Diabetes Mellitus and Oral Health

Diabetes Mellitus

• Diabetes mellitus is a group of metabolic diseases with dysregulation of blood glucose
• Hyperglycemia results from insulin deficiency, inadequate secretion, or insulin resistance.
• Various complications arise from poorly controlled diabetes mellitus, including the following:
  • Kidney failure
  • Retinopathy
  • Atherosclerosis/coronary artery disease
  • Cerebrovascular disease (stroke)
  • Peripheral arterial disease
  • Peripheral neuropathy

Diabetes Impact

• The risk of diabetes is impacted by prediabetes and diabetes prevalence.
• Please refer to page 1000 for more information.

Oral Health Implications

• A relationship exists between periodontal disease and diabetes
• See table 54-1 for oral related findings.

Oral Health Implications of Diabetes Mellitus

• Patients with diabetes have two to four times greater risk for severe periodontal disease
• Individuals with diabetes and severe periodontal disease also have a higher A1c level
• Nonsurgical periodontal therapy and management of periodontal disease have shown to decrease A1c levels on average
• Managing diabetes with physical activity, weight loss, and medications, with controlling periodontitis has a positive effect on the disease

Dental Caries

• Adolescents with diabetes have a 2-3 times higher risk for caries
• Adults with diabetes also have a higher risk of caries development

Endodontic Infections

• Diabetic patients have increased periodontal disease with endodontically involved teeth.
• There is an Increased risk of endodontic failure

Dental Implants

• A similar failure rate is observed in patients with, and those without, diabetes.

Basics About Insulin

• Insulin is a hormone produced by the Beta Cells of the pancreas
• Insulin directly affects every organ of the body
• Beta cells release insulin in response to glucose
• Insulin is key to opening the cells to uptake glucose for energy

Functions Of Insulin

• Facilitates glucose uptake from blood into tissues, which lowers blood glucose level.
• Speeds the oxidation of glucose within the cells to use for energy.
• Speeds the conversion of glucose to glycogen to store in the liver and skeletal muscles and to prevent the conversion of glycogen back to glucose.
• Facilitates the conversion of glucose to fat in adipose tissue.

Absolute Insulin Deficiency Type I

• Hyperglycemia happens when the amount of glucose circulating in the bloodstream reaches a threshold.
• Glycosuria occurs when extra glucose spills into the urine.
• Polyuria leads to large amounts of urine being produced and excreted.
• Polydipsia causes fluid loss which signals excessive thirst to occur.
• Polyphagia occurs when cells starved for glucose cause an increase in appetite and food intake, but weight loss is common.
• No glucose means no energy and the body utilizes fat storage for energy
• Ketones are very acidic resulting in them being the end product of fat metabolism
• Diabetic Ketoacidosis may lead to diabetic coma and death if not treated.

Impaired Secretion or Action of Insulin Type II

• Has Inadequate insulin secretion or diminished tissue response
• Cell surface insulin receptor defects prevent glucose from moving into the cells
• Blood glucose levels increase due to insulin resistance of the cells
• Initially, insulin secretion may increase to accommodate the increased blood glucose
• Over time insulin production decreases and insulin resistance of the cells increases.

Insulin Complications

• Hypoglycemia/Insulin Shock causes too much insulin and results in low blood glucose
• Hyperglycemic unawareness occurs, where the patient cannot identify symptoms and an emergency occurs quickly.
• Individuals who have taken insulin for longer than 5 years with severe hypoglycemia are likely to experience these events - you should ask questions when collecting the medical history

Hyperglycemic Reaction/Diabetic Coma (ketoacidosis)

• Hypoinsulinemia occurs with increased levels of blood glucose (hyperglycemia)
• May be seen in undiagnosed or uncontrolled Type I diabetic presenting with Kussmaul Breathing
• Table 54-2 provides a Comparison of Insulin Complications.

Symptoms of Low and High Blood Glucose

Symptoms of Low Blood Glucose (Hypoglycemia)

• Mental confusion
• Sweating
• Irritability
• Palpitations
• Shakiness
• Pallor
• Headache
• Seizure
• Coma and death (if untreated)

Symptoms of High Blood Glucose(Hyperglycemia)

• Polyuria
• Polydipsia
• Weight loss
• Polyphagia
• Blurred vision
• Increased susceptibility to infections
• Impaired growth
• Ketoacidosis

Managing Hypoglycemia

• Rule of 15s applies here
• Start by immediately recognizing symptoms of hypoglycemia
• Discontinue treatment, the assist patient by sitting them upright in dental chair.

