Diabetes: Part 2

Question 1

Common Insulin Regimens
 Type 1
(2)

Answer 1

◦ Basal-Bolus
◦ Insulin Pump (with or without CGM)

Question 2

Common Insulin Regimens
 Type 2 (typically 2nd or 3rd line agent)
(3)

Answer 2

◦ Basal with oral agents (metformin/others)
◦ Basal-Bolus (with or without metformin/other oral agents)
◦ Basal with Glucagon Like Peptide-1 Receptor Agonists

Question 3

Questions:
 RK is a 38-year-old patient with diabetes who comes to your office for a
routine cleaning and 6 month check up. He is taking the following
medications: insulin aspart, insulin glargine, metformin and
rosuvastatin.
 TRUE OR FALSE?
◦ RK’s is likely to have the diagnosis of type 1 diabetes
 Why or why not?
 Which insulin is RK using as his bolus insulin?
 Which insulin is RK using as his basal insulin?
 Which one of his medications is most likely to cause hypoglycemia?

Question 4

Management of Hypoglycemia
 Rule of 15
 Treat if < 70 mg/dl
(5)

Answer 4

• 15-20 gms fast acting carbs = 3-4
  glucose tablets, 4 oz juice or
  regular soda, 5 lifesavers, 3
  peppermints
• Glucose gel also available – follow
  directions on tube
• If next meal is more than 1 hr away
  consider a small snack to prevent
  recurrence
• Observe patient 30-60 mins after
  recovery. Confirm normal glucose
  level before patient allowed to
  leave
• Consider referring patient to
  physician for follow up

Question 5

Management of Hypoglycemia
 Unconscious patient or unable to swallow
(6)

Answer 5

◦ Call 911 (have someone call or if alone call after administering 1st dose of glucagon)
◦ Stimulates gluconeogenesis - release of stored glucose ( glycogen) from the liver.
◦ 1mg glucagon intravenously or intramuscularly in buttock, arm or thigh (may give IM at almost
any body site if necessary). Repeat at 15 minutes if no response
◦ 0.5 mg for pediatrics < 44 lbs
 Patient needs glucose after injection
◦ OR, give 50ml of 50% dextrose IV
 Turn on side to prevent aspiration

Question 6

Common Agents Used in T2DM

Answer 6

 Metformin
 Glucagon-like peptide-receptor agonists (GLP1-RA)
◦ end in “tide” – exenatide, liraglutide, albiglutide, dulaglutide, lixisenatide, semaglutide
 Glucagon-like, peptide-1 (GLP-1) agonist and glucose-dependent
insulinotropic polypeptide (GIP) agonist (a “twincretin”)
 also ends in “tide”- tirzepatide
 Sodium glucose cotransporter-2 inhibitors (SGLT-2)
◦ “flozins” - canagliflozin, dapagliflozin, empagliflozin, ertugliflozin
 Dipeptidyl-Peptidase-4 Inhibitors (DPP-4)
◦ “gliptins” – sitagliptin, saxagliptin, linagliptin, alogliptin
 Thiazolidinedione (TZD)
◦ “glitazones” – pioglitazone, rosiglitazone
 Sulfonylureas
◦ Start with ”g” and end in “ide” - glipizide, glyburide, glimepiride
 Others (less common)
◦ Meglitinides – “litinides”- repaglinide, netaglinide

Question 7

 Which oral agents are most likely to cause
hypoglycemia?

Question 8

Questions
 Which medication’s primary mechanism of action
decreases the production of glucose (gluconeogenesis) in
the liver?
a. empagliflozin
b. glipizide
c. liraglutide
d. metformin

Question 9

Pharmacologic Therapy for Adults With Type 2 Diabetes
PHARMACOLOGIC APPROACHES TO GLYCEMIC TREATMENT
9.8 Healthy lifestyle behaviors, diabetes self-management education and support,
avoidance of therapeutic inertia, and social determinants of health should be
considered in the glucose-lowering management of type 2 diabetes. A
9.9 A person-centered shared decision-making approach should guide the choice of
pharmacologic agents for adults with type 2 diabetes. Consider the effects on
…
9.10 The glucose-lowering treatment plan should consider approaches that support
weight management goals (Fig. 9.3 and Table 9.2) for adults with type 2 diabetes. A

Answer 9

cardiovascular and renal comorbidities; effectiveness; hypoglycemia risk; impact
on weight, cost, and access; risk for adverse reactions and tolerability; and
individual preferences (Fig. 9.3 and Table 9.2).

