Title	Uncontrolled Diabetic Patients May Benefit From Prophylactic Antibiotics Prior To Dentally Invasive Treatment
Clinical Question	What is the current prophylactic antibiotic regimen recommendation, if any, for an uncontrolled diabetic patient undergoing invasive dental treatment?
Clinical Bottom Line	Given the fact that uncontrolled diabetic patients are systemically compromised with a high risk of wound repair and healing, dentists should be guarded regarding possible bacterial infections post invasive dental treatment. Since such patients are ASA type III to begin with, the use of prophylactic antibiotic regimen is a strong consideration upon investigating the patient’s diabetes control status where a prophylactic load of 2g of amoxicillin or the alternative 600 mg of clindamycin with or without a dispensation of a 7 to 10 day antibiotic regimen recommendation post operatively.
Best Evidence
PubMed ID Author / Year Patient Group Study type (level of evidence) 20139336 Guo/2010 Patients who experience impaired wound healing. Narrative Review Key results Rao et. al., discusses the connection between uncontrolled diabetics and impaired wound healing and reduced immune responses in a four-year study. In addition, polymorphonuclear leukocytes need to have oxygen in order to produce sufficient superoxide to aid in killing pathogens. Diabetes causes poor tissue oxygenation, which will cause a hypoxic wound. 23570007 Ramu/2012 Patients who require antibiotic intervention for dental procedures. Narrative Review Key results Immune compromised patients include uncontrolled diabetic patients, which means there is a high risk of septicemia following introduction of bacteremia during invasive dental procedures. Therefore, it is the dentist’s role to minimize the effects of induced bacteremia before, during, and after treatment. At the time this systematic review was written; “Cephalexin 2g given one hour preoperatively (dental) is suggested for patients not allergic to penicillin and clindamycin 600 mg one hour preoperatively for patients allergic to penicillin” Skaar et. al. 24125632 Younis/2013 Adult rabbits Animal Study Key results 3 groups of rabbits were divided into 3 groups of 16; one control group, one untreated and uncontrolled diabetic group, and one treated diabetic group. This study identifies the importance of the signaling molecules TGF-B3, VEGF, BMP, and IGF- in response to healing of tooth extraction sockets. The rabbits with uncontrolled diabetes expressed less TGFB-3 and more IGF-1R than those in the control group (t=3.64; p= 0.01) and also the treated group, (t=3.64; p-0.01). Increased amounts of IGF-1R slowed the healing time an the decrease in TGFB-3 accounts for less cell proliferation and osteoblast differentiation in the uncontrolled diabetic rabbit. Although the TGF-B was initially high during the first 2 days of healing there was a significant drop after day 10 which resulted in a significant difference in the process of regeneration of tissue and bone in the following days up to day 30.
Evidence Search	antibiotics” [MeSH] and “tooth extraction” [MeSH] and “diabetes mellitus” [MeSH] ("diabetes mellitus"[MeSH Terms] OR ("diabetes"[All Fields] AND "mellitus"[All Fields]) OR "diabetes mellitus"[All Fields] OR "diabetes"[All Fields] OR "diabetes insipidus"[MeSH Terms] OR ("diabetes"[All Fields] AND "insipidus"[All Fields]) OR "diabetes insipidus"[All Fields]) AND ("tooth"[MeSH Terms] OR "tooth"[All Fields]) AND extraction[All Fields]
Comments on The Evidence	Validity: Currently, there are no human clinical trials comparing uncontrolled diabetics and incidence of dental post-operative infections to a control specifically. Therefore, statistically data cannot be compared. Guo et. al., discuss the role of increased risk of poor tissue oxygenation and compromised immunity in uncontrolled diabetics. In the diabetic rabbit study, the different expression of key signaling molecules responsible for the delayed healing is of concern for this clinical question because it challenges whether or not antibiotic pre-medication would help to speed healing. Perspective: Based on evidence found more research with larger groups are needed to prove that antibiotics have a role in either decreasing the healing time for uncontrolled diabetics undergoing invasive dental procedures or aid in reducing risk of bacteremia induced during the treatment. Guo and Ramu narratives are not strong enough evidence to provide an answer to this clinical question. They both discuss in detail the biology of uncontrolled diabetes where Ramu strongly recommends prophylactic antibiotics for dentally invasive procedures. The animal study by Younis, W., is higher quality evidence that there may be delayed healing following tooth extractions specifically in uncontrolled diabetics but does not address whether antibiotics would play any role in reducing or eliminating the post-operative delay in healing found in the study rabbits.
Applicability	The review by Guo et. al., explains the biological effects on the immune system for uncontrolled diabetics; which links an uncontrolled diabetic patients with a systemically immunocompromised status. Younis et. al., identifies reduced cellular TGF-B signaling and an increased IGF-1R signaling in the uncontrolled diabetic study rabbits as the cause of reduced wound healing following tooth extraction. Ramu et. al., completes the link between induced dental surgical bacteremia, immunocompromised patients and a suggested protocol for prophylactic pre-medication.
Specialty	(Public Health) (Oral Medicine/Pathology/Radiology) (General Dentistry) (Oral Surgery) (Periodontics) (Prosthodontics) (Restorative Dentistry) (Dental Hygiene)
Keywords	Uncontrolled diabetes, dental prophylactic antibiotics, oral surgery
ID#	2616
Date of submission	03/24/2014
E-mail	Graym3@livemail.uthscsa.edu
Author	Minda Gray
Co-author(s)
Co-author(s) e-mail
Faculty mentor	Moshtagh R. Farokhi, DDS, MPH
Faculty mentor e-mail	farokhi@uthscsa.edu
Basic Science Rationale (Mechanisms that may account for and/or explain the clinical question, i.e. is the answer to the clinical question consistent with basic biological, physical and/or behavioral science principles, laws and research?) None available
Comments and Evidence-Based Updates on the CAT (FOR PRACTICING DENTISTS', FACULTY, RESIDENTS and/or STUDENTS COMMENTS ON PUBLISHED CATs) None available