Dental considerations for type 1 diabetes

Last July, I took my 10-year-old daughter to urgent care for what I thought was a urinary tract infection. She had been complaining about pain during urination and had been drinking water excessively and urinating frequently. However, when checking her urine, it was discovered she had large ketones. A quick finger stick revealed her blood glucose was 456 mg/dL, and she was diagnosed with diabetic ketoacidosis (DKA).

I was in shock as what I thought was a quick trip to urgent care resulted in a two-night stay in the hospital, receiving IV fluids for dehydration and starting insulin therapy. I had no idea how sick my daughter truly was.

Type 1 vs. type 2 diabetes mellitus

In my clinical practice as a hygienist in periodontics, I see patients with type 2 diabetes (T2DM) on nearly a daily basis. However, my interactions with type 1 (T1DM) patients are much less frequent. Although there are some similarities between the two most common types of diabetes, there are several key differences.

Type 1 DM is a complex autoimmune disorder, constituting approximately 3%–5% of all diabetes cases. T1DM results from the autoimmune destruction of pancreatic islet cells, eventually leading to complete loss of insulin production. It is typically diagnosed in children and young adults, but some studies have reported 15%–30% of cases occur after the age of 30.¹

Additional reading: Did you know there's a new type of diabetes?

Like other autoimmune diseases, genetic, immune, and environmental influences all play a role in development.² Although etiology is not completely understood, the disease pathogenesis is believed to involve T cell-mediated destruction of beta cells. A cure for T1DM is not currently available. Patients must depend on lifelong insulin injections and cannot survive long-term without insulin.³

In contrast, the onset of T2DM usually occurs in adulthood (after age 40) and is characterized by an increase in insulin resistance.¹ T2DM accounts for approximately 95% of all diabetes cases. The insulin levels of affected patients vary, but there is no profound insulin deficiency. However, over time, most people with T2DM show continual decrease in insulin levels. These patients are not completely dependent on insulin, but insulin treatment for some patients (25%–30%) can improve hyperglycemic control. This hyperglycemia is not caused by autoimmune destruction of beta cells, but rather a failure of those cells to meet an increased insulin demand. Obesity is a major risk factor for T2DM as it increases insulin levels and decreases the concentration of insulin receptors. Genetics also play a role in the development of T2DM, although a family history of diabetes is not required for disease development.⁴

Medical considerations for T1DM patients

Prolonged hyperglycemia is the primary factor responsible for the development of diabetic complications for both T1DM and T2DM. This includes increased susceptibility to infection, delayed healing, neuropathy, retinopathy, nephropathy, heart attack, stroke, and amputation. The major classic findings of hyperglycemia are increased urination, thirst, and appetite along with weight loss and fatigue. These are more common in new-onset T1DM patients. Ketoacidosis can develop rapidly, as my daughter experienced. This can potentially lead to coma or death. The goal HbA1c level for a T1DM patient to reduce the risk of long-term complications is <7% (<150 mg/dL).⁴

More concerning in the dental office is the issue of hypoglycemia in T1DM patients. If the patient’s blood glucose drops below 70 mg/dL (80mg/dL for children), then 15 grams of fast-
acting carbohydrates should be given. The best examples to keep on hand are three to four glucose tabs or one dose of glucose gel. You should then wait 15 minutes and then recheck blood glucose levels, repeating the process if the blood glucose is still below 70 mg/dL. In the case of severe hypoglycemia in which the patient is disoriented, unable to swallow, or unconscious, do not give food or drink by mouth due to the risk of choking. Glucagon (Baqsimi) should be administered instead. Glucagon comes in either an injection or nasal spray and should also be stored in the dental emergency cart.⁵

T1DM patients often use continuous glucose monitors (CGMs) to monitor their blood glucose throughout the day and alert them of low or high blood glucose readings. Many patients also use insulin pumps rather than multiple daily injections to simplify diabetes management. Unfortunately, CGMs and insulin pumps can be very expensive and are not always covered by insurance, so many T1DMs do not have access to this diabetes management technology. Although intensive glycemic control, especially through CGMs and insulin pumps, has reduced the incidence of micro- and macrovascular complications, many patients with T1DM are still developing these complications.³

Dental considerations for T1DM

The possible oral complications of uncontrolled DM include xerostomia, infection, decreased healing, increased incidence and severity of caries, gingivitis, periodontitis, candidiasis, periapical abscesses, and burning mouth syndrome. These complications are likely related to the loss of fluids through excessive urination, altered response to infection, microvascular changes, and possibly increased glucose concentrations in saliva. Frequent hypoglycemic events overnight can also contribute to caries due to sugar consumption. For overnight low blood sugars, T1DM patients should rinse their mouth out with water before returning to sleep. Additional fluoride recommendations should also be considered. Some studies suggest a slight, but persistent, tendency to continual periodontal destruction despite effective metabolic control. Supportive periodontal therapy at close intervals of two to three months may be indicated.⁴

Prior to surgical procedures, a medical consult should be completed with the patient’s endocrinologist. The patient may need adjusted insulin doses prior to and following surgery. A diabetic patient with well-controlled disease may not require antibiotics postsurgery, but it is appropriate if there is significant infection, pain, and stress present.⁴

Conclusion

T1DM patients require close dental monitoring due to an increased prevalence of caries, periodontal disease, and infection. Just like with T2DM patients, regular HbA1c values should be recorded in the patient chart. Patients should be monitored during treatment for any signs or symptoms of hypoglycemia and emergency supplies, including a glucometer, should be available.

T1DM is an autoimmune disease and is not caused by diet or lifestyle choices. It’s important for clinicians to have empathy and understanding for how truly complex this disease is and how complicated it can be for patients to manage. Although endocrinologists play a huge role in diabetes care, the daily management of this disease falls almost entirely on the patient or caregiver, which can be incredibly overwhelming. 

Editor's note: This article appeared in the April/May 2026 print edition of RDH magazine. Dental hygienists in North America are eligible for a complimentary print subscription. Sign up here.

References

1. Aspriello SD, Zizzi A, Tirabassi G, et al. Diabetes mellitus-associated periodontitis: differences between type 1 and type 2 diabetes mellitus. J Periodont Res. 2011;46(2):164-169. doi:10.1111/j.1600-0765.2010.01324.x
2. Quattrin T, Mastrandrea LD, Walker LSK. Type 1 diabetes. The Lancet. 2023;401(10394):2149-2162. doi:10.1016/S0140-6736(23)00223-4
3. Katsarou A, Gudbjörnsdottir S, Rawshani A, et al. Type 1 diabetes mellitus. Nat Rev Dis Primers. 2017;3(17016). doi:10.1038/nrdp.2017.16
4. Vernillo AT. Diabetes mellitus: relevance to dental treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;91(3):263-270. doi:10.1067/moe.2001.114002
5. Low blood glucose (hypoglycemia). American Diabetes Association. Accessed January 6, 2026. https://diabetes.org/living-with-diabetes/hypoglycemia-low-blood-glucose