Complications associated with diabetes mellitus after guided tissue regeneration: case report

Dental practitioners need to be aware of the complications that can arise in the management and treatment of patients with diabetes mellitus. Patients with diabetes, and patients with a family history of diabetes, are at-risk dental patients. They are more likely to develop periodontal disease, and the periodontitis is more likely to be severe. Diabetes influences the progression and severity of periodontitis through changes in the small blood vessels, decreased collagen formation, and impairment of the host's defense mechanisms. Furthermore, complications associated with diabetes, such as impaired wound healing, can affect the patient's response to periodontal therapies like guided tissue regeneration (GTR). The case report in this article discusses the postsurgical complications that occurred during GTR treatment of a patient with non-insulin-dependent diabetes. The diabetic's susceptibility to periodontal disease and impaired wound healing can affect the progression of the disease and its treatment. Dental patients with diabetes require close supervision and frequent monitoring of their medical and dental health by the dental clinician.     

Intensified insulin treatment is cost-effective

Both the Diabetes Control and Complications Trial (DCCT) in USA/Canada, and Stockholm Diabetes Intervention Study (SDIS) showed intensified insulin treatment and reduced glycaemia to prevent complications in patients with insulin-dependent (type I) diabetes mellitus. In the DCCT, the intensified treatment was considered cost-effective. In the SDIS, investigation of the direct increase in costs due to the intensified insulin treatment showed the saving in direct costs due to the reduction in photocoagulation requirements, and in the prevalence of renal insufficiency and of amputation, to correspond to 10 years' intensive insulin treatment. Thus, as intensified insulin treatment in type I diabetes reduces direct suffering at a low cost, it may be regarded as 'evidence-based' and mandatory.     

Expanded role of the dietitian in the Diabetes Control and Complications Trial: implications for clinical practice. The DCCT Research Group

Initially, the dietitians' role in the Diabetes Control and Complications Trial (DCCT) was specifically defined to include evaluation of potential study volunteers, collection of dietary histories, provision of nutrition education, and participation in team management meetings. As the study progressed, recognition of the importance of adherence to diet in achieving hemoglobin A1c goals and the occurrence of undesirable weight gain in patients assigned randomly to intensive therapy provided an opportunity for dietitians to use their skills intensively and broadly. The need for dietary adherence made DCCT teams aware that dietitians needed to become more active in recruiting and selecting study volunteers and in implementing and evaluating all aspects of intensive diabetes treatment. Increased involvement in these activities allowed dietitians to develop relationships with research patients that were necessary to negotiate treatment goals and improve insights into dietary issues affecting care. Recognition of the importance of dietitians to the DCCT and the empowering nature of the annual meeting of DCCT dietitians fostered continued expansion of the dietitians' role in the clinical centers and in studywide activities such as promotion of dietary adherence, ancillary studies, and publications. Dietitians participating in clinical trials are encouraged to develop their communication and counseling skills, seek out alliances with other team members, and explore opportunities for ancillary research. Such efforts will help to perpetuate this expanded model of the dietitians' role in clinical trials.     

Issues surrounding tight glycemic control in people with type 2 diabetes mellitus

OBJECTIVE: To review the prospective evidence surrounding the issue of tight glycemic control in people with type 2 diabetes mellitus and resultant long-term complications. DATA SOURCE: Conference proceedings and a MEDLINE search (1966-February 1998) identified pertinent English-language publications on type 2 diabetes in humans. Key search terms included insulin resistance, diabetes mellitus, non-insulin-dependent, macrovascular complications, microvascular complications, and intensive glycemic control. STUDY SELECTION: Selection of prospective epidemiologic and clinical studies were limited to those focusing on the management of type 2 diabetes. All articles with pertinent information relevant to the scope of this article were reviewed. DATA SYNTHESIS: The pathophysiology of type 1 and type 2 diabetes differ; however, both share chronic complications that significantly affect morbidity and mortality. People with type 1 diabetes have an absolute deficiency of insulin, whereas people with type 2 diabetes have varying degrees of insulin resistance and an inadequate compensatory insulin secretory response. The Diabetes Control and Complications Trial (DCCT) has clearly indicated that intense control of blood glucose in type 1 diabetes prevents and slows the progression of microvascular (i.e., retinopathy, nephropathy) and neuropathic complications. The Kumamoto study showed similar results in nonobese patients with type 2 diabetes. Intense insulin therapy in both populations has proven advantageous, thus supporting a common pathophysiologic process for the microvascular and neuropathic complications. Trends were seen toward fewer macrovascular (atherosclerotic disease) complications in the intensive insulin arm of the DCCT. Conversely, trends were seen toward an increase in macrovascular complications in the VA Cooperative study in people with type 2 diabetes using intensive insulin therapy. This may suggest a discordance in the pathophysiology of macrovascular disease between type 1 and type 2 diabetes. Additionally, it remains uncertain whether tight glycemic control prevents the onset or slows the progression of macrovascular disease. Two studies (the University Group Diabetes Program and the Veterans Affairs Cooperative Study on Glycemic Control and Complications in Type 2 Diabetes) to date have examined pharmacotherapy options for patients with type 2 diabetes and resultant macrovascular complications. It has yet to be determined whether any therapeutic intervention will decrease the morbidity and mortality of macrovascular disease in this population. CONCLUSIONS: In type 2 diabetes, limited prospective evidence does support tight glycemic control to help prevent or slow the progression of microvascular and neuropathic complications. It is uncertain whether tight glycemic control decreases macrovascular complications and which pharmacotherapeutic agent(s) is/are the best options. However, therapy that improves glucose control in combination with aggressive risk factor management should be initiated and enforced in patients with type 2 diabetes in an effort to reduce long-term complications.     

