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Introduction
Diabetes mellitus is defined by the World Health Organization (WHO) as a chronic disease characterized by the lack of insulin production by the pancreas or when the insulin produced by the body is not effectively utilized. Uncontrolled diabetes can result to hyperglycemia and may lead to severe damage to different body systems over time. Diabetes can damage the heart, blood vessels, eyes, kidneys, and nerves. (WHO, 2016)
Type 1 diabetes occurs when the pancreas cannot produce enough insulin. Common symptoms of Type 1 diabetes include polyuria (frequent urination), polydipsia (thirst), and polyphagia (constant hunger). Other symptoms are weight loss, changes in vision, and fatigue. Type 2 diabetes occurs when the body cannot effectively use insulin. The symptoms of Type 2 diabetes are somehow similar to the symptoms of Type 1 diabetes, but most of the time are less observed. Hence, diagnosis may be delayed, when complications have manifested. (WHO, 2016)
This current research will look into the relationship between diabetes mellitus and stress and local anesthetics during dental visits. During dental visits, special precaution should be observed for diabetic patients, such as stress control and use of safe and effective anesthetic solution. (dos Santos-Paul, 2015) When the body is under stress, hormone levels increase resulting to a lot of stored energy in the form of glucose and fat. Diabetics may not always have insulin available to act on the energy produced, thereby leaving the glucose in the blood and increasing the blood glucose level. (American Diabetes Association, n.d.) The use of epinephrine as a local anesthesia for diabetic patients is a controversy. Epineprhine was reported to have hyperglycemic effects. (dos Santos-Paul, 2015) Dental practitioners should be mindful about stress and administration of local anesthesia among diabetic patients. This research has a significant implication in the field of dentistry because there a millions of people in the United States with diabetes and dental practitioners should be aware of this concern so they would know how to properly manage their diabetic patients.
Literature Review
Diabetes is of great importance to dental professionals as they are in a position to detect new cases of the disease. Further, they must be capable of providing care to patients who are under medical management for diabetes without compromising their wellbeing. It is very crucial that dental professionals are well aware of details of their diabetic patients such as level of disease severity, level of glycemic control, and presence of other complications. Dental professional should be aware of such patient information so they can provide the appropriate dental treatment. A major precaution in dental management of diabetic patients who are being treated with insulin is to prevent the occurrence of insulin shock during dental appointment. Dental professionals should be cautious in administering anesthesia to diabetic patients. It may not be an issue when diabetes is controlled. However, for diabetic patients with concurrent hypertension or history of recent myocardial infarction, or with a cardiac arrhythmia, the dose of epinephrine should be limited to no more than two cartridges containing 1:100,000 epinephrine as this could result to increase in blood glucose. (Little, 2012)
A publication by Ship (2003) provided an overview of diabetes and oral health. According to Ship, one of the ways to diagnose diabetes is through oral signs and symptoms, such as gingivitis and periodontitis, recurring fungal infections, and compromised wound healing. Hence, dental professionals have an important role in diagnosing and managing patients with diabetes. They should be able to document their patient’s glucose and laboratory tests as well as blood pressure levels in order to assist in oral health supervision. Dentist must also consider modifying medical therapy if necessary. Stress during dental procedures can result to increased serum glucose levels. Also, epinephrine may have to be adjusted as large amounts of it can contradict the effects of insulin and result to hyperglycemia. (Ship, 2003)
The glycemic effect of epinephrine-containing local anesthesia in patients undergoing dental extraction was investigated by Tily and Thomas (2007) among healthy and diabetic patients. The comparative study included 60 patients (30 health and 30 diabetics) of the Oral Surgery Clinic of Ajman University of Science and Technology. Pre-operative glucose was obtained and recorded upon acquiring the patient’s consent to participate in the study. Before the tooth extraction, anesthetic solution with epinephrine was administered. After 10 minutes of the complete extraction, the post-operative blood glucose was obtained. Results were statistically analysed and showed no significant difference in the blood glucose levels between healthy and diabetic patients. However, significant change in glucose levels was noted among diabetic patients who had not taken their pre-operative hypoglycemic medications. (Tily & Thomas, 2007)
In another study, several variables including serum glucose concentration were measured during dental surgery. The study involved 11 normotensive patients who underwent tooth extraction at Kyushu Dental College Hospital. Blood samples were collected prior to administration of anesthesia, 10 minutes after administration of local anesthesia with epinephrine, 10 minutes after the start of the surgery, and 10 minutes after the surgery. Results showed that serum glucose concentration increased significantly and reached its peak after the administration of local anesthetic. The increase in serum glucose concentration might have been due to the administration of epinephrine, hence reached its peak after administration of local anesthesia. The epinephrine content of the local anesthetic is suspected to have leaked into the systemic circulation, thereby increasing the plasma epinephrine and serum glucose concentrations. (Nakamura et al., 2001) The study demonstrated at immediate and very factual evidence of increase in serum glucose concentration after the administration of local anesthetic containing epinephrine. However, the findings of the study, although statistically significant, may not be accurate as the sample size used in the study is too small.
