A Practical Approach to Special Care in Dentistry. Группа авторов

Examination

       Orthopantomogram undertaken (Figure 5.1.1)

       Delayed tooth eruption, with persistence of teeth #64, #74 and #84

       Premature loss of tooth #83, due to eruption of #42

      Structured Learning

      1 Is there any connection with this patient's diagnosis of type 1 diabetes mellitus and coeliac disease?Type 1 diabetes mellitus is often associated with other autoimmune diseasesAlthough the most common coexisting organ‐specific autoimmune disease is autoimmune thyroid disease, coeliac disease may also be presentApproximately 8% of people with type 1 diabetes will also have coeliac diseaseCoeliac disease increases the risk of hypoglycaemia if a strict gluten‐free diet is not followedFigure 5.1.1 Panoramic radiography showing caries and a prior filling in tooth #54.

      2  Why is a dental abscess of particular concern for this patient?Diabetes mellitus is known to be associated with increased risk of infection and impaired wound healing due to the chronic effects of hyperglycaemia:Neutrophil function (adherence, chemotaxis and phagocytosis) may be downregulated; neutrophils also produce fewer free oxygen radicals, thereby reducing their ability to make toxic metabolites for release against microbesMonocyte, macrophage and fibroblast functions are impaired, resulting in impaired tissue turnover and wound repairOral infection, pain and stress can result in alteration of blood glucose levels and lead to poor diabetic controlThe stress response elicited results in the release of hormones such as cortisol and adrenaline which work against the action of insulinAs a result, the body's production of glucose increases, which results in high blood sugar levelsAn insulin adjustment may be required

      3 You decide it would be better to control the acute infection in #54 and extract the tooth at a later date. What should you consider when prescribing antibiotics?Administration of antibiotics can alter the blood glucose level and require an insulin dose adjustmentCoeliac disease may affect the absorption of antibiotics; antibiotics known to be associated with an increased risk of gastrointestinal toxicity should be avoidedAvoid azithromycin and metronidazole because they boost the action of hypoglycaemic agents

      4 What factors are considered important in assessing the risk of managing this patient?SocialConsent: the parents are divorced and do not have a good relationship; their opinion regarding the proposed extraction of the #54 may differ (although there can be legal differences in the law from one country to another)Anxiety may be heightened due to the above social factorsLimited co‐operationMedicalHypoglycaemia risk: unable to eat properly due to the dental pain; fasting after dental procedures can also trigger a hypoglycaemic episodeHyperglycaemia risk: emotional and surgical stress can result in increased glucose levelsReduced co‐operation may be misinterpreted as related to generalised anxiety instead of abnormal glucose levelsEfficacy of oral medication may be impacted by poor absorption secondary to coeliac diseaseDentalIncreased susceptibility to infectionLikelihood of delayed healing after dental extractionIncreased caries risk (xerostomia; father does not assist with toothbrushing)Coeliac disease can cause enamel defects and mouth ulcers (as observed for this patient)Delayed dental development (coeliac disease and diabetes)

      5 The patient injects a daily dose of fast‐acting insulin at 8 a.m. and a dose of long‐acting insulin at 10 p.m. At what time should you schedule the dental extraction?Fast‐acting insulin will have its peak effect between 9 a.m. and noonLong‐acting insulin will have its peak effect around 10 a.m.Ideally, the treatment should be performed in the morning, because the risk of hypoglycaemia is lower when the concentration of endogenous corticosteroids increases. This should be as soon as possible after breakfast (also avoids interfering with the next meal)

      6 What laboratory tests are recommended before the tooth extraction?Serum glucose concentration before starting the procedureRecent HbA1c reading to determine the degree of metabolic control; postpone treatment if HbA1c >9%Figure 5.1.2 (a–c) Severe periodontal disease in a 37‐year‐old male with diabetes mellitus.

      General Dental Considerations

      Oral Findings

       Occasionally, oral findings can represent an initial manifestation of undiagnosed diabetes

       Periodontal disease is the most common oral finding (Figure 5.1.2 ). Its pathogenesis involves vascular changes (microangiopathy), neutrophil dysfunction and collagen metabolism deficiencies. The presence of periodontitis impedes glycaemic control and contributes to the onset of other extraoral complications

       Susceptibility to bacterial (including odontogenic abscesses) and fungal infections (such as oral candidiasis and mucormycosis in the sinuses)

       Xerostomia, which can favour the onset of caries (Figure 5.1.3). Chronic bilateral and asymptomatic inflammation of the parotid glands (sialosis) can develop as a compensatory mechanism

       Burning mouth syndrome (probably related to peripheral neuropathy)

       Circumoral paraesthesia (associated with peripheral neuropathy)

       Glossitis, loss of the filiform papillae and dysgeusiaFigure 5.1.3 Xerostomia – depapillated, smooth dry dorsum of the tongue.

       High prevalence of oral lichen planus

       Mucosal lichenoid reactions and facial flushing (secondary effects of antidiabetic drugs)

       Delayed tooth eruption

      Dental Management

       The dental treatment plan will be determined mainly by the patient's previous oral health and degree of metabolic control (Table 5.1.1)

       The dental team should be aware of how to manage hypoglycaemic events in the dental clinic (Table 5.1.2)

Section II: Background Information and Guidelines

      Definition

      Diabetes mellitus is a chronic metabolic disorder characterised by a relative or absolute absence of insulin. Although various types of diabetes have been described (type 1, type 2 and gestational), all are characterised by high blood glucose levels. Worldwide, there are more than 420 million individuals with diabetes (approximately 9% of the worldwide adult population), although it has been estimated that more than 40% of cases are still undiagnosed.

      Aetiopathogenesis

       Type 1 diabetes: ~8% (previously known as insulin‐dependent or juvenile‐onset)The beta cells in the pancreas produce little or no insulinExogenous insulin must therefore be administered throughout the patient's lifeMost cases have an autoimmune aetiology, although some are idiopathic

       Type 2 diabetes: ~90% (previously known as non‐insulin‐dependent or adult‐onset)The insulin receptors in the target tissues show reduced sensitivity to the action of insulin (insulin resistance), although insulin production can be normalAs the disease progresses, a lack of insulin may also developGenerally associated with a genetic predisposition, obesity or metabolic syndrome (combination of diabetes, hypertension and obesity)

       Gestational diabetesTriggered by an increase in insulin resistance that causes impaired glucose tolerance during pregnancy

       Secondary