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The Hypo/Hyperglycemic Patient

LCDR Carol Barone-SmithLCDR Carol Barone-Smith

Hypo/HyperglycemiaHypoglycemiaHypoglycemialow blood sugarlow blood sugar

HyperglycemiaHyperglycemiahigh blood sugarhigh blood sugar

What is Diabetes Mellitus?

Diabetes Mellitus Disease complexDisease complex resulting from lack of resulting from lack of

insulininsulin Low output of insulin from pancreasLow output of insulin from pancreas Unresponsiveness of peripheral tissues to insulinUnresponsiveness of peripheral tissues to insulin

Metabolic component:Metabolic component: Increased blood glucose from lack of insulin.Increased blood glucose from lack of insulin. Changes in lipid protein metabolismChanges in lipid protein metabolism

Vascular component:Vascular component: AtherosclerosisAtherosclerosis Microangiopathy affecting the kidneys and eyesMicroangiopathy affecting the kidneys and eyes

Diabetes Mellitus What is the Incidence?What is the Incidence?

16+ million people16+ million peoplehealthcare and lost work time = $90 billion healthcare and lost work time = $90 billion Third leading cause of deathThird leading cause of death25% end stage renal disease25% end stage renal disease20,000 amputations per year20,000 amputations per year

What does insulin do? In a healthy patient:In a healthy patient:

insulin secretion tightly controlledinsulin secretion tightly controlled

constant blood glucose level is maintained constant blood glucose level is maintained (65-110 mg/100ml of serum)(65-110 mg/100ml of serum)

blood glucose rises and falls in response to blood glucose rises and falls in response to mealsmeals

What does insulin do? Transfers glucose from blood to insulin-Transfers glucose from blood to insulin-

dependent tissues.dependent tissues. Stimulates the transfer of amino acids Stimulates the transfer of amino acids

from blood to cells.from blood to cells. Stimulates the synthesis of triglycerides Stimulates the synthesis of triglycerides

from fatty acids.from fatty acids. Inhibits the breakdown of triglycerides for Inhibits the breakdown of triglycerides for

the mobilization of fatty acids.the mobilization of fatty acids.

What does insulin do? Glucose stimulates humans’ insulin secretionGlucose stimulates humans’ insulin secretion

Regulates carbohydrates, fat, and protein Regulates carbohydrates, fat, and protein metabolism.metabolism.

Needed for muscle, fat, and liver to utilize glucose Needed for muscle, fat, and liver to utilize glucose from the blood. “insulin dependent tissues”from the blood. “insulin dependent tissues”

When insulin is insufficient or the action of insulin is When insulin is insufficient or the action of insulin is insufficient, glucose accumulates in the tissue fluids insufficient, glucose accumulates in the tissue fluids and blood.and blood.

What is the result? Glycosuria and polyuriaGlycosuria and polyuria result due to the result due to the

kidneys not being able to reabsorb the kidneys not being able to reabsorb the excess glucose.excess glucose.

PolydipsiaPolydipsia is in response to fluid loss is in response to fluid loss (polyuria).(polyuria).

PolyphagiaPolyphagia occurs to compensate for glucose occurs to compensate for glucose loss, but there is still weight loss.loss, but there is still weight loss.

What is the etiology? Diabetes mellitusDiabetes mellitus can occur due to: can occur due to:

A genetic disorderA genetic disorder

Destruction of the islets of Langerhans Destruction of the islets of Langerhans

An endocrine conditionAn endocrine condition

Iatrogenic disease after steroid Iatrogenic disease after steroid administrationadministration

Genetic Diabetes MellitusTwo Major Types

Type I:Type I:Insulin-dependent diabetes mellitus (IDDM)Insulin-dependent diabetes mellitus (IDDM)

Type II:Type II:Non-insulin-dependent diabetes mellitus Non-insulin-dependent diabetes mellitus

(NIDDM)(NIDDM)

Diabetes Mellitus Results from a deficiency of insulinResults from a deficiency of insulin

Due to:Due to:

– low output of insulin from the pancreaslow output of insulin from the pancreas

OR BYOR BY– peripheral tissues being unresponsive to the peripheral tissues being unresponsive to the

insulininsulin

Symptoms of Type I Diabetes (IDDM)

Common symptoms:Common symptoms:polydipsiapolydipsia

polyuriapolyuria

polyphagiapolyphagia

weight lossweight loss

loss of strengthloss of strength

Other symptoms:Other symptoms:

bed wettingbed wetting

skin infectionsskin infections

marked irritabilitymarked irritability

headacheheadache

drowsinessdrowsiness

malaisemalaise

dry mouthdry mouth

Symptoms of Type II Diabetes (NIDDM)

