Diabetes in dentistry

Diabetes in dentistry

Diabetes is one of the chronic pathologies whose incidence has increased the most over the last ten years. The condition has a multi-visceral impact. The oral cavity is not spared, but this aspect is often neglected, or even ignored. Present in type 1 (T1D) or type 2 (T2D) diabetes mellitus, oral signs are sometimes indicative of the condition.

The relationship between diabetes and oral diseases has been established by numerous epidemiological studies. These studies agree, in their great majority, to demonstrate that, on the one hand, diabetes is a risk factor likely to promote the development of oral pathology and on the other hand, that oral infection seems to have an influence on glycemic balance.

Definition :

Diabetes is one of the most common endocrine disorders . It is a chronic condition characterized by hyperglycemia and other metabolic changes that result from inadequate insulin activity within the body.

The latter results either from a reduced circulating insulin concentration or from resistance of target tissues. Due to the importance of certain complications and their prevalence, diabetes can be considered as a syndrome that consists of metabolic abnormalities , affection of the microvasculature ( retinopathy and nephropathy ) and of the major vessels (cardiac and cerebral) and neuropathies.

Classification:

There are different types of diabetes.

Type 1 Diabetes:

Type 1 diabetes or juvenile diabetes is more common in children and young adults. It is an exclusively insulin-dependent diabetes . The term dependent means that not only is insulin necessary for optimal blood glucose control, which can also be true for type 2 diabetes, but without exogenous insulin intake the patient can develop ketoacidotic diabetes.

2-2 Type 2 diabetes:

Type 2 diabetes typically affects overweight individuals over the age of 40. Due to adequate insulin production, these patients do not develop ketoacidotic diabetes. However, this form can develop under severe stress. In these patients, exogenous insulin administration can be used to treat persistent hyperglycemia.

Clinical manifestations:

Polyuria, polydipsia, weight loss, infections and blurred vision are the main symptoms resulting from insulin deficiency.

This leads to a decrease in the entry of blood glucose into the tissues and results in an accumulation of:

The inability of renal resorption of this excess results in glycosuria and polyuria (caused by glucose-induced osmotic diuresis).
The latter must be compensated by a supply of fluid resulting in a

polydipsia.

Loss of glucose through urine results in weight loss despite increased food intake (polyphagia).
Infections, common in the skin and urinary tract, are linked to hyperglycemia which reduces resistance to infection by, among other things, reducing the phagocytic function of neutrophils.
Vision disturbances are caused by changes in the shape and refractory qualities of the lens due to osmotic alterations induced by hyperglycemia.

Diagnosis:

Diabetes is often suspected due to typical clinical manifestations (polyuria, unexplained weight loss, etc.); however, the diagnosis is based on elevated blood sugar (hyperglycemia):

Fasting blood sugar between 1.10 g/l and 1.26 g/l on 2 occasions. Moderate abnormalities confirmed

– Fasting blood sugar ≥ 1.26 g/l (7.00 mmol/l) on 2 occasions. Confirmed diabetes

Blood glucose ≥ 2.00 g/l (11.1 mmol/l) at any time . Accompanied by clinical symptoms
Blood glucose ≥ 2.00 g/l (11.1 mmol/l) 2 hours after a 75 g glucose load (OGTT). Induced oral hyperglycemia (glucose tolerance)

Complications:

They can be acute or chronic. 5-1 Acute complications

Acute complications cause mental and physical deterioration that requires prompt treatment. There are three forms:

ketoacidotic diabetes:
hyperosmolar coma;
hypoglycemic coma:

The etiology of hypoglycemia is either excessive insulin dosage or delay in eating a meal, excessive physical activity or significant stress.

Clinically, the symptomatology manifests itself through two mechanisms: one induced by the stimulation of the production of catecholamines (induced by the fall in serum glucose concentration; this adrenergic stimulation causes: sedation , tachycardia , palpitations and tremors ); the other induced by the depression of glucose in the central nervous system: loss of consciousness

Confirmation of hypoglycemia will be made by determining blood glucose.

5-2 Chronic complications

Diabetic patients frequently develop disorders of the microvasculature ( retinopathy and nephropathy ) and major vessels (cardiac and cerebral) and neuropathies.

6-Processing:

Diabetes is an incurable disease. Treatment, which aims to control the disease, is always highly individualized, and patient cooperation is essential.

The purposes of the processing are:

control of symptoms related to hyperglycemia (polyuria, vision disturbances, weight loss, etc.) which regress with a return to normal of the serum glucose level;
prevention of acute or late complications.

Treatment is based on strict dietary control, the administration of hypoglycemic agents and/or insulin.

Diabetes and odontostomatology:
Oral manifestations :

Various oral manifestations, particularly inflammatory and infectious, are associated with diabetes.

They are mainly due to an alteration of the oral flora, to functional disorders of neutrophil polymorphonuclear cells and to micro-angiopathies.

Candidiasis, persistent gingivitis, periodontitis, polycaries and dry mouth may be among the first oral signs of the disease.