Dental appointments, particularly, oral surgery, may pose patients to stress. Stress can have a significant effect on the health of diabetic patients. When an individual is exposed to stress, the body reacts and prepares to take action. This is called the fight or flight response, during which hormone levels shoot up. The increased level of hormones result to increased heart rate, breathing rate, blood pressure, and metabolism. The net effect of all these is to make a lot of stored energy glucose and fat. In diabetic patients, insulin is not always able to allow the extra energy into the cells. This results to increased glucose level in the blood. (Mitra, 2008)
Lloyd et al. published an article in Diabetes Spectrum in 2005. Their article provided a review of the link between stress and diabetes. The article described a prospective in-depth investigation of the relationship between stressful experiences and changes in glycemic control. Study participants were interviewed using an in-depth interview schedule and were followed-up quarterly for a year with measures of diabetic control. Results showed that participants whose glycemic control deteriorated through time were more likely to report negative stress. In contrary, participants whose glycemic control improved through time were more likely to report positive stress. This study however has a limitation as the stress was perceived stress and people may have different perception of stress. (Lloy et al., 2005)
Conclusion
The review of literature presented above provided justification that dental professionals should be cautious in managing diabetic patients. It would be beneficial for both dental professionals and their patients if both discuss any sign or symptoms of diabetes, any medication being taken for diabetes, and status of blood glucose levels. Dental professionals should know these information in order for them to provide the appropriate care to their patient without compromising their health.
Providing dental treatment to diabetic patients is very complex because of the comorbidities of the disease. Appropriate dental treatment and effective maintenance of diabetes requires a thorough knowledge of the condition. Dentists have a critical role in the diabetes care alongside primary care physicians. Dental professionals should be familiar with the treatment and management of diabetic complications that may arise during dental treatment, such as the possibility of acute increases and drops of blood glucose levels. Dental treatment or procedures should be planned to reduce anxiety and stress and cautious in regards to the need for blood sugar control measures. It cannot be over emphasized that stress and infections, including epinephrine in local anesthetics, have effects on elevating blood sugar levels. Infections and surgical procedures are both very critical conditions for diabetic patients and require antibiotic and surgical management. Hence, dental professionals should also be critical in prescribing antibiotics. (Ostler, 2011)
Dental professionals have a major responsibility to their patients, especially those with current conditions such as diabetes. It is therefore very important that dental professionals make themselves informed about diabetes.
Reference:
American Diabetes Association. (n.d.). Stress. American Diabetes Association. Retrieved from http://www.diabetes.org/living-with-diabetes/complications/mental-health/stress.html
Dos Santos-Paul, M.A., Neves, I.L.I, Neves, R.S., & Ramires, J.A.F. (2015). Local anesthesia with epinephrine is safe and effective for oral surgery in patients with type 2 diabetes mellitus and coronary disease: a prospective randomized study. Clinical Science, 70(3), 185-89.
Little, J.W., Falace, D., Miller, C., & Rhodus, N.L. (2012). Dental management of the medically compromised patient. Elsevier Health Sciences.
Lloyd, C., Smith, J., & Weinger, K. (2005). Stress and diabetes: A review of the links. Diabetes Spectrum, 18(2), 121-127.
Mitra, A. (2008). Diabetes and stress: A review. Ethno-Med., 2(2), 131-135.
Nakamura, Y., Matsumura, K., Miura, K., Kurokawa, H., Abe, I, & Takata, Y. (2001). Cardiovascular and sympathetic responses to dental surgery with local anesthesia. Hypertens Res, 24(3), 209-214.
Ostler, L. (2011). Dental management of the diabetic patient. Oral Systemic Health. Retrieved from https://aaosh.org/dental-management-diabetic-patient/.
Ship, J.A. (2003). Diabetes and oral health: An overview. Journal of American Dental Association, 134, 4-10.
Tily, F.E. & Thomas, S. (2007). Glycemic effect of administration of epinephrine-containing local anesthesia in patients underground dental extraction, a comparison between healthy and diabetic patients. International Dental Journal, 57, 77-83.
World Health Organization (WHO). (2016). Diabetes Fact sheet. World Health Organization. Retrieved from http://www.who.int/mediacentre/factsheets/fs312/en/
