Diabetes-Related Emergencies

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Case Scenario

Your patient, Jeff Johnson, is a 29-year-old male disc jockey in good health. His medical history reveals that he is a controlled Type 1 diabetic who takes insulin daily. He is late for his 8:00 a.m. appointment stating that he did a gig last night and overslept. He had just enough time to administer his medication but did not want to be any later for his dental appointment, so he skipped breakfast.

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Case Scenario

You begin the intra/extra oral examination before the oral prophylaxis and notice he is salivating profusely. You ask him where he is and his response is confused and irrational. You take his vital signs and find a bounding pulse and shallow respirations. He is conscious. From what emergency do you suspect Jeff is suffering?

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Diabetes MellitusCharacterized by elevated levels of blood

glucose resulting from an impaired ability to product or use the hormone insulin.**

Etiology: reduction or absence of production of insulin by beta cells of pancreas or defect of insulin receptors

Insulin aids in conversion of sugar and starches to a form transported to cells and used for energy

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Diabetes Mellitus3 types

Type 1 (formerly IDDM or Juvenile)Type 2 (formerly NIDDM or adult onset)

Gestational4th category pre-diabetes or impaired glucose tolerance

Pg 166, table 16.14-14

Type 1 Diabetes MellitusAbsolute lack of insulinPancreatic beta cells within Islets of

Langerhans destroyed due to immune dysfunctionIn Islets of Langerhans: alpha cells secrete glucagon-raising blood glucose; beta cells secrete insulin lowering blood glucose.

Dependent on supplemental insulin for survival

5-10% of all diabetics4-14

Type 2 Diabetes MellitusThis type of diabetes is increasing

comprising 90-95% of all diabetics due to:Increase in life spanSedentary lifestylePoor diet and exercise of adolescents

Pancreas unable to produce sufficient insulin or the body is not able to use the insulin that is produced

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Physiology of Diabetes**Cells of the body need insulin to

take in glucose.Liver uses insulin to store glucose as

glycogen.If glucose and glycogen are not

available in the body for energy, the body must break down other materials for fuel/energy.

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Gestational Diabetes MellitusGlucose intolerance with initial onset during

pregnancyUsually disappears after pregnancy, but may return

years laterEtiology: enzyme in placenta and destruction of

insulin by placenta causes the development of gestational diabetes.

If untreated infant can have fetal macrosomia (big baby syndrome), hypoglycemia, hypocalcemia, or hyperbilirubinemia( too much bilirubin in infants blood and the newborn’s liver can not process the bilirubin causing jaundice. Bilirubin is produced in the liver, when the liver breaks down red blood cells

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Fetal Macrosomia: big baby syndrome

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Diabetes Testing2 types

Fasting Plasma Glucose Test (FPG)12 – 14 hour fast – blood glucose

between 100 – 125: pre-diabetes; blood glucose: > 126 diabetes

Oral Glucose Tolerance Test (OGTT)12 -14 hour fast and then drinking a

glucose-rich beverage – 2 hours later blood glucose: 140 – 199 prediabetes; blood glucose: > 200 diabetes4-14

Systemic Complications

Many – 4 majorDiabetic retinopathyDiabetic neuropathy

Diabetic nephropathyOral Manifestations

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Diabetic Retinopathy (Eyes)Leading cause of blindness age 20 – 74Mild form – increased vascular permeabilityModerate form – vascular closureSevere form – growth of new blood vessels on

retina and posterior surface of vitreous(layer of collagen)

Macular edema or a retinal thickening from leaky blood vessels can develop at all stages of retinopathy

Prevention: early screening for diabetes and glucose control.4-14

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Diabetic NeuropathyMild to severe forms of nervous system

damage affecting 60-70% of diabetics.

Condition not well understood.

Common symptoms: pain in the feet and hands, slow digestion, other neurological problems.

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Caused by Diabetic Neuropathy

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Macrovascular and Microvascular Complications

Microangiopathic changes where the basement membrane of the capillaries thickens and can lead to the formation of a thrombi, impeding blood flow.

Diminished blood flow can increase the risks of a stroke and/or myocardial infarctions.

Lack of blood flow to nervous tissues can damage the nerves.

Gangrene: loss of blood to a part of the body increasing the risk of losing a limb.4-14

Diabetic Nephropathy (kidneys)Damages small blood vessels in kidneys

Impairs ability to filter impurities from blood

Require transplant or dialysis to cleanse blood

Once occurs 100% morbidity within 10 years

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Oral Manifestations of DiabetesIncreased incidence of:

Delayed wound healing leading to secondary oral and systemic infections

Periodontal diseaseAbscessesXerostomia (dry mouth)CariesLichen planus (white lacy streaks on oral

mucosa)Candidiasis (yeast infection in the oral

cavity)4-14

Lichen Planus

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Candidiasis

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MonitoringBest method to avoid complications

is to maintain optimum glucose levels.

Diabetics test blood several times a dayGlucose monitor used

Lancet – drop of bloodPlaced on test stripInserted into a calibrated glucometer

which will display the patient’s blood glucose readings.

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Glucose ReadingsNormal reading 50 – 150 mg/dL

Less than 50 hypoglycemicGreater than 150 hyperglycemic

Adjustment in medication needed or referral to MD

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Figure 16.1 Glucometer

Glucose TestingAnother important test HbA1c or

glycated hemoglobin testReveals patient’s “average” blood

glucose level over past 3 monthsHome test methods now availableMaintaining optimal levels help reduce the

risk of developing diabetic complications like: blindness, kidney disease, nerve damage, stroke and heart failure.

