Oral Health Topics

Diabetes

Key Points
Diabetes mellitus is a group of metabolic diseases  that lead to high levels of blood glucose
(hyperglycemia), which is caused when the body does not make any or enough insulin, or does
not use insulin well.
Because diabetes is a relatively common condition, practicing dentists are likely to encounter
it frequently.
Type 1 diabetes is a chronic autoimmune disease in which the beta cells in the pancreas create
little to no insulin, and accounts for 5% to 10% of all diabetes cases. In contrast, Type 2
diabetes accounts for 85% to 90% or more of diabetes cases and is one of the commonest
chronic diseases, characterized by decreased response of target tissues to insulin, dysregulation
of insulin production, or a combination of both.
As with any patient, the dentist should review the patient’s medical history, take vital signs,
and evaluate for oral signs and symptoms of inadequately controlled diabetes, which may be
common. Oral manifestations of uncontrolled diabetes can include: xerostomia; burning
sensation in the mouth; impaired/delayed wound healing; increased incidence and severity of
infections; secondary infection with candidiasis; parotid salivary gland enlargement; gingivitis;
and/or periodontitis.
Although patients with diabetes usually recognize signs and symptoms of hypoglycemia and
self-intervene before changes in or loss of consciousness occurs, staff should be trained to
recognize the signs and treat patients who have hypoglycemia.  In such cases, a glucometer
should be used to test patient blood glucose levels, and every dental office should have a
protocol for managing hypoglycemia in both conscious and unconscious patients.

Introduction
Diabetes mellitus is a group of metabolic diseases that leads to high levels of blood glucose
and is caused when the body does not make any or enough insulin, or does not use insulin
well. In 2012, it was estimated that 29.1 million people in the U.S. (i.e., 9.3% of the population)
had some form of diabetes; of these, the disease was undiagnosed in 8.1 million people,
meaning that almost 28% of people with diabetes were undiagnosed. Because diabetes is a
relatively common condition, practicing dentists are likely to encounter it frequently.
Disease Description

Classification
Classification of diabetes is based on the pathogenic processes that can lead to either absolute
or relative lack of insulin, resulting in hyperglycemia (high blood glucose). Insulin is a hormone
produced by pancreatic beta islet cells, which is needed for the uptake of blood glucose by cells
to produce energy. When there is a lack or absence of insulin, or when cells are insensitive to its
actions, a high circulating level of blood glucose results (i.e., hyperglycemia). Although there
are various causes for less common types of diabetes, including drug- or chemical-induced
diabetes, exocrine pancreatic disease, or infections (e.g., cytomegalovirus), the two most
common subtypes of diabetes are known as Type 1 or Type 2 diabetes.

Type 1 diabetes, formerly known as juvenile diabetes, is a chronic autoimmune disease in

which the beta cells in the pancreas create little to no insulin and accounts for 5% to 10% of all
diabetes cases. Autoimmune destruction of beta cells is the most common cause, although any
loss of pancreatic tissue (e.g., pancreatitis, surgical removal of the pancreas) can lead to insulin
dependence. Type 1 diabetes is generally diagnosed in younger individuals (usually younger
than 25 years of age) and has a strong genetic predisposition. Exogenous insulin is needed to
regulate blood glucose levels in people with Type 1 diabetes.

In contrast, Type 2 diabetes accounts for 85% to 90% or more of diabetes cases and is one of
the most common chronic diseases, as well as one of the leading causes of death and disability
in the U.S. Type 2 diabetes is characterized by decreased response of target tissues to insulin,
requiring increasing levels of insulin for an adequate response, dysregulation of insulin
production, and insulin resistance. Type 2 diabetes is associated with excess weight, physical
inactivity, family history of diabetes, and certain ethnicities. Although some people with Type 2
diabetes can help improve their glycemic control with diet, exercise, and weight loss, patients
may require insulin sensitizers that help peripheral tissues take up glucose (i.e., biguanides
[metformin] or thiazolidinediones) or oral hypoglycemic agents that either stimulate release of
insulin (i.e., insulin secretagogues such as sulfonylureas).
Another type of diabetes is gestational diabetes, a state of glucose intolerance that occurs in
pregnant women who don’t otherwise have diabetes. Occurring in the second half of a
pregnancy, gestational diabetes is caused by placental hormones and results in insulin resistance
and relative insulin deficiency. Although true gestational diabetes resolves during the
postpartum period, those who have had gestational diabetes are at increased risk of in
developing Type 2 diabetes later in life. The term “prediabetes” is used when blood glucose
levels are higher than normal, but not high enough for a formal diagnosis of diabetes.
Prediabetes means a person is at increased risk for developing Type 2 diabetes, as well at
increased risk for heart disease and stroke. Although lifestyle modification involving weight
loss and engaging in moderate physical activity can help people with prediabetes delay or
prevent the onset of Type 2 diabetes, it is estimated that as many as 90% of those with
prediabetes are unaware that they have prediabetes.
Symptoms/Diagnosis
Initial symptoms of diabetes include increased thirst and urination. Other symptoms can
include unexplained weight loss, fatigue, blurred vision, increased hunger, and sores that do not
heal.

