Diabetic Patient

 A diabetic patient visiting our clinic requiring dental treatment-
===============================================

 

 What are the factors that you should discuss with the Dentist? 

 

  And what are the factors that the dentist will consider in your management?

 

 

 

 

 Factors which should be discussed with a diabetic patient include:

· * The nature of his diabetic condition, whether it is properly controlled or not, and the line of diabetes control this patient is following

· * The associated chronic complications he/she might be suffering

· * The incidence of acute complications before

· * The nature of the dental treatment required and the most appropriate type of anesthesia, and the associated management of diabetes mellitus.

· * Special precautions before, during and after the dental appointment

· * History taking related to possible dental complications associated with diabetes mellitus

We must determine whether the patient is suffering from type I (insulin dependent diabetes mellitus) or type II (Non insulin dependent diabetes mellitus) or less commonly type III which develops in pregnant females. 

Type I has an early onset in life and it mainly develops as a result of reduced release of insulin from the beta cells of islets of Langerhans in the pancreas. It is mainly treated by the administration of insulin. It is common in Caucasians, Europeans especially in Finland and Sweden.

Type II has a late onset, usually beyond the age of 45. It develops mainly as a result of increased resistance of the peripheral tissues to the action of insulin. It is mainly treated with oral hypoglycaemics. 

Type III develops in pregnant females mainly in the second and third trimester. It develops because of the interference of the placental hormones with the action of insulin. This type of diabetes disappears after delivery. However, this female patient is more liable to develop type ii diabetes later in her life. 

It is important to recognize whether the patient is well controlled or not. We can ask him about the last time his blood glucose level was measured. 

In general a fasting blood glucose level over 250 mg/dl is considered to be uncontrolled. A better indicator of the over all control of diabetes mellitus over the last three months is the blood level of glycoslated hemoglobin (HBA1c or HBA1). 

Ideally it should be within the range of 4.5%. Up to 4.8% it is still considered acceptable. If it is over 6.1% the patient is clearly uncontrolled.

 Normal adult hemoglobin binds to glucose and it persists in the body over the entire life span of the erythrocyte. Therefore it is considered as a good indicator of the cumulative control of blood glucose level. Another long term essay for the control of diabetes mellitus is fructosamine level.

Management of diabetes in general has the following targets: establish a normal blood glucose level, prevent acute complications and prevent chronic complications. Management might consist of:-

· * Dietary control

· * Increased physical activity

· * Food should be given to be in harmony with the level of physical activity

· * Insulin or oral hypoglycaemics to help in the regulation of blood glucose level

· * Frequent monitoring of blood glucose level and glucose in urine

We should determine which line of management the patient follows

· * The patient might be on dietary control alone. In such a case, if the patient is well controlled; he can undergo minor surgical procedures under local anesthesia without special precautions. In moderate surgical procedure that requires general anesthesia; the patient can undergo the surgery without special precautions other than monitoring the urine glucose level on 2 hours basis till feeding is restores.

* In major surgical procedures, the patient should be hospitalized where he is going to be prepared with insulin injections.. 
*We may need you to have basic investigations like Blood and Urine Sugar levels, as well as other tests like HbA1c(for estimating diabetic control), before undergoing a procedure.
*Associated cardiac /renal failure and Neuropathy, if present, should be managed and a Fitness for Procedure obtained from the Specialist concerned, before reporting back for undergoing the procedure.