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CDHO Advisory: Diabetes Type 1, 2 or Gestational

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CDHO ADVISORY

SCOPE

RECOMMENDATIONS

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

CONTRAINDICATIONS

COLLEGE OF DENTAL HYGIENISTS OF ONTARIO ADVISORY

ADVISORY TITLE

Use of the dental hygiene interventions of scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions for persons1 Persons includes young persons and children with diabetes type 1, 2 or gestational.

ADVISORY STATUS

Cite as College of Dental Hygienists of Ontario, CDHO Advisory Diabetes Type 1, 2 or Gestational, 2023-05-03

INTERVENTIONS AND PRACTICES CONSIDERED

Scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions (“the Procedures”).

SCOPE

DISEASE/CONDITION(S)/PROCEDURE(S)

Diabetes type 1, 2 or gestational

INTENDED USERS

Advanced practice nurses
Dental assistants
Dental hygienists
Dentists
Denturists
Dieticians
Health professional students
Nurses
Nutritionists
Patients/clients
Pharmacists
Physicians
Public health departments
Regulatory bodies

ADVISORY OBJECTIVE(S)

To guide dental hygienists at the point of care relative to the use of the Procedures for persons who have diabetes type 1, 2 or gestational, chiefly as follows.

  1. Understanding the medical condition.
  2. Sourcing medications information.
  3. Taking the medical and medications history.
  4. Identifying and contacting the most appropriate healthcare provider(s) for medical advice.
  5. Understanding and taking appropriate precautions prior to and during the Procedures proposed.
  6. Deciding when and when not to proceed with the Procedures proposed.
  7. Dealing with adverse events arising during the Procedures.
  8. Record keeping.
  9. Advising the patient/client.

TARGET POPULATION

Child (2 to 12 years)
Adolescent (13 to 18 years)
Adult (19 to 44 years)
Middle Age (45 to 64 years)
Aged (65 to 79 years)
Aged, 80 and over
Male
Female
Parents, guardians, and family caregivers of children, young persons and adults with diabetes type 1 or 2.

MAJOR OUTCOMES CONSIDERED

For persons who have diabetes type 1, 2 or gestational: to maximize health benefits and minimize adverse effects by promoting the performance of the Procedures at the right time with the appropriate precautions, and by discouraging the performance of the Procedures at the wrong time or in the absence of appropriate precautions.

RECOMMENDATIONS

UNDERSTANDING THE MEDICAL CONDITION

Terminology used in this Advisory

Resources consulted 

  1. Diabetes, a lifelong condition where either the body does not produce enough insulin or it cannot use the insulin it produces. The body needs insulin to change the blood sugar from food into energy. 
  2. Diabetes type 1, the body makes little or no insulin.
  3. Diabetes type 2, the body makes insulin but cannot use it properly; nine out of ten persons with diabetes have type 2.
  4. Gestational diabetes, the body is not able to properly use insulin during pregnancy; it vanishes after the baby is born. 
  5. Blood glucose and blood sugar are generally used to mean the same thing.
  6. Hyperglycemia, high blood glucose.
  7. Hypoglycemia, low blood glucose.
  8. Palliative care, services of care for persons towards the end of life with terminal illnesses such as cancer, when the focus of the care
    1. is relieving symptoms
    2. attending to physical and spiritual needs.
  9. Supportive care, services of care to help persons meet the physical, emotional and spiritual challenges arising from the condition or its treatment.

Overview of diabetes type 1, 2 and gestational

Resources consulted

  1. The goal of treating diabetes is to prevent its symptoms and long-term complications by keeping blood glucose as close to target levels as possible.
  2. The physician works with the diabetes care team to help the patient/client to determine his or her target blood glucose levels.
  3. Diabetes Canada advises that timing and frequency of capillary blood glucose (CBG) testing (formerly referred to as self-monitored blood glucose [SMBG]) should be determined individually based on the type of diabetes, the type of antihyperglycemic treatment prescribed, the need for information about blood glucose levels and the individual’s capacity to use the information from testing to modify healthy behaviours or self-adjust antihyperglycemic agents. Specific recommendations regarding frequency of CBG testing, etc., are found in the continually updated Diabetes Canada Clinical Practice Guidelines.
  4. More than many conditions, treating diabetes requires significant self-care by the patient/client. 
  5. Coping with diabetes is a lifelong challenge, so persons with diabetes should not be afraid to speak with an appropriate healthcare provider if they feel overwhelmed.