Blood tests are generally used in the diagnosis of diabetes and prediabetes.  Tests used include
measurement of hemoglobin A1c*, which is a measure of glycosylation of the hemoglobin
molecule, fasting blood glucose measurement, and/or an oral glucose tolerance test. 

*The A1C test is a common blood test used to diagnose type 1 and type 2 diabetes. If you're
living with diabetes, the test is also used to monitor how well you're managing blood sugar
levels. The A1C test is also called the glycated hemoglobin, glycosylated hemoglobin,
hemoglobin A1C or HbA1c test. An A1C test result reflects your average blood sugar level for
the past two to three months. Specifically, the A1C test measures what percentage of
hemoglobin proteins in your blood are coated with sugar (glycated). Hemoglobin proteins in red
blood cells transport oxygen. The higher your A1C level is, the poorer your blood sugar control
and the higher your risk of diabetes complications.

Complications
Over time, individuals with diabetes sustain progressive damage to nerves and blood vessels
due to elevated levels of circulating glucose, which can increase the incidence and severity of
complications such as heart disease, stroke, kidney disease, blindness, dental disease, and
amputations. Additionally, diabetes may increase susceptibility to other diseases, impair
mobility, contribute to depression, and cause problems during pregnancy.

Glucose Control
Three common complications that can occur when glucose levels are not well controlled are
hypoglycemia, hyperglycemia and diabetic ketoacidosis.

Hypoglycemia is a condition in which blood glucose levels drop below normal. For many
people with diabetes, this means a blood glucose level of 70 milligrams/deciliter (mg/dL) or
less. Hypoglycemia also may be referred to as “insulin shock” or “insulin reaction.” Untreated
hypoglycemia can result in unconsciousness, coma or death.

Several situations can lead to hypoglycemia:

Adverse effect of insulin or other diabetes medications;
Disruption in food intake (timing of a dental appointment, illness/nausea, vomiting, diarrhea,
skipping or delaying a meal, etc.);
Drinking too much alcohol for the amount of food being eaten;
An unexpected/unplanned increase in physical activity.
Symptoms of hypoglycemia may include changes in mental state or emotions, or physical
symptoms.

Symptoms of Mild-to-Moderate Hypoglycemia

 Shakiness
 Sweating
 Fast or irregular heartbeat
 Dizziness or lightheadedness
 Hunger
 Nervousness
 Change in behavior or personality
 Tingling or numbness of the lips or tongue
 Sleepiness
 Blurred vision
 Loss of coordination
 Headaches
 Weakness
 Trouble concentrating, confusion
 Paleness
 Irritability
 Argumentative, combative
Symptoms of Severe Hypoglycemia
 Unable to eat or drink
 Seizures or convulsions
 Unconsciousness

Treatment. If hypoglycemia is suspected, immediate treatment should be implemented.

Check the patient’s blood glucose levels using a glucometer. Levels that are ≤70 mg/dL
indicate hypoglycemia.  
Provide the patient with 15-20 grams of oral carbohydrates to eat or drink, such as:
 4 glucose tablets or one tube of glucose gel;
 ½ cup of fruit juice* or regular (non-diet) soda;
 1 tablespoon of sugar, honey or corn syrup;
 8 ounces of non-fat or 1% milk;
 Hard candies, jelly beans or gumdrops;
 2 tablespoons of raisins.
(*NOTE:  People who have concomitant kidney disease should not drink orange juice for their
15 grams of carbohydrates because of the high potassium content.7 Apple, grape, or cranberry
juice cocktail are good alternatives.)

Wait 15 minutes, then check blood glucose levels again.

Repeat these steps until blood glucose levels are above 70 mg/dL.

In severe cases, hypoglycemia can cause unconsciousness, seizures or coma. If the dental
patient is not awake and/or unable to eat or drink, emergency medical help should be
summoned.  Injectable glucagon, available by prescription, signals the liver to release glucose
into the bloodstream, and can help restore blood glucose levels to normal in emergencies. 
Glucagon may be administered while waiting for help to arrive.

Hyperglycemia.  Hyperglycemia occurs when blood glucose levels are abnormally high.  This
can occur anytime there is not enough insulin in the bloodstream or the body is not using insulin
properly.

