Chapter 54: Patient with Diabetes Mellitus PDF

Chapter 54 The Patient with Diabetes Mellitus Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Learning Objectives  Describe the types of diabetes mellitus and major characteristics of each...

Chapter 54 The Patient with Diabetes Mellitus Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Learning Objectives  Describe the types of diabetes mellitus and major characteristics of each Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Explain current knowledge about the oral health–diabetes link  Describe the risk factors and criteria used for diagnosis of prediabetes and diabetes  Summarize the lifestyle modifications and medications used to prevent and manage diabetes  Identify the key messages dental hygienists need to convey to patients with diabetes Diabetes Mellitus  Definition  Diabetes mellitus is a group of metabolic diseases associated with dysregulation of Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com blood glucose  Hyperglycemia results from an absolute insulin deficiency, inadequate secretion of insulin, and/or resistance to insulin action  Poorly controlled diabetes mellitus has numerous complications  Kidney failure  Retinopathy  Atherosclerosis/ coronary artery disease  Cerebrovascular disease (stroke)  Peripheral Arterial disease  Peripheral Neuropathy Diabetes Mellitus  Diabetes impact Page 1000  Prediabetes prevalence Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Diabetes mellitus prevalence Oral Health Implications of Diabetes Mellitus  Relationship between diabetes and periodontal disease  Findings Associated with Diabetes Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  See Table 54-1, EOE/IOE Oral Health Implications of Diabetes Mellitus  Relationship between Diabetes and Periodontal Disease Diabetes as a Risk Factor for Periodontitis Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  patients with diabetes are at a two to four times greater risk for more severe periodontal disease than individuals without diabetes. Effect of Periodontitis on Glycemic Control Individuals with diabetes had more severe periodontal disease and a higher A1c than healthy individuals. Effect of Periodontal Treatment on Diabetes Nonsurgical periodontal therapy and management of periodontal disease have resulted in an average decrease in A1c Management of diabetes with physical activity, weight loss, antihyperglycemic medications, and controlling periodontitis all have a positive effect on the disease 6 Oral Health Implications of Diabetes Mellitus con’t II.Dental Caries Adolescents with diabetes are at a 2-3 X higher risk for caries Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Higher risk with adults as well. III.Endodontic Infections Diabetic patients have increased periodontal disease with endodontically involved teeth. Increased risk of endodontic failure IV.Dental Implants Failure rate very similar to patients without diabetes 7 Basics about Insulin  Definition: Hormone produced by Beta Cells of the pancreas  Directly affects every organ of the body Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Description: Beta cells release insulin in response to glucose.  Insulin is the key to opening the cells to uptake glucose for energy. 8  Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Functions of Insulin Pancreas and Action of Insulin on Muscle in Health, and Type 1 and Type 2 Diabetes Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com © VectorMine/Shutterstock Absolute Insulin Deficiency Type I  Hyperglycemia: the amount of glucose circulating in the bloodstream has reached a high threshold. Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Glycosuria: glucose spills into the urine  Polyuria: large amounts of urine produced and excreted  Polydipsia: fluid loss signals excessive thirst to the brain  Polyphagia: Cells starved for glucose cause an increase in appetite and food intake, but weight loss is common.  No glucose = No energy. The body utilizes fat storage for energy  Ketones: Are very acidic and are 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  Inadequate insulin secretion or diminished tissue response Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Cell surface insulin receptor defects, glucose cannot move into the cells.  Blood glucose levels increase, as the insulin resistance of the cells increases.  Initially, insulin secretion may increase to accommodate the increased blood glucose.  Over time insulin production decreases and insulin resistance of the cells increases.  How might our standard American diet affect this process? Insulin Complications  Hypoglycemia/Insulin Shock  Hyperinsulinemia: Too much insulin = low blood glucose (Hypoglycemia) Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Hyperglycemic unawareness: The patient is unable to identify symptoms and an emergency occurs quickly.  Individuals who have taken insulin for longer than 5 years with a history of severe hypoglycemia are more likely to experience these events.  ASK QUESTIONS WHEN COLLECTING THE MEDICAL HISTORY Insulin Complications Hyperglycemic Reaction/Diabetic Coma (ketoacidosis) Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Hypoinsulinemia with increased levels of blood glucose (hyperglycemia)  May be seen in undiagnosed or uncontrolled Type I diabetic  Kussmaul Breathing Table 54-2 Comparison of Insulin Complications  Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Symptoms of Low and High Blood Glucose  Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Insulin Complications  Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Managing Hypoglycemia (Rule of 15s) Identification of Individuals at Risk for Development of Diabetes  Diabetes risk factors Page 1005  Genetic: Family History, first-degree relative, African American, Hispanic/Latino, Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com 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 Identification of Individuals at Risk for Development of Diabetes  Prediabetes  Blood glucose level above normal but not meeting criteria for diagnosis of diabetes Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Individuals at high risk for diabetes and 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  Description: 5- 10 % of cases, unknown etiology, autoantibodies Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Former Names: Insulin Dependent DM  Type 2 Diabetes Mellitus  Description: 90-95% of patients, 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 20 Classification of Diabetes Mellitus con’t Gestational Diabetes Mellitus  Prevalence: 7.1% of pregnancies in North America Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Infants are larger & premature births 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. 