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Jada 2003-vernillo-24 s-33s
1. 24S JADA, Vol. 134, October 2003JA DACONTINUI N G E DUCATION✷✷ARTICLE1JA DACONTINUI N G E DUCATION✷✷Dental considerationsfor the treatment ofpatients with diabetesmellitusANTHONY T. VERNILLO, D.D.S., Ph.D.Diabetes mellitus is a complex and pernicioussyndrome. It is characterized by abnormalitiesin carbohydrate, lipid and protein metabolismthat result either from a profound or an abso-lute deficiency of insulin, related to autoim-mune destruction of the insulin-producing pancreatic betacells (type 1, or insulin-dependent diabetes mellitus), orfrom target-tissue resistance to its cellular metaboliceffects, related commonly to obesity (type 2, ornon–insulin-dependent diabetes mellitus). Type 1 diabetesrepresents no more than 5 percent of primary diabetescases, whereas type 2 represents the remainder of theprimary cases.1There is no definitive cure for diabetes. It is the mostcommon endocrine disorder and affects an estimated 16million people in the United States. Anadditional estimated 6 million peoplehave diabetes but do not know it. Withouta proper diagnosis, these people are atsignificant risk of developing life-threat-ening complications.2These includeincreased susceptibility to infection anddelayed healing; neuropathy, retinopathyand nephropathy (microvascular disease);accelerated atherosclerosis with associ-ated myocardial infarction and coronaryartery disease; stroke; atheroscleroticaneurysms (macrovascular disease); andamputation. Hyperglycemia (elevated blood glucose) is ahallmark of diabetes mellitus—as are its chronicmetabolic complications. These are generally moresevere in the patient with type 1 diabetes mellitus.GLYCEMIC CONTROL REVISITEDBlood glucose or glycemic control is fundamental to themedical management of diabetes; prolonged and severeDentists canreduce themorbidity andmortalityassociated withdiabetes bymaintainingtheir patients’oral health.Background. Dentists play a major roleas part of an allied healthteam in providing oral careto patients with diabetes.As such, they maydetect undiagnosedcases of diabetes andrefer patients to physi-cians for further evaluation.Methods. The author describes new con-cepts in metabolic control for diabetes andthe relationship of oral complications to dia-betes mellitus. The treatment of acute oralinfections and the dentist’s role in sup-porting patients in smoking-cessation pro-grams are approaches that may reducemorbidity from diabetes mellitus. In consul-tation with the patient’s physician, the den-tist may need to modify the treatment planwhere systemic complications are present.Results. Working with the physician,nutritionist and dental hygienist, the dentistcan maintain the patient’s oral health andpossibly improve the patient’s metabolic con-trol of diabetes. In consultation with thepatient’s physician, the dentist can discussthe indications and contraindications of med-ications for the treatment of oral complica-tions in patients with systemic complicationsresulting from diabetes. Using a glucometermay avert emergencies related to diabetes.Conclusions. The dental team canimprove the metabolic control of a patient’sdiabetes by maintaining optimal oralhealth. The dentist also can reduce comor-bidity factors by supporting patients intobacco-use cessation programs.Clinical Implications. Dentists canreduce the morbidity and mortality associ-ated with diabetes by maintaining theirpatients’ oral health and by referringpatients with signs and symptoms of oralcomplications suggestive of diabetes tophysicians for further evaluation.hyperglycemia is associated with sys-temic and oral complications. Thus, amanagement plan is needed. This planshould be formulated as an individual-ized therapeutic alliance among thepatient and family, the physician andother members of the health care team,A B S T R A C TJA DACONTINUI N G E DUCATION✷✷ARTICLE2Copyright ©2003 American Dental Association. All rights reserved.