The incidence of complications associated with local anesthesia in dentistry

Local anesthetics are frequently administered in dentistry and thus can be expected to be a major source of drug-related complications in the dental office. Additionally, the dentist will more often be confronted with the treatment of risk patients; thus, the incidence of side effects can be expected to rise. In this study, 2731 patients receiving dental anesthesia were evaluated by questionnaire for risk factors, type and dosage of local anesthetic applied, type and duration of treatment, and complications associated with the administration of the local anesthetic. Of all patients, 45.9% had at least one risk factor in their medical histories, with cardiovascular diseases and allergies being the most frequent. The overall incidence of complications was 4.5%. It was significantly higher in risk patients (5.7%) than in nonrisk patients (3.5%). The most frequently observed complications (dizziness, tachycardia, agitation, nausea, tremor) were transient in nature and did not require treatment. Severe complications (seizure, bronchospasm) occurred in only two cases (0.07%). Articaine was found to be administered in over 90% of all dental anesthesias in Germany despite the great variety of local anesthetics available. Articaine 1:100,000 caused more sympathomimetic side effects than did articaine 1:200,000. Additionally, doses of local anesthetics proved not to be strictly determined according to body weight, especially for patients weighing less than 50 kg. In summary, it can be stated that dental local anesthesia can be considered safe. Nevertheless, the incidence of complications due to dental anesthesia can be expected to be further reduced if (a) patients are routinely evaluated for risk factors with an adequate medical history prior to dental treatment, (b) doses of local anesthetics are strictly determined according to body weight, (c) anesthetics with low concentrations of epinephrine are used, and (d) the concept of a differentiated dental anesthesia is applied.     

The relationship between glycemic control and health-related quality of life in patients with non-insulin-dependent diabetes mellitus

The relationship between glycemic control and health-related quality of life was examined in patients with non-insulin-dependent diabetes mellitus (NIDDM). Within the context of a randomized controlled trial, 275 patients with NIDDM receiving primary care from a Veteran's Administration general medical clinic were enrolled and monitored for 1 year. Glycemic control (glycosylated hemoglobin levels) and health-related quality of life (Medical Outcomes Study Short-Form 36-item Health Survey [SF-36]) were assessed at baseline and at 1 year. Multivariate regression modeling using baseline and change scores during a 1-year period did not find a linear or curvilinear relationship between glycosylated hemoglobin and SF-36 scores (P = .15); this was true even after controlling for five covariates identified a priori (insulin use, number of diabetic complications, duration of diabetes, education, number of hyper-, or hypoglycemic episodes during the preceding month). Health services researchers and clinicians alike need to be aware that these two important outcomes may not be directly related. This lack of association could contribute to the high noncompliance rates observed among patients prescribed complex diabetic regimens. Unless patients perceive a benefit from following such regimens, good glycemic control may continue to be an elusive therapeutic goal, especially in patients with long-standing disease.     