Several conditions can lead to hyperglycemia (e.g., pancreatitis, Cushing’s syndrome,

pancreatic cancer, adrenal hormone insufficiency), but it is a primary symptom of diabetes. 
Untreated hyperglycemia can damage the cardiovascular, circulatory or nervous systems, the
kidneys or vision. It can also result in slowed wound healing. In more serious cases, extreme or
prolonged hyperglycemia, can cause a life-threatening condition called ketoacidosis (see below
for further discussion).

A number of circumstances can lead to hyperglycemia in people with diabetes:

o Low insulin levels, which can occur either when insufficient insulin is used (e.g.
miscalculation in the amount injected or an insulin-pump malfunction) or when insulin is
not used efficiently by the body;
o Eating more than planned or exercising less than planned according to the amount of
insulin taken;
o Stress, either physical (e.g., illness-related or medical/dental procedure-related) or
emotional (e.g., conflict, personal loss).

Symptoms of hyperglycemia include:

 high levels of sugar in the urine;
 frequent urination;
 increased thirst;
 fatigue;
 blurred vision.
Treatment.  Lifestyle changes, like increased exercise or eating a healthy, well-proportioned
diet, may help control hyperglycemia. (NOTE: People with diabetes whose glucose level is
above 240 mg/dL should check their urine for ketones.  If ketones are present, they should not
exercise and should consult their physician for other ways to reduce their blood sugar levels.)  If
these changes don’t help resolve hyperglycemia, a physician may recommend adjusting current
medications or prescribing new or additional medication to better manage glucose levels.

Diabetic Ketoacidosis. 
Diabetic ketoacidosis is a serious condition that can develop when there is not enough insulin
to help the body adequately use glucose.

Diabetic ketoacidosis develops when the balance between glucose and insulin levels is not
well controlled.  The body typically metabolizes glucose to generate energy.  When insulin
levels are too low, the body begins to break down fat cells for energy instead, which results in
the production of acidic ketones in the blood. Buildup of ketones in the blood can be toxic.

Without intervention, which usually must be done in a hospital, coma or death can occur.

Symptoms.  The following symptoms may indicate diabetic ketoacidosis:

 breath that smells fruity;
 very dry mouth;
 high blood glucose levels;
 high levels of ketones in the urine;
 frequent urination;
 shortness of breath;
 constant tired feeling;
 dry or flushed skin;
 nausea, vomiting or abdominal pain;
 difficulty concentrating or confusion.

Treatment.  If ketoacidosis is suspected, the symptomatic person should be taken to the nearest
emergency room or that person’s physician should be immediately contacted.

Monitoring Glucose Levels.  Blood-glucose levels can be checked chairside using a drop of
blood. Glucometers designed for use in a variety of settings, such as nursing homes, health fairs
or dental clinics, are available by prescription. Because they are intended for use by multiple
individuals, they are designed to facilitate thorough cleaning and disinfection between uses to
help prevent the spread of bloodborne pathogens. After each use, the device must be cleaned
and disinfected according to the manufacturer’s instructions.
Staff should be familiar with glucometer use to help avoid errors that could affect the reading
such as improper use, problems with the device or reagents used with the device, or
environmental problems like lighting. Inaccurate readings may occur when the blood sample is
too small; taken from a site not intended by the manufacturer; not properly applied to the strip;
or contaminated.

Periodontal Disease and Diabetes

Periodontal disease is commonly seen in people with diabetes, and is considered a
complication of diabetes. Interestingly, the relationship between diabetes and periodontal
disease is seen to be bidirectional, meaning that hyperglycemia affects oral health while
periodontitis affects glycemic control (e.g., increased HbA1c). Research also suggests that
periodontitis is associated with poor glycemic regulation, but the evidence is inconsistent,
particularly in patients with type 1 diabetes. Most research indicates an association between
periodontal disease and increased risk ofdiabetes-relatedcomplications.

A 2018 systematic review and meta-analysis update of a 2012 review confirmed findings that
periodontitis is associated with (1) higher HbA1c levels in persons without diabetes and persons
with type 2 diabetes, (2) worsened complications from diabetes in people with type 2 diabetes,
and (3) a higher prevalence of complications in persons with type 1 diabetes. The study also
found that periodontitis is associated with higher prevalence of prediabetes, and that severe
periodontitis is statistically significantly associated with an increased risk of developing
diabetes.

Diabetes and smoking are both considered risk factors for periodontitis. There is some
evidence that smoking and diabetes may have a synergistic effect, although the mechanism(s)
responsible are unclear as changes to the oral microbiome, inflammatory response, and even
periodontal health are not consistently reported to be altered when comparing people with
diabetes who do andsdosnotssmoke.