JADA, Vol. 134, October 2003 25Sincluding the family dentist and dental hygienist,and the nutritionist. In developing the plan, theteam should consider several patient aspects:dage;dschool or work schedule and conditions;dphysical activity;dmedications (insulin or oral hypoglycemicagents);ddiet and eating patterns;dsocial situation and personality;dcultural factors;dthe presence of complications (systemic and/ororal) of diabetes;dany other medical conditions.The glycosylated hemoglobin, or HbA1c, test isused widely to assess glycemic control over athree- to four-month period. Prospective random-ized clinical trials have shown that achievingglycemic control, through percentage reductionsin the HbA1c, is associated with decreased ratesof microvascular disease. Furthermore, epidemio-logic studies support the potential of intensiveglycemic control in the reduction of macrovas-cular disease.3-7The goal of medical management is to targetHbA1c values to less than 7.0 percent, or lessthan 150 milligrams/deciliter of blood glucose onaverage, every three to six months; if greaterthan 8.0 percent, then action is recommended.However, it has been shown that other features ofglucose control not reflected in the HbA1c mightadd to or modify the risk of complications. Forexample, recent clinical data demonstrate thatthe risk and severity of complications may beeven more highly dependent on the extent of one-to two-hour postprandial (after meal) hyper-glycemic spikes of blood glucose.8,9Acute hyper-glycemia after meals is associated with increasedfree-radical production that can lead to tissue tox-icity and damage, and, ultimately, may be associ-ated with renal failure. Acute hyperglycemicspikes (or excursions) after a two-hour postloadare associated with an increased risk of death,independent of fasting blood glucose. The risk ofmicrovascular disease increases with the progres-sion in postprandial glucose levels from 180 to260 mg/dL.10Thus, tight control in current med-ical therapy now includes a shift to a new focus:constant, daily self-monitoring of blood glucosewith a glucometer, four to six times per day, andoften before and after meals to target postpran-dial levels and to minimize the occurrence ofacute hyperglycemia and acute tissue toxicity.Glucometers are relatively inexpensive andprovide a rapid (five- to 30-second) and accuratedetermination of blood glucose in a small volume(1 microliter) of blood obtained with a sterilelancet from the fingertip. Except possibly for thepatient who has the classic symptoms of diabetes,with glucose and acetone in the urine, most physi-cians depend on blood chemistry values, not onlyto establish the diagnosis of diabetes but also tomanage it. Furthermore, monitoring glucose inurine is no longer a current practice amongpatients with diabetes; this is because cases havebeen reported with blood glucose levels of 300 to400 mg/dL without any evidence of urinary glu-cose.1However, patients may test urine for ace-tone (that is, ketones) with diagnostic test stripsduring periods when metabolic control is notattained.Walking a “metabolic tightrope” of rigorouscontrol involves risk: patients with diabetes, par-ticularly those with type 1 diabetes who use mul-tiple daily insulin injections or an insulin pump,may fall into profound hypoglycemia or low bloodsugar (insulin shock), which may lead to life-threatening diabetic ketoacidosis.ORAL COMPLICATIONS OF DIABETESThe oral complications of uncontrolled diabetesmellitus are devastating. These may include, butare not necessarily limited to, gingivitis and peri-odontal disease; xerostomia and salivary glanddysfunction; increased susceptibility to bacterial,viral and fungal (that is, oral candidiasis) infec-tions; caries; periapical abscesses; loss of teeth;impaired ability to wear dental prostheses(related in part to salivary dysfunction); tasteimpairment; lichen planus; and burning mouthsyndrome.11Gingivitis and periodontal disease. Thesusceptibility to periodontal disease—often calledthe “sixth complication of diabetes mellitus”12—isthe most common oral complication of diabetes.The patient with poorly controlled diabetes is atgreater risk of developing periodontal disease. Itstarts with gingivitis and then, with poorglycemic control, progresses to advanced peri-odontal disease. Children with diabetes andadults with less-than-optimal metabolic controlshow a tendency toward higher gingivitisscores.13-15In one study, the prevalence of peri-odontal disease was 9.8 percent in 263 patientswith type 1 diabetes, compared with 1.7 percentin people without diabetes.16Several studies haveCopyright ©2003 American Dental Association. All rights reserved.
