DM part 2

Question 1

considerations for choosing DM rx

Answer 1

Consider the effects on cardiovascular and renal comorbidities; effectiveness; hypoglycemia risk; impact on weight, cost, and access; risk for adverse reactions and tolerability; and individual preferences

Question 2

Common Insulin Regimens fot type 1 dm

Answer 2

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

Question 3

common insulin regimens for t2dm

Answer 3

(typically 2 nd or 3 rd line agent)
◦ Basal with oral agents (metformin/others)
◦ Basal-Bolus (with or without metformin/other oral agents)
◦ Basal with GLP1-RA

Question 4

which insulins are most likely to cause hypoglycemmia

Answer 4

rapid acting

Question 5

In adults with type 2 diabetes and 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:

Answer 5

reduce cardiovascular and kidney diseas 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

Question 6

Reducing the risk of macrovascular and microvascular (and
other) complications through:

Answer 6

Reduce the risk of macrovascular and microvascular (and other) complications through glycemic control and controlling co-morbid conditions to which DM contributes
◦ Reduce cardiovascular and renal risk factors
– Control BP
– Control Lipids
– Smoking Cessation

Question 7

MACROVASCULAR COMPLICATIONS of DM

Answer 7

— Atherosclerotic cardiovascular disease (ASCVD)
◦ 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 8

what directly affects reduction of macrovascular
complications?

Answer 8

Consistent glycemic control to goal directly affects reduction of macrovascular
complications

Question 9

ABCS to prevent Heart Attack, Stroke and Peripheral Arterial Disease in DM pts

Answer 9

◦ 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 10

Microvascular Complications

Answer 10

retinopathy, neuropathy, nephropathy

Question 11

Diabetic Kidney Disease
◦ dosing>?
◦ Treatment

Answer 11

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

Question 12

Diabetic Retinopathy
◦ effect?
◦ Treatment from?

Answer 12

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

Question 13

Neuropathies - Diabetic Peripheral Neuropathy
◦ tx with?
– Common side effects?

Answer 13

Neuropathies - Diabetic Peripheral Neuropathy
◦ Common non-opioid adjuvants such as antidepressants and anticonvulsants
– Common side effects - xerostomia

Question 14

DM rx’s with Atherosclerotic cardiovascular disease (ASCVD) benefits

Answer 14

GLP1-RA: albiglutide, dulaglutide, liraglutide, semaglutide
SLGT2I - canagliflozin, dapagliflozin, empagliflozin

Question 15

DM rx with Heart Failure benefits

Answer 15

PREFERRED - SLGT2I : canagliflozin, dapagliflozin, empagliflozin
GLP1-RA: albiglutide, dulaglutide, liraglutide, semaglutide

Question 16

Dm rx with renal benefits

Answer 16

Kidney/Renal PREFERRED - SLGT2I: canagliflozin, dapagliflozin, empagliflozin
GLP1-RA: albiglutide, dulaglutide, liraglutide, semaglutide

Question 17

dm rx with Weight Loss

Answer 17

Greatest weight loss with GLP1-RA,Tirzepatide
Less weight loss with SGLT2Is

Question 18

DM with infections

Answer 18

Having DM increases the risk of infection, more serious infections/ infectious complications and slows healing/recovery

Question 19

recomended vax fo DM pts

Answer 19

Question 20

DM Impact on oral health
* — Diabetes mellitus is one of the strongest systemic risk factors for?
* — Both T1DM and T2DM increase the risk of periodontal disease how much?
* — Control of DM may affect the?
* — Poorly controlled DM may increase the risk of?

Answer 20

• — 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
• — 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)

Question 21

chronic hyperglycemia and the inflammatory response

Answer 21

Chronic hyperglycemia may create host hyper-inflammatory response
◦ 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 22

oral infections and glycemic levels

Answer 22

Oral infections can increase risk of hyperglycemia in DM patients

Question 23

Recognizing Undiagnosed Diabetes through dental exams

Answer 23

• — 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
• Consider referring to health care provider for DM screening

Question 24

potential signs of undiagnosed DM with a dental exam

Answer 24

◦ 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 -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 25

DM Screening in Dental Practice

Answer 25

— 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 26

In patients with controlled DM, is special treatment is required for routine
dentistry?

