Usually for patient with OHA, I take a blood glucose level of 13mmmol/L as the limit. Is there any guidelines I can refer to?
Hi Tengku,
We normally use the NHS guidelines. Hope this is of help (articles are available free online)
Thank you
Arvinder
http://www.diabetes.org.uk/Documents/Professionals/Reports%20and%20statistics/Management%20of%20adults%20with%20diabetes%20undergoing%20surgery%20and%20elective%20procedures%20-%20improving%20standards.pdf
http://www.rcht.nhs.uk/DocumentsLibrary/RoyalCornwallHospitalsTrust/Clinical/Anaesthetics/PreOperativeAssessmentGuidelines.pdf
It's an interesting question ...
In hospital dental practice (while dealing with high risk patients), the main rule that is followed is, in cases of an uncontrolled medical condition, all elective procedures should be avoided. On the other note, in the same patient, any emergent condition that can be life-changing or life threatening must be performed as soon as possible while simultaneously treating the uncontrolled condition.
As an oral and maxillofacial surgeon, we have had to do extractions in patients with higher than normal blood glucose levels! This became necessary because the tooth was the cause of serious fascial space infection in that patient. The patient was being intensively treated for controlling his diabetes and removal of the foci of infection can also help in his glycemic control as infective states can worsen glycemic control.
The main issue of blood sugar is not during the extraction procedure, but what may happen after the procedure during the healing period as in delayed wound healing, dry socket or even osteomyelitis. Co existing conditions in a diabetic (like hypertension) may affect the outcome. The mere increased blood glucose levels are not a risk factor during the procedure. They tolerate the procedure well but in the post extraction period, some complications may be anticipated. Meticulous management of these complications can help avoid issues.
Also, in most uncontrolled diabetics, the problem tooth requiring extraction is usually periodontally compromised and mobile. A uncontrolled diabetic who is on oral hypoglycemic agents will require about 2 weeks before he is reassessed when his glycemic status will be deemed to be in control. In this two weeks, the patient may need to be on prolonged medications (antibiotics, analgesics etc;) and that can have additional complications. There is also this risk of spread of odontogenic infection to fascial space infections which can be life threatening in diabetic patients. Extractions remove the infective foci ...
So in emergency situations requiring hospitalization, we shift the patient to insulin drip or injections and perform the procedure while titrating the dose of insulin and later slowly shifting back to OHA in the post operated period after discharge.
I'd suggest removal of the tooth which is periodontally compromised and hopeless at the earliest even if there is a mild derangement of blood glucose levels after assessing the risk benefit ratio for that particular patient. Also there is an important aspect of treatment of diabetes. If the patient is reasonable and compliant but has fallen into slight derangement of blood glucose levels, it might be prudent to even extract and then refer to a physician if it's mobile periodontally involved teeth. Additional precautions like using antiseptic mouth wash and antibiotic prophylaxis may be considered. Post extraction oral hygiene can help avoid complications.
The strict control of diabetes is required only for minor surgical procedures. On arbitrary terms we can expect more complications in any procedure that may last beyond 30 minutes. If the tooth is abscessed and mobile, immediate removal and referral to physician may be prudent provided the blood glucose levels is not too high (no particular set of guidelines exist).
To summarise the above confusing answer:
1. If the patient can wait for 2 weeks before extraction ? If the answer is yes, refer immediately for blood glucose control and follow up in 2 weeks.
2. If the patient's condition may worsen or if there is risk of involvement of masticatory spaces or floor of mouth etc; immediate management is required preferably in a hospital setting as day care procedure with additional simultaneous medical management either on OPD basis or as in-patient..
3. If the patient's condition is already bad (as in fascial spaces already involved), hospital admission becomes mandatory with IV antibiotics and physician care.
4. If the tooth can be easily extracted, one can do so in the hospital setting with physicain stand-by. (if there is anticipation of complications).
In diabetic states, the potential risks / complications are related to the poor healing capacity, neutrophil which are qualitatively poor (counts are normal usually). A case by case decision may be required before decisions and it's important to remember that 'guidelines' exist for 'guiding' and may need to be adapted per patient per condition.