demonstrated that patients with type 1 diabetesand chronic, marginal metabolic control of thedisease have more extensive and severe peri-odontal disease than do patients who maintainrigorous control of their diabetes. Patients withtype 1 diabetes and retinopathy tend to exhibitmore loss of periodontal attachment by the fourthand fifth decades of life.17Thus, good oral hygieneand frequent checkups with the dentist areextremely important for the patient with type 1diabetes.Fewer studies have been conducted on patientswith type 2 diabetes and periodontal disease. Ithas been shown that patients with type 2 dia-betes are three times more likely to develop peri-odontal disease than are people without dia-betes.18In a study of Pima Indians (40 percent ofwhom have type 2 diabetes), peopleyounger than 40 years of age hadincreased attachment loss com-pared with Pima Indians who didnot have diabetes, as well as alve-olar bone loss that was associatedwith increased glucose intoleranceor poor metabolic control.19In thissame study, periodontal tissuedestruction increased with age andwas higher in people with diabetescompared with people without thedisease in all age groups.19The lossof teeth was also 15 times higher inPima Indians with diabetes than inPima Indians without diabetes.19Other studies have assessedtooth loss and edentulism in peoplewith type 1 diabetes.20When peoplewith diabetes smoke, they are 20times more likely to develop periodontitis withloss of supporting bone than are those withoutdiabetes.18Although primarily related to the presence ofdental plaque, periodontitis appears to be relatedto several pathological events associated with dia-betes,21but the reason for the higher rates of peri-odontal destruction in people with diabetes is notcompletely understood. Studies have shown thatthe microorganisms in the periodontal flora aresimilar in people with diabetes and in thosewithout diabetes. This suggests that differencesin the host response to periodontal pathogens arerelated to the increased tissue destruction in dia-betes.22,23The pathological events in diabetes mayalso include impairment in cell-mediated immu-nity such as neutrophil (polymorphonuclearleukocyte, or PMN) chemotaxis and macrophagefunction24,25and vascular disease. There is alsoevidence that a history of chronic periodontal dis-ease can disrupt control of diabetes, suggestingthat periodontal infections may have systemicrepercussions.26Whereas the exact nature of this complex rela-tionship is not yet clear, it has been shown thatdental infections in patients with diabetes mayexacerbate problems with metabolic control. Fur-thermore, there is evidence that the managementof periodontal infections in the poorly controlledpatient with diabetes may actually help improveglycemic control.27A careful evaluation ofglycemic control, including the patient’s diet,HbA1c and postprandial glucose determinations,is critical in determining the riskassessment for progression to theoral complications, especially peri-odontitis, of diabetes.The oral complications inpatients with uncontrolled diabetesare most likely related to thealtered response to infection,microvascular changes and, pos-sibly, increased glucose concentra-tions in the saliva (salivary hyper-glycemia) and gingival crevicularfluid. Salivary hyperglycemia maybe an important contributory factorto periodontal disease.28Increasedsalivary glucose results in addi-tional bacterial substrate andplaque formation.29Increased gin-gival crevicular fluid glucose maydiminish the ability of periodontalfibroblasts to contribute to periodontal healing.30Thus, preventive periodontal therapy must beincluded in the comprehensive care of the patientwith diabetes. Therapy includes an initial assess-ment of the risk of oral disease progression,explicit oral hygiene instruction, dietary assess-ment and instruction, and frequent periodicdental examinations and prophylaxis.Salivary gland dysfunction and xero-stomia. There are reports of dry mouth com-plaints (xerostomia) and salivary hypofunction inpatients with diabetes,31-33which may be due topolyuria, or an underlying metabolic or endocrineproblem. When the normal environment of theoral cavity is altered because of a decrease in sali-vary flow or alteration in salivary composition, a26S JADA, Vol. 134, October 2003Several studies havedemonstrated thatpatients with type 1diabetes and chronic,marginal metaboliccontrol of the diseasehave more extensiveand severeperiodontal diseasethan do patientswho maintainrigorous control oftheir diabetes.Copyright ©2003 American Dental Association. All rights reserved.