Answer 26

In patients with controlled DM, no special treatment is required for routine
dentistry

Question 27

preffered visit times for DM pts

Answer 27

Morning visits may be preferred – lower insulin activity and/or an
appointment after a meal or snack for patients with history of hypoglycemia

Question 28

routine dental visits with DM and rx with food?

Answer 28

For routine visits – patient with DM should eat normally and take usual
medications prior to the visit
qIMPORTANT TO CONFIRM THIS BEFORE PROCEDING WITH THE VISIT

Question 29

DM pts requiring invasive procdures with fasting

Answer 29

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
qUsually only hold those that cause hypoglycemia (consult with diabetes provider, if
needed)

Question 30

med hx with dm pts

Answer 30

Complete a Medical History to identify patients with diabetes
qWhat type of DM does the patient have?
qHow does the diagnosis impact the DM medications you might see on the
patient’s medication list?

Question 31

Assessing current glycemic control of pts

Answer 31

◦ 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?

Question 32

checking bp with DM pts

Answer 32

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 33

Random blood glucose value for elective tx

Answer 33

◦ Generally, between 70-200 mg/dl for elective dental procedures
◦ Check with office glucometer 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
◦ Long appointments – consider additional checks

Question 34

pt memory of blood glucose levels

Answer 34

Relying on the patient’s memory to provide accurate values is risky
◦ May not remember accurately or don’t know
◦ May be too embarrassed or “fudge” better number to not admit poor control

Question 35

During invasive treatments or procedures how can blood sugar be affected

Answer 35

◦ Most common complication – hypoglycemia
◦ ALSO, be aware of risks of hyperglycemia, especially ketoacidosis in type 1
– presentation similar to hypoglycemia in a conscious patient – blurry vision, difficulty concentrating, increased urination, fatigue, extreme thirst, dry mouth, dizziness, headache, nausea/vomiting, confusion, (others).
– 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 check a blood sugar but symptoms can trigger suspicion

Question 36

If patient is hypoglycemic when checking blood glucose prior
to/during dental interventions:
qFollow?
qOnce glucose is above 70 mg/dl?
qLong appointments – ?
qCheck reading at?
qAt conclusion of the appointment?

Answer 36

• Follow Rule of 15s
• 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 37

Patients with uncontrolled hyperglycemia and ABx

Answer 37

Patients with uncontrolled hyperglycemia may be candidates for prophylactic antibiotic therapy or longer antibiotic therapy for infection.

Question 38

Best Practices for Managing Insulin Pumps during Ambulatory Dental Procedures/Surgery
* — Dependent on?
* — Developing a clear management plan?
* — A signed consent?
* — Recommend patient position pump?
* — Assess the patient’s blood sugar when?

Answer 38

• — 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 39

Basal Rate universal Management
—

Answer 39

— 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

Question 40

Basal Rate Management recomendation options?

Answer 40

— 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
◦ 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

Question 41

Basal Rate Management:
— A lower infusion rate during the procedure can?
— Perioperative hypoglycemia can be managed with?
◦ what should be available Iv?
◦ Typically, maintaining the basal insulin rate and correcting any hypoglycemia with?
— Balance hypoglycemia risk with commonly observed?

Answer 41

— 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 42

Insulin Pump Management
— Patients on pump therapy (DM patient, in general) should
be ideally scheduled for? why?
— Patient should provide a ?
◦ ENSURE UNDERSTANDING OF?
◦ Keep in mind tha?

Answer 42

— Patients on pump therapy (DM patient, in general) should be ideally scheduled for early morning appointments to minimize potential for hypoglycemia or hyperglycemia
— Patient should provide a demonstration of insulin pump controls and the CGM, if present prior to the procedure
◦ ENSURE UNDERSTANDING OF HOW TO TURN THE PUMP OFF 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 2 hours after stopping the infusion.

Question 43

Questions for Pump Operation
— Key Functional Controls of Insulin Pumps to Understand

Answer 43

◦ 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 44

Hypoglycemic unawareness
* — Individuals who are at greatest risk?
* — Can occur with?
* — The counter-regulatory systems?
* — Can also arise due to ?
* — The brain may become ?
* — Beta-blockers?

Answer 44

• — 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 45

Dental Emergency Kits

Special note for alpha-glucosidase inhibitors

Answer 45

— Glucose – tablets/gel
— Glucagon
◦ ** 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 46

Hyperglycemia in dental tx
q Avoid what levels?
q Stress from dental procedures and/or dental inflammation?