Question 10

Pharmacologic Therapy for Adults With Type 2 Diabetes (continued)
PHARMACOLOGIC APPROACHES TO GLYCEMIC TREATMENT
9.17 In adults with type 2 diabetes who have not achieved their individualized weight
goals, additional weight management interventions (e.g., intensification of lifestyle
modifications, structured weight management programs, pharmacologic agents, or
metabolic surgery, as appropriate) are recommended. A
9.18 In adults with type 2 diabetes and …

Answer 10

established or high risk of atherosclerotic
cardiovascular disease, heart failure (HF), and/or chronic kidney disease (CKD), the
treatment plan should include agent(s) that reduce cardiovascular and kidney disease
risk (e.g., sodium-glucose cotransporter 2 inhibitor [SGLT2] and/or glucagon-like
peptide 1 receptor agonist [GLP-1 RA]) (Fig. 9.3, Table 9.2, Table 10.3B, and Table 10.3C)
for glycemic management and comprehensive cardiovascular risk reduction,
independent of A1C and in consideration of person-specific factors (Fig. 9.3) (see
Section 10, “Cardiovascular Disease and Risk Management,” for details on cardiovascular
risk reduction recommendations).

Question 11

DM Goals – Risk Reduction Strategies
 Reduce the risk of —
complications through glycemic control and controlling co-morbid
conditions to which DM contributes

Answer 11

macrovascular and microvascular (and other)

Question 12

◦ Reduce cardiovascular and renal risk factors
(3)

◦ Reduce the risk of vaccine-preventable diseases
(1)

 Minimize periodontal complications due to diabetes mellitus,
provide safe and effective dental care, and promote good oral
health

Answer 12

 Control BP
 Control Lipids
 Smoking Cessation

 Immunizations
 Examples: Flu, Tdap/Td, Pneumococcal, Hepatitis B (others)

Question 13

MACROVASCULAR COMPLICATIONS
 Atherosclerotic cardiovascular disease (ASCVD)

Answer 13

◦ is the leading cause of morbidity and mortality for individuals with diabetes and is the largest
contributor to the direct and indirect costs of diabetes.

Question 14

 Consistent — control to goal directly affects reduction of macrovascular
complications

Answer 14

glycemic

Question 15

ABCS to prevent Heart Attack, Stroke and Peripheral Arterial Disease

Answer 15

◦ Aspirin (low dose) if indicated (based on CV risk)
- Primary prevention – only high risk
- Secondary prevention – YES! (indicated)
◦ Blood pressure control
 Common antihypertensives:
- Thiazide diuretics
- ACE inhibitors (”prils”)
- Angiotensin II inhibitors (“sartans”)
- Others
◦ Cholesterol control
- “Statins”
◦ Smoking cessation

Question 16

Microvascular Complications
(4)

Answer 16

 Optimize Blood Pressure and Glycemic control to prevent complications
 Diabetic Kidney Disease
 Diabetic Retinopathy
 Neuropathies - Diabetic Peripheral Neuropathy

Question 17

 Diabetic Kidney Disease
(4)

Answer 17

◦ Renal dose dosing adjustments
◦ Treatment
 ACE Inhibitor or Angiotensin Receptor Blocker (ARB)
 Added benefit from SLGT2s (preferred to minimize renal complications) and GLP1RAs

Question 18

 Diabetic Retinopathy
(2)

Answer 18

◦ Diminished vision – may impact patient reading prescriptions or written information
◦ Treatment from an ophthalmologist

Question 19

 Neuropathies - Diabetic Peripheral Neuropathy
(2)

Answer 19

◦ Common non-opioid adjuvants such as antidepressants and anticonvulsants
 Common side effects - xerostomia