Comorbidity, complications and associated conditions

Comorbid conditions are those which co-exist with diabetes type 1, 2 or gestational but which are not believed to be caused by it. Complications and associated conditions are those that may have some link with it. Distinguishing among comorbid conditions, complications and associated conditions may be difficult in clinical practice.

Resources consulted 

In Canada, the comorbidities, complications and associated conditions chiefly comprise

  1. Amputation, non-traumatic. 
  2. Blindness, of which diabetes is the leading cause in adults. 
  3. Cardiovascular disease, the leading cause of death in diabetes; it occurs twice to four times more often than in those without diabetes.
  4. Celiac disease (CDHO Advisory), which appears to be more common in people with type 1 diabetes than in the general population.  
  5. Depression (CDHO Advisory), which is diagnosed in about 25 percent of persons with diabetes; the combination of diabetes and depression is linked with poor compliance with treatment.
  6. Digestive problems, which affect nearly 60 percent of persons, such as
    1. constipation, the most common
    2. diarrhea
    3. delayed emptying of the stomach. 
  7. Heart attack or stroke (CDHO Advisory), from which 80 percent of diabetics will die. 
  8. Kidney disease (CDHO Advisory), a serious complication associated with long-term diabetes. 
  9. Multiple chronic health conditions;  in 11 percent of diabetics, three or more such chronic health conditions coexist; compared to the general population, these persons are
    1. 4 times more likely to be admitted to a hospital or a nursing home 
    2. 7 times more likely to need home care
    3. 3 to 5 times more likely to see a healthcare provider.
  10. Neuropathy, the end result of the slow process of damage that diabetes causes to sensory nerves especially in the hands and feet, which results in
    1. loss of sensation, so that foot injuries, such as blisters or cuts, pass unnoticed and untreated
    2. small foot injuries quickly becoming infected, with the risk of serious complications.
  11. Oral problems, which include thrush and dry mouth, which can cause soreness, ulcers, infections and cavities.
  12. Renal failure (CDHO Advisory), end-stage.
  13. Skin problems, which affects as many as 33 percent of people with diabetes, are associated with high blood glucose levels during which
    1. the body loses fluid, leading to dry skin on the legs, feet and elbows
    2. skin cracks develop, facilitating infection
    3. resistance to infections is reduced
    4. healing is slowed.
  14. Thyroid disorders which, like diabetes, involve the endocrine system (CDHO Advisory Hyperthyroidism), (CDHO Advisory Hypothyroidism).  

Oral health considerations

Resources consulted

  1. Persons taking hypoglycemic drugs with or without insulin are at risk of hypoglycemia if they exceed the prescribed dose(s) or if they disrupt their normal intake of food.
  2. Prior to dental treatment, persons with diabetes should have eaten and taken their medication as directed.
  3. Patients/clients treated with insulin may require an increase in dose if an acute oral infection develops; those treated with hypoglycemic agents may require adjunctive, short-term insulin. The physician manages the insulin needs; the oral healthcare provider treats the infection with local and systemic therapies, in liaison with the physician.
  4. Persons with diabetes are at increased risk of serious oral disease, such as gingivitis and periodontitis, because they are generally more susceptible to bacterial infection and they have decreased ability to fight bacteria that invade the gums.
  5. Children and teenagers who have diabetes are at greater risk of oral disease than those without diabetes.
  6. If blood glucose levels are poorly controlled, diabetics are more likely to develop serious gum disease and lose more teeth than non-diabetics. 
  7. As with other infections, serious gum disease may be a factor in causing blood glucose to rise and in making diabetes harder to control.
  8. Other oral problems associated with diabetes include thrush and dry mouth, which can cause soreness, ulcers, infections and cavities.

