A Practical Approach to Special Care in Dentistry. Группа авторов

Cushing disease), drugs (e.g. corticosteroids) or pancreatic disease (surgery, tumour or inflammation)

      Clinical Presentation

       Type 1: usually presents before the age of 40 years

       Type 2: average age of onset is 45 years old

       Classic symptoms, especially those of undiagnosed type 1 diabetesPolyuria (frequent voiding), polydipsia (excessive thirst) and polyphagia (excessive hunger)Fatigue, infections, slow wound healing, blurred vision, weight loss

       Hypoglycaemia (onset can be rapid; more frequent; life‐threatening)Early signs/symptoms: shakiness, dizziness, sweating, hunger, piloerection, tachycardia, inability to concentrate, confusion, irritability or moodiness, anxiety (due to increased epinephrine activity) or nervousness, headacheLater signs/symptoms: clumsiness or jerky movements, inability to eat or drink, muscle weakness, difficulty speaking or slurred speech, blurry or double vision, drowsiness, confusion, convulsions or seizures, unconsciousness, death

       Hyperglycaemia (slower onset, more protracted course)Early signs/symptoms: frequent urination, increased thirst, blurred vision, fatigue, headacheLater signs/symptoms: fruity‐smelling breath, nausea and vomiting, shortness of breath, dry mouth, weakness, confusion, abdominal pain, comaTable 5.1.1 Considerations for dental management.Risk assessmentHypoglycaemia is the main risk and must be managed urgently (see Table 5.1.2)HyperglycaemiaFatigue/reduced tolerance for long treatmentIncreased risk of infectionPoor wound healingIncreased risk of periodontal diseaseComplications related to comorbidities/secondary vascular complicationsCriteria for referralIf HbA1c levels are <7%, any type of dental treatment can generally be performed within the dental clinicFor patients with poorly controlled diabetes (HbA1c >9%), only emergency treatments should be conducted and surgical procedures should preferably be undertaken in a hospital settingWith HbA1c readings >12%, all procedures should be postponed until the glycaemic control has improvedAccess/positionThe sessions should preferably be scheduled for the morning (higher endogenous cortisol levels increase blood glucose and decrease the risk of hypoglycaemia)Avoid scheduling an appointment time that coincides with the maximum insulin activity peak or when it may lead to a meal being missedCommunicationA significant percentage of individuals with diabetes are unaware of their conditionPatients with signs/symptoms or oral findings suggestive of diabetes should be referred to their doctor for investigationCommunication may be impaired if blood glucose levels are not controlled (slurred speech, confusion)Consent/capacityPatients should be informed that the dental treatment plan and its success will be determined by the degree of diabetic control (e.g. success rates for dental implants are lower for patients with suboptimal diabetes control)Patients should be warned of the potential for local and systemic complications resulting from diabetes (increased infection risk, delayed healing)If diabetic control is poor, the patient may be confused, anxious and/or agitated – this will reduce their capacity to give consentAnaesthesia/sedationLocal anaesthesiaAny local anaesthetic may be employed by following the routine precautionsSedationControlling the patient's stress is importantFor patients with poor metabolic control and comorbidities, sedation should be performed in a hospital settingGeneral anaesthesiaThe use of general anaesthesia is determined by the severity of the comorbiditiesDental treatmentBeforeConfirm that the patient has eaten normally and has taken the scheduled medicationThe presence of an oral infection and the administration of antibiotics can change the insulin requirements and might require adjustment by a physicianThe physician should also be consulted if the planned procedure is expected to change the normal eating habitsFor an oral surgical or periodontal procedure, anticipate the postintervention fasting/changes in dietAssess the need for antibiotic prophylaxis (not supported by scientific evidence)Performing a new rapid HbA1c test may be consideredDuringDental implants can be placed successfully in patients with well‐controlled diabetesThe main complication during dental treatment is hypoglycaemiaAfterSlow healing of the surgical wound is commonDue to the increased risk of infection, consider the need for postoperative antibiotics, if an invasive procedure is undertaken (especially for patients with poor disease control)Once the session has finished, slowly sit the patient up from the supine position (postural hypotension due to autonomic neuropathy)Periodontal treatment has been shown to produce a modest improvement in glycaemic controlIt has been suggested that the success rate of endodontic treatment is lower than that for the general population, especially for patients with poorly controlled diabetes (as has been reported for dental implants)Drug prescriptionThe antibiotic of choice is amoxicillinAvoid using metronidazole and azithromycin because they can boost oral hypoglycaemic agentsAvoid ciprofloxacin because it can compete with insulinThe analgesic of choice is paracetamolAvoid using aspirin, ibuprofen, diclofenac and naproxen because they can boost oral hypoglycaemic agentsAvoid corticosteroids because they can decrease the efficacy of oral hypoglycaemic agentsEducation/preventionPatients with diabetes usually recognise the signs and symptoms of hypoglycaemia. In any case, dentists should know how to identify and manage urgent episodes, especially hypoglycaemia (see Table 5.1.2)Maintaining optimal oral hygiene and regular reviews, with a specific focus on periodontal disease, should be routine for patients with diabetesRemoving any removable prosthesis at night and renewing them periodically are essential for preventing denture‐induced stomatitisTable 5.1.2 Managing hypoglycaemia in the dental clinic^a.Alert/responsive patientCheck blood glucose levelIf <3.0 mmol/L (54 mg/dL), give glucose/sugary drink or pure glucose (2 tablets)Recheck blood glucose level after 10–15 minutesGive the patient a complex carbohydrate (biscuits, sandwiches, etc.) to ensure that a sustained release of glucose is maintainedConfused patientCheck blood glucose levelIf <3.0 mmol/L (54 mg/dL), give sublingual dextrose gel (repeated at 10–15 minutes)Recheck blood glucose level after 10–15 minutesAs the level increases, give the patient a complex carbohydrate (biscuits, sandwiches, etc.) to ensure that a sustained release of glucose is maintainedUnconscious patient (blood glucose <2.8 mmol/L or 50 mg/dL)Call for medical assistanceIntramuscular glucagon 1 mg (adults/children over the age of 8 years); 0.5 mg for children under the age of 8 years; not as effective if a patient has liver disease or is anorexicMonitor airway, breathing and circulation throughouta UK Resuscitation Council.