Question 20

Having DM increases the risk of

Answer 20

infection, more serious infections/ infectious complications and slows healing/recovery

Question 21

Parameter: Influenza- indicated for all > 6 months of
age including DM patients
Recommendation/Comments

Answer 21

Annually (all patients > 6 months)

Question 22

Parameter: Specific recommendations for DM - Pneumococcal
vaccines
Recommendation/Comments

Answer 22

NEWER options: PCV 20 (Prevnar 20) or PCV 15 (Vaxneuvance)
with PPSV-23 (Pneumovax) 1 year later

Question 23

Parameter: Hepatitis B - indicated for all adults including
DM patients if no prior history
Recommendation/Comments

Answer 23

Complete series for those 19-59 years if no previous history
of receipt
>60 years with DM if no history of receipt

Question 24

Parameter: Tdap/Td – all adults
Recommendation/Comments

Answer 24

At least 1 Tdap then Every 10 years

Question 25

Parameter: Recombinant Zoster Vaccine (RZV – Shingrix)
Recommendation/Comments

Answer 25

2 doses adults > 50 years old

Question 26

Parameter: Respiratory Syncytial Virus (RSV) -
Recommendation/Comments

Answer 26

1 dose > 60 years or older

Question 27

Dental implications of patients with DM
 Identifying the patient with undiagnosed diabetes:
(4)

Answer 27

◦ What diabetic symptoms might the patient exhibit from a
dental exam?
◦ If suspect, refer patient to primary care provider
 Stress importance of diagnosis (especially early diagnosis)
 Minimize long-term complications

Question 28

Diabetes mellitus is one of the strongest systemic risk factors for —
disease

Answer 28

periodontal

Question 29

Both T1DM and T2DM increase the risk of periodontal disease – fold

Answer 29

3-4

Question 30

 Diabetes mellitus is one of the strongest systemic risk factors for periodontal
disease
 Both T1DM and T2DM increase the risk of periodontal disease 3-4 fold
(4)

Answer 30

 Control of DM may affect the extent and severity of periodontal disease
 Poorly controlled DM may increase the risk of periodontal disease, tooth decay/
dental caries and dental infections (bacterial and fungal)
 Chronic hyperglycemia may create host hyper-inflammatory response
 Oral infections can increase risk of hyperglycemia in DM patients

Question 31

 Chronic hyperglycemia may create host hyper-inflammatory response
(5)

Answer 31

◦ Diminished neutrophil recruitment and function
◦ More severe inflammatory response - increases production of pro-inflammatory cytokines
and chemokines due to:
 Direct activation of several pro-inflammatory pathways
 oxidative stress
 endothelial dysfunction.

Question 32

Recognizing Undiagnosed Diabetes
 Undiagnosed patients may not notice subtle symptoms or relate them to DM – dental exam may be particularly
valuable for identifying suspicion of T2DM
 Dental exam may reveal possible oral manifestations of pre-DM/DM:
(list)
 Consider referring to health care provider for DM screening

Answer 32

◦ Candidiasis or other less common alterations in normal flora
◦ Periodontitis - bleeding gums, gingival inflammation
◦ Tooth mobility
◦ Acetone breath - fruity smelling breath (more likely with T1DM)
◦ Recurrent, acute or chronic gingival and periodontal infections and abscesses
◦ Suppuration
◦ Xerostomia
◦ Increased salivary viscosity/flow
◦ Enlargement of parotid glands (alteration in basement membrane)
◦ Oral burning sensation
◦ Angular cheilosis
◦ Acanthosis nigricans (skin condition that causes thickened, velvety, dark discoloration in body folds – commonly seen on neck) – sign of
insulin resistance
◦ Increased rate of dental caries
◦ Poor wound healing
◦ Note: these clinical signs may be caused by other underlying issues, unrelated to diabetes, but undiagnosed diabetes should be considered

Question 33

Screening in Dental Practice
(3)

