This document provides information on diabetes mellitus and its relevance to dental care. It defines diabetes, describes the different types, and lists common signs and symptoms. It also discusses diabetes complications, diagnosis, treatment planning for dental procedures, oral manifestations of diabetes, and dental management considerations. The goal is to educate dentists on properly treating and managing diabetic patients.

1. Insulin
Classification
Clinical Signs And Symptoms
Diabetes Complications
Diabetes Diagnosis In Dental Office
Treatment Plan For Minor Oral Procedures
Insulin Shock
Dentist’s Instruction Prior To Dental Visit
In Case Of Acute Infection
Oral Manifestations Of Diabetes
Dental Management
INSULIN
Glucose level in blood is increased after food intake.
Insulin is released from beta cells in pancreas and re-
leased into the blood. This hormone bind to specific
receptors in body cells and help absorption of glucose
into these cells, which then, glucose level in blood nor-
malize.
However diabetic patient have problem in secreting in-
sulin, or there is cellular resistance to insulin or both.
This lead to high blood glucose level that lead to many
symptoms and complications.
CLASSIFICATION
Diabetic patient can be classified into:
• Type 1 (less common - 10% - usually younger than
30 yrs): beta cells in pancreas are destroyed and
there is no insulin secretion.
• Type 2 (most common - 90% -usually obese and
older): There is partial insulin deficiency and cel-
lular insulin resistance.
• Gestational: which occur in 5-7% of all pregnan-
cies and results in loss of fetus. In case of surviving
fetuses, they usually overweight. When pregnancy
over, mother glycemic control return to normal but
these women are at risk of developing diabetes in
the next 5-10 years.
• Other specific types: include more than 56 disease
that cause destruction of beta cells such as genetic,
inflammation, cancer, surgery, endocrine condi-
tions such as hyperpituitarism, hyperthyroidism, or
could be drug-induced.
CLINICAL SIGNS AND SYMPTOMS
• Patient with type 1 diabetes: the onset of symp-
toms is sudden and acute. Patient usually non-
obese child or young adult younger than 40 years
old, but could occur at any age. Signs and symp-
toms include: polydipsia, polyuria, polyphagia,
weight loss, loss of strength, marked irritability,
recurrence of bed wetting drowsiness, malaise, and
blurred vision.
Patient also may develop ketoacidosis which charac-
terized by symptoms of vimitting, abdominal pain,
nausea, tachypnea, paralysis and loss of consciousness.
• Patient with type 2 diabetes: usually affect obese
individuals older than 40 years old. Symptoms usu-
ally develop gradually and less common. Symp-
toms include: polydipsia, polyuria, polyphagia,
weight loss, loss of strength.
Dental Management of Diabetes mellitus
Osama Asadi, B.D.S, Published for Savant Dentist Blog
Diabetes mellitus characterized by high blood glucose level and inability to produce/use insulin. More than
240 million person in the world have diabetes mellitus. It’s one of the leading cause of death in United State.
Dentist should recognize diabetic patient by history, clinical signs and symptoms and laboratory tests and
refer it to physician when needed.
LECTURE OUTLINE
CHAPTER
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2. Other symptoms related to complications of diabetes type 1 and 2 includes: skin lesions, cataracts, blindness,
hypertension, chest pain, and anemia
Feature Type 1 Type 2
Frequency 5-10% 90-95%
age Of Onset 15 yrs 40 yrs and over
body Build Normal or thin obese
severity severe mild
insulin Requirement Almost all patients 25-30% of patients
ketoacidosis common uncommon
rate Of Clinical Onset rapid slow
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DIABETES COMPLICATIONS
Generally, Patient with poorly controlled or
uncontrolled diabetes mellitus is at risk of:
• Infection
• Poor wound healing
Complications of diabetes includes:
• Metabolic distrubances: (ketoacidosis)
• Cardiac: atherosclerosis, hypertension, conges-
tive heart failure, and myocardial infarction.
• Eyes: retinopathy, cataracts and blindness.
• Kidney: nephropathy and renal failure.
• Limbs: ulceration and gangrene of feet, which
lead to foot amputation.
• Neuropathies: dysphagia, gastric distention,
diarrhea, sexual impotence, muscle weakness
and cramp, numbness, burning pain.
Diabetes mellitus (DM) is the seventh leading
cause of death in US, mostly due to cardiovascular
complications associated with it.
DIABETES DIAGNOSIS IN DENTAL
OFFICE
Most common type of diabetes is type 2. Dentist
should be able to recognize diabetic symptoms
and interpret screening tests. However, referral to
physician for definitive diagnosis and treatment is
important.