healthy mouth can become susceptible to dentalcaries and tooth deterioration. Dry, atrophic andcracking oral mucosa is the eventual complicationfrom insufficient salivary production. Accompa-nying mucositis, ulcers and desquamation, as wellas an inflamed, depapillated tongue, are alsocommon problems. Difficulty in lubricating, mas-ticating, tasting and swallowing are among themost devastating complications from salivary dys-function and may contribute to impaired nutri-tional intake.An increase in the rate of dental caries hasbeen reported in young patients with diabetesand may relate to salivary dysfunction.34Onestudy showed that patients with diabetes did nothave a higher coronal or root-surface caries ratethan patients without diabetes,independent of glycemic control.35Nonetheless, an association existedbetween older adults with diabetesand active caries and tooth loss; thiswas even more significant inpatients with diabetes having poorglycemic control.35The dentist canoffer topical treatments such asfluoride-containing mouthrinsesand salivarysubstitutes to help prevent cariesand minimize discomfort.Candidiasis. Oral candidiasis is an oppor-tunistic fungal infection commonly associatedwith hyperglycemia and is thus a frequent com-plication of marginally controlled or uncontrolleddiabetes.36, 37Oral lesions associated with candidi-asis include median rhomboid glossitis (centralpapillary atrophy), atrophic glossitis, denturestomatitis, pseudomembraneous candidiasis(thrush) and angular cheilitis. Candida albicansis a constituent of the normal oral microflora thatrarely colonizes and infects the oral mucosawithout predisposing factors. These includeimmunologically compromised conditions (forexample, AIDS, cancer or diabetes), the wearingof dentures in conjunction with poor oral hygieneand the long-term use of broad-spectrum antibi-otics. Salivary dysfunction, compromised immunefunction and salivary hyperglycemia that pro-vides a potential substrate for fungal growth arethe major contributing factors for oral candidiasisin patients with diabetes.Burning mouth syndrome. Patients withburning mouth or burning tongue syndrome usu-ally exhibit no clinically detectable lesions,JADA, Vol. 134, October 2003 27Salthough the symptoms of pain and burning canbe intense. The etiology of burning mouth isvaried and often difficult to decipher clinically.38The symptoms of pain and burning appear to bethe result of one factor, or possibly a combinationof factors.39In uncontrolled or marginally con-trolled diabetes, these etiologic factors caninclude salivary dysfunction, candidiasis andneurological abnormalities such as depression.Autonomic and sensory-motor neuropathies arepart of the diabetes syndrome, and the prevalenceof neuropathy in diabetes mellitus approximates50 percent 25 years after the onset of the disease,with an overall 30 percent rate among adultswith diabetes.40Neuropathy may lead to oralsymptoms of paresthesias and tingling, numb-ness, burning or pain caused bypathological changes involving thenerves in the oral region.1Diabeteshas been associated with oralburning symptoms39,41; however,neuropathy from diabetes is typi-cally associated with pain andburning in other parts of the body,such as the feet.40Of particular significance is thefinding that symptoms of burningmouth or tongue have been foundin undiagnosed cases of type 2 diabetes, most ofwhich also resolved after medical diagnosis andsubsequent treatment directed at improvingglycemic control.42Improvement in glycemic con-trol has a major role in reducing the occurrence ofcomplications such as xerostomia and candidiasis,and these factors may contribute more signifi-cantly to the resolution of the symptoms associ-ated with burning mouth syndrome in the patientwith diabetes.Lichen planus. Lichen planus is a relativelycommon, chronic mucocutaneous disease ofunknown cause. It generally is considered to bean immunologically mediated process thatinvolves a hypersensitivity reaction on the micro-scopic level.39It is characterized by an intense Tlymphocytic infiltrate (CD4+and especially CD8+cells) located at the epithelial–connective tissueinterface. Other immune-regulating cells (forexample, macrophages, dendritic cells, Langer-hans’ cells) are seen in increased numbers inlesions of lichen planus. There appears to be norelationship between lichen planus and eitherhypertension or diabetes mellitus (that is,Grinspan’s syndrome), as previously proposed.39Improvement inglycemic control has amajor role in reducingthe occurrence ofcomplications such asxerostomia andcandidiasis.Copyright ©2003 American Dental Association. All rights reserved.