MEDICATIONS SUMMARY

Sourcing medications information

  1. Adverse effect database
  2. Specialized organizations
  3. Medications considerations
    All medications have potential side effects whether taken alone or in combination with other prescription medications, or as over-the-counter (OTC) or herbal medications.
  4. Information on herbals and supplements 
  5. Little JW, Falace DA, Miller CS and Rhodus NL. Dental Management of the Medically Compromised Patient (9th edition). St. Louis: Elsevier; 2018.
  6. College of Dental Hygienists of Ontario

Types of medications

Warnings

Individual medications may be subject to important warnings, which

  1. change from time to time
  2. may affect the appropriateness, efficacy or safety of the Procedures
  3. are accessible via the links to the particular medications listed below or through the specialized organizations listed above
  4. through the links, should be viewed by dental hygienists in the course of their familiarizing themselves about a medication or combination of medications identified in the patient/client’s medical and medications history.

Medications

  1. Diabetes Type 1
    Persons with type 1 diabetes need insulin injection continually (typically subcutaneously)2 for controlling their blood sugar
    insulin aspart  (NovoLog®)
    insulin deglutec (Tresiba®)
    insulin detemir (Levemir®)
    insulin glargine (Lantus®)
    human insulin (various Humulin® insulins, various Novolin® insulins)
    insulin lispro (Humalog®
    To raise low blood sugar
    glucagon
  2. Diabetes Type 2
    1. Medications for type 2 diabetes are usually taken orally in the form of tablets.
    2. The medications should always be taken around meal times, and as prescribed by the physician. 
    3. When the blood glucose is not controlled by oral medications, the physician may recommend insulin injections.
    4. Medications used to lower blood glucose include oral diabetes medications (also called oral hypoglycemics) and injectable medications such as
      1. Sulfonylureas, less commonly used now with advent of safer, more effective medications; stimulate the pancreas to release more of its stored insulin and to increase the effectiveness of insulin in the body
        glyburide (Diabeta®, Glynase®, Micronase®)
      2. Biguanides, improve insulin sensitivity and reduce the glucose produced by the liver
        metformin (Fortamet®, Glucophage®, Glucophage®, Glumetza®, Riomet®)
      3. Acarbose, prolongs the absorption of carbohydrates after a meal. Must be taken with or after a meal
        acarbose (Prandase®, Precose®) 
      4. Thiazolidinediones, less commonly used now with advent of safer, more effective medications; improve insulin sensitivity
        pioglitazone (Actos®)
        rosiglitazone (Avandia®) 
      5. Meglitinides (also known as glinides or glitinides), lower post-meal glucose levels by stimulating the pancreas to release more of its stored insulin
        nateglinide (Starlix®)
        repaglinide (Prandin®)
      6. Incretin (GLP1) analogues, enhance insulin secretion and delay gastric emptying and suppress prandial glucagon secretion
        exenatide (Byetta®) – injected subcutaneously
        liraglutide (Victoza®) – injected subcutaneously
      7. Dipetidyl Peptidase-4 (DPP4) inhibitors, inhibit enzymatic breakdown of GLP1 and GIP and increase insulin secretion and decrease glucagon secretion
        alogliptin (Nesina®)
        linagliptin (Tradjenta®)
        saxagliptin (Onglyza®)
        sitagliptin (Januvia®)
      8. Amylin analogues, aid absorption of glucose by slowing gastric emptying and promote satiet
        pramlintide (Symlin Pen®) – injected subcutaneously
      9. Sodium-Glucose co-Transporter 2 (SGLT2) inhibitors, which lower blood sugar by causing the kidneys to excrete more glucose into the urine
        ertugliflozin (Steglatro®)
      10. Bile acid sequestrants, which are more frequently used to control cholesterol but which can also reduce blood glucose in persons with type 2 diabetes
        cholestyramine (Locholest®, Prevalite®, Questran®)
        colesevelam (Welchol®)
        colestipol (Colestid®)
      11. Combination Drugs, which are becoming increasingly numerous.

