Heart disease, cancer, stroke, and diabetes cause the most deaths of people with Cancer Society, the American Diabetes Association, and the American Heart …
Preventive Hygiene Insights from The Richmond Institute
Volume IV, Issue III newsletter@youngdentalcom US 600
In This Issue:
Abstract:
To gain an understanding of the important concerns related to the treatment of the diabetic patient in the dental office
Dental Care For The Diabetic Patient
Margaret J Fehrenbach, RDH, MS
Overview of Diabetes
Diabetes mellitus DM is a complex group of endocrine diseases DM is a chronic disease with no cure1 There are now more than 182 million people with DM around 63 of population It is estimated that a third are undiagnosed and it remains the 4th leading cause of death The incidence is expected to double by the year 2010
Learning Objectives:
Identify
common types, tests, medications, and complications of diabetes and document the oral considerations for the diabetic patient
Understand
Undiagnosed DM
DM can be present for 10-20 years before diagnosis Patients can present with complications of DM at the time of diagnosis Patients with risk factors for DM should be screened and referred for medical diagnosis These risk factors include family history, age, and obesity
Editor:
Margaret J Fehrenbach, RDH, MS Adjunct Faculty, Dental Hygiene
Program, Marquette University, Masters Degree in Oral Biology
Screening for DM
Initial screening for DM can be done in a dental office see sidebar These questions can appear on the health history form or can be asked by a dental professional In the future, dental offices may use gingival bleeding for screening2
Metabolic Consequences of DM
Inadequate insulin levels or action results in decreased carbohydrate utilization and accelerated glucose utilization, resulting in hyperglycemia or high blood sugar Decreased insulin signaling also results in increased utilization of fats,causing ketones to build up These metabolic consequences can lead to other related diseases and emergency situations
Dental Office Screening For Diabetes
Do you have a family history of diabetes? Have you had elevated blood sugars at any time in the past? Did you have diabetes with a previous pregnancy or have you had a large baby greater than 9 lbs? Do you urinate frequently, more than six times a day or more than three times a night? Are you thirsty often? Does your mouth frequently become dry? A yes answer to two or more of these questions should prompt a referral to a medical office where further
screening and diagnosis can be performed
Etiology and Types of DM
Provided as a professional service by:
The Richmond Institute
for Continuing Dental Education
A division of Young Innovations, Inc
DM results when one of the following conditions occurs:insulin released from the pancreas is impaired or insulin action at peripheral tissues is impaired3 Insulin is the key to the use of glucose in the body
In Conjunction With:
There are four types of DM:
Type 1 - 5 of diabetics Type 2 - 90 of diabetics Gestational - present only during pregnancy Other - caused by various metabolic disorders, drugs or surgery
Type 1 DM
Type 1 DM is less common than Type 2 and was formerly called juvenileonset The main cause is thought to be immune destruction of the source of insulin secretion, the pancreatic beta cells Differentiating between Type 1 and 2 can be assisted by immune tests Type 1 usually presents with a rapid onset of symptoms and is often more difficult to control than Type 2 Treatment requires daily injections of insulin
Figure 1: Glucose Levels
Type 2 DM
Formerly called adult-onset, Type 2 DM is more common than Type 1 and usually develops later in life It has a gradual
onset of symptoms; many patients go undiagnosed for an extended period of time Type 2 affects women more than men and has a higher incidence in people of color The main cause is thought to result from a relative lack of insulin, predominately ranging from insulin resistance to deficient insulin secretion Treatments include diet and weight loss, oral DM meds, and frequently insulin injections to control blood glucose levels Type 2 is usually diagnosed after the individual has had the disease for an average of 7 years because the onset of Type 2 occurs with a lack of early symptoms
FPG
Tests for DM
OGTT
SIGNS AND SYMPTOMS OF DM HYPERGLYCEMIA
Polyuria excessive urination Polydypsia excessive thirst Polyphagia increased appetite Glycosuria glucose in the urine Frequent bladder or vaginal infections, especially fungal infections Itchy, dry skin; slow to heal wounds Weakness, fatigue and flu-like symptoms Blurred vision Tingling/burning in hands or feet especially in Type 2 Possible oral signs
In order to determine whether or not a patient has pre-DM or DM a Fasting Plasma Glucose Test FPG or an Oral Glucose Tolerance Test OGTT is used Figure 1 While the FPG uses a fast,
with the OGTT test, a persons blood glucose level is measured after a fast and 2 hours after drinking a glucose-rich beverage Other tests for DM include: Glycosylated Hemoglobin Test GHb: This test measures how much glucose attaches to hemoglobin Hb on the red blood cell, about the same proportion as glucose exists in the bloodstream Since a red blood cell with its Hb has a 3-4 month life span, a sample of blood can reflect the average blood glucose levels over that time Therefore, no fasting is required before the test Levels higher than 9-20 of total Hb indicate poor control and the need to reassess the present treatment This does not replace the daily testing of blood glucose Home Glucose Monitoring see sidebar :This is recommended for all DMs More frequent monitoring is required for patients on intensive insulin therapy,pregnant patients,those having a hard time controlling blood glucose levels, those that have increased ketones noted in their urine, or those with an illness A patient will not directly feel the subtle changes in their glucose level The method consists of the use of a meter glucometer to read the glucose concentration Salivary tests may replace these tests
