Diabetes  

Diabetes  

1. Definition

Diabetes is a disorder of the assimilation, use and storage of sugars (carbohydrates) provided by food. It results in chronic hyperglycemia (high blood glucose levels) resulting from a deficiency in insulin secretion, abnormalities in the action of insulin on target tissues or a combination of both.

• Diabetes is confirmed when fasting blood sugar is ≥ 1.26 g/l on two occasions or 
• ≥ 2 g/l at any time of the day.
• There are  two main types of diabetes  : 

• type 1 diabetes which affects approximately 6% of diabetics 
• type 2 diabetes, which affects 92% of them. 
• Other types of diabetes concern the remaining 2% (MODY, LADA or diabetes secondary to certain diseases or medication).
• Type 1 diabetes  : formerly called insulin-dependent diabetes (IDDM) or diabetes mellitus, is usually discovered in young people: children, adolescents or young adults.

• It results in intense thirst (polydipsia), 
•  abundant urination (polyuria) 
•   rapid weight loss.
•   This diabetes results from the disappearance of the beta cells of the pancreas leading to a total deficiency of insulin. The glucose unable to enter the cells returns to the blood and raises the blood sugar level.
•  Type 1 diabetes is said to be an autoimmune disease. It is treated by taking insulin daily

• Type 2 diabetes , formerly called non-insulin-dependent diabetes (NIDDM) or fatty diabetes, usually appears in people over the age of 40.
• The causal process differs from that of type 1 diabetes. Two abnormalities are responsible for hyperglycemia:

• either the pancreas still produces insulin but not enough, in relation to blood sugar: this is insulinopenia;
•  either this insulin acts poorly, we then speak of insulin resistance.
• Overweight, obesity and lack of physical activity are the leading cause of type 2 diabetes in genetically predisposed people. 
•  It is treated with oral antidiabetics or insulin therapy.
•  In both cases, treatment is based on self-monitoring of blood sugar, physical activity and dietary monitoring.

2. General clinical manifestations:

•  Microangiopathies  can lead to chronic renal failure or retinopathies.

– Macroangiopathies  due to the formation of atheroma plaques lead to a significant increase in cardiovascular risk (myocardial infarction, stroke, etc.).

– Peripheral neuropathies  are represented by paresthesias, hypoesthesias, etc.

– Infectious complications are frequent and sometimes difficult to treat.

– The risk  of hypoglycemia  (especially in patients treated with insulin, hypoglycemic sulfonamides or glinides).

3. Oral clinical manifestations:

• Periodontal diseases:  There is a close relationship between diabetes and periodontal health. On the one hand, there is an increase in the incidence and severity of periodontal diseases in diabetic patients (3 times higher risk of developing periodontal disease).
•  On the other hand, the imbalance of diabetes is explained by insulin resistance following the production of pro-inflammatory cytokines during periodontal inflammation. 

Diabetes  

• Xerostomia  is common in diabetics. It is accompanied by an increase in salivary glucose and a decrease in salivary pH. This rapidly leads to a proliferation of dental plaque.

 – The increased  risk of caries  is explained by xerostomia and by the modification of the oral flora.

• The increased  risk of bacterial, viral and fungal infections  is explained by immunosuppression, following the disruption of leukocyte functions. Oral mycoses are the most common.
• – Alteration of taste is observed especially in diabetics treated with biguanides (Glucophage®).

Diabetes  

4. Complications of diabetes:

Repeated and prolonged hyperglycemia leads to long-term damage to the nerves and blood vessels throughout the body. 

 Complications that result in blindness, foot damage that can lead to amputations, heart attacks and strokes, erectile dysfunction, kidney failure or periodontal disease.

• Diabetes is a major risk factor for periodontal disease . 
• Periodontitis is three times more common in diabetic patients than in non-diabetics. 
• Which makes periodontitis the 6th complication of diabetes 
• Diabetes, especially when poorly controlled, leads to gingival inflammation and delays defense and healing processes.  
•  Conversely, periodontitis is also an aggravating factor in diabetes since periodontal inflammation increases insulin resistance via the blood (liver, muscle and fat cells become less sensitive to insulin and capture less glucose). 
• Classic periodontal treatment reducing oral bacterial impact decreases the glycated hemoglobin level by 0.4% in 3 months. 

5. Diabetes management in the dental office

Dental care is based on the balance of diabetes 

Diabetes  

• In diabetics, blood sugar testing provides an instant picture of blood sugar levels. But only measuring the glycosylated hemoglobin level can assess disease control  : in the dental office, management is based on Hb A1C.

1. Diabetic classification

HbA1c < 7% balanced diabetes

An HbA1c between 7% and 8% moderately balanced

An unbalanced HbA1c > 8% 

2. Key points

Stress can cause high blood sugar in diabetics due to the release of stress hormones, such as adrenaline. 

-An infection can lead to an imbalance in diabetes and the risk of an infectious focus spreading increases when blood sugar levels rise. 

[ Any poorly controlled diabetes makes an infection worse, and any infection makes diabetes worse .] 

3. General precautions

A complete annual or bi-annual dental examination is recommended for diabetic patients (balanced or not). 

– Limit patient  stress :

+Sedative premedication 

+Ensure effective analgesia is available before starting treatment.

