Odontologia

Dent Clin N Am 50 (2006) 591–606

Dental Management of Patients
with Diabetes
Samuel J. McKenna, DDS, MD
Oral and Maxillofacial Surgery, Vanderbilt University School of Medicine,
1623 The Vanderbilt Clinic, Nashville, TN 37232-5225, USA

Diabetes mellitus (DM) is a disease of glucose, fat, and protein metabolism resulting from impaired insulin secretion, varying degrees of insulinresistance, or both. Hyperglycemia is the most clinically important metabolic
aberration in DM and the basis for its diagnosis. Apart from the obvious
impact of impaired glucose metabolism, DM and chronic hyperglycemia
are associated with important ophthalmic, renal, cardiovascular, cerebrovascular, and peripheral neurological disorders. Management of the diabetic
dental patient must take intoconsideration the impacts of diabetes on dental
disease and dental treatment, as well as a clear appreciation for the comorbidities that accompany long-standing DM.

Classification
Most cases of DM can be classified as type 1 (formerly, insulin-dependent
diabetes) and type 2 (formerly, noninsulin-dependent diabetes). Blood glucose elevation that does not satisfy the definition of type-1 or type-2 DMis classified as impaired glucose tolerance or impaired fasting glucose.
Secondary forms of DM also exist (Box 1). For example, diseases of the
pancreas, such as pancreatitis, may produce a state of absolute insulin deficiency. Numerous drugs may create a diabetic state, glucocorticoids being
the most notable. Glucocorticoids not only increase insulin resistance in
liver and muscle, but alsoimpair the response of pancreatic beta cells to elevated plasma glucose. Recognition of secondary forms of DM is important
because removal or management of the underlying cause can reverse the
diabetic condition.

E-mail address: samuel.mckenna@vanderbilt.edu
0011-8532/06/$ - see front matter Ó 2006 Elsevier Inc. All rights reserved.
doi:10.1016/j.cden.2006.06.008
dental.theclinics.com

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Box 1. American Diabetic Association classification of diabetes
mellitus
Type 1
 Immune mediated
 Idiopathic (type 1B)
Type 2
Other specific types
Genetic pancreatic beta-cell defects
Genetic defects in insulin receptor
Pancreatic disease
 Trauma
 Infection
 Inflammation
 Neoplasm
Endocrinopathies
 Growth hormone (acromegaly)
 Cortisol (Cushing’s syndrome)
Glucagon (glucagonoma)
 Epinephrine (pheochromocytoma)
Drug- or chemical-induced
 Nicotinic acid
 Glucocorticoids
 Thyroid hormone
 Phenytoin
 Thiazides
Infections
 Viral infection
Rubella
Coxsackievirus B
Cytomegalovirus
Adenovirus
Mumps
Uncommon immune-medicated
 Anti-insulin receptor antibody
 Stiff-man syndrome
Other genetic syndromes
 Down’s syndrome
 Turnersyndrome
 Klinefelter’s syndrome
 Wolfram’s syndrome
Gestational diabetes mellitus
Impaired glucose tolerance, impaired fasting glucose

PATIENTS WITH DIABETES

593

Another form of DM less likely to present in the dental care setting is gestational diabetes or DM presenting during pregnancy. Gestational diabetes is
the result of insulin production insufficient to overcome insulinresistance produced by placental anti-insulin hormones (eg, estrogen, prolactin, cortisol).
Epidemiology
Type-1 DM accounts for 5% to 10% of cases of DM in the United States,
Canada, and Europe. Based on 1995 data, the prevalence of type-1 DM in
the United States is 1.7 per 1000 in those younger than 19 years and 2.1 per
1000 in adults [1]. Estimates of the annual incidence of type-1 DM are 18 per100,000 in those 19 years of age and younger and 9 per 100,000 in those over
19 years of age. Approximately 30,000 cases of type-1 DM are diagnosed
yearly in the United States. Type-1 DM is more common in whites than
in African-Americans.
Type-2 DM accounts for 80% of cases of DM in the United States, Canada, and Europe [1]. Based on 1994 data, the prevalence of type-2 DM is 51
per 1000 for...