Diabetes Mellitus: Types, Risks, and Management

Diabetes Mellitus

• Diabetes mellitus involves a group of metabolic diseases associated with blood glucose dysregulation.
• Hyperglycemia can result from insulin deficiency, inadequate insulin secretion, and/or resistance to insulin action.
• Poorly controlled diabetes can lead to complications like kidney failure, retinopathy, atherosclerosis, cerebrovascular disease, peripheral arterial disease, and peripheral neuropathy.

Oral Health Implications of Diabetes Mellitus

• A relationship exists between periodontal disease and diabetes.
• Individuals with diabetes have a two to four times greater risk for severe periodontal disease.
• More severe periodontal disease and higher A1c levels are observed in individuals with diabetes.
• Nonsurgical periodontal therapy and management of periodontal disease has resulted in an average decrease in A1c
• Managing diabetes through physical activity, weight loss, antihyperglycemic medications, and controlling periodontitis has a positive effect on the disease.
• Adolescents with diabetes have a 2-3 times higher risk for dental caries, and adults are also at higher risk.
• Patients with diabetes and increased periodontal disease can have endodontically involved teeth and increased risk of endodontic failure.
• Dental implant failure rates are similar in patients with and without diabetes.

Basics about Insulin

• Insulin is a hormone produced by the beta cells in the pancreas.
• Insulin directly affects every organ in the body.
• Beta cells release insulin in response to glucose.
• Insulin opens cells to uptake glucose for energy.
• Facilitates glucose uptake from blood into tissues, lowering blood glucose levels.
• Speeds the oxidation of glucose in cells for energy.
• Speeds conversion of glucose to glycogen for storage.
• Facilitates conversion of glucose to fat in adipose tissue.

Absolute Insulin Deficiency: Type I

• Hyperglycemia is when glucose circulates in the bloodstream and reaches a high threshold.
• Glycosuria is when glucose spills into the urine.
• Polyuria is when large amounts of urine is produced and excreted.
• Polydipsia is when fluid loss signals excessive thirst to the brain.
• Polyphagia is when cells starved for glucose increase appetite, but weight loss is common.
• No glucose means no energy, and the body utilizes fat storage for energy.
• Ketones are acidic and are the end product of fat metabolism.
• Diabetic ketoacidosis can lead to diabetic coma and death if not treated.

Impaired Secretion or Action of Insulin: Type II

• Inadequate insulin secretion or diminished tissue response
• Glucose cannot move into the cells due to cell surface insulin receptor defects.
• Blood glucose levels increase, as insulin resistance of the cells increases.
• Insulin secretion may initially increase to accommodate the increased blood glucose.
• Over time, insulin production decreases, and insulin resistance of the cells increases.

Insulin Complications

• Hypoglycemia/Insulin Shock can occur with hyperinsulinemia.
• Hyperinsulinemia is excess insulin and represents low blood glucose.
• Hyperglycemic unawareness is the inability to identify symptoms.
• Individuals with over 5 years of insulin and severe hypoglycemia history are more likely to experience events.

Hyperglycemic Reaction/Diabetic Coma (ketoacidosis)

• Hypoinsulinemia: Increased levels of blood glucose (hyperglycemia)
• Can be seen in undiagnosed or uncontrolled Type I diabetic

Managing Hypoglycemia (Rule of 15s)

• Immediately recognize symptoms of hypoglycemia and discontinue treatment.
• Sit patient upright
• For unconscious patient, ACTIVATE EMERGENCY MEDICAL SYSTEM (EMS).
  • Place the patient in supine position and provide basic life support.
  • Dentist may administer intramuscular injection of glucagon from Emergency Kit
  • EMS will transport the patient to hospital
• For conscious patient, apply the 15/15 Rule
  • Have patient consume 15 grams of carbohydrate
    • Tube of glucose gel (preferred) or 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 still <70 mg/dL, give another 15 grams of carbohydrate.
  • Wait 15 minutes and test blood glucose with glucometer.
    • If blood glucose still <70 mg/dL, ACTIVATE EMERGENCY MEDICAL SYSTEM (EMS).
  • If the patient has recovered, have the patient eat a snack to stabilize the blood glucose until the next meal
    • Crackers and cheese
    • Crackers and peanut butter
    • Part of a sandwich

Identification of Individuals at Risk for Development of Diabetes

• Diabetes risk factors include genetics, metabolic factors, and environment.
• Genetic risk factors: Family history, first-degree relative, African American, Hispanic/Latino, Asian, Native American/Alaska Native/Indigenous People, Pacific Islander
• Metabolic risk factors: Hypertension, Polycystic Ovarian Syndrome, Obesity, Age, having a baby over 9 pounds or gestational diabetes, history of prediabetes.
• Environmental risk factors: physical inactivity, unhealthy diet.