Regards,
Dr. Akilesh R
Consultant Oral and Maxillofacial Surgeon
Though the question is very simple, we have to see the detailed assessment of the patient prior to procedure and able to clinically judge/interpret the importance of the available result , in a tertiary care set up i strongly recommend to seek the opinion of the Endocrinologist/internist for the patients who are at high risk (CV risks/high risk for infection etc.,0
The following observation " Diabetes: A Multifaceted Syndrome Treatment Considerations in Dentistry" may give a better understanding on the concerned question:
Prior to initiating any invasive dental treatments, blood glucose levels of patients with diabetes should be less than 200 mg/dL. Consider that the physical and emotional stress that may occur during treatment can cause blood glucose levels to rise even higher and possibly place the patient at risk for a medical emergency. In addition, uncontrolled diabetes can also be a factor towards increasing healing time and place the patient at risk for infection. If the patient had forgotten to take the recommended dose of their diabetes oral agent and/or insulin, this can be done and the blood glucose value retested. Caution the patient not to take more than the prescribed amount. Also, since blood glucose values will decrease with activity, the patient could walk around the office for 15 minutes and be retested. If the blood glucose level is still above 200 mg/dL, the patient should be referred to their diabetes healthcare team and the dental appointment reschedulConducting noninvasive procedures, such as radiographs or an oral examination, may be warranted prior to dismissal.
Blood glucose levels tend to be more stable in the morning; therefore, morning appointments may be more beneficial for this patient. Stress reduction techniques, such as use of headphones, and short appointments may help keep blood glucose levels from rising.
The dental patient with uncontrolled hyperglycemia may require prophylactic antibiotic therapy. Systemic antibiotic therapy or topical antimicrobial therapies are accepted treatment modalities for aggressive treatment of oral infections. Recare appointments should be at least every three months to monitor wound healing and minimize periodontal infection.
Since epinephrine antagonizes the action of insulin, resulting in hyperglycemia, local anesthesia without vasoconstrictors is recommended when possible for patients with uncontrolled diabetes. Another consideration is to use glucocorticosteroids with caution since they also have the potential to raise blood glucose levels.
Dental hygiene management also includes fluoride therapy for patients with a high caries rate and recommendations to relieve xerostomia if necessary. Since a patient with uncontrolled diabetes has an exaggerated response to plaque, encouragement of meticulous oral hygiene is essential.
Follow Guidelines and avoid the error. Even if every rule may have its exception. So follow guidelines and keep attention to the care of diabetes, perhaps with the help of a specialist.
Gum (periodontal) disease. Experiencing pain whenever chewing food is a sign of diabetes. For those with more serious gum problems, this may even lead to teeth loss. To treat gum disease, diabetics must work on controlling the diabetic condition. Gum disease is the result of too much glucose in the blood, which damages oral health.
Periodontal Problems (Gingivitis & Periodontitis) Perio-dontal means: "around the tooth". It is basically an infection that happens around the tooth. Periodontal "disease" is a term that is sometimes used to describe both an inflammatory condition of the gums (gingivitis) or an inflammation around the tooth (periodontitis). It is second only to the common cold as the most prevalent infectious ailment. It is the major cause of adult tooth loss. It is more prevalent in people over 50.
Healthy gums are pink and do not bleed. Gingivitis is characterized by gum redness, changes in the gum, and bleeding. It is essentially painless.
It is created when plague (sticky deposits of bacteria, mucus and food particles) adheres to the teeth, hardens and irritates the gum. The accumulation of this plaque causes the gums to become infected and swollen. As the gums swell, pockets form between the gums and the teeth and act as a trap for more plague. It can then become sore bleeding gums when brushing your teeth. The irritated gums bleed and eventually start to recede.
Irritation can be fought by introducing Vitamin C which fights the formation of plaque. Formation of plaque can be due to high levels of calcium that is not being absorbed during digestion. This can be due to low stomach acid or any other inability to absorb calcium. Gingivitis, untreated, can progress to periodontal disease or pyorrhea. The bacteria-plaque starts attacking the root of the teeth and the jawbone, and if not treated, you might even lose some teeth.
Periodontal means "located around the tooth". Periodontal Disease Tooth Periodontitis is characterized by localized pain, loose teeth, pockets between the gum and the tooth, redness, swelling and/or signs of infection.