Answer 33

 A recent study estimated about 30% of patients ages 30 years
and older, who were seen in general dental practices had
hyperglycemia.
 The utility of chairside oral screening to determine the need, as
well as, have the ability to refer a patient with potential DM to
primary care could improve the diagnosis, and therefore
treatment of prediabetes and diabetes and ultimately decrease/
minimize periodontal disease.
 More extensive research is needed to demonstrate the feasibility,
effectiveness and cost-effectiveness of screening in this setting

Question 34

Asking a Patient about Diabetes Management
(7)

Answer 34

 What type of diabetes do you have, and when was it diagnosed?
◦ May be able to determine by patient’s medication
 Have you been experiencing any issues related to your diabetes?
 Are you taking all of the medications that have been prescribed
for you? If not, which one(s) don’t you take and why?
 Have you taken your diabetes medication today?
 What is your most recent A1C level? When was the last A1C
taken?
 How often do you check your blood glucose level, and what was
the most recent value? What have your values ranged over the
last few weeks?

Question 35

Questions to ask patients with diabetes
(6)

Answer 35

 Tell me about your carbohydrate intake (do you watch your
consumption?). What time did you last eat? What did you consume?
(This question will give you hints about how well-educated the patient is about their disease and may
be important to discuss if dental problems impact a patient’s eating or how diet impacts oral health.)
 What health care providers help you manage your diabetes? Do you see
your physician, nurse, or dietitian, other diabetes specialist on a regular
basis? When was your last visit? Does anyone at home help you manage
your diabetes day to day? (with medications, following a diet, etc.)
 Do you experience low blood sugar levels? If so, how often? What are
your symptoms? When was your last event? What do you do when you
have low blood sugar?
 Do you smoke or use any tobacco products? If so, how much?
 What are your blood sugars running at home?
 Others….

Question 36

Dental management considerations for patient with
diabetes
(4)

Answer 36

 In patients with controlled DM, no special treatment is required for routine
dentistry
 Morning visits may be preferred – lower insulin activity and/or an
appointment after a meal or snack for patients with history of hypoglycemia
 For routine visits – patient with DM should eat normally and take usual
medications prior to the visit
IMPORTANT TO CONFIRM THIS BEFORE PROCEDING WITH THE VISIT
 If patient needs to be fasting for invasive procedure/treatment and is not
eating, or is not eating normally due to dental pain, the patient may need to
hold/or adjust diabetes medications
Usually only hold those that cause hypoglycemia (consult with diabetes provider, if
needed)

Question 37

Dental management considerations for patient with
diabetes, continued

Answer 37

 Complete a Medical History to identify patients with diabetes
What type of DM does the patient have?
How does the diagnosis impact the DM medications you might see on the patient’s
medication list?
 Assess current glycemic control
◦ Glucose levels/A1c - if known
 Is patient using a CGM?
◦ Ask if patient currently experiencing any signs/symptoms of hypoglycemia
◦ Frequency of hypoglycemic episodes?
◦ Medication evaluation
 What common diabetes medications might you see in this patient?
 Because of increased risk of hypertension, important to check BP (whether diagnosed
with hypertension or not – provide recommendations for follow-up/referral if concerned)

Question 38

Dental Treatment/Procedures
 Random blood glucose values:
◦ Generally, between — mg/dl for elective dental procedures
◦ Check with office — or ask patients to bring their monitor or get
CGM readings and obtain value prior to invasive treatment
◦ The patient’s meter or CGM application will likely have a memory where
trends can be assessed, if needed
◦ — appointments – consider additional checks
 Relying on the patient’s memory to provide accurate values is risky
(2)

Answer 38

70-200
glucometer
Long

◦ May not remember accurately or don’t know
◦ May be too embarrassed or “fudge” better number to not admit poor
control

Question 39

Dental management considerations, continued
 During invasive treatments or procedures, addressing:
◦ Most common complication – —
◦ ALSO, be aware of risks of —, especially ketoacidosis
in type 1
 presentation similar to hypoglycemia in a conscious patient –
 Consider appropriate treatment of anxiety and/or pain (stress/pain may increase
cortisol and epinephrine secretion which can precipitate hyperglycemia)
 Best way to determine hypo- or hyper- glycemia is to …

