A 63-year-old man with 15-year history of type 2 diabetes is scheduled for removal of two third molar teeth.

Medical history

Based on discussions with the patient’s physician, his metabolic control is good, with an HbA1c of 6.9%. Current medications for diabetes mellitus are metformin (1,000 mg in the morning, 500 mg in the evening) and pioglitazone (15 mg qd).

Other medications include a statin (lovastatin 20 mg qd) and an ACE inhibitor (enalapril 5 mg qd) for mild hypertension.

Dental history and history of the current problem

The patient demonstrates excellent oral hygiene, has minimal caries experience, and has mild gingivitis with a few areas of limited attachment loss. The two third molars on the left side (#16 and 17) have been affected by pericoronitis (interproximal to #15/16 and #17/18). The patient is often uncomfortable, abscesses occur intermittently, and there is concern for loss of bone on the distal surfaces of the second molar teeth. The two third molar teeth are not impacted but have a slight mesial inclination. Extraction is recommended.

Treatment

A large number of oral medications are used to treat type 2 diabetes mellitus, and these are associated with different levels of risk of hypoglycemia (Table 1).

The most important question here is which oral agents is the patient using. There are two classes of currently used oral agents that are associated with an increased risk of hypoglycemia (if a patient takes them without eating). These are the sulfonylureas (examples include glyburide [generic only], glipizide [Glucotrol^®], and glimepiride [Amaryl^®]) and meglitinides (examples include nateglinide [Starlix^®] and repaglinide [Prandin^®]).