Diabetes Part 2 Flashcards
what are the common insulin regiments for type 1 diabetes
- insulin therapy essential
- basal-bonus
- insulin pump
- others
what are the common insulin regimens for type 2 diabetes
- typically 2nd or 3rd line agent
- basal with oral agents (metformin/others)
- basal with glucagon like peptide 1 receptor agonists (GLP-1 RA)
- basal- bonus (with or without metformin/other oral agents)
what is the management of hypoglycemia
- rule of 15s
- treat if < 70mg/dl
- oral route preferred if patient able to swallow
- 15-20gms fast acting carbs = 3-4 glucose tabs, 4 oz juice or regular soda, 5 lifesavers, 3 peppermints
- glucose gel also available
- if next meal is more than 1 hour away consider a small snack to prevent recurrence or eat meal
- observe pt 30-60 mins after recovery. confirm normal glucose level before patient allowed to leave office
- consider referring pt to physician for follow up
what is the rule of 15s
- check blood sugar
- ear or drink 15g carbs
- wait 15 mins and check blood sugar
- if still low eat another 15g carbs
- check again after 15 minutes
what is the management of hypoglycemia if the patient is unconscious/unresponsive and patient is unable to swallow
- call 911 after administering 1st dose of glucagon or have someone else call
- stimulates gluconeogenesis - release of stored glucose (glycogen) from the liver
- 1mg glucagon intravenously or intramuscularly in buttock, arm or thigh. repeat 15 minutes if no response
- 0.5mg for pediatric patients < 44lbs
- intranasal glucagon also available: dose - adults and children over 4 yo 3mg (1 intranasal device in one nostril). can give another 3mg if no response after 15 minutes
- pt will need glucose after injection or give 50mL of 50% dextrose IV
- turn on side to present aspiration
what are the common agents used in T2DM
- metformin
- GLP1-RA: end in “tide”
- GIP/GLP-1 Receptor Go-agonist
- sodium glucose cotransporter 2 inhibitors
- dipeptidyl- peptidase-4 inhibitors
- thiazolidinedione
- sulfonylureas
- meglitinides
what are the injectable T2 DM therapy
- GLP-1RA or
- dual GIP +GLP-1Ra
- prior to insulin in most individuals
what are the risk reduction strategies for DM
- reduce the risk of macrovascular and microvascular complications through glycemic control and controlling co-morbid conditions to which DM contributes
- minimize periodontal complications due to DM, provide safe and effective dental care and promote good oral health
which oral agents are most likely to cause hypoglycemia
- sulfonylureas and melitinides
which medications primary mechanism of action decreases the production of glucose in the liver
metformin
how can you reduce cardiovascular and renal risk factors
- control BP
- control lipids
- smoking cessation
how can you reduce the risk of vaccine-preventable diseases
immunizations: flu, T-DAP, pneumococcal, hep B
what are the macrovascular complications
- atherosclerotic cardiovascular disease
describe atherosclerotic disease in macrovascular complications
the leading cause of morbidity and mortality for individuals with diabetes and is the largest contributor to the direct and indirect cost of diabetes
what directly affects reduction of macrovascular complications
consistent glycemic control to goal
what are the ABCs for
to prevent heart attack, stroke and peripheral arterial disease
what are the ABCS
- aspirin (low dose)
- blood pressure control
- cholesterol control
- smoking cessation
when is aspirin indicated
- primary prevention - only high risk
- secondary prevention - yes indicated
what are the common blood pressure control medications in diabetics
- thiazide diuretics
- ACE inhibitors (“prils”)
- angiotension II inhibitors (“Sartans”)
- others
what are the cholesterol control meds for diabetics
statins
what must be done to minimize microvascular complications
optimize blood pressure and glycemic control
what are the microvascular complications
- diabetic kidney disease
- diabetic retinopathy
- neuropatheis- diabetic peripheral neuropathy
describe diabetic kidney disease and what is the treatment
- renal dose dosing adjustments
- treatment: ACE inhibitor or angiotensin receptor blocker, added benefit from SLGT2s (preferred to minimize renal complications) and GLP1RAs
what is diabetic retinopathy and what is the tx
- diminished vision- may impact patient reading prescriptions or written information
- treatment from opthalmologist
what are the treatments for neuropathies and what are the side effects of these meds
- common non-opioid adjuvants such as antidepressants and anticonvulsants
- SE: xerostomia
what are the diabetic medications help atherosclerotic cardiovascular disease
- GLP-1RA
- SLGT2I
what diabetic medications help heart failure
- preferred: SLGT2I
- GLP1RA
what diabetic medications help kidney/renal disease
- SLGT2I
- GLP1-RA
what diabetic medications help with weight loss
- GLP1-RA
- less weight loss with SGLT2Is
having DM increases the risk of:
infection, more serious infections/infectious complications and slows healing/recovery
what are the immunizations recommended for adult pts with diabetes
- influenza
- pneumococcal vaccines
- Hep B
- Tdap
- recombinant zoster vaccine
- RSV
what is the recommendation for the flu vaccine
annually
what is the recommendation for the pneumococcal vaccine