Diabetic patients are also prone to delayed healing and ulcerations that may persist despite usual therapeutic approaches.

In addition, these symptoms include the smell of acetone in the breath, the rapid re-formation of tartar, hypotonicity of the tongue and hyperviscosity of saliva.

Assessment in daily practice:

In daily practice, the dental surgeon may be required to provide care to two types of patients:

a first type where there is suspicion of diabetes
a second type where the diagnosis is made whether the diabetes is controlled or not.

Assessment in the presence of suspected diabetes:

Any patient presenting the cardinal symptoms of diabetes (polydipsia, polyuria, polyphagia, weight loss and/or oral manifestations that may be highly suggestive of the disease: candidiasis, persistent gingivitis, periodontitis, polycaries and dry mouth, delayed healing and persistent ulcers that are resistant to usual treatments) a biological assessment should be requested. Diabetes is diagnosed by an increase in blood glucose levels:

Fasting blood sugar between 1.10 g/l and 1.26 g/l on 2 occasions. Moderate abnormalities confirmed
Fasting blood glucose ≥ 1.26 g/l (7.00 mmol/l) on 2 occasions. Confirmed diabetes
Blood glucose ≥ 2.00 g/l (11.1 mmol/l) at any time . Accompanied by clinical symptoms
Blood glucose ≥ 2.00 g/l (11.1 mmol/l) 2 hours after a 75 g glucose load (OGTT). Induced oral hyperglycemia (glucose tolerance)

The patient should be referred to a general practitioner or a diabetologist.

Assessment of the patient diagnosed as diabetic:

The purpose of this assessment will be to determine; depending on the nature of the diabetes, the treatment followed, the presence of associated complications, the history of hypoglycemic accidents and/or the history of hospitalization. The severity and effectiveness of the treatment followed (by monitoring blood sugar levels to judge whether the diabetes is controlled or not = assess glycemic balance ) and thus define the patient’s medical status.

Biological parameters for assessing glycemic balance:

Glycated hemoglobin (HbA1c) is the biological parameter that allows us to assess glycemic balance:

This is the indicator of the average blood sugar levels over a two-month period.
Its normal value is usually between 3.5 and 6.0%, in adults, children or adolescents.
HbA1c is a much better measure of diabetes than fasting blood sugar.
The therapeutic approach to the diabetic patient varies, depending on the state of their glycemic balance.

Management of a balanced diabetic patient:

The balanced diabetic patient is considered “healthy.” Precautions will be the same as for any other patient.

Management of an unbalanced diabetic patient:

General precautions:

In daily practice, the practitioner’s primary objective will be to avoid metabolic disorders or imbalances during the treatment period.

As a general rule, the patient must be informed precisely about the steps to follow regarding his diet and/or treatment (insulin treatment, hypoglycemic medications, etc.) and also to ensure that the patient is not fasting , in order to minimize any risk of hypoglycemic accidents.

The dentist must be particularly attentive to the risk of infection and stress.

The patient must take his medication and must be informed about it.

The treatment will be performed in the morning and the patient will be invited to eat a normal breakfast. The session should be short.

If an appointment overlaps the normal mealtime, a break in care should be considered to allow the patient to eat (usually orange juice is perfectly appropriate).
If, after treatment, the patient has limited masticatory function, a prescription for soft or liquid foods should be made in order to maintain caloric intake.

Precautions regarding susceptibility to infection:

Hyperglycemia reduces the phagocytic function of granulocytes and can promote the growth of certain microorganisms. A broad-spectrum antibiotic prescription is recommended. It can be started the day before tooth extraction and continued for the next 7 days.

Precautions regarding stress :

Due to the stimulating effect of stress on the production of adrenaline and corticosteroids, which are hyperglycemic, the patient’s psychological approach must be reassuring. In cases of significant anxiety, sedative premedication must be prescribed.

Precautions during anesthesia:

The use of the adrenaline vasoconstrictor “may be inadvisable” due to its hyperglycemic effect.

The use of the vasoconstrictor noradrenaline is authorized because it has no hyperglycemic effect.

There are no contraindications to performing truncal anesthesia.

Precautions to take when prescribing:

Unless there is an associated condition (which requires a change in dosage), the usual prescription antibiotics in dentistry, sedatives and usual analgesics can be used without complications. However, the prescription of anti-inflammatories, particularly steroids, must take into account their hyperglycemic effects and their possible interactions with current treatments.

Hypoglycemic discomfort:

Diabetic patients are particularly susceptible to hypoglycemic symptoms. Excess insulin or skipping a meal, despite taking insulin, can cause low blood glucose levels.

Hypoglycemic discomfort may be precipitated by stress, infection, or anxiety.

It is characterized among other things by sweating, marked asthenia, disturbances of consciousness, tremors and tachycardia, etc.

It can be treated by immediate administration of glucose in the form of breadfruit juice or sugar. If such administration is not possible, due to loss of consciousness for example, intravenous administration of glucose serum or glucagon should be performed.