Common symptoms:Common symptoms: same as IDDM but less same as IDDM but less

commonly seencommonly seen

gain or loss of weightgain or loss of weight

urination at nighturination at night

blurred/decreased blurred/decreased

visionvision

parasthesias / loss of parasthesias / loss of sensationsensation

ImpotenceImpotence

postural hypotensionpostural hypotension

Comparing IDDM and NIDDM

IDDM NIDDM% of diabetics 5-10% 85-90%

age at onset 15 y.o 40+ y.o.

body build normal/thin obese

severity severe mild

Insulindependency

almost all 25-30%

oralhypoglycemics

few respond 50% respond

Comparing IDDM and NIDDM

IDDM NIDDMketoacidosis common uncommon

onset of disease rapid slow

complications 90% in 20 yrs. Less common

stability unstable stable

family history common more common

insulin receptordefects

uncommon common

Other complications of Diabetes

cataractscataractsblindnessblindnesshypertensionhypertensionchest painchest painanemiaanemiaskin lesionsskin lesions

Diabetic Ketoacidosis Signs and Signs and

Symptoms:Symptoms:

–polyuriapolyuria

–thirstthirst

– fatiguefatigue

–nauseanausea

– vomitingvomiting– tachycardiatachycardia– tachypneatachypnea– mental mental

confusionconfusion

Complications of Diabetes MetabolicMetabolic

Inability to utilize glucose in normal amountsInability to utilize glucose in normal amountsAccelerated fat catabolismAccelerated fat catabolism

Blood vessel diseaseBlood vessel diseaseAtherosclerosisAtherosclerosisMicroangiopathyMicroangiopathy

NeurologicNeurologicAutonomic neuropathyAutonomic neuropathy

Complications of Diabetes Increased incidence of infection due to the Increased incidence of infection due to the

three primary manifestations of diabetes:three primary manifestations of diabetes:1. 1. Hyperglycemia:Hyperglycemia: decreases phagocytic

function of granulocytes. Facilitates microorganisms to grow.

2. 2. Ketoacidosis: Ketoacidosis: delays migration of granulocytes to injury. Dec. phagocytic activity.

3.3. Vascular Wall Disease: Vascular Wall Disease: Vascular insufficiency causing dec. blood flow to injury.

End result: Inc. susceptibility to infection, dec. ability to End result: Inc. susceptibility to infection, dec. ability to fight infection once started, delayed wound healingfight infection once started, delayed wound healing

Diagnosing DiabetesLab tests demonstrating Lab tests demonstrating

abnormal glucose metabolism:abnormal glucose metabolism: Fasting Plasma Glucose (FPG) Fasting Plasma Glucose (FPG)

test:test: (The “gold standard” lab test). Patient (The “gold standard” lab test). Patient fasts 10-16 hrs. For fasting blood glucose, fasts 10-16 hrs. For fasting blood glucose, normal = 70-115mg/100ml of plasma. Results normal = 70-115mg/100ml of plasma. Results >126mg/100ml with 2 tests = dx. diabetes m. >126mg/100ml with 2 tests = dx. diabetes m.

Diagnosing DiabetesLab tests (continued):Lab tests (continued):

Oral glucose tolerance test (OGTT):Oral glucose tolerance test (OGTT): Dx. Dx. impaired glucose tolerance and diabetes mellitus. impaired glucose tolerance and diabetes mellitus. Do a fasting blood draw and then the patient Do a fasting blood draw and then the patient ingests a 75 gm glucose load. Blood specimens ingests a 75 gm glucose load. Blood specimens obtained 1/2 hr, 1, 1 1/2 and 2 hours. Dx. obtained 1/2 hr, 1, 1 1/2 and 2 hours. Dx. diabetes mellitusdiabetes mellitus when the plasma glucose level when the plasma glucose level is >200mg/100ml.is >200mg/100ml.

Urinary glucose and acetone:Urinary glucose and acetone: tests glucose and tests glucose and acetone in the urine. Not all diabetics have these acetone in the urine. Not all diabetics have these in their urine. Not specific for diabetes. in their urine. Not specific for diabetes.

