Introduction
Diabetes is a chronic disease resulting in hyperglycemia due to insufficient insulin production by the pancreas, or from ineffective utilization of insulin that is produced. If not controlled, it can result in cardiovascular, cerebral and peripheral diseases.
With respect to dental treatment, a primary concern is when poorly controlled glucose levels act to impair a patient's immune function. This can lead to delayed or inadequate wound healing and possibly infection when performing invasive dental procedures such as surgeries, extractions or periodontal treatment. Research shows increased an incidence of gingival inflammation and alveolar (tooth socket) bone loss in poorly controlled diabetics.
Diabetic patients whose symptoms are adequately controlled are at far less risk from these issues. Studies show that diabetic patients who maintain good oral hygiene and dietary management are at no greater risk of developing caries than the general population.
Diabetic control can be monitored short-term by measuring plasma glucose levels. A fasting plasma glucose of 70-100 mg/dL is normal whereas greater than 200mg/dL indicates diabetic condition. A more accurate long-term glycemic monitoring system measures glycosylated hemoglobin (HbA1c) levels, which is essentially glucose attached to hemoglobin found in red blood cells.
Dental Treatment of the Diabetic Patient
Patients with well controlled diabetic condition are good candidates for routine dental treatment and oral surgical procedures done in a general practice, with local anesthesia or moderate sedation (inhalation and/or oral). However, those patients with poor glycemic control and/or severe complications may need to have their dental care performed in a hospital setting.
When doing any sort of dental treatment on the diabetic patient, consideration should be given to the timing and length of the appointment. Early morning and early afternoon appointments are preferred as this is less likely to disturb food and drug routines.
There is no evidence supporting the need for use of prophylactic antibiotics for well-controlled diabetic patients, as there is no proven greater risk of post-operative infection compared to healthy patients. Antibiotic prophylaxis should only be given in situations where it would also be used for a systemically healthy individual, as well as for uncontrolled diabetics undergoing invasive emergency procedures. Poorly controlled diabetics should be referred to their primary care physician to ensure controlled glycemic levels are achieved before any elective dental treatment is planned.
An important consideration to take into account when assessing a diabetic patient is the reciprocal relationship that exists between periodontal health and glycemic control. Although more research is needed, is has been shown that treating periodontal disease in the diabetic patient can significantly improve glycemic control. This is in part due to how periodontal disease allows oral pathogens to gain access to systemic circulation. The chronic bacteremia that ensues results in an elevated systemic inflammatory state. It thereby follows that acting to rid periodontal tissues of the source of chronic bacteremia can improve overall systemic health.