However, a study of 40 patients with lichenplanus found that 11 patients (28 percent) hadovert or latent diabetes, compared with none inthe control group, implying that diabetes may berelated to the immunopathogenesis of lichenplanus.43Acute oral infections. Representative exam-ples of acute oral infections—such as recurrentbouts of herpes simplex virus, a periodontalabscess or a palatal ulcer—illustrate the severityof these conditions, particularly in marginallycontrolled diabetes. Case reports have been pub-lished on a life-threatening deep neck infectionfrom a periodontal abscess44and on fatal palatalulcers in patients with diabetes.45In the latter,the ulcers were not superficial, but representeddeep granulomatous disease. To what extent suchincidents are part of the broader spectrum ofinfection in people with diabetes has not yet beenestablished. It is possible that the samepathogenic mechanisms associated with theincreased susceptibility to periodontal infections(for example, impaired wound healing, dimin-ished chemotaxis and PMN function) may play arole in the greater likelihood of developing acuteoral infections.Glycemic control in diabetes management isthe key to reducing the impact of acute oralinfections.GENERAL MANAGEMENT CONSIDERATIONSThe dentist plays a major role in referral ofpatients with diabetes to physicians for additionalevaluation.1Any undiagnosed dental patient whohas the cardinal signs and symptoms of diabetes(that is, polydipsia, polyuria, polyphagia, weightloss, weakness), or who presents with an oralmanifestation (for example, xerostomia or can-didiasis), should be referred to a physician fordiagnosis and treatment.With a glucometer, a dentist can test blood glu-cose from a patient’s fingertip. If the result is con-sistent with hyperglycemia, then immediatefollow-up with a physician is indicated. Even ifthe patient were to have a normal glucose levelwith such testing, immediate follow-up with aphysician would still be indicated, particularly ifthe patient had the above signs or symptoms ororal manifestations suggestive of uncontrolled,undiagnosed diabetes.If the physician to whom a dentist has referreda patient subsequently diagnoses the patient withdiabetes mellitus, then the patient may be spared28S JADA, Vol. 134, October 2003from life-threatening complications. However, animportant caveat must be mentioned here: theglucometer is not accepted as a diagnostic deviceand the dentist is not qualified medicolegally tomake a diagnosis.All patients with diagnosed diabetes must beidentified by history. A thorough understandingof their medical treatment—including medica-tions, regimen and the degree of glycemic control,as well as any systemic complications resultingfrom diabetes—then must be methodically estab-lished. In the case of systemic complications fromdiabetes mellitus (for example, hypertension, car-diovascular disease, retinopathy, renal insuffi-ciency or failure), the dentist must consult withthe patient’s physician to discuss any modifica-tions to the dental treatment plan, particularlywhen surgical procedures are anticipated.For example, in the patient with cardiovas-cular disease, monitoring blood pressure isextremely important, as is the possible modifica-tion of anticoagulant drugs (for example, aspirin)before and after surgery. A current recommenda-tion in medical therapy is the use of aspirin (75-325 mg/day) in all adult patients with diabetesand macrovascular disease.46The avoidance ofnephrotoxic drugs in dental management (forexample, acetaminophen in high doses, acyclovir,aspirin, nonsteroidal anti-inflammatory drugs) isrecommended in patients with renal disease, aswell as obtaining a complete blood cell count,monitoring the blood pressure at every appoint-ment, assessing the risk of endarteritis (renaldialysis shunt) or endocarditis, and managing thepatient receiving dialysis who is on heparintherapy.1With respect to surgical procedures, the dentistshould also test the patient’s blood sugar with aglucometer to avert emergency-related eventssuch as insulin shock (profound hypoglycemia) orketoacidosis with severe hyperglycemia before,during or after an invasive procedure. Anypatient with diabetes who is going to receiveextensive periodontal or oral surgery proceduresother than single, simple extractions should begiven dietary instructions after surgery; theseinstructions should be established in concert withthe patient’s physician and nutritionist. It isimportant that the total caloric content and theprotein-carbohydrate:fat ratio of the diet remainthe same so that proper glycemic control of thediabetes is maintained. The patient’s physicianshould be consulted about dietary recommenda-Copyright ©2003 American Dental Association. All rights reserved.
