Diabetes - Dental Considerations

In the previous article, I talked about the pathophysiology of how a diabetic patient can experience hypoglycemia.

Let us now talk about how diabetes affects dental treatment and what are the possible emergencies that may arise in a diabetic patient.

We know that in diabetes either there is insulin deficiency (Type 1) or the body becomes resistant to the physiologic effects of insulin (Type 2).

In either case, there is hyperglycemia.

The patient with uncontrolled hyperglycemia will exhibit stiffening of blood vessels (atherosclerosis) because of increased cholesterol deposition in the vessel walls.

As the vessels are stiff and they are not able to change their lumen size by relaxation of the smooth muscles present in their walls.

Also if this cholesterol deposition continues, then it will lead to decrease in size of the lumen of the blood vessel.

As the size of the lumen is reduced, it leads to increased water pressure. Same principle can be applied in case of diabetes where atherosclerosis leads to hypertension.

This leads to blood applying more pressure over the vessel walls.

This leads to hypertension.

If this continues for a prolonged duration then it will cause hampered blood supply to different tissues of the body. This in turn may lead to necrosis. For example - neuropathy (peripheral nerve necrosis).

Also in diabetes, macrophages and leukocytes are dysfunctional.

Macrophages are responsible for the removal of necrotic debris from the site of injury.

Leukocytes (as we all know) are responsible for immunity.

Also, dysfunctional macrophages, leucocyte and high blood glucose concentration gives the invading microorganisms the favourable environment to flourish.

So a diabetic with uncontrolled blood glucose levels is prone to infection.

Also there is impaired collagen-3 formation in diabetes.

Add to that the hampered blood supply and dysfunctional macrophages and we have delayed wound healing.

Hence the things that we need to keep in mind while performing any procedure on a diabetic are as follows -

• Delayed healing process.

• Increased risk of Infection.

• Patient with poorly controlled diabetes has a major risk of developing periodontal disease.

• Diabetics are more prone to developing burning mouth syndrome.

• Xerostomia (Dry Mouth)

• Loss of joint flexibility and increased stiffness are common clinical findings in Diabetes Mellitus.

• There is high prevalence of Osteoporosis in Type 1 Diabetes. Hence great care must be taken while performing surgery, in order to prevent Iatrogenic fractures.

So now let us discuss some emergency.

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As discussed earlier, if a known diabetic takes his medications on time but skips a meal, then he will experience hypoglycemia.

A hypoglycemic is going to experience signs and symptoms that we see in syncope.

These are as follows -

• Dizziness.

• Blurred vision.

• Sweating.

• Hunger.

• Irritability

• Anxiety

• Nausea and vomiting

• Headache

• Tachycardia

• Drowsiness

• Lack Muscle Coordination

• Unconsciousness

• If untreated, death.

Hypoglycemia (although easy to manage) is a life threatening medical emergency that may lead to death within minutes.

Hyperglycemia on the other hand is not an immediately life threatening medical emergency. It takes approximately 2-3 days from the onset of the emergency to progress to the death of the patient.

So, in hyperglycemia, we have sufficient time to shift the patient to a hospital where he will be diagnosed properly and receive the required treatment.

Severe Hyperglycemia will manifest as -

• Headache

• Blurred Vision

• Fatigue

• Tachycardia

• Drowsiness

• Nausea and vomiting

• Lack Muscle Coordination

• Fruity-smelling breath

• Diabetic Ketoacidosis

• Coma

• If untreated for 2-3 days, Death.

Rarely, there may be a case where a patient is an undiagnosed diabetic with high blood glucose levels.

You start a dental procedure on this patient but the patient starts feeling dizzy.

Now the problem here is that hypoglycemia and hyperglycemia have signs and symptoms that are common to both.

So without a prior medical history, it might be difficult to diagnose whether it is hypoglycemia or hyperglycemia.

When in confusion always assume it is hypoglycemia.

Rationale for this is as follows -

Hypoglycemia is a medical emergency that can lead to death in minutes whereas hyperglycemia progresses slowly and (if untreated) will lead to death in approximately 48 hours.

So, in case we misdiagnosed hyperglycemia as hypoglycemia, we still have approximately 48 hours to transfer the patient to a medical facility where a proper diagnosis and management can be done.

If we misdiagnosed hypoglycemia as hyperglycemia, chances are high that it will lead to death of the patient.

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Let us now talk about management of the Medical Emergency Hypoglycemia.

This is a no brainer, stop the procedure immediately.

Any medical emergency that happens in a dental clinic should be managed by following the P-C-A-B-D protocol.

P – Position

C - Circulation

A - Airway

B - Breathing

D - Definitive

All the steps in P-A-B-C are the same as that given in the Syncope Article.

Coming to the definitive management.

As we have established that the clinical signs are because of hypoglycemia.

So the next logical step is to administer glucose to elevate the blood glucose levels.

If the patient is conscious, then administer hypertonic glucose solution orally.

There are many such glucose powder available to just mix with water and administer orally. These should be kept at a clinic at all times.

Alternatively, if glucose solutions is not available then anything sweet with sugar can be given to the patient to eat. For example, juice, chocolate or a candy.

Chocolates can be life saving in Hypoglycemia.

If the patient is unconscious, DO NOT administer glucose orally.

Instead administer IV 50 % dextrose.

If the IV dextrose solution is not available, then IV Inj. Glucagon 1mg/KG can be administered alternatively.

Preferably Inj. Dextrose is to be given in an unconscious hypoglycemic but when it is not available Inj. Glucagon can be administered.

If even Inj. Glucagon is not available, then Inj. Epinephrine 0.3 mg 1:1000 can be administered Intramuscularly or Subcutaneously. BUT, Epinephrine cannot to be used in a patient with Cardiovascular diseases.

Inj. Epinephrine can be given in a hypoglycemic when dextrose or glucagon is not available.

Alternatively in such conditions, Inj. Dexamethasone 8 mg can be administered IV or IM.

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So that's what you do when in doubt whether the emergency is Hypoglycemia or Hyperglycemia.

Let me know in the comment section, whether you have experienced any such complication and how you managed it.

Also, do let me know what topics would you want me to write about next. The topics can be from local anesthesia, Oral & Maxillofacial Surgery or Medical emergencies.