Chapter 69 The Patient with Diabetes Mellitus Discussion
IntroductionYou are seeing this patient for the first time today. He usually has Cathy, the other dental hygienist in the office, “clean” his teeth. There was a change in the schedule so you will be seeing him for the first time today. As you walk him into the treatment room you ask if there have been any changes to his health and he states “no”. You were in a rush to seat him because you were running late and you failed to look at the medical history or the drug list before starting treatment. While preforming a dental prophylaxsis, you notice your patient has started to sweat and he seems confused about where he is and asks “who are you?” You open the drug list and notice he is taking glyburide. What do you think is happening with this patient? How should you proceed?Remember: All posts and responses should contain proper grammar, be free of spelling errors, be substantial, and reflect critical thinking.
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DEH 2806 Ch 69
Chapter 69– the patient with diabetes mellitus. Diabetes mellitus it covers several types of diabetes but
they’re all characterized by high blood glucose levels, meaning they have hyperglycemia. If you think about
our huddle meetings in the morning and when we call off conditions of the patients, many of our patients
present with diabetes. So as we go through this PowerPoint, be cognizant of the signs and symptoms when a
patient might be having an episode in our clinic. We have on several occasions had patients that present with
hypoglycemia, so it’s a good thing to know what the signs and symptoms are.
There are several statistics on this slide. You do not need to memorize them. They are not going to be on any
examination. This is just to give you an idea of the prevalence of diabetes in the United States. So 9.3% of the
population in the United States has diabetes. The risk of dying is 50% higher for somebody with diabetes
when you compare them to persons without diabetes. And there’s also about one in three adults in the
United States that have pre-diabetes, and we’re going to discuss that further on in this PowerPoint.
This slide shows a mapping of diabetes prevalence in 2013 and as you can see where it’s concentrated is in
the southern states. And on the next slide, I’m going to show you something else that has to do with mapping
in obesity. But obesity is directly related to diabetes. Now, if you see that state right in the middle there that
has a percentage from zero to 7.83, that’s Colorado. The area that is a little bit darker that would be right
about where Denver is. Colorado is the skinniest state in the United States.
If you read about it, the reason being is they’re very, very active in that state. My family lives out there and
they bicycle, they hike, they run. And I read an interesting article that why people are thinner in Colorado.
When they come back from a weekend and they go to work rather than asking what did you eat? Where do
you go out to eat? What did you have to drink? What they ask each other is what did you do? Did you go
biking? Did you go hiking? Did you go running? So they’re a very, very active state. This slide here is a
mapping of the prevalence of self-reported obesity among US adults in 2012. Very close to the other mapping
that was 2013.
And we all know what that BRFSS is. It’s the Behavioral Risk Factor Surveillance System. We talked about that
in the beginning of the semester. But what you can see on this map is that obesity goes along about the same
way as type 2 diabetes. Obesity is the number one risk factor for type 2 diabetes, and we’re going to go
through this PowerPoint and distinguish between type 1 and type 2 diabetes.
What is diabetes? It’s an endocrine disorder that’s associated with metabolism. So when we eat food, it’s
broken down into glucose which is a form of sugar in our body. And our body uses that glucose as the main
fuel for itself. As I have underlined here, normal blood glucose levels in a healthy person range from 60 to
100 milligrams per deciliter. The A1C test that we’re going to discuss later on in the PowerPoint– that is less
than 5.7%. If it’s 5.7% or over, then it’s pre-diabetes, but we’ll go over that later in this PowerPoint.
So when glucose enters the blood, the pancreas it automatically produces the right amount of insulin to
move that glucose from the blood into our cells so the cells can use it. In people with diabetes, the pancreas
either produces little or no. Insulin– that would be type 1 diabetes. Or the cells do not respond appropriately
to the insulin that is produced– that’s type 2 diabetes.
Type 1 diabetes is an autoimmune disease. The immune system it attacks the insulin-producing beta cells
that are located in the isles of Langerhans. Those are in the pancreas and what they do is destroy those cells.
