The Dental Learning Network
The Dental Patient with Diabetes
7 Homestudy Credit Hours
Beverly Thomassian, RN, BC-ADM, MPH, CDE
The Dental Learning Network is a recognized ADA CERP provider
ebsite: W 4 North P 800-522-1207/703-935-2190 fax
Email: [email protected]
74 North P Table of Contents
Table of Contents...... 4 Course Objectives...... 6 Course Introduction...... 7 Historical Perspective...... 7 About the Author...... 8 Beverly Thomassian, RN, BC-ADM, MPH, CDE...... 8 Glucose Metabolism and Hormonal Regulation Review ...... 9 Introduction...... 9 Effect of Exercise and Stress on Blood Glucose Levels ...... 11 Diabetes Mellitus...... 12 Introduction...... 12 Etiologic Classification of Diabetes Mellitus ...... 13 Diabetes Mellitus Type 1...... 15 Etiology...... 15 Pathophysiology...... 15 Epidemiology...... 16 Diabetes Mellitus Type 2...... 18 Introduction...... 18 Etiology (Risk Factors) ...... 18 Pathophysiology...... 19 Epidemiology...... 20 Gestational Diabetes Mellitus (GDM)...... 21 Pre Diabetes: Impaired Glucose Homeostasis...... 22 Other Specific Types of Diabetes ...... 23 Introduction...... 23 Genetic Defects of the ß-Cell ...... 23 Diseases...... 23 Endocrinopathies...... 23 Drug/Chemical-Induced Diabetes ...... 23 Infections...... 23 Uncommon Forms of Immune-Mediated Diabetes...... 23 Genetic Syndromes...... 23 Diagnosing Diabetes...... 24 Urine Tests...... 24 Blood Tests ...... 24 Diagnosis ...... 25 Glucose Monitoring...... 26 Self-monitoring of Blood Glucose (SMBG)...... 26 A1c and Fructosamine Testing...... 26 Urine Testing for Ketones...... 27 Professional Monitoring...... 27 Complications of Diabetes ...... 29 Acute Complications...... 29 Chronic Complications ...... 29 Kidney Disease (3,19,21,23) ...... 30 Diabetic Neuropathy (3,19,22)...... 30 Macrovascular Disease (3,19,22) ...... 31
4 The Dental Patient with Diabetes...... 33 Oral Complications...... 33 Etiology and Pathogenesis of Factors Affecting Periodontal Disease Process in Diabetics ...... 34 Other Oral Complications ...... 35 Treatment of Periodontal Disease...... 35 Dental Intervention, Education, and Treatment Planning...... 36 Education ...... 37 Successful Intervention of Diabetic Emergencies ...... 39 Introduction...... 39 Hypoglycemia...... 39 Hyperglycemia...... 41 Diabetic Ketoacidosis ...... 41 Hyperglycemic Hyperosmolar Syndrome (HHS) ...... 42 Prevention and Treatment of DM...... 43 Introduction...... 43 Diet/Nutrition...... 43 Exercise...... 44 Pharmacological Intervention ...... 45 Administration...... 46 Method of Injection...... 46 Oral Hypoglycemic Agents ...... 47 Secretagogues ...... 48 Biguanides (Metformin) ...... 48 Thiazolidinediones (Actos, Avandia) ...... 48 Glucosidase Inhibitors (Precose, Glyset) ...... 48 Combination Medications ...... 48 Diabetes Medications...... 50 Conclusion...... 51
Glossary...... 57 References for Glossary...... 64 Appendices...... 65 Appendix A Diabetes Monitor ...... 65 Appendix B Number of Deaths with Diabetes as Underlying or Contributory Cause, by Age, Sex, and State, United States, 1994...... 66 Appendix C Estimated Percentage of Adults with Diagnosed Diabetes, by Age, Sex, and State, United States, 1994 ...... 68 References...... 70
5 Course Objectives
After completing this course, the learner will be able to:
• List factors pertaining to the etiology and pathogenesis of diabetes mellitus. • Recognize criteria relevant to the diagnosis of diabetes mellitus. • Describe complications associated with diabetes mellitus. • Discuss concepts related to dental intervention, education and treatment planning of patients with diabetes mellitus. • Identify key factors in maintaining optimal blood glucose levels. • Describe life saving procedures for individuals experiencing a diabetic emergency.
Note: In this course, terms in bold are defined in the glossary.
6 Course Introduction
Historical Perspective
“Yes, I am an old enemy of the human race, but I am not that unbeatable once my name is said…” John McLeod (From a Native American story about diabetes)
Writers describe people with symptoms of diabetes mellitus as early as 1500 BC. The disease name (meaning, “to siphon”) originated with the Greeks in 230 BC, and related to the excessive urination and wasting that occurs with untreated diabetes. Early classifications of diabetes are credited to the Susrata of the Hindus, the father of medicine in India. Later, classifications of diabetes mellitus (mellitus is Latin for “honey-sweet”) are refined, and suggested treatments vary from the removal of diuretic food to taking tepid baths.
th During the 19 Century, Claude Bernard theorized glycogenolysis as connected to the cause of diabetes mellitus. By the 1920’s scientists recognized insulin’s role in the regulation of blood glucose. Today the pathophysiology of diabetes is more clearly understood yet the cure remains elusive. (1,2,7)
7 About the Author
Beverly Thomassian, RN, BC-ADM, MPH, CDE
Author, Nurse, Educator and Clinician, Beverly Dyck Thomassian has specialized in diabetes management for the past thirteen years. She has been awarded board certification in Advanced Diabetes Management and has been published in the American Journal of Nursing, NurseWeek, Progress for Cardiovascular Nursing, Stanford Nurse and the Japanese Journal of Nursing.
Beverly is a nationally recognized speaker and consultant, dedicated to improving diabetes care. She is a working educator, currently serving as a Diabetes Program Manager and is an Assistant Clinical Professor in the graduate-nursing program at the University of California, San Francisco. She knows what you need TODAY in your clinical practice!
8 Glucose Metabolism and Hormonal Regulation Review
Introduction
Human energy requirements are met predominately by glucose. Cellular plasma membrane’s permeability to glucose varies according to type of tissue. Glucose transporters control diffusion of glucose into the cell. These transporters are specific to each type of tissue. Hormonal and neural devices control homeostasis of blood glucose levels. At least eight hormones secreted by various endocrine glands play a role in blood glucose levels.
Insulin (secreted by the pancreas) is the chief glucose regulatory hormone. Insulin is synthesized by beta cells (ß-cells) located in the islets of Langerhans. Insulin decreases blood glucose levels though increased glycogenesis and the transport of glucose into muscle, liver and adipose tissue. Muscle, liver and adipose cells require activation by insulin at insulin receptors in order to facilitate glucose transport into the cell. Neural tissue and erythrocytes do not require insulin for glucose utilization. Once glucose has entered the cell, it may be oxidized for energy (glycolysis) or stored (glycogenesis) in the muscle or liver (See Figure 1). (3,6)
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