Answer 39

hypoglycemia
hyperglycemia

blurry vision,
difficulty concentrating, increased urination, fatigue, extreme thirst, dry
mouth, dizziness, headache, nausea/vomiting, confusion, (others).

check a blood sugar
but symptoms can trigger suspicion

Question 40

Dental management considerations, continued
If patient is hypoglycemic when checking blood glucose prior
to/during dental interventions:
Follow Rule of 15s
(4)

Answer 40

Once glucose is above 70 mg/dl have patient consume a snack and recheck
blood glucose before proceeding with a dental intervention (or reschedule)
Long appointments – recheck glucose (may need additional carbohydrates)
Check reading at end of appointment to be sure patient is safe to leave
office
At conclusion of the appointment, the patient should be advised to eat a
meal or an additional small snack if next meal is more than 1 hr to prevent
recurrence

Question 41

If Identify Diabetic Related Medical
Issues/Concerns/Complications
(3)

Answer 41

 Determine if issue warrants immediate or urgent medical
attention before elective dental procedures
 Refer patient to diabetes provider or ask when patient
has the next scheduled visit for less urgent issue
 Patients with uncontrolled hyperglycemia may be
candidates for prophylactic antibiotic therapy or longer
antibiotic therapy for infection.

Question 42

Best Practices for Managing Insulin Pumps during
Ambulatory Dental Procedures/Surgery
(5)

Answer 42

 Dependent on the specific manufacturer and type of pump being utilized
 Develop a clear management plan with the patient that includes how the
pump will be managed intraoperatively, especially in the event of
hypoglycemia or hyperglycemia
 A signed consent from the patient/guardian to continue pump use
throughout the perioperative period - recommended
 Recommend patient position pump at a site at least 24 hours prior to
surgery to minimize problems, such as cannula occlusion or erratic
absorption, and to allow time to verify correct functioning of the pump and
any accompanying CGM system, if present
 Assess the patient’s blood sugar preoperatively, at regular intervals during
the procedure and prior to discharge

Question 43

Basal Rate Management
No universal management strategy for determining or adjusting the basal infusion rate intraoperatively,
Consider consulting with the health care team managing the patient’s diabetes for recommendations
Patient should stop bolus insulin while NPO but continue normal basal preoperatively
Generally, 2 options for managing the basal rate of insulin delivery during surgery

Answer 43

◦1) maintain the normal basal infusion rate
◦2) reduce the basal rate, commonly down to 80% of normal
◦Additional option: some pump systems will have an exercise rate, which is a reduced infusion rate to
account for higher glucose demands during periods of increased physical exertion; this option can be
selected
 A lower infusion rate during the procedure can alleviate the potential for perioperative hypoglycemia
Perioperative hypoglycemia can be managed with exogenous dextrose even without making changes to the
continuous pump system’s basal rate
◦IV dextrose should be available
◦Typically, maintaining the basal insulin rate and correcting any hypoglycemia with IV dextrose is often the
common plan
Balance hypoglycemia risk with commonly observed intraoperative hyperglycemia - the body tends to be in
a relative state of insulin deficiency

Question 44

Insulin Pump Management
 Patients on pump therapy (DM patient, in general) should
be ideally scheduled for early morning appointments to
minimize potential for …
 Patient should provide a demonstration of …, if present prior to the procedure
◦ ENSURE UNDERSTANDING OF HOW TO TURN THE PUMP — IN
CASE OF HYPOGLYCEMIA
◦ Keep in mind that slow absorption of insulin from the infusion site
will cause the effects of the basal infusion to persist for up to – hours
after stopping the infusion.

Answer 44

hypoglycemia or hyperglycemia
insulin pump controls and the CGM
OFF
2

Question 45

Questions for Pump Operation
 Key Functional Controls of Insulin Pumps to Understand
(7)

Answer 45

◦ How to check the blood glucose using the CGM?
◦ How to check normal functioning of the pump’s basal infusion?
◦ How to manually stop or turn off the pump?
◦ Is there a sensor augmented function that will deliver insulin at a
set blood glucose?
◦ Is there a threshold suspend mechanism that will stop the pump
at a set blood glucose?
◦ How to manually deliver a bolus of insulin if required?
◦ What types of alarms are on the pump or CGM?