They destroy the beta cells. Why have that in red italicized? That was a previous national board question. So
what happens then is the pancreas produces little or no insulin, so that person is diagnosed then as having
type 1 diabetes and they depend on exogenous, meaning outside the body, insulin to stay alive.
There’s different terms I’m going to go over on this slide. Please make sure you’re aware of what they mean.
So when insulin is not adequate, glucose builds up in the blood– that’s hyperglycemia– and overflows into
the urine– glycosuria. Glycosuria induces excretion of large amounts of urine– polyuria and water and
electrolytes are lost when that happens. So fluid loss signals excessive thirst– polydipsia then the cells
starving for glucose. They may cause the person to increase food intake– polyphagia– but weight loss can
Without glucose, the cells don’t have glucose. Even though it’s in the blood, the insulin did not produce from
the pancreas, and so the glucose in the blood doesn’t get used. So what happens then is the body needs
energy, and it metabolizes fat for energy. The end products of fat metabolism are harmful ketones that
accumulate in the blood. Ketones are acidic, and they’re usually neutralized in the blood. But when there’s
that large amount of ketones, the neutralizing effect is depleted very rapidly and a condition called metabolic
acidosis results. And metabolic acidosis leads to a diabetic coma. That is a life-threatening condition. It’s
In addition to the symptoms mentioned in the previous slides, the excessive thirst, excessive urination, and
excessive hunger, a person with type 1 diabetes that is undiagnosed may also have blurred vision and
extreme fatigue. When a person is treated for type 1 diabetes, they would not have these symptoms.
Individuals with other autoimmune disorders such as Graves’ disease and Hashimoto’s thyroiditis– they’re
also prone to develop type 1 diabetes more often than the general public. Please don’t hold me to
pronunciation. I’m not sure I’m pronouncing that correctly, but at least you know what it is.
There’s a lot of research being done on diabetes but presently scientists don’t know exactly what causes the
body’s immune system to attack the beta cells. They believe it to be multi-factorial meaning it involves the
autoimmune system, genetics, environmental factors, and possibly even viruses. Type 1 diabetes accounts for
about 5% to 10% of the diagnosed diabetes in the United States. I want you to know that statistic. It develops
most often in children and young adults, but it can appear at any age.
Another statistic I want you to know the most common form of diabetes is type 2, and it accounts for 90% to
95% of the people with diabetes. So as I just said on the previous side, if type 1 accounts for 5% to 10%, then
type 2 is going to account for 90% to 95%. Type 2 diabetes is increasingly being diagnosed in children and
adolescents in children as young as three years of age. About 80% of the people with type 2 diabetes are
overweight, and as I stated before obesity is the number one risk factor for type 2 diabetes.
It’s increasingly being diagnosed in younger and younger people because our society is getting larger and
larger. This picture here also shows you other chronic diseases that are associated with obesity. These are
other risk factors associated with type 2 diabetes. Please read through them and be familiar with them. The
tests that are listed on the bottom of the slide, we’re going to go over those later in the PowerPoint.
There is a high-risk factor associated with race and ethnicity especially if it’s in conjunction with the previous
risk factors on the other slide. Why have this picture here? It is the Pima Indians. They are located mainly in
Arizona. Studies on diabetes are done on them all the time because they have such a high-risk factor. That’s
where children as young as three years old have been diagnosed with type 2 diabetes. But what this is
showing you is when the Pima Indians lived in Mexico where they originated from the prevalence of diabetes
was only 8%. When they migrated into the United States, mainly in Arizona, that prevalence jumped to 50%.
So once their ethnicity was combined with other factors such as how we eat in the United States, it really
increased the prevalence rate of their diabetes.
This picture was taken from your textbook. And it’s a new picture in the new textbook and so is this
condition. I’m not going to try to pronounce it because I know I will mispronounce it. But this skin condition is
seen in patients that are at risk for type 2 diabetes. When type 2 diabetes is diagnosed, the pancreas usually
is producing enough insulin, but for unknown reasons, the body cannot use the insulin effectively. And it’s a
condition called insulin resistance. And after several years of insulin resistance, insulin production decreases,
so this systemic result is the same as for type 1 diabetes.