        Long‐term complications cause significant morbidity and mortalityOverproduction of reactive oxygen species as a result of metabolic disturbance results in endothelial dysfunction and inflammation; this provokes diabetic vascular changesMacrovascular changes include:Table 5.1.3 Criteria for the diagnosis of diabetes (WHO).NormalPrediabetesDiabetesFasting plasma glucose (FPG)≤5.5 mmol/L (<100 mg/dL)5.6–6.9 mmol/L (100–125 mg/dL)≥7.0 mmol/L (126 mg/dL)Oral glucose tolerance test (OGTT) – 2 hours after 75 g anhydrous glucose dose dissolved in water≤7.7 mmol/L (<140 mg/dL)7.8–11.0 mmol/L (140–199 mg/dL)≥11.1 mmol/L (200 mg/dL)Glycated haemoglobin in plasma (HbA1c) – glycaemic history for lifespan of an erythrocyte (2–3 months)≤39 mmol/mol (<5.7%)(39–47 mmol/mol) (5.7–6.4%)≥48 mmol/mol (≥6.5%)Symptoms of high blood sugar and random plasma glucose test––≥11.1 mmol/L (200 mg/dL)Angina pectoris, myocardial infarction, cerebral infarction and claudicationMicrovascular changes include:Diabetic retinopathy (neovascularisation, vitreous haemorrhaging, retinal detachment and blindness)Diabetic nephropathy, which is the main cause of dialysis and kidney transplantation in high‐income countriesPeripheral sensory polyneuropathy and autonomic neuropathyRecurrent infectionsDelayed healingIncreased risk of developing dementia

      Diagnosis

       When symptoms of diabetes are present, 2 or more repeat tests are undertaken to confirm the diagnosis, as summarised in Table 5.1.3

       Elevated HbA1c