CONDUCT TO FOLLOW WHEN WORKING WITH A DIABETIC PATIENT
Dr. BENAOUF. S
Course 4th year
2023-2024
I- Introduction
The evolution of medical knowledge has profoundly changed the attitude of dentists
towards many patients, particularly those suffering from a general illness.
Given its very high rate and its multiple complications, diabetes, in fact, requires
special care, specific to it…
This patient care implies not only knowledge of the disease and
its oral expressions, but also its therapeutic modalities and especially the conduct to adopt and the
precautions to take with regard to diabetic patients.
II- Definitions of the term “diabetes”
1- Diabetes insipidus:
It is a functional disorder characterized by an inability of the kidneys to concentrate urine
, i.e. there is a defect in the reabsorption of water by the kidney in relation to a deficiency or a defect
in the action of the antidiuretic hormone, resulting in polyuria and polydipsia.
2- Renal diabetes:
Characterized by the excessive presence of glucose in the urine while the
blood glucose level is normal. This functional disorder is due to a defect in the reabsorption of glucose
by the renal tubules.
3- Diabetes mellitus:
Diabetes is one of the most common endocrine and metabolic disorders, it is a chronic condition characterized by a disorder in the metabolism of carbohydrates which results from inadequate activity of insulin within the body leading to chronic hyperglycemia.
The American Diabetes Association and the French National Agency for Accreditation and Evaluation in Health (ANAES) define diabetes according to the following criteria:
a subject is considered diabetic if he or she has a fasting blood sugar level greater than 7 mmol/l (greater than 1.26 g/l) on two occasions;
a subject is considered normal if he or she has a fasting blood sugar level less than 6.1 mmol/l (greater than 1.10 g/l).
Two new concepts to consider:
Concept of glycoregulation
Concept of glucose intolerance
are considered to have abnormal glycoregulation:
subjects with moderate fasting hyperglycemia, blood glucose > 6.1 mmol/l and < 7 mmol/l (> 1.10 g/l and < 1.26 g/l)
subjects with glucose intolerance:
fasting blood glucose < 7 mmol/l (< 1.26 g/l) and blood glucose 2 hours after taking 75 g of glucose > 7.6 mmol/l (> 1.40 g/l) and < 11 mmol/l (< 2 g/l).
Diabetes is diagnosed if blood sugar exceeds 2 g/l on two samples taken at any time of the day or if blood sugar exceeds 2 g/l in the presence of a specific complication.
Currently the approach to diabetics is much more nuanced. New concepts are being introduced.
III- Physiology of glycoregulation
IV- WHO classification
Type 1 Diabetes (T1D): formerly: insulin-dependent diabetes (formerly: IDDM)
Begins before the age of 30
Represents 5 to 10% of cases of diabetes
It is the consequence of the destruction of the beta cells of the pancreas by an autoimmune mechanism, leading to an absolute insulin deficiency
Clinical signs:
Polyuria
Polydipsia
Polyphagia
Asthenia
Weight loss
Biological signs
Glycosuria: the presence of glucose in the urine.
Hyperglycemia: increase in blood glucose compared to normal 0.65-1.10 g/l.
Ketoacidosis: accumulation of ketone bodies in the blood.
Type 2 Diabetes: formerly non-insulin-dependent diabetes (NIDDM)
Mainly affects the obese population and those aged around 50 years old
Accounts for 90 to 95% of cases of diabetes
Due to insulin resistance and insulin secretion disorders.
Clinical signs:
Polyuria
Polydipsia
Polyphagia
Asthenia
Biological signs:
Hyperglycemia
Glycosuria
Gestational diabetes:
Transient diabetes mellitus occurring during pregnancy, detected during the second month of pregnancy characterized by hyperglycemia and glycosuria due to placental and maternal hormone production.
MODY diabetes (Maturity onset diabetes of the youth):
Similar to type 2 diabetes, but occurs
much earlier, in late adolescence or young adulthood; linked to genetic defects in pancreatic ß-cell function (e.g., glucokinase gene mutation).
V- Biological tests:
– Fasting blood sugar: VM = 0.65-1.10 g / l (7 mml / l).
– Postprandial blood sugar:
This is a blood sugar measured 1h 30 after the end or 2h after the start of the main mid-day meal that contains carbohydrates
VM = inf 7.7 mml / L.
Oral hyperglycemia (OGTT):
In this case, blood sugar is measured 2 hours after taking 75 g of glucose for adults and 1.75 g / kg of weight for children.
VM = inf 2 g / l (11 mml / l).
Glycated hemoglobin (Hb1 Ac ) = glycosylated:
This is hemoglobin that glycates proportionally to the blood sugar level. Given the
average lifespan of red blood cells which is 2 to 3 months, this is a marker of glycemic balance.