Side effects of medications

See also the links to individual medications listed above.

Of particular relevance to oral healthcare, hypoglycemia may be induced or potentiated by
ASA
NSAIDs in high doses over long periods, particularly in combination with sulfonylureas
ketoconazole (Nizoral®) used to treat thrush

THE MEDICAL AND MEDICATIONS HISTORY

The medical  and medications history-taking should 

  1. Focus on screening the patient/client prior to treatment decision relative to
    1. key symptoms
    2. medications considerations
    3. contraindications
    4. complications
    5. comorbidities.
  2. Explore the need for advice from the appropriate primary or specialized care provider(s).
  3. Inquire about
    1. patient/client’s having eaten and taken their medication as directed prior to the Procedures and oral healthcare treatment generally
    2. history of trouble keeping blood glucose levels under control
    3. diabetes-related problems with previous dental/dental hygiene care
    4. symptoms indicative of inadequate control of blood sugar
    5. the patient/client’s understanding and acceptance of the need for oral healthcare
    6. medications considerations, including over-the-counter medications, herbals and supplements
    7. insulin pumps and continuous glucose monitors (CGMs)3, both of which are typically worn externally
    8. problems with previous dental/dental hygiene care
    9. problems with infections generally and specifically associated with dental/dental hygiene care
    10. the patient/client’s current state of health
    11. how the patient/client’s current symptoms relate to
      1. oral health
      2. health generally
      3. recent changes in the patient/client’s condition.

IDENTIFYING AND CONTACTING THE MOST APPROPRIATE HEALTHCARE PROVIDER(S) FOR ADVICE

Identifying and contacting the most appropriate healthcare provider(s) from whom to obtain medical or other advice pertinent to a particular patient/client

  1. Record the name of the physician/primary care provider most closely associated with the patient/client’s healthcare, and the telephone number.
  2. Obtain from the patient/client or parent/guardian written, informed consent to contact the identified physician/primary healthcare provider.
  3. Use a consent/medical consultation form, and be prepared to securely send the form to the provider.
  4. Include on the form a standardized statement of the Procedures proposed, with a request for advice on proceeding or not at the particular time, and any precautions to be observed.

UNDERSTANDING AND TAKING APPROPRIATE PRECAUTIONS

Diabetes

Resources consulted 

  1. The best time for scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions is when the blood glucose level is in the target range and the diabetes medication action is low. 
  2. If the patient/client takes insulin, a morning visit after a normal breakfast is usually best.
  3. The patient/client should have taken the usual medications unless the physician/primary care provider has recommended that the patient/client should change the dose or medication prior to the dental care.
  4. The oral healthcare provider should consult with the physician/primary care provider to decide about adjustments in diabetes medications, or to decide if antibiotic prophylaxis is needed before invasive procedures to prevent infection.

Infection control

Dental hygienists are required to keep their practices current with infection control policies and procedures, especially in relation to

  1. the CDHO’s Infection Prevention and Control Guidelines (2022)
  2. relevant occupational health and safety legislative requirements
  3. relevant public health legislative requirements
  4. best practices or other protocols specific to the medical condition of the patient/client.