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Medications and Treatments for Type I Diabetics

Usually some type of insulin: Humalog, Novalog

Different types based on time of onset, peak effectiveness, effective duration and maximal duration

Need to be refrigerated to lengthen effectiveness

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Medications and Treatments for Type II Diabetics

Medication prescribed on the basis of cause and severity of condition

More common medications:Metformin (Glucophage)Tolbutamide (Orinase)Glyburide (Micronase, DiaBeta, Glynase)

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Advances in Type I Diabetes Treatment

Insulin pumps to replace daily injectionsCompact device with insulin filled syringe that is attached to a subcutaneously inserted catheter

Catheter changed every 4-6 daysBetter glycemic and metabolic controlPatient’s with pumps still need to monitor glucose levels

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Figure 16.2 12-year-old Type 1 patient with insulin pump

Figure 16.3 Insulin pump in place

Transplantations in Type I Diabetics

Pancreas or pancreatic islet cell transplantation

Concerns: need for continuous immunosuppression to prevent rejection of the islet cells or pancreas.

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Role of Dental ProfessionalQuestions to ask all diabetic patientsDo you monitor glucose levels? If so, how often?

What were your most recent glucose levels?

How are you feeling?Do you take medication and if so, did you take it today?

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Role of Dental ProfessionalQuestions to ask all diabetic patientsHave you eaten today? If so, when?Are you having problems with your eyes, feet, legs?

Do you see your physician regularly?Do you see an eye doctor yearly?Do you know your average hemoglobin value?

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Role of Dental ProfessionalStrategies to implement:

Schedule appointments in early to mid-morning**

Keep appointments short**Instruct patients to continue normal dietary intake prior to appointment**

Check patient’s blood glucose level prior to any invasive procedure or if patient complains of not feeling well

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Role of Dental ProfessionalStrategies to implement:

Frequent recall examinations and prophylaxis

Use of topical fluoride: Prevident 5000 paste or gel, Gelkam

Recommending saliva substitutes: Biotene or Oral Balance

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Diabetic Medical EmergenciesDiabetic Ketoacidosis (DKA)- severe

hyperglycemia

Hyperosmolar Hyperglycemic Nonketotic Syndrome (HHNKS)

Hypoglycemia

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Diabetic Ketoacidosis (DKA): severe hyperglycemia

Not a common occurrence in dental officeTypes of patients at risk for DKA

Newly diagnosed Type 1 diabeticsPatients that are not medicating or eating

properlyBrittle diabetics(when type 1 diabetics have

unstable glucose levels)Patients with infectionsAlcohol and cocaine

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Diabetic Ketoacidosis (DKA)Etiology: insufficient insulin levels in

blood to sustain normal fat metabolism- severe hyperglycemiaGlucose metabolism insufficient energy

source so body metabolizes fatty acids for energyBy products of fatty acids are ketones which

cause the blood to be more acidicKetones are one of a number of substances that increase in the blood as a result of faulty carbohydrate metabolism

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Diabetic Ketoacidosis (DKA)Body exhales carbon dioxide in an attempt to reverse acidosis

Leads to tachypnea and increased depth of respirations – Kussmaul respirations (air hunger)

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Signs and Symptoms of DKA**

Polydipsia: excessive thirstPolyuria: excessive urinationPolyphagia: excessive hungerNauseaDry flushed skinDeep and rapid respirations (Kussmaul’s

respiration)Weak and rapid pulse“Fruity” breath odorMay become unconscious4-14

Treatment of DKAStop dental treatmentNeed to lower blood glucose level with insulinShould only be administered by medical professional to prevent hypoglycemia

Contact EMSIV fluids needed to reverse dehydrationMonitor vital signsPosition patient supine

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Hyperosmolar Hyperglycemic State

Patient will be hyperglycemic and dehydrated, but not acidotic

Usually affects infirm, neglected, institutionalized, or mentally deficient diabetic patientsCannot recognize thirstUncommon in dental office

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Diabetic Emergency: hypoglycemia or hyperinsulinism**

Occurs when too much insulin is present and the person’s blood glucose is abnormally low.

Below 50 mg/dLMay occur when patient increases insulin dosage, omits a meal, vomits or exercises excessively.

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Signs and symptoms of hypoglycemia**Sudden onsetAltered level of consciousnessConfusionAnxiousnessIncoherenceUncooperativePale, moist skinDizzinessWeaknessNot be thirsty and have normal breath odor

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Treatment of Severe Hypoglycemia

Conscious PatientAdminister 15-20 grams of sugar: table sugar, honey, candy, OJ, glucose tablets/paste

Secure airwayMonitor vital signsPositive response should occur within 10 – 15 minutes

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Figure 16.4 Oral glucose tablets, paste, sugar packets

Treatment of Severe Hypoglycemia

Unconscious PatientTx of choice is Glucagon: 1 mg administered subcutaneously, intramuscularly or intravenously.

Contact EMSMaintain airwayMonitor vital signs

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Figure 16.5 Injectable glucagon

Case Resolution:

Jeff’s signs and symptoms are those of severe hypoglycemia.

Indication of too much insulin and not enough glucose.

Jeff was given 6 glucose tablets, which quickly reversed the symptoms of hypoglycemia.

He was monitored in office for 30 minutes, given info on managing his diabetes and

rescheduled for an appt immediately after lunch.