-HbA1c less than 7%: good control (green zone)
– HbA1c between 7 and 8%: imperfect control (orange zone)
– HbA1c greater than 8%: poor control (red zone)
Some benchmarks giving the equivalence between HbA1c and average blood sugar:
- 6% equals 1.2 g/l
- 7% equals 1.5 g/l
- 8% equals 1.8 g/l
- An increase of 1% is equivalent to + 0.3 g/l
VI- complications of diabetes
1-degenerative lesions:
-Macro angiopathy: results from the formation of atheromatous plaque (atherosclerosis)
-Micro angiopathy: results from the glycation of capillary proteins leading to their fragility, these consequences are renal and ocular damage.
2-cardiovascular complications:
-Myocardial infarction, angina pectoris.
-Cerebrovascular accident (CVA).
-Hypertension.
3-nervous complications:
Diabetic neuropathy: resulting from damage to the nerves, it mainly affects the lower limbs and causes a loss of sensitivity in the feet.
4-Digestive complications:
Intestinal disorders
Vomiting
Diarrhea
5-Renal complications:
Glomerular nephropathy
Urinary tract infection
Papillary necrosis
Renal failure
6-Infectious complications: due to alteration of chemotaxis, bactericidal action and phagocytosis of polymorphonuclear cells
Pulmonary: tuberculosis
Cutaneous: furuncle
VII-Risks in diabetics
1-Comatose risk:
Hyperosmolar coma:
This is a rare complication of T2D in subjects over 60 years old.
Characterized by very significant hyperglycemia with dehydration without acidosis.
The triggering factors are mainly linked to excessive water loss during febrile infections, significant ingestion of glucose, or taking diuretics.
Urgent hospitalization is required for rehydration and insulin therapy.
Ketoacidosis
This is a complication of untreated type 1 D.
Due to an absolute insulin deficiency which results in hyperglycemia and lipolysis (excessive accumulation of ketone bodies in the blood leading to acidosis
- Clinical signs:
Acidosis gives the diabetic a particular breath smell (reinette apple)
The patient loses weight quickly.
Suffers from dizziness, digestive disorders,
Respiratory disorders (polypnea)
The diagnosis is confirmed by acetonuria - Treatment is based on 4 elements:
Insulin administration
Correction of dehydration
Supply of electrolytes and minerals (Ca++, K+, bicarbonate)
Treatment of precipitating factors and complications.
Hypoglycemic coma
It is due to:
- Decrease in food intake.
- Insulin dosage error.
– Potentiation of the hypoglycemic effect of insulin by concomitant use of other medications (sulfamides, salicylate analgesics, alcohol).
Manifested by:
A neurovegetative syndrome: pallor, tremors, anxiety, irritability, tachycardia, sweating and painful hunger
Neuroglucopenic syndrome: linked to glucose deficit in brain cells
(headaches, asthenia, visual, sensory and motor disorders and sometimes a stroke)
Treatment:
– Oral administration of sugars - In case of confusion and impaired consciousness, an IM or subcutaneous injection of 1 mg of glucagon is given, repeated after 15 minutes if there is no improvement.
CONDUCT TO FOLLOW WHEN WORKING WITH A DIABETIC PATIENT
2-The risk of infection
Hyperglycemia, ketoacidosis and disease of the vascular walls promote infection and delayed healing in diabetic patients (especially those who are not balanced).
Hyperglycemia:
- reduces the phagocytic function of granulocytes and may promote the growth of certain microorganisms.
- accelerates the degradation of collagen fibers during synthesis, which has an adverse effect on healing.
Ketoacidosis:
Delays granulocyte migration and affects phagocytosis.
Vascular wall changes:
Reduce blood flow, oxygen content, and granulocyte mobilization.
Tooth infection makes it difficult to balance diabetes and can also unbalance a previously stable diabetes.
There is a vicious cycle between diabetes and infection:
VIII-Oral manifestations
1- infectious:
bacterial
Periodontal disease: (gingivitis, periodontitis) due to immune dysfunctions, alteration of bacterial flora, collagen metabolism and periodontal vessels
Dental:
cervical caries
Diffuse and necrotic cellulitis
Thrombophlebitis
Fungal
Oral candidiasis
Angular cheilitis
Median glossitis
Stomatitis
2- salivary gland dysfunctions:
-Microangiopathy and vegetative neuropathy alter the function of the salivary glands responsible for dry mouth (xerostomia)
-Decrease in salivary pH.
CONDUCT TO FOLLOW WHEN WORKING WITH A DIABETIC PATIENT
3- lesions of the oral mucosa:
Ulcerations
Oral lichen planus
Atrophy of the mucous membranes
4- paresthesia and taste disorders: metallic taste and burning sensation in the tongue
5- delayed healing
Due to the reduction in the functions of polymorphonuclear cells, collagen production and an increase in the production of collagenase
NB:
all the lesions are certainly caused by oral causes but also favored by a glycemic imbalance, hence the notion of risk:
IX-Caring for a diabetic:
A- Renal and insipidus diabetes:
The CAT will be the same as for chronic renal failure but the degree of
failure must be specified.
B- Diabetes mellitus:
1- a diabetic who is not followed by a diabetologist should never be treated except in an emergency.
