Diabetes in a Dental Environment

Many people have symptoms of type 2 diabetes when they are diagnosed, but diabetes screening and identification procedures are oftentimes inadequate.9 Less than half complain of diabetes symptoms like polyuria, lethargy, or polydipsia. Because classic symptoms do not always appear, it is imperative that healthcare providers, including dentists and dental hygienists, participate in more aggressive recognition of symptoms of patients with type 2 diabetes or pre-diabetes. The updated medical history and oral exam offer excellent opportunities to assess each patient. In reviewing a patient’s medical history, here are some practical questions that you can ask, keeping in mind that questions should be individualized to help determine the patient’s glycemic control and overall approach to diabetes care management:

  1. What type of diabetes do you have, and when was it diagnosed?
  2. Have you been experiencing any health problems over the last few days, weeks, or months?
  3. Are you taking all of the medications that have been prescribed for you? If not, which one(s) don’t you take and why? Have you taken your diabetes medication today?
  4. What is your A1C level? When was the last A1C taken?*
  5. How often do you check your blood glucose level, and what was the most recent value?
  6. Do you watch your carbohydrate intake and follow an exercise regime? What time did you last eat? What did you consume?
    (This question will give you hints about how well-educated the patient is about their disease.)
  7. Who helps you manage your diabetes? Do you see your physician, nurse, or dietitian on a regular basis? When was your last visit?
  8. Do you experience low blood sugar levels? If so, how often? What are your symptoms? When was your last event?
  9. Do you smoke or use any tobacco products? If so, how much?
  10. Do you drink alcoholic beverages? If so, how often and how much do you drink on a weekly basis?
* A1C level refers to the hemoglobin A1c test. Table 1 provides the accepted value. This is a simple lab test that shows the average amount of glucose in a patient’s blood over the last three to four months. Glucose binds to hemoglobin in the red blood cells, which has a life span of 120 days. It’s the best way to find out if the patient’s blood glucose is under control. Monitoring blood glucose values via a glucometer can be equated to taking pictures with a camera. Each value is a snapshot of that moment. Blood glucose levels vary throughout the day. Having and A1c is similar to a video. This value gives a longer running value, an average over 3-4 months. All people with diabetes should have a hemoglobin A1c test two to four times a year depending on their glycemic control and changes to therapy.6

Since many undiagnosed patients may be asymptomatic, probing questions related to the chronic complications during the medical history and a thorough oral examination can lead the dental professional to be the first to recognize the possibility of undiagnosed diabetes. The oral exam in an individual with undiagnosed diabetes might reveal:

  • Candidiasis
  • Gingival inflammation
  • Suppuration
  • Tooth mobility
  • Fruity smelling breath
  • Recurrent, acute or chronic gingival and periodontal infections and abscesses
  • Xerostomia
  • Increased salivary viscosity
  • Angular cheilosis
  • Enlargement of parotid glands
  • Oral burning sensation
  • High caries rate in patients with uncontrolled or poorly controlled diabetes
    (See Recommended Diabetes Values in Table 1)

The American Diabetes Association recommends testing for high-risk patients for early diagnosis of diabetes and to prevent the associated chronic complications (Tables 4A and 4B). Testing is to be done within a health care setting in which appropriate follow-up is available.

Table 4A. Criteria for Type 2 Diabetes Testing for High-risk Patients.
Adults
  • Any age
    • BMI ≥ 25 kg/m2 or ≥ 23 kg/m2 in Asian Americans
    • At least 1 risk factor
    • Repeat every 3 years
Children and Adolescents
  • Overweight and at least 2 risk factors
    • BMI > 85th percentile, weight for height > 85th percentile, or weight > 120% of ideal for height
    • Heredity
    • Race/ethnic group
    • Presence of symptoms
  • Age 10 or onset of puberty
  • Repeat every 3 years
Table 4B. Risk Factors for Type 2 Diabetes.6
  • Age ≥ 45
  • Overweight (BMI ≥ 25 kg/m2)
  • Family history
  • Sedentary lifestyle
  • Race/ethnic group
  • Previously identified as IFG or IGT
  • History of Gestational Diabetes or delivery of baby weighing > 9 pounds
  • Hypertension (≥140/90 mm Hg)
  • HDL cholesterol less than 35 mg/dL and/or a triglyceride level > 250 mg/dL
  • Polycystic ovary syndrome
  • History of CVD