someday
Until the last few years, Type 2 was rare in young people but now is more common Increasing obesity and inactivity in children is believed to play a major role In addition, about 40 of Type 2 patients eventually need insulin within 10 years Finally, many individuals that are overweight are being noted for having metabolic syndrome The syndrome is closely associated with a generalized metabolic disorder called insulin resistance, in which the body cannot use insulin efficiently and it makes those who suffer from it predisposed to Type 2 and other cardiovascular complications Recently the term, prediabetes is being used to describe the state where blood glucose levels are higher than normal, but are not yet those of DM Type 2 It can include both impaired glucose tolerate or impaired fasting glucose, which is discussed later Prediabetes means that a person is more likely to develop DM, usually within 10 years, and might already be experiencing the diseases adverse side effects4 Research shows that early lifestyle invention can return elevated blood glucose levels to normal range
A patient will not directly feel the subtle changes in their glucose level
Treatment of
Diabetes
Diagnosis of DM
Both main types of DM result in hyperglycemia or high blood sugar if The goal is to reduce blood glucose levels to near normal levels while the person goes without treatment This results in certain signs and minimizing the risk of hypoglycemia or low blood sugar Treatment symptoms see sidebar
MONITORING LEVELS OF BLOOD GLUCOSE
70 mg/dl: Too low; tendency towards hypoglycemia Provide 15 mg of carbohydrates 3 glucose tables or 4 oz of fruit juice and wait 15 min If this continues, check with a physician Risk for emergency situations 80-150 mg/dl: Normal levels 150-240 mg/dl: Higher levels; monitor infections, insulin intake, stress, food intake 240 mg/dl: Too high; tendency towards hyperglycemia Check with physician Risk for emergency situations
Human Insulin Injections
Since it is a protein, it needs to be injected subcutaneously so it is not broken down during digestion It is given to patients with Type 1, but can also be given to a patient with poorly controlled Type 2 Each person responds individually to insulin Usually more than one injection of insulin is required daily to achieve optimal control Many are using the new external pump system This
device consists of a syringe filled with a predetermined amount of short-acting insulin, a plastic canula, and a needle and pump that periodically delivers the desired amount The pump is strapped to the patients waist with a belt The needle is inserted into the fat under the skin of the abdomen and attached to the canula Devices are either manual or automatic to adjust to meals and snacks
Oral Hypoglycemic Agents
depends on the type Common treatments include diet, exercise, oral Complications of DM meds, and injections of insulin Patients should be advised that oral There are many serious complications with DM 
due to the problems medications and insulin are not a cure but only a means of with glucose, as well as chronic diseases involving cardiac, kidney, nerve controlling it, and that it is important to continue to comply with and eye problems from other related system changes such as dietary and exercise requirements triglycerides Importantly for the dental office team, these can include the following that may lead to acute emergency situations: Hypoglycemia Low blood sugar Can occur when the patient takes the regular amount of insulin or oral DM meds but forgets to eat, or
when the patient takes more than the regular amount of insulin or oral DM meds The patient is also at risk if they have a decreased insulin requirement due to weight loss, exercise, meds, or alcohol The patient initially has polyphagia and weakness, feels cold with clammy skin, and has a strong and rapid pulse, dilated pupils, profuse perspiration, with no change in respirationThe patient can then develop headaches, staggering gait, and irritability, slurred speech, blurred vision, and tingling in arms and legs Initially alert, the patient can lapse into seizures and insulin shock, and become unconscious It is the most common emergency situation Hyperglycemia High blood sugar Less common emergency situation but is the major cause of complications It can occur in a patient who has a flu or cold and takes regular amounts of insulin, or in those who have undiagnosed Type 2 with ineffective levels of their own insulin It can also result from an unplanned increase in food intake or decreased exercise, or increased
These stimulate the pancreas to produce more insulin hormone In addition, these lower the blood glucose levels, while making the cells more receptive to glucose There are two
generations; most patients are using the second one, which can be taken in smaller doses These are primarily used in Type 2 They can work alone or in combination with other oral DM meds or insulin for increased effectiveness A newly approved injected drug from Gila monster saliva, Exenatide, can now also be used with these sulfonylureas Side effects include an overproduction of insulin, which can lead to hypoglycemia This increase in insulin can result in weight gain, possibly in already obese patients, making blood-glucose management more difficult
Patients should be advised that oral medications and insulin are not a cure but only a means of controlling it, and that is important
Insulin Sensitizing Agents
These can work with oral hypoglycemics and help increase the response to insulin hormone by making the cells more receptive to glucose and lower blood glucose levels without hypoglycemia They work without weight gain and modestly improve cholesterol and triglyceride levels, which are associated with cardiovascular disease However, their use can be associated with liver or renal failure
Insulin Resistance Agents
