PaAbstract:
Background: Diabetes is one of the most common endocrine disorders reported worldwide. There have been various reports in the literature showing alteration in the plasma glucose levels by administration of local anaesthetic containing adrenaline which has been a subject controversy. The present study was conducted to assess the effect of epinephrine in diabetic patient undergoing extraction of third molar. Materials and methods: The present study was conducted in Department of Dentistry, Karwar Institute of Medical Sciences ,Karwar. The study involved total of 150 patients reporting to the hospital for the purpose of third molar extraction. Blood glucose levels were measured before administrating Local Anaesthesia(LA), after administrating LA and after extraction of third molars. The glucose levels were estimated using electronic glucometer. Postoperative suturing was done in all patients.The data was arranged in a tabulated form and analysed using SPSS software. The results were compared using student t test. Result:The mean age of the patients was 36.21 +/- 8.91 years. The mean glucose levels before and after administration of LA in healthy individuals (GroupI)were 107.54”20.22 mg/dl and 108.65”19.23, in patients who were diabetic but on anti-diabetic drug(Group II) was195.33”29.08 and 197.54”30.54,in patients who were diabetic but not on anti-diabetic drug(Group III) was 170.45”23.11and 168.46”22.65 respectively showing no significant difference in glucose level. The mean glucose level before and after extraction in Group I were 107.54”20.22 and 105.46”21.25, in Group II 195.33”29.08 and 199.87”32.21, in Group III 170.45”23.11and 223.65”43.44 respectively showing a significant difference in glucose level in Group III patients before and after tooth extraction with p value lesser than 0.05.Conclusion: Adrenaline does not exert any significant affect on healthy and diabetic patients but in patients with untreated diabetes the glucose levels tend to rise significantly if local anaesthesia with adrenaline is administered.
Keywords: Adrenaline, diabetes, extraction, glucose, third molar
Introduction:
Diabetes is one of the most common endocrine disorder worldwide known to affect around 200 million people .1 According to WHO in the year 2000 its prevalence was 2.8% and it is expected to increase to 4.4% by 2030.2 The International Diabetes Federation (IDF) estimates in India the total number of diabetic subjects to be around 40.9 million which is further set to rise to 69.9 million by the year 2025 .3It is of two types- type 1 diabetes mellitus in which there is autoimmune destruction of beta cells of pancreas and type 2 diabetes mellitus in which there is resistance of body cells to insulin. Pain relief is one of the major goals while doing any dental treatment which is provided by the use of local anaesthesia.To prolong the duration of action of local anaesthetics a vasoconstrictor is added which offers various unmatchable advantages.4 Addition of adrenaline or other catecholamines provide a prolong anaesthesia5by decreasing the systemic absorption of the drug and hence decreasing its side effects6. It also provides a bloodless field of surgery.7 However there have been various reports in the literature that show that there is alteration in the plasma glucose levels by administration of local anaesthetic containing adrenaline.4 Even though there have been many studies regarding this issue but none of the studies provide us with conclusive evidence. Therefore, the present study was conducted to assess the effect of epinephrine in diabetic patient undergoing extraction of third molar.
Materials and methods:
The present prospective study was conducted in the Department of Dentistry, Karwar Institute of Medical Sciences, Karwar for a period of 3 months after the approval of institutional ethical committee and written consent was obtained from all the patients in their vernacular language .The study involved total of 150 patients reporting to the hospital for the purpose of third molar extraction.
The study was divided into three groups. In Group I, all the patients with no medical history of diabetes were included. In Group II, diabetic patients who were on anti diabetic drugs were included. Group III included diabetic patients not on any anti diabetic drugs. Patients with head and neck space infection of nonodontogenic origin and patients with unknown antibiotic intake before reporting were excluded from the study .Each category comprised of 50 patients each. Patient’s complete history with demographic details was recorded. Special emphasis was given to past dental history and medical history. Patients were advised to eat before extraction and take their usual course of medications. Blood glucose levels were measured before administrating LA, after administrating LA and after extraction of third molars. The glucose levels were estimated using electronic glucometer. Postoperatively suturing was done in all patients.The data was arranged in a tabulated form and analysed using SPSS software. The results were compared using student t test.