Prenatal diagnosis of congenital toxoplasmosis: comparative value of fetal blood and amniotic fluid using serological techniques and cultures

The management of patients with acute, severe ulcerative colitis requires careful in-hospital assessment of the patient and the coordinated treatment of a team of experienced gastroenterologists and surgeons. Complete understanding of the potential complications and their management, especially toxic megacolon, is essential. We review the current medical arsenal and advocate a standardized approach to management that includes continuous, high dose intravenous hydrocortisone, more aggressive use of topical steroids as well as feeding the patients and continuing (but not initiating) oral 5-aminosalicylic acid (5-ASA) agents. For those patients whose disease proves refractory to intravenous steroids, intravenous cyclosporin (with an acute response rate of 82%) is an essential component in the medical management of these patients. Antibiotics should be used only when specifically indicated. Total parenteral nutrition has not been shown to be helpful in the acute setting. Air contrast barium enema and colonoscopy have been used to predict response but may be dangerous diagnostic modalities in these acutely ill patients and are no better than good clinical judgement. We review and advocate long-term management of acute response using 6-mercaptopurine or azathioprine. The surgical experience and the postoperative complications of the ileal pouch anal anastomosis, which include acute pouchitis in 50-60%, chronic pouchitis in 5-10% and recent reports of dysplasia among patients with chronic pouchitis, must be considered before colectomy is advised. Over 80% of patients with acute severe colitis can be spared colectomy using our current arsenal of medical therapies.     

Clinical interview skills and identification of emotional disorders in primary care

BACKGROUND: This study focuses on the detection of medically compromised dental patients in the Netherlands by means of a validated patient-administered medical risk-related history (MRRH). Due to social changes and scientific innovations in the past decade, more medically compromised patients will be needing special dental treatment. METHODS: The medical problems of 29,424 dental patients (age 18 years and over) from 50 dental practices in the Netherlands were registered by means of the MRRH. The patients were classified according to the ASA risk-score system, which was modified for dental treatment. An inventory of the number and nature of medical problems and the modified ASA risk score was drawn up in relation to dental treatment and age. RESULTS: The average age of the patients was 37.1 +/- 13.5 years. According to the current guidelines, dental treatment must be modified if the patient has an ASA score of III or IV. A relatively high percentage of patients ages 65-74 (23.9%) and 75 or over (34.9%) did have an ASA score of III or IV. Furthermore, the medical problems were classified into 10 categories, and the relationship to age was examined. The conditions that increased with age were hypertension and cardiovascular, neurological, endocrinological, infectious, and blood diseases. CONCLUSIONS: For the dental practice, these results mean that the MRRH can play an important role in adapting dental treatment to the specific needs of patients. This is especially important in the case of elderly patients.     

How have patients reacted to the implications of the DCCT?

OBJECTIVES: To assess the reactions of people with insulin-treated diabetes (ITD) to the results of the Diabetes Control and Complications Trial (DCCT). RESEARCH DESIGN AND METHODS: A leaflet documenting the purpose and results of the DCCT was circulated to all 771 patients ages 15-60 years with ITD attending our clinic. Patients were invited to complete and return a questionnaire on their responses. RESULTS: Of 550 respondents, 330 felt encouraged to improve glycemic control. Female respondents (P = 0.003) and younger age-groups (15-25 years, P = 0.001) were most likely to want to improve control. Patients with long duration of diabetes (> 20 years, P = 0.00001), hypoglycemia unawareness (P = 0.0001), or previous severe hypoglycemia (P = 0.001) were less likely to want to improve their control. Fear of hypoglycemia concerned all age-groups, whereas female respondents were most likely to be worried about the potential for weight gain (P = 0.00006). CONCLUSIONS: Knowledge of the results of the DCCT encourages significant numbers of patients to want to improve glycemic control. Fear of hypoglycemia and, in women, weight gain may prove significant impediments to the clinical implementation of the results of the DCCT.     

