Diabetes mellitus

Dental aspects
Insulin-treated diabetes
• Circumoral paraesthesia a sign of impending
hypoglycemia.
• Neuropathy may cause cranial nerve deficits and
swelling of the salivary glands.
• Temporary lingual and labial paraesthesia may follow
the removal of mandibular third molar teeth.
• Burning mouth sensation in the absence of physical
changes.
• Dry mouth from dehydration.
• ‘Grinspan syndrome’ (diabetes, lichen planus and
hypertension).
 Dental aspects
Hypoglycemia
• Oral glucose should be administered just before the dental
appointment if a patient has taken their medication but has
not had the appropriate meal.
• Blood glucose level may be tested using a point-of-care
device prior to treatment, particularly before surgical
procedures, and oral glucose given if the level is < 5
mmol/L (180 mg/dL).
• If normal eating will not be resumed at lunchtime, a
postoperative blood glucose level may be taken and further
glucose given.
 Dental aspects
Drugs
• Drugs used should be sugar-free, avoiding those that can disturb diabetic
control:
– Corticosteroids, which increase blood glucose.
– Doxycycline, tetracyclines and ciprofloxacin, which enhance insulin hypoglycemia.
• Paracetamol (acetaminophen) or codeine is the analgesic of choice.
• NSAIDs should be used with caution:
– Renal damage.
– Risk of gastrointestinal bleeding.
– Many diabetics are on aspirin for prophylaxis of ischemic heart disease.
• The dentist should manage infections aggressively, as people with diabetes
may be immunocompromised, amoxicillin is the antibiotic of choice.
• LA can usually be safely used in diabetics.
• CS with benzodiazepines can usually be safely used.
 Dental aspects
• Autonomic neuropathy in diabetes can cause orthostatic hypotension;
therefore the supine patient should be slowly raised upright in the dental chair.
• Routine non-surgical procedures under LA can be carried out with no
special precautions, apart from ensuring that treatment does not interfere with
eating.
• In a well-controlled diabetic patient, providing that normal diet has been,
and can be, taken, it is feasible to carry out even minor surgical procedures,
such as simple single extractions under LA, as long as the procedure is carried
out within 2 hours of breakfast and the morning insulin injection, with no
change in the insulin regimen.
• More protracted procedures, such as multiple extractions, must only be carried
out in hospital.
• Poorly controlled diabetics (whether type 1 or 2) should also be referred for
improved control of their blood glucose before non-emergency treatment is
performed.
 Dental aspects
• Minor surgical procedures (e.g. simple single extractions
under LA, or minor operations under GA in hospital) can
be carried out provided that:
– Well-controlled insulin-dependent diabetic.
– Normal diet can be taken.
– The procedure is carried out within 2 hours of breakfast and
the morning insulin injection.
– No change in the insulin regimen.
– Operating early in the morning.
– Withholding both food and insulin from the previous
midnight, until after the procedure.
 Adrenal disorders
• The adrenal cortex secretes steroid hormones (such as
glucocorticoids, mineralocorticoids and sex steroids).
• The adrenal medulla secretes catecholamines (such as
adrenaline, noradrenaline and dopamine).
• Patients on long-term steroid treatment need a higher
dose during trauma, illness or surgery; otherwise, an
adrenal (Addisonian) crisis may occur.
• An adrenal crisis presents with hypotension, nausea,
vomiting, hypoglycaemia and drowsiness/coma.
 Dental aspects
• Phaeochromocytoma is occasionally associated with
oral mucosal neuromas (multiple endocrine adenoma
(MEA) type III syndrome).
• If bilateral adrenalectomy has been carried out, the
patient is at risk from collapse during dental treatment
and therefore requires corticosteroid cover.
• Patients, once treated, are maintained on
corticosteroid replacement therapy and are then at
risk from an adrenal crisis if subjected to operation,
anaesthesia or trauma.
Anterior pituitary hyperfunction
Growth hormone excess: gigantism and acromegaly
• Overproduction of growth hormone by an anterior pituitary adenoma causes
gigantism before the epiphyses have fused, and acromegaly thereafter.

• Dental management may be complicated by:

– Blindness, diabetes mellitus, hypertension, cardiomyopathy, arrhythmias and
hypopituitarism
– kyphosis and other deformities affecting respiration, which may make GA
hazardous.
• Mandibular enlargement leads to prognathism (class III malocclusion) with
spacing of the teeth and thickening of all soft tissues (face).
• Sialosis (diffuse, non-inflammatory, non-neoplastic recurrent enlargement
of the major salivary glands) may develop.
 Hypothyroidism
• The main danger is precipitation of myxoedema coma by the use of:
– Sedatives (including diazepam or midazolam).
– Opioid analgesics (including codeine) or tranquillizers.
• LA is satisfactory for pain control.
• CS can be carried out with nitrous oxide and oxygen.
– Diazepam or midazolam may precipitate coma.
• GA may be complicated because of:
– Possible ischemic heart disease and the danger of coma.
– The respiratory centre is also hypersensitive to drugs such as opioids or sedatives.
• GA, if unavoidable, should be delayed if possible until thyroxine has been
started.
• Associated problems may include hypoadrenocorticism, anaemia,
hypotension, diminished cardiac output and bradycardia.
• Povidone–iodine and similar compounds are best avoided.
 Hyperthyroidism
• Patients with sympathetic over activity in untreated
hyperthyroidism can be anxious and irritable, and may faint.
• The treated thyrotoxic patient presents no special problems in
dental treatment.
• LA is the main means of pain control.
• CS is frequently desirable to control excessive anxiety.
– Benzodiazepines may potentiate antithyroid drugs.
– Nitrous oxide is safer.
• Povidone–iodine and similar compounds are best avoided.
• Carbimazole occasionally causes agranulocytosis, which may
cause oral or oropharyngeal ulceration.
 Hypoparathyroidism

• There may be facial paraesthesia and facial twitching caused by tetany

(Chvostek’s sign).
• Congenital hypoparathyroidism may show:
– Enamel hypoplasia.
– Shortened roots with osteodentine formation.
– Delayed eruption.
– Chronic mucocutaneous candidiasis.
• LA is satisfactory.
• CS can be given, preferably after replacement therapy.
• Dental management may be complicated by:
– Tetany and seizures.
– Psychiatric problems or learning disability.
– Hypoadrenocorticism and diabetes mellitus.
– Arrhythmias.
 Hyperparathyroidism
• Dental changes
– Loss of the lamina dura.
– Generalized bone rarefaction.
– Giant cell lesions (brown tumours) are late and uncommon.
• LA is the main means of pain control, especially if hypertension and
arrhythmias are present.
• CS is preferably carried out with nitrous oxide and oxygen.
• GA may be challenging because of cardiovascular complications and
sensitivity to muscle relaxants.
• Dental treatment in hyperparathyroidism may be complicated by:
– Renal disease.
– Peptic ulceration.
– Bone fragility.