newer options: PCV21, PCV 20, or PCV with PPSV-23
what are the recommendations for the hep B vaccine
complete series for those 19-59 years if no previous history of recovery > or equal to 60 years with DM
what is the recommendation for TDAP
at least 1 every 10 years
what is the recommendation for recombinant zoster vaccine
2 doses adults over 50 years old
what is the recommendation for RSV
1 dose for greater than 60 years old
what is the impact of diabetes on oral health
- T1Dm and T2DM increase the risk of periodontal disease 3-4 fold
- 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
how does chronic hyperglycemia create host hyper inflammatory response
- diminished neutrophil recruitment and function
- more severe inflammatory response- increases production of pro inflammaotry cytokines and chemokines due to:
- direct activation of several pro inflammatory pathways
- oxidative stress
- endothelial dysfunction
what are the oral manifestations of pre/Dm/DM
- candidiasis
- periodontitis- bleeding gums, gingival inflammation
- tooth mobility
- acetone breath - fruity smelling breath (more common with type 1)
- recurrent, acute or chronic gingival and periodontal infections and asscesses
- suppuration
- xerostomia
- increased salivary viscosity/flow
- enlargement of parrotid glands
- oral burning
- angular cheilosis
- acanthosis nigricans- sign of insulin resistance
- increased rate of dental caries
- poor wound healing
what are the dental management considerations for patients with diabetes
- no special tx or accomodations are required for routine dentistry
- morning visits may be preferred- lower insulin activity
- for routine visits patient with DM should eat normally and take usual medications prior to visit
- if patient needs to be fasting for invasive procedure and is not eating the pt may need to hold or adjust meds
what is the ideal blood glucose for elective dental proceudres
70-200mg/dl
what is the most common complication during invasive treatments
hypoglycemia
when should you be aware of hyperglycemia
during invasive treatments especially ketoacidosis in type 1
what is the presentation of hyperglycemia
- blurry vision, difficulty concentrations, increased urination, fatigue, extreme thirst, dry mouth, dizziness, headache, nausea/vomiting, confusion
why is it important to consider appropriate treatment of anxiety and/or pain in DM
stress/pain may increase cortisol and epinephrine secretion which can precipitate hyperglycemia
if patient is hypoglycemic when checking blood glucose prior to/during dental interventions:
- follow rule of 15s
- once glucose is above 70mg/dl have patient consume a snack and recheck blood glucose before proceeding with dental intervention
- long appointments
- check reading at end of appointment to be sure patient is safe to leave office- duration of hypoglycemia depends on duration of medication
- pt should be advised to eat a small snack at the end of an appointment if the next meal is more than 1 hour to prevent recurrence
what should you do to determine diabetic related medical issues
- determine if issue warrants immediate or urgent medical attention before elective dental procedures
- refer pt to diabetes provider or ask when patient has the next shceduled visit for less urgent issue
- pt with uncontrolled hyperglycemia may be candidates for prophylactic antibiotic therapy or longer antibiotic therapy for infection
what are the best practices for managing insulin pumps during ambulatory dental procedures
- depends on the manufacturer and type of pump
- develop a clear management plain with the pt that includes how the pump will be managed intraoperatively, especially if there is hypo or hyperglycemia
- a signed consent form from the patiens/guardian to continue pump use throughout periperative period
- recommended pt 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 accompanying CGM system
- assess the patients blood sugar preoperatively at regular intervals during the procedure and prior to discharge
describe basal rate management
- pt should stop bolus insulin while NPO but continue normal basal preoperatively
- generally 2 options for managing the basal rate of insulin delivery during surgery
- a lower infusion rate during the proceudre can alleviate the potential for perioperative hypoglycemia
- perioperative hypoglycemia can be maanged with exogenous dextrose even without making changes to the continuous pump systems basal rate
- no universal management strategy for determining or adjusting basal infusion rate intraoperatively
what are the 2 options for managing the basal rate of insulin delivery
- maintain the normal basal infusion rate
- 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
why should you blaance hypoglycemia risk with intraoperative hyperglycemia
the body tends to be in a relative state of insulin deficiency
what is the insulin pump management
- pts on pump therapy should be scheduled for early morning appointments to minimize potential for hypoglycemia or hyperglycemia
- pt should provide demonstration of insulin pump control and the CGM
- ensure understanding of how to turn the pump off in case of hypoglycemia
slow absorption of insulin from the infusion site will cause the effects of the basal infusion to persist for up to _____ after stopping the infusion
