Geist, Shin-Mey R., James R. Geist, Claudine M. Sordyl, and Jan LeBow
Two major concerns in managing diabetic dental patients are hypoglycemic episodes and increased risk of surgical site infection (SSI) due to hyperglycemia. Standards of medical care in diabetes published by the American Diabetes Association (ADA) recommend the glycemic control goal for non-pregnant adults in general should be HbA1c <7 percent (equivalent to an estimated average glucose less than 154 mg/dl). Although this goal is aimed at reducing the long-term complications of DM, it increases the frequency of hypoglycemia. Dental school treatment times are prolonged, and many patients tend not to eat before or after the treatment. For these reasons, the risk of hypoglycemia in the dental clinic is high for diabetic patients who are on an intense treatment regimen that will meet the ADA’s glycemic control goal. On the other hand, hyperglycemia (>200 mg/ dl) around the time of the surgical procedure increases the risk of SSI. Our patients’ profile has shown that many of our diabetes patients are not in the intense treatment regimen and do not check their blood glucose regularly. These patients may have perioperative glucose levels higher than 200 mg/dl, which exposes them to greater risk of SSI than nondiabetic patients. In 2007, the University of Detroit Mercy dental clinic started to take casual random blood glucose (CRBG) measurements without charge for self-reported diabetes patients when information on the standard health questionnaire (e.g., most recent HbA1c, glycemic control goal, medications and eating before dental appointment, history of hypoglycemic episodes, etc.) indicated the risk for either hypoglycemia or hyperglycemia. Precautions were taken for patients based on their blood sugar levels. For our regular diabetes patients, if the CRBG measurements were repeatedly higher than their estimated average glucose level, consultation letters were sent to their physicians for further evaluation. From March 2007 to June 2010, there were 279 individual measurements, ranging from 39 to 600 mg/dl. There were seventy-four (26.5 percent) measurements above 200 mg/dl and fourteen (5 percent) lower than 70 mg/dl. We were able to prevent severe hypoglycemia requiring a 911 call to 100 percent. No 911 call was made during this period of time, compared to two to three calls per year prior to this policy. There was no report of SSI in diabetic patients whose preoperative CRBG levels were above 200 mg/dl and received surgical procedures as needed. Other diabetes patient management policies starting in March 2007, including routine request of HgA1c level, standard health questionnaire, and teaching CRBG in our CPR courses, ensure that we have a high awareness of the importance of diabetes patients’ glycemic control and their dental care.