Oral manifestations of diabetes

inc. rate of cariesinc. rate of caries infectioninfection

xerostomiaxerostomia

impared healingimpared healing

inc. enamel inc. enamel hypoplasiahypoplasia

increased gingival increased gingival inflammation and inflammation and incidence of incidence of periodontal diseaseperiodontal disease

abnormal eruption abnormal eruption patternspatterns

candidiasiscandidiasis

Dental Management of the diabetic patient

determine the status of the diabetic pt.determine the status of the diabetic pt. thorough medical historythorough medical history type of diabetestype of diabetes medicationsmedications ? how they monitor their glucose levels? how they monitor their glucose levels results of last medical evaluationresults of last medical evaluation

Dental management of the NIDDM patient

all dental procedures can be done.all dental procedures can be done.

for dental tx., no special precautions needed for dental tx., no special precautions needed unless symptoms of diabetes are present.unless symptoms of diabetes are present.

take normal dosage of oral hypoglycemics for take normal dosage of oral hypoglycemics for outpatient proceduresoutpatient procedures

Dental management of the IDDM patient

Depends on how well their disease is Depends on how well their disease is controlled.controlled.

If well controlled, routine treatment If well controlled, routine treatment should be well tolerated using should be well tolerated using precautions.precautions.

If poorly controlled IDDM patient, do If poorly controlled IDDM patient, do medical consult.medical consult.

Dental management of the IDDM patient

Precautions when treating the IDDM pt.Precautions when treating the IDDM pt.Brief morning appts. Dec stress. Brief morning appts. Dec stress.

Pt. should take normal insulin dosage and Pt. should take normal insulin dosage and eat normal breakfast. Confirm this with pt.eat normal breakfast. Confirm this with pt.

Consult physician if procedure will affect the Consult physician if procedure will affect the patient’s ability to eat. Physician may alter patient’s ability to eat. Physician may alter the insulin therapy/diet for patient.the insulin therapy/diet for patient.

Dental management of the IDDM patient

Precautions (continued):Precautions (continued):Minimize risk of infection: consider Minimize risk of infection: consider

antibiotic coverage after surgery and tx. in antibiotic coverage after surgery and tx. in presence of suppuration.presence of suppuration.

Have a source of sugar available.Have a source of sugar available.

Consider adjunctive sedation.Consider adjunctive sedation.

Dental management of the diabetic patient

If the patient has an acute oral infection:If the patient has an acute oral infection:Treat aggressively with definitive therapy Treat aggressively with definitive therapy

such as:such as:– I&DI&D– extractionextraction– pulpectomypulpectomy

Indicated Indicated = antibiotic therapy, culture, and = antibiotic therapy, culture, and medical consultation.medical consultation.

infectioninfection, causing alteration of blood glucose , causing alteration of blood glucose control, can necessitate change in insulin control, can necessitate change in insulin therapy and hospitalization.therapy and hospitalization.

Indications for periodic screening for Diabetes Mellitus

Those people who have/are:Those people who have/are: Showing signs or symptoms of diabetes or its Showing signs or symptoms of diabetes or its

complicationscomplications Diabetic relativesDiabetic relatives Obese individualsObese individuals Over 40 years oldOver 40 years old Delivered large babiesDelivered large babies Spontaneous abortions or stillbirthsSpontaneous abortions or stillbirths

HypoglycemiaLow blood sugar:Low blood sugar:

Happens with diabetic and non-Happens with diabetic and non-diabetic patientsdiabetic patients

Blood glucose < 50 mg/mlBlood glucose < 50 mg/ml

Causes of hypoglycemia Oversecretion of insulinOversecretion of insulin

Exertion of musclesExertion of muscles

PregnancyPregnancy

Anorexia nervosaAnorexia nervosa

Hypoglycemia: Insulin shock

Usually from pt. not eating normally but Usually from pt. not eating normally but still taking their regular insulin therapy.still taking their regular insulin therapy.

Can occur from overdosage of insulin or Can occur from overdosage of insulin or oral hypoglycemic medication.oral hypoglycemic medication.

Excessive insulin can cause a reaction or Excessive insulin can cause a reaction or shock that occurs in three stages.shock that occurs in three stages.