Pharmacotherapies for alcohol abuse. Withdrawal and treatment

Pharmacologic management of alcoholism is only one part of the management of both alcohol dependence and withdrawal, which also includes the provision of a calm, quiet environment; reassurance; ongoing reassessment; attention to fluid and electrolyte disorders; treatment of coexisting addictions and common medical, surgical, and psychiatric comorbidities; and referral for ongoing psychosocial and medical treatment. For further discussion of these topics, the reader is referred to previously published sources. A survey of alcoholism treatment programs revealed that although benzodiazepines were the most commonly used drugs, standardized monitoring of patients' withdrawal severity was not common practice, and a significant minority of clinicians were using a variety of other drugs, some not known to prevent or treat the complications of withdrawal. Treatment should be based on the available evidence (Working Group on Pharmacological Management of Alcohol Withdrawal: American Society of Addiction Medicine Committee on Practice Guidelines: Pharmacological management of alcohol withdrawal: An evidence-based practice guideline. Unpublished draft, 1997). Patients with significant symptoms, patients with complications such as seizures or delirium tremens, and patients at higher risk for complications of alcohol withdrawal should receive benzodiazepines, particularly chlordiazepoxide, diazepam, or lorazepam, because of their safety and documented efficacy in preventing and treating the most serious complications of alcohol withdrawal. These drugs may be dosed on a fixed schedule for a predetermined number of doses on a tapering schedule over several days, or they may be administered by front-loading. An alternative approach for selected patients without seizures or acute comorbidity is symptom-triggered therapy, which individualizes treatment and decreases the duration and dose of medication administration. With either of the regimens, patients should have their withdrawal severity monitored until symptoms are resolving. Once withdrawal from alcohol is safely completed, the focus should turn to helping to prevent relapse. Disulfiram may be useful in highly motivated subsets of patients and when compliance-enhancing strategies are used. Naltrexone is useful in the broader population of patients entering treatment for alcohol dependence. These pharmacologic interventions should be given in the context of ongoing psychosocial support. There is substantial evidence that pharmacologic management of alcohol abuse and dependence is effective. As would be predicted from alcohol's myriad cellular effects, no panacea exists for alcoholism. For alcohol withdrawal, however, although treatment regimens have only recently been refined, evidence for effective treatment of symptoms and prevention of complications with benzodiazepines has been available for decades. Within the last decade, effective treatments, including naltrexone, have been shown to reduce alcohol intake in alcohol-dependent persons. Given the prevalence and cost of alcohol-related problems, all effective therapies (including pharmacologic treatments) should be considered to treat alcohol abuse and dependence.     

Natural products and diabetes treatment

Many natural products are promoted to improve the health status of patients with diabetes by people making a profit on these products. Few of these claims have any scientific basis. Certain natural products are potentially damaging to patients with chronic diseases, especially if the products are used instead of proven scientific treatment regimens. Many individuals believe that if a product is natural it must be effective and safe. What is ironic is that if the products were safe and effective, and if studies would have been done on humans to prove safety and effectiveness, the sales of the products would greatly increase (as opposed to present limited sales as herbs from health food stores). Some of the products do have a beneficial effect, especially as a placebo if the patient believes that the product is going to work. As can be seen from the summary of products that are listed here that claim to improve the treatment of patients with diabetes, very few are available in a standard form that would produce a known positive effect. The few products that do have a mild impact on lowering blood glucose levels are much less effective than standard treatments. In a recent review of the role of plant-derived drugs and herbal medicines in healthcare, no natural products were listed as having a beneficial effect on diabetes. Diabetes care providers need to confront the issue of the use of natural products with their patients. Patients should be taught the importance of using proven, effective treatment regimens. Any patient who decides to use a natural product should be followed closely to make sure that no toxic effects occur and that treatment objectives are achieved.     

Progress in HIV and AIDS care

These recent meetings emphasized the considerable progress that has been made in HIV/AIDS. The prospect for non-progression of the disease, improved management of complications arising from the condition, and the potential for additional progress were the hallmarks of these meetings. The considerable developments that have occurred make it necessary for the dental profession to continue to play a role in the recognition, diagnosis, and management of oral conditions, and to keep abreast of the considerable developments in this field-and the implications that these developments have for patients presenting with complications related to other conditions, which may include bacterial, fungal or viral infections and malignant disease.     

Insulin therapy in type II diabetes

The results of conventional intensified insulin therapy (4 injections per day) in type II diabetics correspond more to those of conventional therapy (2 injections per day). Compared to a conventionally treated collective with strict dietetic regimen the intensified treated type II diabetics did not lead to an improved metabolic control. The frequency of hypoglycemic episodes did not differ in both collectives. Intensified insulin therapy is associated with subjectively increased comfort and increased life quality despite the seldom use of the advantages of the therapy. The management of the intensified therapy probably has to be learned in an earlier stage of life and requires repeated and more intensified education in elderly patients. The regression of typical late complications of diabetes mellitus as seen in the DCCT may possibly be achieved by a greater effort in therapy and empowerment of the patient.     