Glucose builds up in the blood– hyperglycemia– and the body cannot make efficient use of its own main
source of fuel. Symptoms for type 2 diabetes are very similar to type 1 diabetes. That includes fatigue or
nausea, frequent urination, unusual thirst, weight loss, blurred vision, frequent infections, and slow healing
of wounds or sores. Some patients with type 2 diabetes have no symptoms. This table was taken out of your
textbook and it’s a comparison of type 1 and type 2 diabetes.
What is pre-diabetes? It’s blood glucose levels that are higher than normal, but not high enough to be
characterized as diabetes. Many people that have pre-diabetes they go on to develop type 2 diabetes within
10 years unless they do some type of intervention. And this is when the doctor steps in and says you need to
exercise more and you need to eat properly. Those two things can ward off the development of type 2
diabetes. So you may hear people in clinic patients say and they may even put on their health history that
they have diabetes and that they are controlling it with exercise and food.
Gestational diabetes simply means that diabetes was discovered in a test while the woman was pregnant.
Women who have gestational diabetes– they have about 50% chance of developing diabetes within five to
10 years. You don’t need to know the statistics on this slide. Women who have gestational diabetes– they are
prone to having larger babies. If you can see down here in that picture what happens as the mother’s blood
brings extra glucose to the fetus then the fetus makes more insulin to handle that extra glucose. And then
that extra glucose gets stored as fat. So that makes the baby larger. Women who have gestational diabetes
are also prone to having babies that are born prematurely with the incidence of congenital malformations
and prenatal death being higher.
The diagnosis of diabetes– type 1 diabetes is usually identified after some acute symptom occurs, such as the
person is thirsty all the time, they urinate all the time, they may go in for testing and discover they have type
1 diabetes. In a child what happens sometimes– and I had this happen in practice– is that a child will
suddenly start to wet the bed when they have not done that for years. I had a five-year-old patient diagnosed
when I was in practice. She started wetting the bed which she had not done that for three years. Her mom
took her in, they did a test, and she had type 1 diabetes.
Type 2 diabetes– screening is recommended if the individual is 45 years of age and then has any of the risk
factors that we’ve talked about previously. Screening is also recommended for children and adolescents who
are overweight and have other risk factors also. If a person presents with signs or symptoms of diabetes,
they’re usually referred to a physician for a complete evaluation that will include one or more of the tests
that we’re showing on the next few slides.
This test here called the fasting plasma glucose test– known as the FPG. This is the one that’s recommended
by the American Diabetes Association because it’s easier, faster and less expensive to perform. So what the
patient does is they fast for eight to 10 hours then the blood is drawn. A level between 100 and 125
milligrams per deciliters– that signals pre-diabetes. If there’s a level of 1.26 or higher, that indicates diabetes.
The oral glucose tolerance test– it adds another step to the test that we just talked about. Meaning the
person fast for eight to 10 hours, then they go to the lab, and they drink this glucose-rich beverage, then
blood is drawn. If the level is between 140 and 199, they have tested as having pre-diabetes. If it’s 200 or
higher, they are said to have diabetes.
The glycated hemoglobin assay– it can be used for two things. It can be used for diagnosis. But what it’s often
used for is if patients have already been diagnosed with diabetes, they go in and have their blood drawn and
it checks the blood glucose levels over the past 6 to 12 weeks. So it sees how people are monitoring their
diabetes. Now as far as a diagnostic test, pre-diabetes is diagnosed if that value is from 5.7 to 6.4. If it’s 6.5 or
higher, they’re diagnosed as having diabetes.
The complications associated with diabetes– there’s many of them. I think the public has a misinterpretation
or a misunderstanding of diabetes as it not being a very serious disease. It is a very serious disease. So people
with diabetes they’re more susceptible to infections and impaired healing obviously especially if it’s not
controlled. Failure to treat these infections intensifies symptoms and increases the severity of diabetes. Some
of these infections can be life-threatening or precipitate a diabetic coma.