Hypoglycemia: Insulin shock

Mild stage:Mild stage:Most commonMost commonOccurs before Occurs before

mealsmeals

During exerciseDuring exercise

Lack of foodLack of food

Characterized by:Characterized by:HungerHungerWeaknessWeaknessTremblingTremblingTachycardiaTachycardiaPallorPallorSweatingSweatingParasthesiasParasthesias

Hypoglycemia: Insulin shock

Moderate stage:Moderate stage: More severeMore severeIncoherentIncoherentUncooperativeUncooperativeBelligerentBelligerentResistiveResistiveJudgement / orientation = poorJudgement / orientation = poor

Driving is the primary danger in this stageDriving is the primary danger in this stage

Hypoglycemia: Insulin shock

Severe stage:Severe stage:UnconsciousnessUnconsciousnessPresence or absence of seizure activityPresence or absence of seizure activityHypotensionHypotensionHypothermiaHypothermiaRapid, thready pulseRapid, thready pulseSweatingSweating

Dental management of the hypoglycemic patient

Mild and moderate stages:Mild and moderate stages:Recognize hypoglycemic signs and Recognize hypoglycemic signs and

symptomssymptomsTerminate the procedureTerminate the procedureGive the patient anything containing sugarGive the patient anything containing sugarPosition the patient; do BLSPosition the patient; do BLSSummon medical assistance if necessary Summon medical assistance if necessary

and monitor the patientand monitor the patient

Dental management of the hypoglycemic patient

Severe stage:Severe stage:Unconscious patientUnconscious patientStop the procedureStop the procedurePosition the patient; do BLSPosition the patient; do BLSSummon medical assistanceSummon medical assistanceGive 50% IV dextrose orGive 50% IV dextrose or1 mg glucagon IM 1 mg glucagon IM

In the life of a diabetic (IDDM)

My MomMy Mom Born on Memorial Day 1936Born on Memorial Day 1936 Married at age 19 @128 lbs.Married at age 19 @128 lbs. Family history of diabetes: aunt and cousinFamily history of diabetes: aunt and cousin Had 2 children: Cathy (1958) weighing 8 lbs 2 Had 2 children: Cathy (1958) weighing 8 lbs 2

oz. and me (1965) weighing 9 lbs 15 1/2 oz.oz. and me (1965) weighing 9 lbs 15 1/2 oz. Mom weighed 185 lbs with Cathy and 213 lbs Mom weighed 185 lbs with Cathy and 213 lbs

with me.with me.

In the life of a diabetic (IDDM)

My MomMy Mom Diagnosed with diabetes in June 1975 during Diagnosed with diabetes in June 1975 during

routine check-up: 39 y.o.routine check-up: 39 y.o. Used oral hypoglycemics from 1975 until Used oral hypoglycemics from 1975 until

NOV 1989 when she was put on insulin.NOV 1989 when she was put on insulin. DEC 1989: in hospital for phlebitis in left leg. DEC 1989: in hospital for phlebitis in left leg.

and was told to quit work or risk losing the legand was told to quit work or risk losing the leg Doesn’t run the sweeper or iron standing up.Doesn’t run the sweeper or iron standing up.

In the life of a diabetic (IDDM)

My MomMy Mom Diagnosed with kidney problems: 5 yrs. agoDiagnosed with kidney problems: 5 yrs. ago Kidneys work at 15% of normal capacity and Kidneys work at 15% of normal capacity and

so she says “my blood is not in good so she says “my blood is not in good condition”condition”

Dialysis? In a year? Kidney transplant, Dialysis? In a year? Kidney transplant, NO!NO! Diet: “Don’t eat too many fruits or Diet: “Don’t eat too many fruits or

vegetables.’’ No bananas, broccoli, potatoes!vegetables.’’ No bananas, broccoli, potatoes!

In the life of a diabetic (IDDM)

My MomMy Mom 1988: Left foot deformed so much she could 1988: Left foot deformed so much she could

not wear dress shoes. “Charcot foot”not wear dress shoes. “Charcot foot” Neuropathy in feet and up to the knees. Neuropathy in feet and up to the knees.

Could lead to braces.Could lead to braces. Neuropathy in fingers: Cannot sew because Neuropathy in fingers: Cannot sew because

she cannot feel the needle. Buttons are a she cannot feel the needle. Buttons are a problem and tearing up mail is a problemproblem and tearing up mail is a problem

In the life of a diabetic (IDDM)

My MomMy Mom ““Worst thing about my health - get extremely Worst thing about my health - get extremely

tired.”tired.” Fingernails and toenails curl under. “Hammer Fingernails and toenails curl under. “Hammer

toes” “Fingernails tell about one’s health.”toes” “Fingernails tell about one’s health.” 1993: laser surgeries on her eyes - 10 1993: laser surgeries on her eyes - 10

surgeries on the left eye and 9 on the right.surgeries on the left eye and 9 on the right.

Would have gone blind in 5 years without tx. Would have gone blind in 5 years without tx.

In the life of a diabetic (IDDM)

My MomMy Mom MAR 1998: Cataract operation on right eye.MAR 1998: Cataract operation on right eye.

Can still see well enough to drive and read.Can still see well enough to drive and read.

Questions?