Unconcious application

• Place in supine position
• Provide basic life support
• Dentist may administer intramuscular injection of glucagon from Emergency Kit
• Activate EMS and hospital transport

Concious application

• Have patient consume 15 grams of carbohydrate using the 15/15 Rule
  • Tube of glucose gel (preferred)
  • 3 glucose tablets
  • Half cup (4 ounces) fruit juice or regular soda
  • 1 tablespoon sugar
• Wait 15 minutes and test blood glucose with glucometer.
• If blood glucose is still <70 mg/dL, give another 15 grams of carbohydrate and measure again after 15 more minutes.
• If blood glucose still <70 mg/dL, ACTIVATE EMERGENCY MEDICAL SYSTEM (EMS)

Recovered Patient

• Have the patient eat a snack with carbohydrate and protein such as:
  • Crackers and cheese
  • Crackers and peanut butter
  • Part of a sandwich
• Goal is to stabilize the blood glucose until the next meal.

Identification of Risks for Diabetes Development

• Page 1005 provides more information
  • Genetic: Family History, first-degree relative, African American, Hispanic/Latino, Asian, Native American/Alaska Native/Indigenous People, Pacific Islander
  • Metabolic: Hypertension, Polycystic Ovarian Syndrome, Obesity, Age, having a baby over 9 pounds or gestational diabetes, history of prediabetes.
  • Environmental: Physical inactivity, unhealthy diet

Prediabetes

• Has Blood glucose level above normal but not meeting criteria for diagnosis of diabetes
• Individuals at high risk are:
  • Diabetes
  • Cardiovascular disease
• Weight loss and exercise show a reduction in the progression
• Metformin is most frequently used to manage blood glucose in prediabetes

Classification of Diabetes Mellitus

Type 1 Diabetes Mellitus

• 5-10% of cases
• Unknown etiology
• Autoantibodies
• Formally named Insulin Dependent DM

Type 2 Diabetes Mellitus

• 90-95% of patients
• Insulin resistance
• Screening: Age 45 & older every 3 years & earlier in obese patients
• Formally known as Non-insulin dependent DM or Adult-onset
• Screen children who are overweight or obese and have other risk factors

Gestational Diabetes Mellitus

• Prevalence: 7.1% of pregnancies in North America
• Infants are larger and premature births are more frequent
• Obstetricians identify risk and test early
• Women with a history of GDM have a 10-fold risk of developing type 2

Other Specific Types of Diabetes Mellitus

• Monogenic Diabetes Syndromes: Genetic origin/before 6 months
• Cystic Fibrosis-Related Diabetes: insufficient production of insulin
• Post-transplantation Diabetes Mellitus (PTDM) due to immunosuppressants and glucocorticoid steroid use

Diagnostic Tests

• Diagnose based on symptoms, medical history, and physical exam
• Diagnostic tests include;
  • Glycated hemoglobin assay (HbA1c or A1c) - also known as Glazed donut analogy
  • Fasting plasma glucose
  • Two-hour plasma glucose

Glycated Hemoglobin Assay (HbA1C)

• Measures glucose bound to a hemoglobin molecule on red blood cells
• Represents average blood glucose over a 2-3 month period
• A1c of 5.7-6.4% is considered prediabetes
• A1C > 6.5% = Diabetes

Fasting Plasma Glucose Test

• Patient should fast for 8 hours before
• A blood test is then taken;
  • Diabetes measures > 126 mg/dL
  • Pre- diabetes measures 100 mg/dL – 125 mg/dL
  • Normal measures below 100 mg/dL

2 Hour Plasma Glucose

• Oral Glucose Tolerance test is taken with these steps:
  • Patient drinks 8 oz of glucose
  • An another blood test is taken 2 hours later.
• This test simulates eating a meal for the patient

Interpretation Of Results

• Prediabetes: 140-199 mg/dL
• Diagnosis of diabetes: > 200mg/dL

Standards of Care for Diabetes Mellitus

• Early diagnosis by assessing risk and refer for evaluation
• Managing prediabetes with education and life style adjustments
• Diabetes self-management education, this includes glucometer and continuous glucose monitor
• Interprofessional team/educational resource, this involves medical nutrition planning and therapy implementation
• Physical activity plan execution
• Reviewing habits: Tobacco/Alcohol
• Addressing psychosocial issues of managing a chronic disease

Pharmacologic Therapy

• Insulin therapy
• Type and action is dependant on dosage from Table 54-4
  • Types/action of insulin: Table 54-4
  • Dosage is affected by illness, stress, exercise, food intake, and infection.
    • Methods for administration: Subcutaneous (insulin pen, pump) or Inhalable insulin
• Antihyperglycemic therapy is done via review from Medication information from Table 54-5

Table 54-4 : Types and Action of Insulin

The table 54-4 provides the 4 types of insulin along side their type/name, the onset of action, it's peak effect, and the duration, for the following insulins:

Rapid Acting

• The rapid acting insulin includes:
  • Lispro (Humalog)
  • Aspart (NovoLog)
• Its onset starts within 15 - 30 minutes
• Their effectiveness peaks within 2 - 3 hours
• Its duration lasts about 4 1/2 - 7 hours