DECIDING WHEN AND WHEN NOT TO INITIATE THE PROCEDURES PROPOSED

Resources consulted

  1. In an otherwise healthy patient/client whose blood glucose is close to target levels, who has taken medications as directed, and who has recently eaten, there is no contraindication to the Procedures. 
  2. With a patient/client whose symptoms are under control and whose treatment is proceeding normally, the dental hygienist should implement the Procedures, though these may be postponed pending medical advice, which is likely to be required if the patient/client 
    1. is feeling or looks unwell (particularly a concern for hypoglycemia or significant hyperglycemia)
    2. gives a history of previous or existing problems such as infection, comorbidity, complication or an associated condition of diabetes type 1, 2 or gestational
    3. has not recently or ever sought and received medical advice relative to oral healthcare procedures
    4. has recently changed significant medications, under medical advice or otherwise
    5. has recently experienced changes in his/her medical condition such as medication or other side effects of treatment
    6. is deeply concerned about any aspect of his or her medical condition.
  3. Initiation of Procedures is contraindicated if
    1. blood glucose is < 3.9 mmol/L [70 mg/dL – hypoglycemia] or is > 11.1 mmol/L [200 mg/dL – significant hyperglycemia]; medical clearance is particularly important in the presence of various comorbidities4, and blood glucose < 3.9 mmol/L [70 mg/dL] should typically involve prompt administration of carbohydrates
    2. there are any concerns about the patient/client’s suitability for Procedures regardless of blood glucose level (including oral infection or infection elsewhere in the body).
  4. If there is the potential for electromagnetic interference (EMI) from dental/dental hygiene equipment5 that could affect operation of an insulin pump, initiation of Procedures should be deferred pending safety clarification. However, most dental/dental hygiene procedures do not involve strong electromagnetic signals and thus are unlikely to interfere with insulin pumps (and continuous glucose monitors). Generally, there are few instances in the dental/dental hygiene setting in which disconnecting, turning off, or adjusting an insulin infusion pump is necessary or practically useful.
    Addendum: An external insulin pump does not need to be disconnected for dental x-rays as long as it is covered by a lead apron. If the insulin pump cannot be adequately shielded in situ, then the pump should be disconnected prior to radiographs being taken and removed from the room where the x-rays are being taken (or otherwise be adequately shielded). While insulin pumps should not be exposed to x-rays, radiation from other sources, or strong electromagnetic fields (EMFs)6, removal of insulin pumps can be risky for patients/clients with diabetes, and disconnection can lead to hyperglycemia and even diabetic ketoacidosis.

DEALING WITH ANY ADVERSE EVENTS ARISING DURING THE PROCEDURES

Resources consulted

Focus of adverse event: hypoglycemia (blood glucose < 3.9 mmol/L):

  1. The goals of treatment for hypoglycemia are to 
    1. detect and treat a low blood glucose level promptly by using an intervention that provides the fastest rise in blood glucose to a safe level
    2. eliminate the risk of injury
    3. relieve symptoms quickly.
  2. Classification of symptoms7 and severity of hypoglycemia
    1. MILD
      1. The individual is able to self-treat
      2. The symptoms comprise
        1. Trembling
        2. Palpitations
        3. Sweating
        4. Anxiety
        5. Hunger
        6. Nausea
        7. Tingling
    2. MODERATE
      1. The individual is able to self-treat
      2. The symptoms comprise
        1. Difficulty concentrating
        2. Confusion
        3. Weakness
        4. Drowsiness
        5. Vision changes
        6. Difficulty speaking
        7. Headache
        8. Dizziness
    3. SEVERE
      1. Individual requires assistance of another person
      2. Unconsciousness may occur.
  3. Treatment
    1. Mild to moderate hypoglycemia should be treated with the oral ingestion of 
      1. 15 g of carbohydrate, preferably as glucose or sucrose tablets or solution OR
      2. 15 mL (3 teaspoons) or 3 packets of table sugar dissolved in water.
    2. Severe hypoglycemia in a conscious person should be treated by the oral ingestion of 20 g of carbohydrate, preferably as glucose tablets or equivalent 
      1. Patients/clients should be encouraged to wait 15 minutes, retest blood glucose and re-treat with another 15 g of glucose if the blood glucose level remains below 4.0 mmol/L.
      2. Severe hypoglycemia requires caregivers or support persons to call for emergency services; the episode should be discussed with the diabetes healthcare team as soon as possible. With no intravenous access, 1 mg glucagon should be given subcutaneously or intramuscularly.
    3. All patients/clients with symptomatic hypoglycemia, even if corrected in the dental hygiene office, should be referred for prompt medical attention.