Answer 46

q Avoid hyperglycemia – blood glucose levels < 200 mg/dl before initiating any invasive dental treatments
q Stress from dental procedures and/or dental inflammation/infections may cause increased glucose levels

Question 47

how does hyperglycemia occur with dental tx

qIncrease endogenous?
qUncontrolled DM and healing/infection?
q what may help minimize a rise in glucose from stress?

Answer 47

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

Question 48

Use of vasoconstrictors in local anesthetics in dm pts
* Epinephrine stimulates ?
* Routine use of local anesthetic with 1:100,000 epinephrine is?
* Usewhat doses/concentration?
* Consider what LAS with uncontrolled DM

Answer 48

• 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
• Use lowest effective dose/concentration
• Consider local anesthetics without vasoconstrictors in uncontrolled DM, if dental procedure can’t be delayed

Question 49

Use of corticosteroids in DM

Answer 49

Use of corticosteroids can increase glucose and cause hyperglycemia

Question 50

Assess patients for infections and delayed/poor wound healing?

Answer 50

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

Question 51

Avoid elective and complex procedures in patients with?

Answer 51

Avoid elective and complex procedures in patients with poorly controlled diabetes (> 200 mg/dl)

Question 52

Decreased visual acuity (from microvascular complications and/or poor glucose control) and its effecct on dental care

Answer 52

◦ may make self examination of mouth and performance of oral hygiene difficult
◦ challenges reading directions on prescription bottles or other printed information

Question 53

Renal disease with DM pts and its effect on dental care

Answer 53

Renal 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.

Question 54

— If the patient is on a daily aspirin for CV risk, patients may?

Answer 54

— If the patient is on a daily aspirin for CV risk, patients may bleed more easily

Question 55

Diabetes and diabetic medications may causewhat oral changes?

Answer 55

Diabetes and diabetic medications may cause xerostomia/taste
changes

Question 56

Education and Follow-up fo DM pts
— Patients with diabetes should be strongly encouraged to?
— Educate about dental risks with?
◦ Patients don’t typically receive education on the impact of DM on oral cavity in?
◦ Importance of normalizing blood glucose =??
— Encourage smoking?
◦ Compounded risks with?
— Dental visits how oftren?

Answer 56

— Patients with diabetes should be strongly encouraged to maintain a good
oral hygiene:
◦ brushing after every meal
◦ using floss daily
◦ keeping dentures clean
◦ saliva substitutes for severe xerostomia
— Educate about dental risks with DM
◦ 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 health
— Encourage smoking cessation for oral and CV health
◦ Compounded risks with smoking and DM to oral health
— Dental visits q 6 months

Question 57

Post procedure/op considerations for DM pts

Answer 57

— Prophylaxis/treatment of infection, when appropriate
— Proper dietary intake
— Proper anti-diabetic drug therapy

Question 58

Diabetes Self-Management and Education

Answer 58

— Diabetes self-management and education is important aspect for treatment plan
— Requires the expertise of a variety of healthcare professionals including dental professionals
◦ 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
— Recognize relationship between diabetes and depression
◦ Poorer glucose control and oral hygiene
◦ Referral to primary care or mental health provider
— Communicate relationship between diabetes and macrovascular/microvascular complications

Question 59

Management of Xerostomia and Oral Candidiasis in dm pts
—
— Most common contributors of candidiasis in pts with DM?

Answer 59

— Common oral complications of DM – decreases saliva production
— Most common contributors of candidiasis in pts with DM - xerostomia and possibly poor glycemic control

Question 60

DM and xerostomia mechanism

Answer 60

◦ Associated with decreased salivary gland function due to autonomic neuropathy
– DM affects the nerves that control salivary gland secretion
◦ DM may cause structural changes to parotid glands
◦ Some studies show independent of poor glycemic contro

Question 61

Most common candidiasis manifestation with DM
◦ app?
◦ May complain of?
◦ who is at greatest risk

Answer 61

Most common manifestation is chronic atrophic (erythematous) candidiasis
◦ 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 62

Treatment for xerostomia and candidiasis
◦ candidiasis tx
◦ Xerostomia tx
◦ patients with high caries rate?

Answer 62

◦ 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