21 Diagnosis of Diabetes  Diabetes symptoms  See Table 54-3 Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Diagnostic tests  Glycated hemoglobin assay (HbA1c or A1c)  Glazed donut analogy  Fasting plasma glucose  Two-hour plasma glucose Glycated Hemoglobin Assay (HbA1C) Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Measures 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 Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Fast for 8 hours  Diabetes = > 126 mg/dL  Pre- diabetes 100 mg/dL – 125 mg/dL  Normal is below 100 mg/dL 2 Hour Plasma Glucose  Oral Glucose Tolerance test  Drink 8 oz of glucose Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  After 2 hours test  Simulates eating a meal  Prediabetes: 140-199 mg/dL  Diagnosis of diabetes: > 200mg/dL 25 The Road to Type 2 Diabetes Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Centers for Disease Control and Prevention. https://www.cdc.gov/diabetes/pdfs/library/socialmedia/road-to-diabetes- infographic.pdf. Reference to specific commercial products, manufacturers, companies, or trademarks does not constitute its endorsement or recommendation by the U.S. Government, Department of Health and Human Services, or Centers for Disease Control and Prevention Standards of Medical Care for Diabetes Mellitus  Early diagnosis: Assess risk and refer for evaluation Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  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  Types/action of insulin: Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Table 54-4  Dosage is affected by illness, stress, exercise, food intake, and infection.  Methods for insulin administration  Subcutaneous: insulin pen, pump  Inhalable insulin  Antihyperglycemic therapy  Medications: see Table 54-5  Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Types and Action of Insulin Complications of Diabetes  Infection  Amputation/neuropathy & vascular disease Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Neuropathy  Peripheral/ Charcot Joints  Pregnancy complications  Autonomic/Tachycardia, orthostatic  Mental health hypotension, gastroparesis  Nephropathy/ leading cause of renal disease  Retinopathy/blindness, glaucoma, cataracts  Cardiovascular/Stroke, MI Hypercholesterolemia, hypertension, Dentistry IQ  https://www.dentistryiq.com/dentistry/oral-systemic-health/video/14206113/medi cal-history-mysteries-diabetes-and-the-dental-appointment Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com 31 Dental Hygiene Care Plan (1 of 2)  Appointment planning  Time Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Precautions: prevent/prepare for emergency  Emergency management: see Figure 54-6 Managing hypoglycemia (rule of 15s)  Patient history  Medical history: see Box 54-3, Common diabetes screening questions, and Box 54- 4 for questions and answers for patient who is diabetic (in chapter) Dental Hygiene Care Plan (2 of 2)  Consultation with primary care provider Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Figure 54-7, Average blood glucose to HbA1c conversion Acanthosis Nigricans Dental hygiene assessment and treatment Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com *EOE/IOE: Acanthosis nigricans *Biofilm control/scaling/debridement *Tobacco Cessation Counseling *Fluoride Reproduced from DeLong L, Burkhart N. General and Oral Pathology for the Dental Hygienist. Philadelphia: Lippincott Williams & Wilkins; 2015. DH Treatment & Continuing Care Appointments on a regular 3- to 6-month basis as needed Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Probe carefully Assess soft tissue with attention to areas of irritation related to fixed and removable prostheses Identify any changes requiring consultation or referral to patient’s primary care provider Check for dental biofilm control 35  Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com Common Medical History Questions to Screen for Diabetes Documentation  Record status of blood glucose control, including most recent HbA1c and other daily monitoring such as fasting blood glucose levels the patient has performed Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  Update current medications and doses  Confirm compliance with medication intake and food consumption  Record discussion about relationship between oral health status, oral hygiene status, risk factors, and diabetes  Box 54-5 contains an example progress note for a patient with diabetes Factors to Teach the Patient (1 of 2)  Importance of regular medical and dental care; eye examinations; blood pressure checks; blood tests for cholesterol, lipids, and kidney readings; and Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com practicing self-examination, particularly of feet, for nerve involvement or delayed healing  Connection between oral health and diabetes and need for meticulous oral self- care Factors to Teach the Patient (2 of 2)  The patient’s role in self-management of diabetes with an emphasis on the need to be compliant with lifestyle modifications including healthy eating, Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com physical activity, weight management, glucose monitoring, tobacco cessation, good oral self-care, limiting or avoiding alcohol, stress management, and use of prescribed medications  The value of seeking immediate medical attention for any signs of complications from diabetes Factors to Teach Patients at Risk for Diabetes  Need for regular medical examinations and screening for diabetes Copyright © 2024 by Jones & Bartlett Learning, LLC. www.jblearning.com  How to recognize the early warning signs of diabetes and seek medical consult  Factors that affect a healthy lifestyle, including healthy diet, daily exercise, no tobacco products, avoiding alcohol, and maintaining ideal weight  How to practice meticulous oral hygiene to prevent dental caries and periodontal disease  Stress reduction techniques