Question 46

Hypoglycemic unawareness
(6)

Answer 46

 Individuals with long standing Type 1 DM are at greatest risk
 Can occur with Type 2 DM
 The counter-regulatory systems of glucagon and epinephrine secretion which cause
symptoms such as palpitations and tremors to not be triggered in some patients
with long-standing use of exogenous insulin
 Can also arise due to diabetes neuropathy blunting the effects mediated by the
autonomic nervous system in response to hypoglycemia.
 The brain may become desensitized to the symptoms of hypoglycemia as it
becomes “used to” low blood sugar levels.
 Beta-blockers (cardiovascular medications ending in “olol” or “ilol” such as
metoprolol, carvedilol, etc.) can mask signs and symptoms of hypoglycemia (except
sweating)

Question 47

Dental Emergency Kits
(2)

Answer 47

 Glucose – tablets/gel
 Glucagon

Question 48

 Glucagon
(5)

Answer 48

◦ ** Special note for alpha-glucosidase inhibitors**
◦ Acarbose (Precose) and miglitol (Glyset)
◦ Don’t cause hypoglycemia as monotherapy but are often
prescribed with other antidiabetic medications that do
◦ If patient becomes hypoglycemic and is taking acarbose or
miglitol only use oral glucose or lactose (yogurt or low/nonfat
milk) or glucagon if severe to treat hypoglycemia
◦ Alpha-glucosidase inhibitors will block absorption of other sugars

Question 49

Hyperglycemia
Avoid hyperglycemia – blood glucose levels < — mg/dl
before initiating any invasive dental treatments
Stress from dental procedures and/or dental
inflammation/infections may cause increased — levels

Answer 49

200
glucose

Question 50

Stress from dental procedures and/or dental
inflammation/infections may cause increased glucose levels
(3)

Answer 50

Increase endogenous catecholamine secretion = increase heart rate,
blood pressure, and blood glucose levels from
stress/infection/inflammation
Uncontrolled DM can cause increased healing time and put patient at
higher risk of infection
Stress reduction techniques or shorter appointments may help
minimize a rise in glucose from stress

Question 51

Considerations for dental management for patients
with diabetes
(4)

Answer 51

Use of vasoconstrictors in local anesthetics
Use of corticosteroids can increase glucose and cause hyperglycemia
Assess patients for infections and delayed/poor wound healing
Avoid elective and complex procedures in patients with poorly controlled
diabetes (> 200 mg/dl)

Question 52

Use of vasoconstrictors in local anesthetics
(4)

Answer 52

• Epinephrine stimulates hepatic glucose production and inhibits of glucose uptake by
  insulin-dependent tissues which may lead to hyperglycemia
• Routine use of local anesthetic with 1:100,000 epinephrine is generally well tolerated in
  DM patients

Question 53

Assess patients for infections and delayed/poor wound healing
* Patients with diabetes are at increased risk, especially if their diabetes is

Answer 53

poorly controlled

Question 54

How could the complications of diabetes impact dental
care?
 Decreased — acuity (from microvascular complications and/or poor
glucose control)
◦ may make self examination of mouth and performance of oral hygiene difficult
◦ challenges reading directions on prescription bottles or other printed information
 — disease can affect drug metabolism for drugs metabolized by the
kidney
◦ adjustment of the dosages of antibiotics or analgesics (or avoidance of NSAIDs in
patients with GFR < 30ml/min) may be required.
 If the patient is on a daily aspirin for CV risk, patients may bleed more
easily
 Diabetes and diabetic medications may cause — changes

Answer 54

visual
Renal
xerostomia/taste

Question 55

Education and Follow-up
 Patients with diabetes should be strongly encouraged to maintain a good oral hygiene:
(4)
 Educate about dental risks with DM
(2)
health
 Encourage smoking cessation for oral and CV health
(1)
 Dental visits q 6 months