tions and dosage modifica-tions to medications duringthe postoperative phase ofdental treatment. In the caseof an acute oral infection, notonly may antibiotics be indi-cated—particularly in poorlycontrolled diabetes—but alsomodifications in the patient’smedications may be needed(for example, increasing theinsulin dose to prevent hyper-glycemia related to the painand stress from infection).Typically, patients alsoshould receive short morningappointments to reducestress. The release of endogenous epinephrinefrom stress can have a counter-regulatory effecton the action of insulin, thereby markedly stimu-lating the breakdown of glycogen in muscle (andto a lesser extent in liver) and leading to hyper-glycemia.47In the adult patient with diabetes andno history of hypertension, or in the adult patientwith diabetes who has well-controlled hyperten-sion, epinephrine can be administered in theusual ranges.1Importantly, the inclusion ofepinephrine is advisable because it will promotebetter dental anesthesia and thus may signifi-cantly reduce the release of far greater amountsof endogenous epinephrine in response to painand stress.Finally, the dentist must play a major role inmodifying a patient’s destructive health habits,especially those that introduce a comorbidityfactor. For example, a large body of evidence fromepidemiologic, case-controlled and cohort studiesprovides convincing documentation of the causallink between cigarette smoking and health riskssuch as diabetes48and oral cancer.49,50Much of theresearch documenting the impact of smoking onhealth did not discuss separately results on sub-sets of individuals with diabetes, suggesting theidentified risks are at least equivalent to thosefound in the general population.Other studies of people with diabetes consis-tently found a heightened risk of morbidity andpremature death associated with the developmentof macrovascular disease complications amongsmokers.48Smoking also is related to the prema-ture development of microvascular complicationsof diabetes and may play a part in the develop-ment of type 2 diabetes.48Large, randomized clin-JADA, Vol. 134, October 2003 29Sical trials have demonstrated the efficacy andcost-effectiveness of counseling in changingsmoking behavior. Such studies, combined withthe others specific to people with diabetes, sug-gest that smoking-cessation counseling is effec-tive in reducing tobacco use.51,52A summary ofimportant general management considerationsfor the patient with diabetes is shown in the box.MANAGEMENT OF THE ORALCOMPLICATIONS OF DIABETESRisk of disease progression. The comprehen-sive management of oral infections in patientswith diabetes is beyond the scope of this article.Other sources are available that provide adviceand examples of detailed therapeutic regimens.1,53Nevertheless, clinical recommendations on thetreatment of some common oral manifestations ofdiabetes are provided below.In general, adults with well-controlled type 1or type 2 diabetes may have no more significantrisk of experiencing oral disease progression thando those without diabetes, and, hence, can betreated similarly. For example, a coronal cariouslesion that has not yet penetrated dentin in apatient with well-controlled diabetes may requireno immediate intervention, whereas a similarlesion in a poorly controlled patient (moderate tosevere hyperglycemia) may need immediate oper-ative treatment, given its higher risk of progres-sion. In general, the risk of progression of oralcomplications is related to glycemic control and isassessed in part by the interpretation of HbA1cvalues and postprandial blood sugar levels.Treatment regimens for candidiasis. Giventhe centrality of candidiasis as a marker ofBOXSUMMARY OF GENERAL MANAGEMENTCONSIDERATIONS FOR THE PATIENTWITH DIABETES.dAssess glycemic controldRefer patients with signs and symptoms suggestive of undiagnoseddiabetes to a physician for diagnosis and treatmentdObtain a consultation with the patient’s physician if systemiccomplications are present and/or assess the use of medications to treatoral complicationsdUse a glucometer to avert emergencies related to diabetesdAggressively treat acute oral infectionsdSchedule patients for frequent recall visits to monitor and treat oralcomplications and maintain optimal oral hygiene and dietdSupport and follow up patients in smoking-cessation programsCopyright ©2003 American Dental Association. All rights reserved.