Focus of adverse event: diabetic ketoacidosis (DKA, where blood glucose is usually > 14 mmol/L)8:

  1. Diabetic ketoacidosis is a potentially life-threatening condition (more common in Type 1 than in Type 2 diabetes), and emergency services should be contacted immediately if DKA is suspected, and all Procedures should be stopped.
  2. The clinical presentation of DKA includes signs and symptoms of hyperglycemia, acidosis, and precipitating illness. Signs/symptoms include “fruity” acetone breath, frequent urination, excessive thirst, nausea and vomiting, dry skin and mucous membranes, flushed facial appearance, abdominal tenderness, confusion, and rapid, deep breathing.
  3. In-hospital treatment protocol includes fluid resuscitation, avoidance of hypokalemia, insulin administration, avoidance of rapidly falling serum osmolality, and search for precipitating cause.

General

  1. Dental hygienists are required to initiate emergency protocols as required by the College of Dental Hygienists of Ontario’s Standards of Practice, and as appropriate for the condition of the patient/client.
  2. First-aid provisions and responses as required for current certification in first aid.

RECORD KEEPING

Subject to Ontario Regulation 9/08 Part III.1, Records, in particular S 12.1 (1) and (2)

For a patient/client with a history of  diabetes type 1, 2 or gestational, the dental hygienist should specifically record

  1. A summary of the medical and medications history.
  2. Any advice received from the physician/primary care provider relative to the patient/client’s condition.
  3. The decision made by the dental hygienist, with reasons.
  4. Compliance with the precautions required.
  5. All Procedure(s) used.
  6. Any advice given to the patient/client.

ADVISING THE PATIENT/CLIENT

The patient/client is urged to alert any healthcare professional who proposes any intervention or test that he or she has a history of diabetes type 1, 2 or gestational.

Resources consulted 

The patient/client is strongly advised, as follows.

  1. Inform the oral healthcare provider of any problems with infections or trouble keeping the blood glucose levels under control.
  2. Eat before seeing the dentist or dental hygienist. The best time for dental work is when the blood glucose level is in the target range and the diabetes medication action is low. If insulin is taken, a morning appointment after a normal breakfast is best.
  3. Take the usual medications before a dental visit unless the dentist or physician advises change in the dose preparatory to dental surgery. 
  4. The dentist should consult with the physician to decide about adjustments in the diabetes medicines, or to decide if an antibiotic is needed before surgery to prevent infection.
  5. Stick to the normal meal plan after dental work. If chewing is difficult, plan how to get the calories needed. Consider use of the sick-day meal plan that calls for soft or liquid foods.
  6. If the diabetes is in poor control, postpone scaling of teeth and root planing including curetting surrounding tissue, orthodontic and restorative practices, and other invasive interventions, and dental surgery until the blood glucose is better controlled.
  7. If dental needs are urgent, such as pain or swelling, consult the dentist and physician about having dental treatment in a hospital or special setting where he or she can be monitored during and after surgery. 

As appropriate, discuss 

  1. The importance of the patient/client’s
    1. self-checking the mouth regularly for suspicious signs or symptoms
    2. reporting to the appropriate healthcare provider any changes in the mouth indicative of suspicious lesions.
  2. The need for regular oral health examinations and preventive oral healthcare. 
  3. Oral self-care including information about 
    1. choice of toothpaste
    2. tooth-brushing techniques and related devices
    3. dental flossing
    4. mouth rinses
    5. management of a dry mouth. 
  4. The importance of an appropriate diet in the maintenance of oral health.
  5. For persons at an advanced stage of a disease or debilitation
    1. regimens for oral hygiene as a component of supportive care and palliative care
    2. the role of the family caregiver, with emphasis on maintaining an infection-free environment through hand-washing and, if appropriate, wearing gloves
    3. scheduling and duration of appointments to minimize stress and fatigue 
  6. Comfort level while reclining, and stress and anxiety related to the Procedures.
  7. Medication side effects such as dry mouth, and recommend treatment.
  8. Mouth ulcers and other conditions of the mouth relating to diabetes type 1, 2 or gestational, comorbidities, complications or associated conditions, medications or diet.
  9. Pain management.