Regular or Short Acting

• The regular or short acting insulin includes:
  • Humulin R
  • Novolin R
• Its onset starts within 30 minutes
• Their effectiveness peaks within 30 minutes to 2 1/2 hours
• Its duration lasts about 8 hours

Intermediate Acting

• The intermediate release insulin includes:
  • NPH (Humulin N
  • Novolin N)
• Its onset starts within 1 - 2 hours
• Their effectiveness peaks within 4 - 12 hours
• Its duration lasts about 14 - 24 hours

Long Acting

• The intermediate release insulin includes:
  • Detemir (Levemir)
  • Glargine (Lantus)
• Its Onset starts within 3 - 4 hours
• Their effectiveness peaks within 3 - 9 hours
• Its duration lasts within 6-23 hours:

Inhaled, Rapid Acting

• The rapid acting insulin includes:
  • Afrezza
• Its Onset starts within 12 minutes
• Their effectiveness peaks within 35-55 minutes
• Its duration lasts about 1 1/2 - 4 1/2 hours

Complications of Diabetes

• Infection
• Neuropathy
  • Peripheral/ Charcot Joints
  • Autonomic/Tachycardia, orthostatic hypotension, gastroparesis
• Nephropathy/ leading cause of renal disease
• Retinopathy/blindness, glaucoma, cataracts.
• Cardiovascular/Stroke, MIHypercholesterolemia, hypertension
• Amputation/neuropathy & vascular disease
• Pregnancy complications
• Mental health

DentistryIQ

• Additional learning may be found at URL listing

Dental Hygiene Care Plan

• Appointment planning: Scheduling enough time and taking necessary precautions.
• Managing emergency's, this includes Hyperglycemia or Hypoglycemia (rule of 15s
• Patient History: Reviewing the patient medical history.

Medical History Review

• Use Box 54-3 for common diabetes screening questions.
• Use Box 54-4 for various questions and answers for patient who is diabetic
• Consultation with primary care provider consultation figure 54-7: this chart helps average the blood glucose to HbA1c conversion

Dental Hygiene Treatment

• Involves checking Dental Acanthoris Niggricans
• EOE/IOE: Acanthosis nigricans
• Scaling and debridement for biofilm control
• Tobacco Cessation Counseling if necessary
• and Fluoride application

DH Treatment & Continuing Care

• Schedule Appointments on a regular 3- to 6-month basis as needed
• Probe carefully to ensure proper measurements
• Assess soft tissue with attention to areas of irritation related to fixed and removable prostheses Identify any changes requiring referral/consultation to primary care provider Check for dental biofilm control

Medical History Questions

• Box 54-3, Common Medical History Questions to Screen for Diabetes
  • Have you ever been diagnosed with prediabetes, borderline diabetes, or diabetes?
  • Have any members of your family ever been diagnosed with diabetes?
  • Do you urinate frequently? How many times per day?
  • Are you frequently thirsty?
  • Does your mouth feel dry?
  • Have you had any unexplained weight loss?
  • Do you experience excessive hunger?
  • Did you have recent blurred vision?

Further Questions

• Gather detailed information on all current prescribed and over-the-counter medications, including recommended dose.
• Gather information on vitamins and homeopathic or herbal supplements

Documentation

• Includes Record status of blood glucose control, including most recent HbA1c and other daily monitoring such as fasting blood glucose
• Includes updating current medications and doses
• Confirm patient is complaint with medication intake and food consumption
• Record any discussion between oral health status, oral hygiene status, risk factors, and diabetes
• Box 54-5 contains an example progress note for a patient with diabetes

Patient Education on Diabetes

• Teach them The importance of regular medical and dental care.
• Patients should have: eye exams, blood pressure checks, blood tests for cholesterol, lipids, and kidney readings
• Also teach to practice self-examination, and to check their feet and nerve involvement or delayed healing
• Should also note the Connection between oral health and diabetes, and the need for meticulous oral self-care

Reinforcing Patient Role

• Patient's role includes self-management through lifestyle changes. This includes:
  • Healthy eating habits
  • Proper amount of Physical activity
  • Weight and Glucose monitoring
  • Limit intake of Alcohol or avoid it
  • Stress management
• Encourage patients to use prescribed medications correctly, since they are vital
• Discuss the Value of seeking immediate medical attention for any signs of complications

At Risk Patients & Teaching Points

• Need for regular medical examinations and screening for diabetes
• How to recognize the early warning signs of diabetes and seek medical consult
• Lifestyle and Healthy Diet:
  • Emphasize healthy diet
    • Daily exercise practices
    • Avoiding all Tobacco or alcohol products
    • Maintaining of ideal weight
• Proper Education:
  • Meticulous oral hygiene education to prevent dental caries and periodontal disease
    • Stress reduction techniques

Understanding how diabetes mellitus affects oral health is crucial. Periodontal disease and glycemic control are interlinked; uncontrolled diabetes exacerbates gum disease. Effective oral hygiene and regular dental visits are vital for patients with diabetes.