30S JADA, Vol. 134, October 2003marginally or uncontrolled diabetes, and its sec-ondary relationship to salivary dysfunction, somerepresentative topical and systemic medicationsfor the treatment of oral candidiasis are shown inTables 1 and 2. It generally is advised that thedentist first assess the sugar content in some ofthe antifungal preparations before prescribingthem. For example, clotrimazole troches shouldbe avoided as these have a relatively high sugarcontent that may warrant against their use inpatients with diabetes (see Table 1 for treatmentguidelines54). Some representative topical medica-tions, such as creams, for the treatment ofangular cheilitis are shown in Table 2. Some ofthese combination creams contain corticosteroidsthat provide an anti-inflammatory and antipru-ritic effect to aid healing; however, steroids canhave an antagonistic or counterregulatory effecton the action of insulin and, thus, have the poten-tial to cause hyperglycemia. Nonetheless, it isunlikely that such combination creams will causea significant elevation of blood glucose, particu-larly if these are applied to a relatively small areaof angular cheilitis.Management of salivary gland dysfunc-tion and xerostomia. The rationale for thetreatment of xerostomia is to provide salivarystimulation or replacement therapy to keep themouth moist, prevent caries and candidal infec-tion, and provide palliative relief. The manage-ment approach for dry mouth can include the useof saliva substitutes and stimulants; thisapproach may minimize progression of, or preventthe development of, dental caries.55Management of recurrent HSV infections.For the patient with diabetes and recurrent orofa-cial HSV infection, treatment should be initiatedas early as possible in the prodromal stage toreduce the duration and symptoms of the lesion.Oral acyclovir, prophylactically and therapeuti-cally, may be considered when frequent recurrentherpetic episodes interfere with daily functionand nutrition. In the patient with diabetes andrenal insufficiency or renal failure, acyclovirshould be avoided because of its potential fornephrotoxicity.1Management of burning mouth syndrome.For the adult patient with burning mouth syn-drome, multiple factors may interact synergisti-cally. In uncontrolled diabetes, xerostomia andcandidiasis can contribute to the symptoms asso-ciated with burning mouth. In addition to thetreatment of these conditions, an improvement inglycemic control is essential to mitigate the symp-toms. Given in low dosages, benzodiazepines, tri-cyclic antidepressants and anticonvulsants can behelpful in reducing or eliminating the symptomsafter several weeks or months.1,38The dosage ofthese drugs is adjusted to the patient’s symptoms.A potential side effect includes xerostomia. Con-sultation with the patient’s physician is necessarybecause of the potential of these drugs for addic-* Source: The Dental Standards of Care Committee, New York State Department of Health.54† Use with caution because of sugar content.‡ Although this preparation is not designed for oral use, clinicians have found it useful for the treatment of oral candidiasis when the sugarcontent of other topical anticandidal medications is of concern. A sugarless, flavored lozenge may be dissolved simultaneously in the mouth tomask the taste of nystatin.§ Must use with caution; monitor for hepatotoxicity with liver function tests.¶ Should be used for resistant strains of Candida albicans.TABLE 1TREATMENT FOR ORAL CANDIDIASIS.*AGENT DURATION LABELTopicalClotrimazole troches†Nystatin vaginal suppositories‡SystemicFluconazoleKetoconazole§Itraconazole¶Two weeksTwo weeksTwo weeksTwo weeksTwo weeksSlowly dissolve a 1- to 10-milligram troche inmouth five times/daySlowly dissolve one tablet (100,000 units) inmouth six to eight times/day100 mg/day200 mg/day200 mg/dayCopyright ©2003 American Dental Association. All rights reserved.
JADA, Vol. 134, October 2003 31Stion and dependence. Commonly used medica-tions include amitriptyline, nortriptyline, clo-nazepam and gabapentin.1,38Interestingly,amitriptyline has also been used to treat auto-nomic neuropathy in diabetes.40Surgical considerations and periodontalmanagement. The dentist can perform peri-odontal surgical procedures, although it is impor-tant for the patient to maintain a normal dietduring the postsurgical phase to avoid hypo-glycemia (low blood sugar and insulin shock) andensure effective repair. The dental practitionermust review any previous history of complications,assess the patient’s glycemic control and maintainan ongoing dialogue with the patient’s physicianand nutritionist. The longer the duration of thediabetes, the greater the likelihood of the patient’sdeveloping severe periodontal disease.Supportive periodontal therapy should be pro-vided at relatively close intervals (two to threemonths). Periodontal infections may complicate theseverity of diabetes mellitus and the degree ofmetabolic control.26The adult patient with well-controlled diabetes generally does not requireantibiotics following surgical procedures. However,the administration of antibiotics during the post-surgical phase is appropriate, particularly if thereis significant infection, pain and stress. The selec-tion of antibiotics