General information for diabetic patients/clients

Resources consulted 

  1. Gum disease: the most common problem affecting gums and teeth of persons with diabetes, though it also makes you prone to other mouth problems.
  2. Oral infection: a cluster of germs causing problems in one area of your mouth. 
  3. Infection: can make your blood glucose hard to control. By planning ahead and discussing a plan of action with your oral healthcare provider and physician, you will be prepared to handle any adjustments required.
  4. Fungal infections: persons with diabetes are more prone to fungal infections such as thrush. If you tend to have high blood glucose levels or take antibiotics often, you are even more likely to have thrush. It makes white (or sometimes red) patches in areas of your mouth, which become sore and may turn into ulcers.
  5. Thrush: thrives in moist places that may be chafed or sore, for example under poorly fitting dentures. Stopping smoking and limiting the time dentures are worn can reduce the risk of getting thrush. If you think you have thrush or other infection, talk to your oral healthcare provider or physician.
  6. Poor healing: with poorly controlled diabetes, you heal more slowly and you increase your chance of infection after dental surgery. For the best chance for good healing, keep the blood glucose under control before, during, and after surgery.
  7. Dry mouth: may be caused by medications or high blood glucose levels. It can increase the risk of cavities because less saliva is available to wash away germs and take care of the acids they create. It may sometimes lead to other problems, such as salivary gland infections. Try drinking more fluids, or chewing sugar-free gum or sugar-free candy to help keep the saliva flowing. Saliva substitutes are available at pharmacies.

BENEFITS/HARMS OF IMPLEMENTING THE RECOMMENDATIONS

POTENTIAL BENEFITS

  1. Promotion of health through oral hygiene for persons who have diabetes type 1, 2 or gestational.
  2. Reduction of the risk of hypoglycemia by
    1. careful attention to the preparations for oral healthcare, with particular reference to minimizing the risk of hypoglycemia
    2. generally increasing the comfort level of persons in the course of dental hygiene interventions 
    3. using appropriate techniques of communication
    4. providing advice on scheduling and duration of appointments.
  3. Reduction of risk of oral health needs being unmet.

POTENTIAL HARMS

  1. Failing to recognize mild, moderate or severe hypoglycaemia during an oral healthcare visit.
  2. Failing to recognize hyperglycemic emergencies; specifically, diabetic ketoacidosis or hyperosmolar hyperglycemic state.
  3. Performing the Procedures at an inappropriate time, such as 
    1. when the patient/client has not eaten, has not taken medications as directed, or is not close to his/her blood glucose target
    2. in the presence of complications for which prior medical advice is required
    3. in the presence of acute oral infection without prior medical advice.
  4. Disturbing the normal dietary and medications routine of a person with diabetes type 1, 2 or gestational.
  5. Inappropriate management of pain or medication.
  6. Causing infection.
  7. Inappropriate management of pain or medication.
  8. Malfunction of and/or damage to insulin pump.

CONTRAINDICATIONS

CONTRAINDICATIONS IN REGULATIONS

Identified in the Dental Hygiene Act, 1991 – O. Reg. 218/94 Part III

ORIGINALLY DEVELOPED

2009-11-24

DATE OF LAST REVIEW

2010-07-15; 2014-10-14; 2019-12-18; 2023-05-03

ADVISORY DEVELOPER(S)

College of Dental Hygienists of Ontario, regulatory body
Greyhead Associates, medical information service specialists

SOURCE(S) OF FUNDING

College of Dental Hygienists of Ontario

ADVISORY COMITTEE

College of Dental Hygienists of Ontario, Practice Advisors

COMPOSITION OF GROUP THAT AUTHORED THE ADVISORY

Dr Gordon Atherley
O StJ , MB ChB, DIH, MD, MFCM (Royal College of Physicians, UK), FFOM (Royal College of Physicians, UK), FACOM (American College of Occupational Medicine), LLD (hc), FRSA

Dr Kevin Glasgow

MD, MHSc, MBA, DTM&H, CHE, CCFP, DABPM, FACHE, FCFP, FACPM, FRCPC

Lisa Taylor
RDH, BA, MEd

Elaine Powell
RDH 

Robert Farinaccia
RDH, BSc

Kyle Fraser
RDH, BComm, BEd, MEd

Carolle Lepage
RDH, BEd

ACKNOWLEDGEMENTS

The College of Dental Hygienists of Ontario gratefully acknowledges the Template of Guideline Attributes, on which this advisory is modelled, of The National Guideline Clearinghouse™ (NGC), sponsored by the Agency for Healthcare Research and Quality (AHRQ), U.S. Department of Health and Human Services.

