should immediately contact a dentist
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48. Instructions to be given to a diabetic
The patients should be encouraged to quit
smokingas it greatly increases the
risk of periodontal disease in diabetic
patients
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49. Instructions to be given to a diabetic
Diabetics should be informed that they are more likely to
catch dental diseases than the normal ones.
Awareness and knowledge increases the tendency to seek
preventive dental care, and
 Improves chances of maintaining healthy mouth.
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50. Conclusion
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51. MCQ
• 1)TYPE 1 DM is associated with
a)insulin resistance
b)defect in mitochondrial DNA
c)islet cell auto Antibodies
d)beta cell dysfunction

52. • 2)glycosylated haemoglobin assay(hbA1c)level of
4%_6% indicates
a)normal value
b)good diabetes control
c)moderate diabetes control
d)poor diabetes control

53. • 3)Enzyme deficient in diabetes mellitus is
a)glucokinase
b)hexokinase
c)phosphorylase
d)pyrophosphate dehydrogenase

54. • 4)oral hypoglycemic, which should be stopped prior to
surgery under GA
a)pioglitazone
b)gliclazide
c)metformin
d)glibenclamide

55. • 5)An individual has a fasting blood glucose concentration
of 115 mg/dl on three occasion,what is your conclusion?
a)he is normal
b)he is diabetic
c)he has impaired glucose tolerance
d)he needs further evaluation by other boichemical tests.

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