Patient is diagnosed with diabetes when one of
these tests is confirmed:
• Fasting blood glucose level ≥ 126 mg/dL
• Random blood glucose + (symptoms) ≥ 200
mg/dL
• Oral glucose tolerance test ≥ 200 mg/dL
• HbA1C ≥ 6.5%
TREATMENT PLAN FOR MINOR ORAL
PROCEDURES
• Patient with uncontrolled or poorly controlled dia-
betes should be send to physician for treatment.
• Patient with controlled type 1 diabetes: in case
of non-invasive dental procedure, patients can be
treated just like non-diabetic patients, however, be
aware of patient’s susceptibility to infection and
poor wound healing.
In invasive dental procedure: after consultation with
patient physician, blood glucose level is taken. If it is
between 70-200 mg/dL then dental procedure can be
done. If it is ≥ 200 mg/dL, then elective dental proce-
dure should be deferred until glucose level normalize.
• Patient with controlled type 2 diabetes: No treat-
ment modification required. Be cautious of pa-
tient’s susceptibility to infection and impaired
wound healing.
For diabetes type 1 and 2, major surgical procedure
with general anesthesia require special management
other than what described above.
These guidelines are for diabetic patient who suffers
only from diabetes mellitus without any other compli-
cations. Medically compromised diabetic patient who
suffer from diabetic complications (such as hyperten-
sion, renal impairment, etc..) require special attention
and treatment plan modification.

3. INSULIN SHOCK
When patient take their insulin and do not eat, this re-
sults in hypoglycemia that called insulin shock. It also
occur when they eat but take insulin overdose, or oral
hypoglycemic medication overdose.
The initial signs and symptoms include: hunger, weak-
ness, trembling, tachycardia, pallor, and sweating. If
left undetected it can lead to sever symptoms (hypoten-
sion, hypothermia, tonic clonic movements) and loss of
consciousness.
Dentist should instruct the patient to take their usual
meal and insulin injection before coming to the clinic.
Morning appointment is preferred.
DENTIST’S INSTRUCTION PRIOR TO
DENTAL VISIT
• Patient should eat normal meals before appoint-
ment and take their medication.
• Take a morning appointment
• Have their medication and glucose (juice, non-diet
cola, etc..) available at dental visit.
• Inform the dentist about any insulin reaction when
they first occur.
After dental appointment, patient should keep his eat-
ing routine and medications. They should keep good
oral hygiene and restrict to dentist’s instruction to pre-
vent infection and impaired wound healing, dry socket,
and osteomylitis from happening.
IN CASE OF ACUTE INFECTION
Antibiotic prophylaxis for patient after dental proce-
dure is not required unless patient suffer from infection
and/or systemic symptoms of infection (lymphadenop-
athy, fever).
In case of patient with infection, patient’s insulin dos-
age should be altered with consultation, and infection
is treated locally.
Insulin dosage guidelines
• Oral hypoglycemic-controlled patients: may re-
quire insulin, consult with physician.
• Insulin-controlled patient: may need increased in-
sulin dosage, consult with physician.
• Patient with brittle diabetes (fluctuating, too high
and too low) and patient receiving high dose of in-
sulin: culture is taken from infected area for antibi-
otic sensitivity test. Culture is sent to testing, and
antibiotic therapy is initiated with penicillin or its
alternatives in case of allergies. If patient condi-
tion did not response to medication, antibiotic is
selected from test result and therapy is initiated.
In all cases, infection should be treated locally with:
• Warm intraoral rinses
• Incision and drainage
• Pulpotomy, endodontics, or extraction
• And antibiotic
ORAL MANIFESTATIONS OF DIABETES
Patient with uncontrolled diabetes mellitus may suffer
from:
• Xerostomia
• Poor wound healing
• infection
• Oral ulceration and lesions
• candidiasis
• Burning pain in the mouth
• Periapical abscess
• caries
These are due to excessive loss of tissue fluid, altered
response to infection, microvascular changes, and in-
creased glucose level in saliva.
Patient with diabetes has increased inflammatory re-
sponse, reduced wound healing, and microvasculature
changes which contribute to:
• Periodontal diseases
• Gingival diseases and proliferation
• Periodontal abscess
DENTAL MANAGEMENT
Follow what have been discussed earlier regarding
management and treatment planning for such patient.
• Analgesia: avoid aspirin and NSAIDs in patient
taking sulfonylureas, because it can worsen the hy-
poglycemia
• Antibiotics: antibiotic prophylaxis is not required
unless there is an infection or brittle diabetes.
• Anesthesia: usual dose. However, in patient with
cardiac symptoms, limit dose to 2 cartridge con-
taining 1:100,000 epinephrine.
• Blood pressure: monitor blood pressure, because
diabetes is associated with hypertension.
REFERENCE
Little and Falace’s Management of Medically
Compromised Patients, 8th Edition.
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