Diabetes: Part 2 Flashcards

Question

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

Answer 1

2 doses adults > 50 years old

Answer 2

1 dose > 60 years or older

Answer 3

◦ 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

Answer 4

periodontal

Answer 5

 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

Answer 6

◦ 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.

Answer 7

◦ 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

Answer 8

 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

Answer 9

 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?

Answer 10

 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....

Answer 11

 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)

Answer 12

 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)

Answer 13

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

Answer 14

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

Answer 15

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

Answer 16

 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.

Answer 17

 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

Answer 18

◦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

Answer 19

hypoglycemia or hyperglycemia insulin pump controls and the CGM OFF 2

Answer 20

◦ 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?

Answer 21

 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)

Answer 22

 Glucose – tablets/gel  Glucagon

Answer 23

◦ ** 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

Answer 24

200 glucose

Answer 25

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

Answer 26

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)

Answer 27

* 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

Answer 28

poorly controlled

Answer 29

visual Renal xerostomia/taste

Answer 30

◦ 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

Answer 31

◦ 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

Answer 32

◦ 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

Answer 33

saliva candidiasis autonomic neuropathy salivary gland secretion parotid

Answer 34

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

Answer 35

◦ 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