X-rays may reveal destruction of bone. This is because the bone supporting the teeth begins to erode due to the infection. Abscesses are common. There is sometimes halitosis, with bleeding, and often, painful gums. Although oral hygiene is of great importance in treating and preventing periodontal disease, it is not sufficient in most cases. In addition to proper dental care, good nutrition and immune system health need to be addressed if development and progression of the disease are to be controlled. Bacterial plague is the causative agent in most forms of periodontal disease. However, it is now widely accepted that poor nutrition wrong foods (refined foods such as white flour and white sugar), constipation, chronic illness, glandular disorders, blood disease, smoking, drugs, and excessive alcohol consumption as well as poor immune function make an individual prone to bacteria and thus to periodontal disease.
Some experts question whether periodontal disease is a chronic, unrelenting condition and instead suggest that it gets worse or gets better depending on the response of the immune system.
Helpful Periodontal treatments:
Diet: Fresh fruits, and vegetables, whole grains, and fiber should be the mainstay of the menu. Vegetables & fruits enhance enzyme function. fermented dairy products, such as yogurt help maintain intestinal health. Calcium gotten either from milk or vegetables. However, calcium is easier for the body to digest via vegetables.
A reduction in the amount of cooked protein eaten at one meal is wise; people who have followed a vegetarian diet for twenty years or more, show less bone loss then those who eat meat.
Increase your intake of sardines, canned salmon, dark green leafy vegetables (spinach, collards, kale, turnip greens, mustard greens) broccoli, brazil nuts, tofu and all soy products, sunflower seeds, and hulled sesame seeds.
It is advised to stop using or consuming items that cause calcium to become deficient and or toxic. This includes products such as ice cream, fruit yogurt, tea, coffee, cigarettes and aluminum.
Exercise: Exercise that stress the long bones in the body - jumping rope, basketball, tennis, jogging, walking, rebounding on a trampoline, cycling, and dancing all effective to help with this type of problem. Vitamin D is needed for calcium absorption, so getting outdoors in the sun is advised.
http://www.mcvitamins.com/periodontal_disease.htm
I think the whole picture of the disease should be taken. More details presentations of the patient and the clinical judge/interpret are fundamental. I think it is a package of the clinical and biochemical data rather than the blood glucose level.
Brilliant answers! As a periodontologist however, I only want to add that we should remember the effect of moderate to severe chronic Periodontitis on glycemic control. Keeping a periodontally compromised tooth in the mouth for long while waiting for the blood glucose to be controlled might result in a wild goose chase.
On this basis, I will personally want to us to be dynamic in determining how long we keep the tooth before extraction. I would reason that either an emergency glycemic control with insulin and early tooth extraction OR reduction of the oral inflammatory burden with chlorhexidine. Using chlorhexidine will reduce the oral inflammatory burden while glycemic control is being pursued to an acceptable level for a safe extraction.
We should also remember the role of doxycycline as a an antibiotic as well as MMP=8 inhibitor. The effect of doxycycline on blood sugar however should also be borne in mind!!
thank you everyone, for the answers.
I agree, in hospital setting it would be much easier for managing these patients, where we can request for blood tests and has a record of patient's diabetic control. In small clinic, there are always patient turn up saying that they were newly diagnosed diabetics and on some kind of OHA, requesting a removal of a non-restorable tooth but with no abscess or fascia involvement . Finger prick glucose test may be used to determine that the patient is not hypoglycemic for the procedure. But I'm not quite certain about the upper limit of hyperglycemia level to ensure a good healing process and, of course, to avoid any inadvertent consequences.
post prandial sugar levels upto 200mg/dl usually have uneventful healing after extractions.
In Kuwait, about 15% of population are diabetics, therefore we face the question daily. Many patients coming for extraction are poorly controlled (on random glucometer check before extraction BS>11mmol/l). Like it was emphasized in previous posts, the most important aspects of decision making are: 1. possibility of hypoglycemia in patients on insulin, 2. risk of complicated healing and infection in hyperglycemic patients.
Following article is relevant to the second aspect.
Aronovich S, Skope LW, Kelly JP, Kyriakides TC. The Relationship of Glycemic Control to the Outcomes of Dental Extractions. J Oral Maxillofac Surg 68:2955-2961, 2010: This prospective observer-blinded study showed no difference in postextraction epithelialization and thus healing between well-controlled and poorly controlled diabetic patients. This finding is related to simple extractions only, not surgical extractions.
My recommendations are following:
Easy extraction can be done regardless BS level. Consider antibiotic prophylaxis.
Surgical extraction in uncontrolled patient should be postponed and the patient referred to a diabetologist.
Cases of acute infection necessitating extraction should be managed in a hospital setting.
- Badges
- Science topic
- Similar topics
- Correction