PeriodontalsTreatmentsandsGlycemicsControl
There is inconsistent, but suggestive, evidence that periodontal treatments, including scaling
and root planing, may result in improvement of glycemic control. A 2018 systematic review of
observational studies found “insufficient evidence to evaluate the impact of periodontitis on
glycemic control” in persons with type 1 diabetes, but that periodontitis is associated with
higher HbA1c and worse diabetes-related complications in persons with type 2 diabetes. A 2018
systematic review of meta-analyses of randomized controlled trials (RCTs) reaffirmed earlier
findings that periodontal treatment (i.e., scaling and root planing) significantly reduces HbA1C
levels at 3 months, with even more reduction after 6 months. Results from RCTs, however, are
not entirely consistent: a 2013 study of patients with type 2 diabetes found no improvement in
glycemic control following periodontal therapy, and a 2018 study found no significant change
in glycemic control in patients with Type 1 or Type 2 diabetes. Despite lack of a consensus on
treatment outcomes in controlling glycemic levels, it is generally agreed that patients with
diabetes benefit from periodontal therapy in conjunction with good oral health maintenance at
home.

Dental Considerations for People with Diabetes

Diabetes can arise in individuals at any age. As with all patients, the dentist should review the
patient’s medical history, take vital signs, and evaluate for oral signs and symptoms of
inadequately controlled diabetes, which may be common. Oral manifestations of uncontrolled
diabetes can include xerostomia, burning sensation in the mouth (which may possibly be related
to neuropathy), impaired/delayed wound healing, increased incidence and severity of infections,
secondary infection with candidiasis; parotid salivary gland enlargement; gingivitis and/or
periodontitis.

Key questions a dentist may want to ask a patient with diabetes follow:

o How old were you when you were diagnosed with diabetes and what type of diabetes do
you have? How long has it been since the diagnosis?
o What medications do you take?
o How do you monitor your blood sugar levels?
o How often do you see your doctor about your diabetes? When was your last visit to the
doctor?
o What was the most recent HbA1c (A1C) result?
o Do you ever have episodes of very low (hypoglycemia) or very high blood sugar
(hyperglycemia)?
o Do you ever find yourself disoriented, agitated, and anxious for no apparent reason?
o Do you have any mouth sores or discomfort?
o Does your mouth feel dry?
o Do you have any other medical conditions related to your diabetes, such as heart disease,
high blood pressure, history of stroke, eye problems, limb numbness, kidney problems,
delays in would healing, history of gum disease? Please describe.

In general, morning appointments are advisable in patients with diabetes since endogenous
cortisol levels are typically higher at this time; because cortisol increases blood sugar levels, the
risk of hypoglycemia is less. For patients using short- and/or long-acting insulin therapy,
appointments should be scheduled so they do not coincide with peak insulin activity, which
increases the risk of hypoglycemia.  It is important to confirm that the patient has eaten
normally prior to the appointment and has taken all scheduled medications. If a procedure is
planned with the expectation that the patient will alter normal eating habits ahead of time (e.g.,
conscious sedation), diabetes medication dose may need to be modified in consultation with the
patient’s physician. Patients with well-controlled diabetes can usually be managed
conventionally for most surgical procedures. If the patient’s food consumption will be affected
after oral or dental surgery, a plan to balance the patient’s diabetes medications and food intake
should be established in advance.
Dentists should be on the side of caution when treating patients with marginally or poorly
controlled diabetes.  Exercising good clinical judgment is essential because, in some situations,
elective dental treatment may need to be delayed  until the patient’s diabetes is considered
stable or better controlled. Dental implants can be placed in patients with well-controlled
diabetes, and possibly in those with moderately controlled disease. However, implant placement
in patients with poorly controlled disease has an unpredictable prognosis and, if possible,
should be avoided.

Coordination with the patient’s physician may be necessary to determine the patient’s health
status and whether planned dental treatment can be safely and effectively
accomplished. Physicians should make laboratory test results available to the dentist upon
request, and inform the dentist of any diabetic complications of relevance to the individual
patient prior to dental procedures.  The physician may need to adjust the patient’s diabetes
medication to help ensure sustained metabolic control, before, during, and after surgical
procedures.

Emergency Management.  Although patients with diabetes usually recognize signs and
symptoms of hypoglycemia and self-intervene before changes in or loss of consciousness
occurs, they may not. Staff should be trained to recognize the signs (e.g., unusual behavior or
profuse sweating in patients who have diabetes) and treat patients who have hypoglycemia; a
glucometer should be used to test patient blood glucose levels. Every dental office should have
a protocol for managing hypoglycemia in conscious and unconscious patients. Having snack
foods or oral glucose tablets or gels available, especially in practices where a large number of
surgical procedures are performed, is also prudent.