Denise Lalande
Final layout and proofreading

© 2009, 2010, 2014, 2019, 2023 College of Dental Hygienists of Ontario

FOOTNOTES

1 Persons includes young persons and children.
2 Some insulin solutions (e.g., human insulins such as Myxredlin®, Humulin R U-100®, and Novolin R®) may be injected intravenously by a doctor or nurse in a healthcare setting. Insulin inhalation (e.g., Afrezza®) is used in combination with a long-acting insulin to treat type 1 diabetes, as well as in combination with other medications to treat type 2 diabetes. As well, insulin pumps are becoming increasingly common. These are typically battery-powered, peristaltic-driven, externally worn devices. They usually attach to a plastic cannula system for subcutaneous administration of insulin. Some pumps, known as “patch pumps”, do not use tubing and instead adhere directly to the skin; such pumps are programmed from a remote device using wireless technology. Although originally developed for the management of type 1 diabetes as an alternative to a multiple daily injection (MDI) regime for insulin administration, pumps may also benefit persons with type 2 diabetes who require insulin therapy. Implantable insulin pumps also exist, but these are not currently commercially available in North America, and dental hygienists in Ontario are unlikely to encounter them.
3 CGMs are “stick-on” diagnostic systems that use a needle-like sensor and transmitter to measure glucose levels in the subcutaneous interstitial space (a surrogate for blood glucose levels). In addition to stand-lone devices, there are combination CGM-insulin pumps that work together to titrate insulin dose to glucose levels.
4 Co-morbidities of concern include post-myocardial infarction, kidney disease, heart failure, symptomatic angina, advanced age, cardiac dysrhythmia, cerebrovascular accident (stroke), and hypertension (with blood pressure > 180/110 mm Hg).
5 Information on potential sources of EMI in the dental/dental hygienist office setting can found in the Cardiac Implantable Electronic Device Fact Sheet. However, in the extant dental/medical literature, most, if not all, of these sources have not been identified as areas of specific concern for insulin pumps and continuous glucose monitors.
6 Radiation and EMFs may interfere with, or damage, the electronic circuitry and semiconductor materials of “direct motor” pumps, resulting in malfunction (i.e., inappropriate insulin delivery) and/or reduced device lifespan. The use of electrocautery and insulin pumps is a potential concern that ideally would involve questioning the device’s manufacturer regarding the implications of possible electromagnetic interference (EMI). Of note, pump damage or subsequent pump failure have not been documented from dental electrocautery. Pumps have been used safely concurrently with surgical electrocautery, but it is advisable to place the pump as far away from the site of electrocautery as possible. Most manufacturer and institutional warnings/concerns relate to removal of insulin pumps in the context of computed tomography (CT) scans, magnetic resonance imaging (MRI), fluoroscopy, and electrocautery surgery, all of which entail considerably more radiation or EMI than would be typically found in the dental hygiene setting.
7 Hypoglycemic unawareness may occur, especially in persons with type 1 diabetes who have had frequent episodes of hypoglycemia.
8 Blood glucose may even be lower in DKA, especially with the use of SGLT2 inhibitors. Particularly elevated risk occurs with blood glucose > 22.2 mmol/L (> 400 mg/dL). Another overlapping (although less common) hyperglycemic emergency is hyperosmolar hyperglycemic state (HHS). In DKA, ketoacidosis is prominent, whereas in HHS the main features are extracellular fluid volume depletion and hyperosmolarity.