Providing dental treatment for patients with cardiovascular disease

The appropriate management of dental patients with cardiovascular disease is contingent on appropriate assessment and evaluation. Baseline vital signs, a good medical history and medical evaluation are all essential for the safe delivery of care. All patients with cardiovascular disease can be managed using the following guidelines: 1. Properly assess the patient. This should include an assessment by the dentist and also a medical consultation if required. 2. Establish what medications the patient is taking along with the dose and timing and note any potential drug interactions and side effects. 3. Use short appointments (less than one hour), preferably in the morning. 4. Premedication should be considered to alleviate anxiety. The intraoperative use of nitrous oxide and oxygen is also a reasonable strategy for patients with cardiovascular disease, particularly those with ischemic heart disease. 5. Effective local anesthesia is important in order to avoid undue stress during the appointment as long as the guidelines for the administration of epinephrine are followed. The use of epinephrine impregnated gingival displacement cord should be strictly avoided in patients with cardiovascular disease. 6. For patients with angina pectoris, a fresh supply of nitroglycerin should be available at the time of the appointment. Prophylactic nitroglycerin has been shown to be effective in the prevention of both hypertension and angina pectoris during dental treatment. The appointment should be terminated early if the patient becomes overly anxious. In the event of cardiovascular symptoms during dental treatment, all work should be stopped. Emergency measures should be instituted if necessary. Preparations for emergencies should be undertaken by all dentists. The treatment of patients with cardiovascular disease is relatively simple if the proper steps are taken. The use of blood pressure measurements on all patients will help to screen for undiagnosed hypertension and all patients who are potentially hypertensive should be referred for medical evaluation. A preventive approach to the treatment of these patients will serve to prevent untoward outcomes and provide safe and simple delivery of dental care for cardiovascular patients.     

Medical risk report: improving patient management and record keeping through a problem-oriented approach

The problem-oriented record satisfies the needs of the contemporary practitioner by addressing the transition from diagnosis to treatment. The technique organizes collected data, identifies all patient problems (medical and dental), defines solutions and/or management of those problems, and documents treatment rendered. Predictably, the problem-oriented record will avoid problems associated with malpractice litigation, conform to regulations of third-party payers, and facilitate practice analyses and quality assessment, i.e., through computer-assisted tracking of patient care based on problems and not just treatment rendered. As many practices today focus on a "patient-centered" approach to practice, the problem-oriented record clearly supports such a philosophy in its completeness of managing patient care information. The dentist, in consultation with other health care providers, can and should feel confident treating patients from the growing population of patients with medical risk. By integrating the problem-oriented approach into patient management and record keeping, dentists can more easily develop a plan for the complexities that accompany patients. Whether these complexities are of a medical, dental, or combined nature, the problem-oriented record helps the practitioner organize information, plan for treatment, and document patient care in a complete and concise manner.     

Type 2 diabetes: patient education and home blood glucose monitoring. 3

Successful treatment of type 2 diabetes requires the interaction of the patient, his or her family, and a variety of healthcare professionals. Education is the most powerful tool doctors have to convince patients, especially those who are asymptomatic, of the serious complications that can result from uncontrolled diabetes. Home blood glucose monitoring is a key to the doctor-patient partnership. Physicians may have to consider a patient's cultural and dietary customs in developing a manageable program of weight loss, diet, and physical activity, the most effective forms of treatment. Referrals should be made to local diabetes organizations with patient support programs, when available. Patient empowerment and education are key to effective management.     

Management of ophthalmic complications of homocystinuria

OBJECTIVE: To determine the safety and efficacy of surgical versus medical management in the treatment of ophthalmic complications of homocystinuria, and also to document ocular complications of homocystinuria other than lens dislocation. DESIGN: Retrospective case series. PARTICIPANTS: Forty-five patients with ophthalmic complications of homocystinuria participated. INTERVENTION: Eighty-four surgical procedures were performed on 40 patients. There were 82 procedures done with the patients under general anesthesia and 2 with the patients under local anesthesia. Medical therapy was attempted initially in all patients with lens dislocation and was the sole therapy used for five patients. MAIN OUTCOME MEASURES: Complications resulting from medical or surgical treatment and final visual acuity were studied. RESULTS: All patients had a history of lens subluxation or dislocation. Fourteen (31%) were receiving dietary treatment at the time of presentation and 29 (64%) were mentally retarded. Eighty-two procedures were performed with the patients under general anesthesia with 2 surgical complications and 1 postsurgical complication. Lens dislocation into the anterior chamber was the most frequent indication for surgery (50%) followed by pupillary block glaucoma (12%). Prophylactic peripheral iridectomy was not successful in preventing lens dislocation into the anterior chamber in five patients. Anesthetic precautions such as stockings to prevent deep venous thrombosis, preoperative hydration, or aspirin were given in 85% of cases. Other common ophthalmic complications found include optic atrophy (23%), iris atrophy (21%), anterior staphylomas (13%), lenticular opacities (9%), and corneal opacities (9%). CONCLUSION: Laser iridectomy was unsuccessful in preventing lens dislocation into the anterior chamber. With appropriate anesthetic precautions and modern microsurgical techniques, the risks associated with the surgical management of ocular complications of homocystinuria are reduced. Surgical treatment should be considered, especially for cases of repeated lens dislocation into the anterior chamber or pupillary block glaucoma. If a conservative, nonsurgical approach is undertaken, these patients must be observed carefully for repeat episodes of lens dislocation.     