is predicated on multiple factors(for example, sensitivity and specificity results,spread of infection), and should be conducted inconsultation with the patient’s physician.The mainstay of periodontal therapy forpatients with diabetes is nonsurgical, given thatsurgical procedures may necessitate modificationof the patient’s medications before and aftertreatment, and also may lead to a prolongedhealing phase owing to diabetes. The combinationof nonsurgical débridement and tetracyclineantibiotic therapy in patients with diabetes mel-litus who have advanced periodontitis may have apotential positive influence on glycemic control.The use of tetracycline in the treatment of peri-odontal disease was associated with an improve-ment in glycemic control as assessed by HbA1cassays.26Several published papers have reported anadditional therapeutic benefit from tetracyclinesin periodontal therapy, principally as inhibitors ofthe connective tissue–degrading enzymes, thehuman matrix metalloproteinases. For example,low-dose doxycycline has been shown to inhibithuman gingival crevicular fluid collagenase atdoses that are not antimicrobial, significantlyeliminating the risk of bacterial resistance. Tetra-cyclines can thus function as inhibitors of boneresorption or bone loss, and this property is inde-pendent of their antimicrobial use, providing anadded dimension to the therapeutic managementof periodontitis.56-59Oral disease management with cortico-steroids. Therapies with corticosteroids andimmunomodulating drugs have the potential forside effects. Therefore, close collaboration withthe patient’s physician is needed. The use ofsteroids in the treatment of erosive lichen planusin the adult patient with diabetes is of consider-able concern because steroids can antagonize theaction of insulin and lead to hyperglycemia. Thepatient should be given instructions to self-monitor blood glucose levels frequently duringsteroid therapy. Prolonged use of topical steroids(for a period of greater than two weeks continu-ously) may result in mucosal atrophy and sec-ondary candidiasis1—conditions that also com-monly occur in uncontrolled diabetes. Once theerosive oral lichen planus has resolved, topicalsteroids should be tapered to alternate-day or* Source: The Dental Standards of Care Committee, New York State Department of Health.54† Some clinicians have found combination creams to be more effective than antifungal medications alone in the treatment of angular cheilitis.These include combination preparations of topical hydrocortisone, antifungal agents and hydrocortisone-iodoquinol cream, which combines anantifungal-antibacterial agent with an anti-inflammatory antipruritic.TABLE 2TOPICAL MEDICATION FOR ANGULAR CHEILITIS.*AGENT DURATION LABELAntifungal cream (clotrimazole 1%, miconazole 2%,ketoconazole 2%)Combination creams†(hydrocortisone-iodoquinolcream, betamethasone dipropionate–clotrimazolecream, triamcinolone-nystatin cream)Two weeksTwo weeksApply to affected areafour times/dayApply to affected areathree times/dayCopyright ©2003 American Dental Association. All rights reserved.
32S JADA, Vol. 134, October 2003less-frequent therapy, depending on the control ofthe erosions and the tendency toward recurrence.Emerging nonsteroidal immunomodulator drugs(for example, tacrolimus ointment, topicalthalidomide) may be useful in the medical man-agement of the patient with concomitant oralmucosal disease and uncontrolled diabetes.CONCLUSIONThe dentist plays a major role with allied mem-bers of the health team in helping a patient main-tain glycemic control by properly treating oralinfections, and by instructing the patient withdiabetes to maintain rigorous oral hygiene and aproper diet.The dentist also can play a vital role in refer-ring patients with signs and symptoms suggestiveof undiagnosed diabetes to a physician for addi-tional evaluation.Finally, as an integral member of the healthcare team, the dentist can counsel patients withdiabetes to stop smoking—a risk factor that mayexacerbate some of the vascular complicationsassociated with diabetes.The patient with diabetes who is receiving goodmedical care and who maintains rigorousglycemic control generally can receive any indi-cated dental treatment. The adult with well-controlled diabetes who is without systemiccomplications should be treated similarly to apatient without diabetes—namely, antibioticsmust not be prescribed unless they are absolutelynecessary (for example, an acute oral infection).The patient with systemic complicationsresulting from diabetes may require modificationof the dental treatment plan following a consulta-tion with the patient’s physician. sDr. Vernillo is a professor, Department of Oral Pathology, Division ofBiological Science, Medicine and Surgery, New York University Collegeof Dentistry, 345 E. 24th St., New York, N.Y. 10010-4086, e-mail“firstname.lastname@example.org”. Address reprint requests to Dr. Vernillo.The author thanks Dr. Jonathan Ship for coordinating this specialedition to JADA on diabetes mellitus.1. Little JW, Falace DA, Miller CS, Rhodus NL. Dental managementof the medically compromised patient. 6th ed. St. Louis: Mosby;2002:154, 248-70, 548-632.2. 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