Answer 55

◦ brushing after every meal
◦ using floss daily
◦ keeping dentures clean
◦ saliva substitutes for severe xerostomia

◦ Patients don’t typically receive education on the impact of DM on oral cavity in formal DM
education programs
◦ Importance of normalizing blood glucose = improved oral health, which ultimately effects overall

◦ Compounded risks with smoking and DM to oral health

Question 56

Post procedure/op considerations
 Prophylaxis/treatment of infection, when appropriate
 Proper dietary intake
(5)
 Proper anti-diabetic drug therapy
(5)

Answer 56

◦ If the patient is expected to have difficulty in eating solid food after dental procedure, diet should be modified to soft solids or liquids
◦ Keep carbohydrate intake consistent
◦ Consult diabetes provider or dietician for post-op diet plan, if appropriate
◦ Using a blender or lower carbohydrate liquid meal replacement (Glucerna) may be an option
◦ Maintain adequate hydration

◦ Consider if meal-time insulin therapy needs to be adjusted for changes in eating
◦ Consider if rapid/fast acting insulin or insulin secretors/secretagogues should be decreased or held until
patient resumes full meals
◦ Consider adjustments in other medications (not usually necessary)
◦ In some cases, glucocorticoids, stress from procedure, infection, inflammation and/or delayed healing may
warrant closer monitoring of blood glucose and temporarily adjustment (increases) in diabetic therapies
◦ Consult with diabetes provider for plan for post-op drug therapy, if appropriate

Question 57

Diabetes Self-Management and Education
 Diabetes self-management and education is important aspect for treatment
plan
 Requires the expertise of a variety of healthcare professionals including dental
professionals
(2)
 Recognize relationship between diabetes and depression
(2)
 Communicate relationship between diabetes and
macrovascular/microvascular complications

Answer 57

◦ Dental professionals can become Certified Diabetes Educators (The National
Certification Board for Diabetes Educators – NBCDE)
 Promotes self-management to achieve individualized behavioral and treatment goas that optimize
health outcomes

◦ Poorer glucose control and oral hygiene
◦ Referral to primary care or mental health provider

Question 58

Management of Xerostomia and Oral Candidiasis
 Common oral complications of DM – decreases — production
 Most common contributors of — in pts with DM - xerostomia and possibly poor
glycemic control
◦ Associated with decreased salivary gland function due to —
 DM affects the nerves that control —
◦ DM may cause structural changes to — glands
◦ Some studies show independent of poor glycemic control

Answer 58

saliva
candidiasis
autonomic neuropathy
salivary gland secretion
parotid

Question 59

Management of Xerostomia and Oral Candidiasis
 Most common manifestation is chronic atrophic (erythematous) candidiasis
(3)

Answer 59

◦ Red or velvet textured plaques
◦ May complain of burning sensation or taste alterations
◦ Smokers and denture wearers with poor oral hygiene at greater risk

Question 60

SP’s insulin glargine is best classified as a:
a. rapid-acting insulin
b. short-acting insulin
c. intermediate-acting insulin
d. long-acting insulin

Question 61

Management of Xerostomia and Oral Candidiasis
 Treatment
(4)

Answer 61

◦ Topical antifungal agents for candidiasis
 Usually, topical administration (nystatin, others) is effective, unless the infection is severe, then systemic agents (fluconazole) may be indicated
◦ Xerostomia - treatment with salivary stimulants, artificial saliva/saliva substitutes, sipping water/non-caffeine-
free, sugar-free drinks, use of sugar-free chewing gum, etc. to minimize symptoms
◦ Topical fluoride interventions for patients with high caries rate

Question 62

Which of SP’s medications is most likely to cause
hypoglycemia?
a. metformin
b. dapagliflozin
c. insulin glargine
d. lisinopril

Question 63

What is the mechanism of action for dapagliflozin?
a. works in the kidneys to block the reabsorption of glucose
b. works in the liver to decrease gluconeogenesis
c. works in the pancreas to stimulate beta cells to release insulin
d. works in the muscles to increase glucose uptake by enhancing
the effectiveness of endogenous insulin