1: Patient with Diabetes

Case 1
Patient with Diabetes

Medical History

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.

Dental History

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.

Social History

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.

Dental Examination

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).

Image described by caption and surrounding text.

Figure 10.1.1: Periapical radiographic series showing generalized moderate horizontal bone loss, with localized severe vertical bone loss on tooth #22.

Treatment Plan

  • 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.

Diagram displaying 2 upward arrow for A1C (left) and FPG (right) having 3 segments for normal, prediabetes, and diabetes with values of < 5.7% and < 100 mg/dl, ≥ 5.7% and ≥ 100 mg/dl, and ≥ 6.5% and ≥ 126 mg/dl, respectively.

Figure 10.1.2: A1C and fasting plasma glucose normal values.

A table displaying values under columns for test score and fasting blood sugar (mg/dL), with 1st–6th rows for action suggested, 7th–8th rows for good, and 9th–11th rows for excellent. A two-headed arrow is at the left.

Figure 10.1.3: The A1c test score (%) on left as compared to the fasting blood sugar (mg/dl).

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.

Class Side Effect
Coreg Beta blocker Orthostatic hypotension
Diovan Angiotensin II Receptor Blocker (ARB) Orthostatic hypotension

Table 10.1.3: Common antidiabetic medications.

Short‐acting insulin

  • regular insulin (Humulin and Novolin)

Rapid‐acting insulins

  • insulin aspart (NovoLog, FlexPen)
  • insulin glulisine (Apidra)
  • insulin lispro (Humalog)

Intermediate‐acting insulin

  • insulin isophane (Humulin N, Novolin N)

Long‐acting insulins

  • insulin degludec (Tresiba)
  • insulin detemir (Levemir)
  • insulin glargine (Lantus)
  • insulin glargine (Toujeo)

Combination insulins

  • NovoLog Mix 70/30 (insulin aspart protamine‐insulin aspart)
  • Humalog Mix 75/25 (insulin lispro protamine‐insulin lispro)
  • Humalog Mix 50/50 (insulin lispro protamine‐insulin lispro)
  • Humulin 70/30 (human insulin NPH‐human insulin regular)
  • Novolin 70/30 (human insulin NPH‐human insulin regular)
  • Ryzodeg (insulin degludec‐insulin aspart)

Medications for type 2 diabetes
Alpha‐glucosidase inhibitors
These medications help your body break down starchy foods and glucose in the diet resulting in lower blood glucose levels.

  • acarbose (Precose)
  • miglitol (Glyset)

Biguanides decreases glucose production by the liver. They decrease how much sugar your intestines absorb, make your body more sensitive to insulin, and help your muscles absorb glucose. The most common biguanide is metformin (Glucophage, Metformin Hydrochloride ER, Glumetza, Riomet, Fortamet). Metformin can also be combined with other drugs for type 2 diabetes. Hypoglycemia risk is decreased unless combined with other antidiabetic medications.

  • metformin‐alogliptin (Kazano)
  • metformin‐canagliflozin (Invokamet)
  • metformin‐dapagliflozin (Xigduo XR)
  • metformin‐empagliflozin (Synjardy)
  • metformin‐glipizide
  • metformin‐glyburide (Glucovance)
  • metformin‐linagliptin (Jentadueto)
  • metformin‐pioglitazone (Actoplus)
  • metformin‐repaglinide (PrandiMet)
  • metformin‐rosiglitazone (Avandamet)
  • metformin‐saxagliptin (Kombiglyze XR)
  • metformin‐sitagliptin (Janumet)

DPP‐4 inhibitors
DPP‐4 inhibitors help the body continue to make insulin. They work by reducing blood sugar without causing hypoglycemia.

  • alogliptin (Nesina)
  • alogliptin‐metformin (Kazano)
  • alogliptin‐pioglitazone (Oseni)
  • linagliptin (Tradjenta)
  • linagliptin‐empagliflozin (Glyxambi)
  • linagliptin‐metformin (Jentadueto)
  • saxagliptin (Onglyza)
  • saxagliptin‐metformin (Kombiglyze XR)
  • sitagliptin (Januvia)
  • sitagliptin‐metformin (Janumet and Janumet XR)
  • sitagliptin and simvastatin (Juvisync)

Glucagon‐like peptides (incretin mimetics)
These drugs are similar to the natural hormone called incretin. They increase B‐cell growth and how much insulin your body uses. They decrease your appetite and how much glucagon your body uses.

  • albiglutide (Tanzeum)
  • dulaglutide (Trulicity)
  • exenatide (Byetta)
  • exenatide extended‐release (Bydureon)
  • liraglutide (Victoza)

Table 10.1.4: Signs and symptoms of hypoglycemia.

(BLOOD SUGAR < 70 mg dl−1)
  • Sweating/chills/diaphoresis
  • shakiness
  • Nervousness/anxiety
  • Irritability/impatience
  • Rapid heart beat
  • Nausea
  • Headache
  • Weakness
  • Seizure
  • Unconsciousness

Specific Considerations

  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?
  2. The risk of poor wound healing and increased risk of infection is assessed with hemoglobin A1C
  3. The risk of hypoglycemia – be alert for signs and symptoms and be ready to treat hypoglycemia if it occurs.

Take‐Home Hints

  1. It is important to assess the current status of patients diagnosed with diabetes prior to any treatment.
  2. Be well versed in drug side effects and how they impact your patient and how you develop your management plan.

Jul 18, 2020 | Posted by in Dental Hygiene | Comments Off on 1: Patient with Diabetes

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