Insulin requirements may need to be adjusted, meaning increased, if a person has a fever, infection,
inflammation, trauma, bleeding, pain, or stress. Once those conditions are removed, then the insulin can be
reduced. People that have tightly controlled blood glucose levels– they tend to have much fewer
Neuropathy is another complication of diabetes and then has to do with the feeling. The sense of feeling
mainly in the extremities is the person has a lack of feeling, so they may have an ulcer or an infection in one
of their extremities and not be aware of it because they don’t feel it. Also, it affects the gastrointestinal tract.
It can impair digestion. It affects cardiovascular systems, and it can also lead to sexual dysfunction.
Nephropathy is a disease of the kidney. Diabetes is a leading cause of renal disease which is kidney disease.
As I go and do research in the dialysis centers, almost every person there has diabetes.
Retinopathy is a degenerative disease of the retina. Diabetic retinopathy is the leading cause of blindness in
the United States, and it affects about half of the population that has diabetes. This slide describes what
happens in diabetic retinopathy. The blood vessels they swell and leak fluid into part of the retina, and that
lets us see detail. And when that fluid makes the macula swell that’s why the person has blurred vision. In
other people, abnormal new blood vessels start to grow on the surface of the retina. Either way without
treatment the retina is destroyed and the person goes blind.
A person with diabetes is more prone to cardiovascular disease such as heart attack and stroke. Often it’s
recommended that they take a low dose aspirin. Diabetes is a major cause of limb amputation– usually the
foot. Also, there’s a great deal of psychosocial problems that occur when patients have diabetes, especially
children. If you can imagine being very young and have to have injections or something that makes you
different from other children it’s very stressful. They have camps for kids to go to so that they can be with
other people like themselves and try and deal with their diabetes.
This slide shows insulin therapy to manage hyperglycemia. So there are different forms of insulin and each of
them have a different pharmacological action. So there’s rapid, short, intermediate, and long-acting forms.
The dosage it depends on the individual. And there are many factors that will either increase or decrease the
need for insulin. That includes food, whether the person’s is ill, whether they’re under stress, how much
exercise they’re doing, or infections. And why I have that underlined is periodontal disease is an infection,
and if it’s chronic it can increase the need for insulin. Also listed here are the methods for insulin
administration. And there are different sites that are used. You don’t need to memorize this. It won’t be on
any examination or quiz.
An insulin pump is one way of delivering insulin to the body. It’s a pre-programmed continuous rate of
insulin. Now, the person can adjust that. Let’s say they want to eat a piece of chocolate cake. They can pump
in more insulin by adjusting their pump. It’s also convenient because it can be worn in a pocket, or on a belt,
or on a waistband, and so it’s more convenient than injecting yourself several times a day. There are also oral
medications. You should be familiar with those from pharmacology and also from the patients that present
on the clinic when you look at their medical history.
The dental complications are generally related to poor glycemic control. So as far as periodontal disease, it is
a common problem in persons with diabetes and is more severe in individuals that are not well controlled.
And the reason for the periodontal destruction is not quite clear, but the alteration in host responses to the
periodontal pathogens that seems to be the major cause.
Xerostomia is a common problem seen in persons with diabetes. It’s not really known why. Enlargement of
the parotid glands– I have that italicized because now we’re seeing that in several other conditions. Bulimia
was one of them. Alcohol abuse was another one. Sjogren’s disease is another one. Fruity smelling breath-that is a classic sign of diabetes. As far as candidiasis that is more prevalent in persons with diabetes.
As far as a dental hygiene appointment, you want to try and reduce stress as much as possible because stress
creates hypoglycemia. Hypoglycemia is a condition most often seen in the dental office and in our clinic.
Always treat a patient on a full stomach. Do not interfere with their regularly scheduled meals– their eating
schedule. And prepare for a diabetic emergency, meaning hypoglycemia, by keeping something sweet in the
office. Fruit juice, cake frosting. What you do is give it to the patient, and it will reverse what’s happening
with the hypoglycemia.
This table is taken from your textbook, and it compares hypoglycemia to hyperglycemia. This graphic is also
taken from your textbook, and it shows you how to manage hypoglycemia. And this concludes chapter 69.
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Chapter 69 The Patient with Diabetes Mellitus Discussion