1: A patient with type 1 diabetes mellitus is seen for dental care

Case 1
A patient with type 1 diabetes mellitus is seen for dental care

Ira B. Lamster, DDS, MMSc; Nurit Bittner, DDS, MS; and Daniel Lorber, MD

A 31-year-old woman with type 1 diabetes presents to her dentist for periodontal and prosthodontic care. A fixed partial denture is needed to replace tooth #4. Teeth #3 and #5 require crown lengthening procedures.

Medical history

The patient was diagnosed with type 1 diabetes mellitus at the age of 15. Medical management of her diabetes is with a multiple-dose insulin regimen, consisting of insulin glargine 16 units hs (long-acting insulin, see Table 1) and insulin aspart (rapid-acting insulin, Table 1) before meals. The dose of insulin aspart is calculated based on the carbohydrate content of the planned meal and the blood glucose level as determined by a fingerstick test. Her most recent hemoglobin A1c (HbA1c) was 6.8%, indicating excellent metabolic control. She has no history of severe hypoglycemic events. She takes no other medications.

Table 1 Insulin chart.a

Insulin preparation Onset of action Peak Duration of action
Lispro (Humalog ® ) < 15 minutes 1–2 hours 3–6 hours
Aspart (Novolog ® ) < 15 minutes 1–2 hours 3–6 hours
Glulisine (Apidra ® ) < 15 minutes 1–2 hours 3–6 hours
Regular (Novolin ® R, Humulin ® R) 30–60 minutes 2–4 hours 6–10 hours
Humulin ® R Regular
30–60 minutes 2–4 hours Up to 24 hours
NPH (Novolin ® N, Humulin ® N, ReliOn ® ) 2–4 hours 4–8 hours 10–18 hours
Glargine (Lantus ® ) 1–2 hours Usually no peak Up to 24 hours
Determir (Levemir ® ) 1–2 hours Usually no peakb Up to 24 hours b
Premixed insulins c Onset of action Peak Duration of action
Novolin ® 70/30, Humulin ® 70/30 30–60 minutes 2–10 hours 10–18 hours
Humalog ® 75/25, Novolog ® 70/30, Humalog ® 50/50 10–30 minutes 1–6 hours 10–24 hours

aInformation derived from a combination of manufacturer’s prescribing information and clinical studies. Individual response to insulin preparations may vary.

bPeak and length of action may depend on size of dose and length of time since initiation of therapy.

cPremixed insulins are more variable in peak and duration of action. For instance, even though the literature states that the effects may last for up to 24 hours, many people find that they will need to take a dose every 10–12 hours.

Modified from www.dlife.com/diabetes/insulin/about_insulin/insulin–chart.

Dental history and history of the current problem

Tooth #4 was extracted more than 10 years ago. The tooth was replaced with a fixed partial denture extending from #3 to #5. The patient visited her dentist intermittently, and received dental cleanings. She occasionally required amalgam and composite restorations, but noticed the fixed partial denture appeared loose approximately two months ago. Upon clinical evaluation, it was determined that the cement seal had been lost, and caries was present on the remaining tooth structure of the abutment teeth. In order to fabricate a new fixed restoration, periodontal surgery is necessary to expose sound tooth structure on the abutment teeth (crown lengthening procedure). The patient is scheduled for periodontal surgery in the morning and will not eat (NPO) after midnight in preparation for surgery. The dentist is concerned that she may become hypoglycemic before or during the procedure and contacts her endocrinologist for guidance.

Aug 31, 2016 | Posted by in ENDOCRINOLOGY | Comments Off on 1: A patient with type 1 diabetes mellitus is seen for dental care
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