Prediabetes

• Blood glucose level are above normal but does not meet criteria for diagnosis of diabetes
• Individuals are at high risk for diabetes and cardiovascular disease
• Weight loss and exercise show a reduction in the progression
• Metformin is used to manage blood glucose in prediabetes

Classification of Diabetes Mellitus

• Type 1 Diabetes Mellitus:
  • Account for 5-10% of cases, and has unknown etiology
  • Autoantibodies are present
  • Formerly named Insulin Dependent DM
• Type 2 Diabetes Mellitus:
  • Description: 90-95% of patients and features insulin resistance.
  • Screening: Age 45 & older every 3 years & earlier in obese patients
  • Former Names: Non-insulin dependent DM or Adult-onset
  • Screen children who are overweight or obese and have other risk factors
• Gestational Diabetes Mellitus:
  • Prevalence of 7.1% of pregnancies in North America
  • Infants are larger & premature births more frequent
  • Obstetricians identify risk and test early
  • Women with GDM history 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.

Diagnosis of Diabetes

• Diagnose using symptoms and diagnostic tests.
• Diagnostic tests for glycemic control, including:
  • Glycated hemoglobin assay (HbA1c or A1c)
  • Fasting plasma glucose
  • Two-hour plasma glucose

Glycated Hemoglobin Assay (HbA1C)

• Measures the amount of glucose bound to a hemoglobin molecule.
• Average blood glucose over a 2-3-month period.
  • 5.7-6.4% is considered prediabetes
  • A1C > 6.5% = Diabetes

Fasting Plasma Glucose Test

• Fast for 8 hours
• Diabetes occurs at > 126 mg/dL
• Pre- diabetes is 100 mg/dL – 125 mg/dL
• Normal occurs below 100 mg/dL

2 Hour Plasma Glucose

• Oral Glucose Tolerance test
  • Drink 8 oz of glucose
  • 2 hours test after consumption to simulate glucose eaten during meal
    • Prediabetes occurs at 140-199 mg/dL
    • Diabetes is diagnosed when reading is > 200mg/dL

Standards of Medical Care for Diabetes Mellitus

• Early diagnosis: Assess risk and refer for evaluation
• Management of prediabetes
• Diabetes self-management education: - Glucometer - Continuous Glucose Monitor
• Interprofessional Team/Educational resources
• Medical nutrition therapy
• Physical activity
• Habits: Tobacco & Alcohol
• Psychosocial issues of managing a chronic disease"

Pharmacologic Therapy

• Insulin therapy includes
  • Types/action of insulin
  • Dosage affected by illness, stress, exercise, food intake and infection.
  • Methods for Insulin Administration-Subcutaneous and Inhalable
• Antihyperglycemic therapy

Complications of Diabetes

• Infection, neuropathy, nephropathy, retinopathy, are cardiovascular/stroke/MI
• Amputation, pregnancy complications, mental health issues.

Dental Hygiene Care Plan

• Appointment planning must factor time, precautions, and emergency management (hypoglycemia).
• Critical components for patient history like diabetes screening and assessment questions exist.
• Consult primary provider
• Establish and review medical history to include:
  • Blood Glucose levels
  • Medications for diabetes

Dental hygiene assessment and treatment

• Examination (EOE/IOE): Acanthosis nigricans
• Controlling biofilm through proper scaling and debridement
• Provide tobacco cessation counseling
• Fluoride applications may assist the patient

DH: Treatment & Continuing Care

• Schedule appointments on a regular 3- to 6-month basis.
• Probe carefully through out the treatment.
• Assess the soft tissue through out the oral cavity.
• Identify any changes requiring consultation or referral to patient's primary care provider and refer.
• Check for dental biofilm control.

Teach Patient About Risk For Diabetes

• Regular medical examinations and screening for diabetes are extremely important
• Should patient notice any early warning signs, a medical consult is always necessary.
• Patient should focus on a healthy daily lifestyle.
• They should practice meticulous oral hygiene to prevent dental caries and periodontal disease
• Always recommend stress reduction techniques. "

Test your knowledge of diabetes mellitus, including gestational diabetes, prediabetes, type 1 diabetes, and post-transplantation diabetes. Questions cover risk factors, management strategies, and characteristics of different classifications of diabetes. This quiz assesses understanding of diabetes and related conditions.