This patient gives a history of a diagnosis of diabetes and hypertension five years ago. He states that his blood pressure is well controlled, but his diabetes “goes up and down.” He checks his blood sugar at home three times/week and sees the numbers >225 on a regular basis. His last visit to his physician was two months ago for examination and blood work.
- Vital signs:
- Blood pressure: 130/79 mmHg
- Pulse: 83 beats/min
- Height: 5′ 10”
- Weight: 250 lbs
- BMI: 35.9
- Medications: Glucophage® (metformin), Victoza® (luraglutide), Coreg® (carvedilol), Diovan® (valsartan), and fish oil.
Patient has not had a dental exam or prophylaxis in five years. He brushes once daily with a soft toothbrush. He tells you that his last dental office had recommended scaling and root planing but he did not follow through with treatment. He tells you he has a feeling of “bad breath” and a “bad taste” in his mouth.
He currently smokes half a pack of cigarettes/day but used to smoke two packs per day. He rarely drinks alcohol and used marijuana in his teens and 20s.
The intra and extraoral soft tissue exam was unremarkable. The patient is missing teeth #s 2,3,14, 18, 19, and 30. No caries visible radiographically or clinically. Probing depths vary from 3 to 5 mm with localized pocketing of 4–6 mm and attachment loss in the lower anterior teeth. In addition, there is 50% bleeding on probing and calculus is visible radiographically as well as clinically.
Radiographic examination revealed the presence of generalized moderate horizontal bone loss, with localized severe vertical bone loss on tooth #22 (Figure 10.1.1).
- Oral hygiene instructions to reduce plaque, bleeding on probing, and sensitivity.
- Initial scaling and root planing to eliminate calculus and reduce periodontal pockets.
- Further assessment after six weeks as to the results of scaling and root planing and assessment as to overall prognosis of teeth – extraction(s), periodontal surgery, assessment for prosthetics.
Medical Considerations: Diabetes
Diabetes is caused by the lack of insulin production or decrease or inability of tissue to respond to insulin. It is divided into three categories: Type 1 (body doesn’t make enough insulin) and can develop at any age; Type 2 (body doesn’t use insulin properly); and gestational diabetes (diabetes that develops during pregnancy). According to the Center for Disease Control and Prevention (CDC), as of 2012, 29.1 million people in the United States have been diagnosed with diabetes and one‐quarter are unaware they have the disease. Periodontal disease is more common in diabetics with about one‐third having severe periodontal disease with loss of attachment >5 mm. These patients are also at risk of other systemic issues such as heart disease, stroke, hypo/hyperglycemia, renal disease, and blindness. An increased risk of postoperative infection and poor wound healing are also concerns. Undiagnosed or poorly controlled diabetics may have complaint of polydipsia (excessive thirst), polyuria (excessive urination), and polyphagia (excessive hunger). Keep in mind that not all diabetics have periodontal disease, despite how controlled or uncontrolled they are.
How do we as oral health professionals assess the control of our patients who are diagnosed with diabetes, as well as the undiagnosed diabetic? The “Gold Standard” is the hemoglobin A1c (HbA1c) blood test. This test assesses the average blood glucose for the past three months. Patients are diagnosed as normal, prediabetic, and diabetic (Figure 10.1.2). Diabetics with A1c results of seven or less are considered well controlled. As the A1c increases, the patient is considered less controlled. A1c results >9 (Figure 10.1.3) are indicative of a patient who is poorly controlled. In the dental setting, oral complications may include poor wound healing, post‐operative bacterial infections and fungal infections.
Fasting plasma glucose (FPG) or fasting blood sugar (FBS) is another means of assessment although not as accurate for assessing overall control as the hemoglobin A1c (Figure 10.1.2). Patients can perform this test at home. Normal FBS should be less than 100. As these numbers climb, so does the hemoglobin A1c. FBS levels that are consistently >200–250 result in a hemoglobin A1c > 9.
Treatment for well‐controlled diabetics without comorbidities or serious complications (e.g., hypertension, renal disease) should not be altered. For those patients with diabetes who have serious complications, treatment may need to be altered after consultation with a physician. The decision regarding nonemergency surgical procedures for patients whose diabetes is poorly controlled should be assessed on a case‐by‐case basis. Recommendations may include scaling and root planing and extractions. Consideration should also be given to patient’s ability to eat following surgery and as to whether their medication dose needs altering, especially insulin. It is the responsibility of the oral health‐care provider to collect a thorough medical history, carry out appropriate bloodwork and, if warranted, have a conversation with the primary care provider to assess the patient’s health status. (Little et al. 2013)
The dental health professional must consider precautions for this patient as they are on two medications (Table 10.1.1 and Table 10.1.2) that have the potential of causing orthostatic hypotension as a side effect. During procedures where the patient is reclined for a long period of time, even for a simple prophylaxis visit, the chair should be raised slowly to minimize the risk of syncope (fainting). It is important to keep in mind that all antidiabetic medications do not cause hypoglycemia and those that do cause it to differing degrees (Table 10.1.3). The dental professional should always be prepared to treat a hypoglycemic event (Table 10.1.4) by maintaining a glucose source handy. Some examples of these sources are glucose tablets and icing.
Table 10.1.1: Oral health concerns as they relate to risks and etiology.
|Problems||Related to Risks and Etiology|
|Periodontal disease||Poor oral hygiene, poorly controlled diabetes|
|Taste disorder||Side effects of metformin|
|Orthostatic hypotension||Side effects of antihypertensive medication|
|Increased risk of postoperative infection and poor wound healing||Poorly controlled diabetes|
|Hypoglycemic Event||Side effect of antidiabetic medications|
|Increased risk of periodontal disease||Generalized heavy biofilm, slight supra, and subgingival calculus with bleeding upon probing in select anterior and posterior sites|
Table 10.1.2: Medical management considerations: antihypertensive medications.
|Coreg||Beta blocker||Orthostatic hypotension|
|Diovan||Angiotensin II Receptor Blocker (ARB)||Orthostatic hypotension|
Table 10.1.3: Common antidiabetic medications.
Medications for type 2 diabetes
Glucagon‐like peptides (incretin mimetics)
Table 10.1.4: Signs and symptoms of hypoglycemia.
|SIGNS AND SYMPTOMS OF HYPOGLYCEMIA
(BLOOD SUGAR < 70 mg dl−1)
- Proper assessment of the diabetic patient includes the following questions:
- Did you take your medication today?
- When did you last eat?
- Do you check your blood sugar at home? If so, how often and do you ever see numbers >200.
- When was your last visit to the doctor and your last A1c? Do you know the results of that test?
- The risk of poor wound healing and increased risk of infection is assessed with hemoglobin A1C
- The risk of hypoglycemia – be alert for signs and symptoms and be ready to treat hypoglycemia if it occurs.
- It is important to assess the current status of patients diagnosed with diabetes prior to any treatment.
- Be well versed in drug side effects and how they impact your patient and how you develop your management plan.