These can work with oral hypoglycemic agents as they act to slow
carbohydrate digestion after meals and decrease the sharp rise in blood glucose experienced by DMs This slowing allows the patients own insulin to better regulate blood glucose levels Side effects include gas, abdominal discomfort and diarrhea, but are usually moderate and Figure 2: Periodontal abscess in diabetic patient diminish over time
levels of stress The increase in the utilization of fats can lead to ketoacidosis The patient needs working insulin to regulate the system The patient initially experiences weakness, polyphagia, polydipsia, xerostomia, polyuria, and glycosuria, and feels warm with a rapid, thready pulse, deep and rapid respiration, and warm, flushed, dry skin, without any perspiration Headaches, staggering gait and irritability are possible Although initially alert, seizures may occur, and the patient can lapse into ketoacidosis If unresolved, coma may occur Ketoacidosis A serious condition that usually happens in Type 1 when the patient is ill or uncontrolled The body breaks down stored fats for energy instead, leading to high levels of ketones The body will try to remove the ketones by excreting them in the urine since they are toxic to the system which
brings about ketonuria The removal of ketones through the urine is never complete This can cause a drop in blood pH, leading to emergency situations It develops very slowly Initially, it has the same symptoms as hyperglycemia As it progresses, the patient may experience dry or flushed skin, tiredness, nausea, prolonged vomiting, shortness of breath, and fruity acetone breath If not resolved, it can lead to coma
uncontrolled or undiagnosed, or the patient is in need of a medical consult These infections can involve bacterial or fungal infections Figure 2
Xerostomia Dry Mouth and DM
This can be due to hyperglycemia, which leads to polyuria, and can result in a lowering of fluids like saliva Xerostomia may also be a side effect of other medications See the past The Preventive Angle: Volume 3, Issue 2 Common Orofacial Lesions in the Geriatric Population for more information on dry mouth treatment
Caries and DM
Due to the low sugar diets followed by most DMs, many do not have many carious lesions, restorations, or enamel decalcification8 Exceptions are the cervical caries noted in Type 2 with high sugar diets, those that drink soft drinks, and those with xerostomia If the patient
also has oral fungal infections, the topical antifungal medications have a high sugar content and can promote caries See the past The Preventive Angle: Volume 3, Issue 4 Remineralization, Protection, and the Caries Experience for more information on caries treatment
Diabetes and the Dental Treatment Plan
Certain patients may need a medical consult before elective dental treatment5 Many patients may have complications such as cardiovascular disease, renal disease, blindness, or side effects from related medications It is vital for the dental professional to always be prepared for emergency situations and immediately control any serious oral infections When treating a patient with poorly controlled DM, treatment options may include use of systemic antibiotic therapy as a precaution to prevent post-treatment infections Many patients may have oral signs discussion below6 Others may need appropriate patient education in the areas of disease information, oral hygiene care, diet counseling, and tobacco cessation7
Periodontal Disease and DM
Both Type 1 and Type 2 have an increased in incidence and severity of periodontal disease due to changes in periodontal tissues Figure 3 and it is
considered the sixth complication of diabetes In fact, studies are now showing almost three times the rate9, 10 Adult DMs patients have greater tooth loss than non-DMs Uncontrolled Type 1s have increased susceptibility to acute periodontal abscesses DM smokers have even a higher risk of periodontal disease High blood glucose levels may allow plaque pathogens to thrive in oral tissues and there are also changes in the immune system and vascular system that increase the risk11 Treatment of periodontal disease in DMs is similar to treatment in non-DMs One major difference is the strong collaboration required by the dental professional with the patients medical caregivers Studies show that there can be a temporary increase in the control of DM when periodontal disease is controlled In addition, the dental professional may recommend systemic antibiotic therapy before extensive treatment to prevent post-treatment infections Proper oral hygiene care may arrest periodontal disease if treatment is aimed at daily plaque removal and timely calculus removal12 Today, DMs that undergo dental implant treatment do not encounter a higher failure rate than the normal population, if the plasma
glucose level is close to normal
Oral Infections and DM
When a DM patient is found to have a serious acute oral infection, immediate treatment or medical referral is required, even if DM is
Scheduling Considerations for Diabetic Dental Patients
Morning appointments are recommended, preferably 11/2 hours after breakfast and morning meds to avoid the peak action time for those who take insulin injections Do not schedule appointments during lunch breaks or as the last appointment of day before dinner since blood sugar levels can be low and oral health care procedures can interfere with eating In the case of Type 1, ask the patient to bring their own monitoring device to the appointment to monitor their glucose if there is any question as to their control Avoid dental appointments when the patient: Has not had meds or eaten Has cold, or flu, or tiredness Has not recently seen their physician Has levels 70 mg/dl or 150 mg/dl Has had a recent emergency
Figure 3: Diabetic patient with periodontal disease
2260 Wendt St Algonquin, IL 60102
2260 Wendt St Algonquin, IL 60102 847 458-0063
2260 Wendt St, Algonquin, IL 60102
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Source:medicare.gov