2 hours
what are the key functional controls of insulin pumps to understand
- how to check blood glucose using the CGM
- how to check normal functioning of the pumps basal infusion
- how to manually stop or turn off the pump
- is there a sensory 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
who is at the greatest risk for hypoglycemic unawareness
type 1
what causes hypoglycemic unawareness
- the counter regulatory systemic 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 becomes desensitized to the symptoms of hypoglycemia as it becomes used to low blood sugar levels
what medications can mask the signs and symptoms of hypoglycemia
beta blockers
what should be in a dental emergency kid
- glucose tabs/gel
- glucagon
- alpha glucosidase inhibitors
what are the considerations with alpha glucosidase inhibitors
- acarbose and miglitol
- dont cause hypoglycemia as montherapy 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 or glucagon if severe to treat hypoglycemia
- alpha glucosidase inhibitors will block absorption of other sugars
what is hyperglycemia
blood glucose less than 200 mg/dl
when do you avoid elective and complex dental proceudres with hyperglycemia
over 200 mg/dl
should you treat hyperglycemia emergently in the dental office
no
how can stress from dental procedures and/or dental inflammation cause increased glucose levels
- increase endogenous catecholamines secretion- increase HR, BP and blood glucose levels
- uncontrolled DM can cause increased healing time and put pt at higher risk of infection
- stress reduction techniques or shorter appointments may help minimize a rise in glucose from stress
what are the considerations with epinephrine, glucocorticoids and opioid analgesics
- may impact insulin requirements
- use with caution in DM especially if uncontrolled
what are the considerations with general anesthetics
- may increase risk of acidosis
- use with CAUTION in uncontrolled diabetes
what are the considerations with vasoconstrictors in LA in pts with DB
- epinephrine stimulates hepative glucose production and inhibits of glucose uptake by insulin dependent tissues which may lead to hyperglycemia
- routine use of LA with 1:100,000 epi is generally well tolerate in DM patients
- use lowest effective dose/concentration
- consider LA without vasoconstrictors in uncontrolled DM if dental proceudre cant be delayed
what are the considerations with corticosteroids with DM pts
use can increase glucose and cause hyperglycemia
how can the complications of diabetes impact dental care
- decreased visual acuity
- renal disease
- if the pt is on daily aspirin there may be more bleeding
- diabetes and diabetic meds may cause xerostomia/taste alterations
what id decreased visual acuity caused by and what are the considerations
- 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 info
what are the considerations with renal disease and dental care
adjustment of the dosages of antibiotics or analgesic (or avoidance of NSAIDs in pts with GFR < 30ml/min) may be required
pts with diabetes should be strongly encouraged to maintain good OH such as:
- brushing after every meal
- use floss daily
- keep dentures clean
- saliva substitutes for severe xerostomia
what is the education and follow up protocol with diabetes pt
- maintain OH
- educate pt about dental risks with DM
- encourage smoking cesssation for oral health and CV health
- dental visits q 6months
what are the post procedure/op considerations
- prophylaxis/treatment of infection when appropriate
- proper dietary intake
- proper anti diabetic drug therapy
what is the proper dietary intake post op
- modify to soft food diet
- keep carbs intake consistent
- consult diabetes provider or dietician for post op diet plan
- using a blender or low carb liquid meal replacement
- maintain adequate hydration
what are the anti diabetic drug therapies post op
- consider meal time insulin therapy needs to be adjusted for changes in eating
- consider fast acting insulin should be decreased or held until pt resumes full meals
- consider adjustment of other meds
- glucocorticoids, stress from proceudres, infection, inflammation and/or delayed healing may warrant closer moniitoring of blood glucose, and temporarily adjustment in diabetic therapies
- consult with diabetes provider for plan for post op drug therapy
what are the most common contributors of candidiasis in pts with DM
xerostomia and poor glycemic control
what causes xerostomia in DM
- decreased salivary function due to autonomic neuropathy
- DM affects the nerves that control salivary gland secretion
- DM may cause structural changes to parotid glands
what is the most common manifestation of candidiasis in DM
chronic atrophy (erythematosus) candidiasis
what is chronic atrophic candidiasis
- red or velvet textured plaques
- may complain of burning sensation or taste alterations
- smokers and denture wearers with poor OH at greater risk
what is the tx for xerostomia and oral candidiasis
- topical antifungal agents for candidiasis
- xerostomia - treatment with salivary stimulants, artificial saliva/saliva substitutes, sipping water/non caffeine free, sugar free drinks, use of sugar drinks, use of sugar free chewing gum
- topical fluoride interventions for patients with high caries rate