Results:
The study was conducted involving 150 patients. The patients were aged between 25-50 years. The mean age of the patients was 36.21 +/- 8.91 years.Table 1 shows the mean glucose levels in healthy controls before and after administrating LA. The mean levels of glucose before LA administration was 107.54+/- 20.22 and after LA administration was 108.65 +/- 19.23. There was no significant difference in the glucose levels.The mean glucose levels in amongst diabetic patients(on medications) before and after LA. The mean levels of glucose before LA administration was 195.33+/-29.08 and after LA administration was 197.54+/- 30.54. There was no significant difference in the glucose levels as seen in table 2.Among the diabetic patients (without medications)the mean glucose level before and after administrating LA. The mean levels of glucose before LA administration was 170.45+/-23.11and after LA administration was 168.46+/- 22.65. There was no significant difference in the glucose levels as depicted in Table 3 and figure 1.
Table 4 shows the mean glucose levels amongst healthy controls before and after extraction of third molar. The mean levels of glucose before extraction was 107.54+/- 20.22 and after extraction was 105.46 +/- 21.25. There was no significant difference in the glucose levels. The mean glucose levels amongst diabetic patients (on medications) before and after extraction of third molar. The mean levels of glucose before extraction was 195.33+/-29.08 and after extraction was 199.87 +/- 32.21. There was no significant difference in the glucose levels as seen in table 5.Amongst diabetic patients (without medications) the mean glucose level before and after extraction of third molar. The mean level of glucose before extraction was 170.45+/-23.11and after extraction was 223.65+/- 43.44. There was significant difference in the glucose levels with p value greater than 0.05 as shown in Table 6 and Figure 2.
Discussion:
There is paucity of literature regarding the effect of local anaesthesia on hemodynamic responses of our body.8,9 Our study evaluates the effect of local anaesthesia on glucose levels amongst diabetic and healthy patients. In this study we see that there has been no significant difference in the glucose levels before and after administrating local anaesthesia amongst all the groups but significant difference was found in glucose levels in Group III ( without medications) before and after extraction which is similar to study conducted by Tily and Thomas in 200710 who concluded that local anaesthesia with adrenaline can be used both in healthy and diabetic patients without any significant changes in glucose levels. In their study significant changes were observed in diabetic patients who were not taking any medications after extraction. According to a study by Khawaja et al11, local anaesthesia can be safely administered in diabetic patients taking medications and healthy patients. They also observed that glucose levels significantly rises after extraction in diabetic patients who were not taking any medications as in our study .Study by John and Meechan et al12 were epinephrine injection was given at 10 and 20 minutes and compared with the baseline too showed that there was significant rise in glucose levels (<0.05) in diabetic patients who were not taking any medications. Thus indicating that hypoglycaemic medications mask the effect of adrenaline on glucose levels. Sherwin et al13 has theoretically proved that increase in blood glucose levels has been associated with diabetic patients after administration of local anaesthesia with adrenaline. Cryer et al14 and Ra et al15 have found out that both endogenous and exogenous catecholamine release affects suppression of the insulin secretion stimulating both glycogenolysis and glyconeogenesis Vernillo et al 16 to produce hyperglycemia.
Study conducted by Mahima goel et al17, in the year 2016 also observed similar results. There was significant increase in glucose levels amongst diabetic patients who were not on hypoglycaemic drugs. According to a study by Ad et al18 they said that addition of adrenaline to LA produces a profound anaesthetic effect, thus reducing the stress on patient and hence reduction in the release of endogenous epinephrine. The major drawback associated with our study was smaller sample size and the anxiety of the person was not taken into consideration.
Conclusion
Adrenaline does not exert any significant affect on healthy and diabetic patients. But in patients with untreated or undiagnosed diabetes, the glucose levels tend to rise significantly if local anaesthesia with adrenaline is administered.
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