-In insulin-dependent  diabetics , plan treatment preferably after a meal . 

-A source of glucose should be used in case of hypoglycemia. – Precautions regarding drug interactions. 

1. Clinical situation: HbA1c ≤ 7%

All treatments are possible while respecting general precautions. 

2. Clinical situation: HbA1c between 7% and 8%

                                 Non-invasive procedures

-Prevention actions 

-Conservative care

 -Non-bloody prosthetic care 

-Removal of stitches 

-Fitting of removable prostheses

 -Fitting/adjustment of orthodontic appliance 

 -Taking intraoral x-rays 

Observe general precautions 

3.    Clinical situation: HbA1c between 7% and 8% 

Invasive acts

All procedures involving manipulation of the gum, pulp or periapical region of the tooth, or in the event of damage to the oral mucosa (apart from local or locoregional anesthesia)

Limited invasive procedures:                                               

Scaling, simple extraction, endodontics….                           

Observe general precautions 

-Anti-infective protocol: level A 

Extensive invasive procedures: surgery… 

Respect general precautions – Anti-infective protocol: level B 

Anti-infective protocol: level A

Before care

-Any active infectious focus must be treated with curative antibiotic therapy 

-Reduce bacterial load: 

+Remove dental plaque and tartar present in the mouth 

+Prescribe antiseptic mouthwashes (CHX 0.12%) 

– Motivate the patient to oral hygiene

Antibiotic prophylaxis 

In the hour before treatment, the patient must take: 

-Orally: 2g of amoxicillin in adults, 50 mg/kg in children

 -If allergic to penicillins, orally: 600 mg of clindamycin in adults, or 20 mg/kg in children from 6 years old 

Anti-infective protocol: level A 

During care

If there is an infectious focus, administer the anesthesia at a distance from it. 

-Shortest possible session

 -Endodontics: care under dam 

-Surgery: 

+Maximum preservation of surrounding tissues 

+Rinsing the surgical wound with an antiseptic before suturing 

+Sutures by bringing the banks together 

         Anti-infective protocol: level A

After care

Antiseptic mouthwash for 7 days (CHX 0.12%)

 -Removal of sutures after 7 to 10 days with monitoring of mucosal healing 

Anti-infective protocol: level B

Before and during care

The same anti-infective protocol: level A

After care

Antiseptic mouthwash (CHX 0.12%) during the mucosal healing phase

 -Continuation of antibiotics during the mucosal healing phase (generally 7 to 10 days)

Antiseptic mouthwash (CHX 0.12%) during the mucosal healing phase -Continuation of antibiotics during the mucosal healing phase (generally 7 to 10 days) -Removal of sutures after 7 to 10 days with monitoring of mucosal healing -Removal of sutures after 7 to 10 days with monitoring of mucosal healing 

4. Clinical situation: HbA1c > 8%

A medical consultation is necessary before any therapeutic act. 

No intervention will be performed until the diabetes has stabilized.

There are two exceptions to this rule: 

• When the dental home is solely responsible for the diabetes imbalance,
• When dental lesions are urgent (pulpitis, cellulitis, etc.). 
• At this point, it is a question of intervening in a hospital environment…. 
• Precautions regarding anesthesia

Vasoconstrictors are not contraindicated 

-The injection should be slow and without force. 

5. Precautions regarding common prescriptions in dentistry

-Antibiotics: No special precautions regarding antibiotics generally prescribed by dentists. 

– Analgesics and anti-inflammatories: Corticosteroids should be used with caution in diabetics (high risk of hyperglycemia). If necessary, the treatment should be short and blood sugar monitoring should be reinforced. 

Some NSAIDs potentiate the effect of hypoglycemic sulfonamides inducing acute hypoglycemia. 

-Antifungals: 

+Miconazole (Daktarin°) by general route or oral gel is contraindicated in diabetics taking hypoglycemic sulfonamides (high risk of hypoglycemia). 

+Fluconazole (Triflucan°) is not recommended for diabetics taking hypoglycemic sulfonamides (high risk of hypoglycemia). 

If necessary, blood sugar monitoring must be reinforced. 

6. CONCLUSION

Diabetes is a common chronic noncommunicable disease with several complications and clinical manifestations that are more pronounced when diabetes is uncontrolled or poorly controlled. The WHO and the International Diabetes Federation (IDF) have declared diabetes a global pandemic. Their activities aim to raise awareness  of diabetes  and its complications,  improve the quality and access to diabetes education  , and  raise standards of treatment and care  worldwide.

There is a close relationship between endocrine balance and oral health, hence the crucial role of the dentist in screening and monitoring patients.

 In daily practice, the practitioner may be confronted with 3 risks in the diabetic patient, namely the risk of infection, the risk of hypoglycemic discomfort and the risk linked to the drug prescription. 

A good understanding of the risks and the patient’s condition will allow for optimal care

Diabetes  

  Sensitive teeth react to hot, cold or sweet.
Sensitive teeth react to hot, cold or sweet.
Ceramic crowns perfectly imitate the appearance of natural teeth.
Regular dental care reduces the risk of serious problems.
Impacted teeth can cause pain and require intervention.
Antiseptic mouthwashes help reduce plaque.
Fractured teeth can be repaired with modern techniques.
A balanced diet promotes healthy teeth and gums.
 

Diabetes