2- It is necessary to work in collaboration with the treating physician.
3- It is necessary to specify:
The type of diabetes
Antidiabetic treatment: insulin or oral hypoglycemics.
The age of diabetes.
Number, occasion and date of the coma.
Low risk patients
Patients who are well controlled, stable, asymptomatic and have no neurological, vascular or infectious complications will be considered low risk. Glycosuria should be minimal (0 to 1+), ketonuria should be zero and blood glucose concentration should be less than 2 g/l (11 mmol/l).
Moderate risk patients
Patients who are generally controlled
(but occasionally have symptoms) and have no history
of hypoglycemia or ketoacidosis will be considered at moderate risk. Only a few complications may
be present, but they must be under treatment. Glycosuria may be between 0 and 3+, ketonuria 0 and blood glucose less than 2.5 gil (14 mmol/l).
High risk patients
Patients will be classified as high risk when they present with
multiple complications. Insufficient control requiring a
constant need for readjustment of insulin dosage. Glycosuria
occasionally associated with ketonuria will be present and blood glucose levels will vary significantly and often exceed 2.5 g/l (14 mmol/l).
In this case we will be faced with 2 possibilities: Normal glycoregulation and Abnormal glycoregulation:
Normal glycoregulation: it is the patient who
- its weight is stable over time.
- glycosuria does not exceed 10% compared to carbohydrate intake.
- which does not cause discomfort.
- Urine and blood do not contain ketone bodies.
- who can take care of his professional life without difficulty.
-glycemic values are close to normal and are stable over time
4- never make appointments during
meal times.
5- Make sure that the patient is not fasting.
6- Psychological and sedative preparation if necessary (in case of stress)
7- Antibiotic therapy is not systematic except
in the case of a declared infection. ATB must be energetic in dose, duration and molecule.
8-prescription should be avoided:
9- actions limited in their success are to be avoided:
- root canal treatment in chronic periapical lesions on molars,
- conservative pocket treatment by filling,
-complex orthodontic treatment.
10- Prevention must be of the order: regular scaling, preventive treatment of cavities, extraction of DDS before their accident of eruption, periodic visits.
11- Request a radiological assessment.
12- During anesthesia: the use of vasoconstrictors is not contraindicated due to the low concentrations of adrenaline which do not allow a significant increase in blood glucose levels, except in cases where the anesthesia requires the injection of several cartridges.
13- The intervention must be rapid and as non-traumatic as possible.
14- Ensure hemostasis
15- Patient monitoring until healing.
16- in case of hypoglycemic discomfort:
Place the patient in the safety lateral decubitus position.
Free the upper airways of any objects that could obstruct them and proceed with re-sugaring:
Conscious patient:
Re-sweetening per os with fast sugars (2 to 4 sugar cubes, sugary drink).
Then relay with slow sugars (bread, biscuit).
Unconscious patient: re-sugarization by parenteral route (IV) 20 to 40 ml of glucose serum.
In case of significant agitation: subcutaneous or (IM) injection of 1 mg of glucagon.
Except in emergencies: all procedures will be postponed until the diabetes is regulated or act in a hospital environment.
Special cases:
1-In case of maxillary trauma:
Open fracture:
Hospitalization of the patient – Massive ATBpie for at least 15 days – BBM – monitoring.
Closed fracture:
ATB for at least 15 days – BBM – monitoring.
2- In the event of a declared infection: cellular accident:
It is necessary to act quickly given the risk of extension (emergency hospitalization).
Blood sugar control
Massive ATBpie – incision and drainage
Etiological treatment as soon as the trismus is lifted.
3-In the event of concomitant pathologies:
The presence of associated pathologies (hypertension, renal failure, etc.) requires taking additional precautions specific to these pathologies as well as with regard to the prescriptions included in their treatments.
4- Case of a pregnant woman previously diabetic:
Work in close collaboration with the treating physicians (diabetologist – obstetrician).
Do not act during the 1st and 3rd trimester except in case of emergency and in a hospital environment.
5- Gestational diabetes: patients are automatically put on insulin (same precautions).
- Same behavior as before
CONDUCT TO FOLLOW WHEN WORKING WITH A DIABETIC PATIENT
Conclusion
Oral pathology is an integral part of the complications of diabetes. The restoration
of the oral cavity and the establishment of satisfactory oral hygiene are fundamental
in diabetic patients and determine the quality of glycemic balance.
The dental professional must actively integrate into the medical-surgical balance ensuring the prevention, diagnosis and treatment of complications linked to diabetes.
CONDUCT TO FOLLOW WHEN WORKING WITH A DIABETIC PATIENT
Baby teeth need to be taken care of to prevent future problems.
Periodontal disease can cause teeth to loosen.
Removable dentures restore chewing function.
In-office fluoride strengthens tooth enamel.
Yellowed teeth can be treated with professional whitening.
Dental abscesses often require antibiotic treatment.
An electric toothbrush cleans more effectively than a manual toothbrush.