The dental assessment of the patient waiting for a liver transplant

Until the last several years liver transplantation was considered an experimental treatment procedure. Nowadays virtually any disease process, that is in terminal stage, is treatable with transplantation. The introduction of cyclosporine in 1980 and the recent use of OKT3 monoclonal antibody now allows a 5-year survival rate of 60-70%. The causes of early death of patients who survive after surgery are infective complications, multiorgan failure and acute rejection of the allograft. In the literature and in our experience, bacterial sepsis is the most common cause of deaths occurring during the first postoperative months while most deaths after one year are generally related to chronic rejection of the allograft. The risk of infection is also increased by the over-immunosuppression of these patients always treated with a high dose of immunosuppressive agents when evidence of acute graft rejection is found. Regarding these problems, patients being prepared for liver transplantation should be evaluated for their dental health. The medical indications of 80 transplant recipients and the current status of liver transplantation are reviewed in this article. We describe the dental status of these patients that should receive indicated dental care before surgery. Most patients (90%) were affected by chronic active hepatitis while the number of primitive cirrhosis was significantly lower. Very poor dental hygiene was found in 85% of patients while 45% were affected by advanced periodontal disease and 12% by a chronic gingivitis. Dental caries were observed in 67% while in 20% of cases endodontic periapical lesions were found and only 2% of these resulted as radicular cysts. Indicated dental care consisted in 87% of cases in dental hygiene instructions, in 85% in scaling and root planing, in 63% in conservative restorations and in 40% in endodontic treatments. Dental treatment guidelines before transplantation are described with particular attention to prevent risk of infection using antibiotic prophylaxis for invasive dental procedures. Dentists, after surgery must be also prepared to deal with excessive bleeding related to a severe liver disfunction; for this purpose an appropriate protocol is also described. The monitoring of oral and general health conditions and the achievement of specific protocols of prophylaxis are helpful in the prevention of complications and are fundamental to obtain the best results with liver transplantation improving the quality of life of these patients.     

Profuse epistaxis: an argument for conservative medical management

A review of 10 years' experience of all patients with profuse epistaxis requiring hospitalisation in a tertiary care centre in India is presented. There were 106 patients among which only 72% of cases had associated medical illness. Hypertension (44%) and bleeding diathesis (11%) were found to be the most frequently associated aetiological medical conditions noted in this study. Although there is controversy regarding the optimum treatment in profuse epistaxis in literature, our experience suggests that it can be successfully managed with conservative medical management alone and surgical intervention with its potential complications may not be necessary in most cases.     

Are European standard deviation targets for haemoglobin A1c too strict?

The Diabetes Control and Complications Trial (DCCT) has provided objective evidence for desirable glycaemic control in Type 1 patients and defines the benefits of good glycaemic control in terms of haemoglobin A1c (HbA1c) values. However, HbA1c assays vary, leading to suggestions that glycaemic control be classified according to numbers of standard deviations (SD) from a local non-diabetic population mean. We have classified the glycaemic control of 339 UK Type 1 diabetic patients (182 male, 157 female, median age 36 (range 15-74) years) using the DCCT to set HbA1c targets and compared this with the SD method. Using age matched controls (mean HbA1c 4.02%, SD 0.28%, n=106), SD guidelines classified 1% of patients into good (HbA1c <3SD from reference mean), 4% into borderline (3-5SD) and 95% into poor (>5SD) glycaemic control. When calibrating the same instrument to the DCCT analyser (r=0.996), 37% of patients had HbA1c results lower than the 7% median value found in the intensively treated DCCT group, while only 12% of patients had values greater than the 9% conventionally treated median HbA1c. DCCT subjects with HbA1c values of less than 8% belonged predominantly to the intensively treated group. In this study, 71% of patients fell into this category. Thus, guidelines based on numbers of SD away from a non-diabetic mean may overestimate the glycaemic control required to reduce microvascular complications in Type 1 patients. Standardizing to DCCT targets is more appropriate.