By: Jessica A. Davis, RDH
What is diabetes mellitus?
Diabetes mellitus is a family of conditions where the body cannot properly utilize glucose as a form of energy due to either low production of insulin, no insulin, or resistance to insulin within the body. The most common form of diabetes is Type 2 diabetes, caused by inadequate insulin production or insulin resistance and usually presents in middle to late-aged adults. Other forms of diabetes include gestational diabetes in pregnant individuals, prediabetes in those at early stages of type 2 diabetes, diabetes insipidus, and type 1 diabetes. According to the American Diabetes Association, over 11% of the American population in 2019 was estimated to have diabetes.
How does Type 1 Diabetes differ?
Type 1 diabetes differs from the other forms of diabetes mellitus in that it is an autoimmune disease. The body’s immune system destroys the cells in the pancreas responsible for insulin production, which means people with type 1 diabetes are entirely insulin dependent. Type 1 diabetes typically has an acute onset, often in early childhood, but anyone can develop type 1 diabetes. In rare instances, someone with type 2 diabetes could cease to produce all insulin and would then be treated similarly to someone with type 1 diabetes. People with type 1 diabetes follow similar dietary guidelines as other diabetics. However, they are at an increased risk for hypoglycemic events where blood sugars drop dangerously low. They are also at an increased risk for dangerously high blood sugar levels and diabetic ketoacidosis (DKA). They also have the same increased health risks as more severe cases of type 2 diabetes, including high blood pressure, diabetic retinopathy, heart failure, hearing loss, dementia, nerve damage, kidney disease, liver disease, and death. Additionally, because type 1 diabetes is an autoimmune disease, those with type 1 diabetes are at an increased risk of developing another autoimmune disease. Patients with type 1 diabetes are more susceptible to adverse health and oral health outcomes when their A1c is above 7% or above an average blood glucose level of 154 mg/dL.
A thorough medical history is essential.
As hygienists, we encounter patients with diabetes almost every day in clinical practice. We know a two-way road connects periodontal health and maintaining a healthy A1c. We know people with diabetes are at an increased risk for high blood pressure, heart disease, and other health conditions. Maintaining an accurate health history and medication list combined with taking vitals at every appointment is the standard of care for all patients, not just those with diabetes. However, for diabetics, some additional questions need to be asked.
- Have you eaten today?
- Did you take your blood sugar today?
- What was your last A1c, and when was it taken?
- Do you wear an insulin pump and/or automated glucose monitor?
Consider their medical equipment when preparing for the appointment.
People with type 1 diabetes, or completely insulin-dependent type 2 diabetes, must check their glucose levels often because they are completely insulin dependent and do not produce any insulin on their own. Those with these forms of diabetes often use electronic glucose monitors placed on a limb or abdomen. These monitoring sites remain for a week at a time and should only be moved if necessary due to the cost and limitations of supplies. An insulin pump requires a cannula to be inserted in a leg or along the waist, with an external unit worn near the site. Insulin pumps deliver rapid-acting insulin on a need basis, and closed-loop systems utilize communication between the automated glucose monitor and an insulin pump to act as an artificial pancreas. Every precaution to avoid damaging the medical equipment people with Type 1 diabetes, or completely insulin-dependent type 2 diabetes, rely on to live needs to be taken. Interference with some insulin delivery systems from radiation, radio frequencies, and electromagnetic energy can disrupt insulin distribution, permanently damage the insulin pump, or even cause the insulin pump unit to expel all loaded insulin creating a severe medical emergency. That said, not all people with type 1 diabetes or completely insulin-dependent type 2 diabetes utilize insulin pumps and closed-loop systems. Other management methods include needle and syringe delivery, insulin pens, insulin inhalants, jet injectors, and other medications to protect vital organs and prevent high blood pressure. Ensure to include brand, model, manufacturer safety recommendations, and other pertinent information about medical equipment in the patient’s medical history and appointment notes. Patients who use monitoring devices or insulin pumps do not need antibiotic prophylaxis.
When in doubt, check the manufacturer’s recommendations for equipment safety.
If your office uses RF communication headsets- it may affect portable medical equipment, including some insulin pumps, due to the proximity. Never drape the cord from ultrasonic units over the patient, over the insulin pump, or near glucose monitors. Some insulin pump manufacturers recommend removing specific devices and sensors for X-rays, while others do not. If the patient is treatment planned to undergo root canal therapy or other procedures involving high-frequency energy, electromagnetic energy, or soundwaves, the insulin pump manufacturer should be consulted before the procedure. The prescribing endocrinologist should also be consulted if the pump needs to be removed for the procedure. It is always within best practices to contact the manufacturer if the patient does not know the specific instructions for their medical equipment for the safety of the patient.
Provide in depth patient education.
Many people with type 1 diabetes have lived with the condition for most of their lives and are aware of the health risks they face daily. Educating them specifically about the connection between periodontal health and healthy blood glucose levels is essential for their oral and long-term health. Regular dental visits and proper homecare are essential to maintain the oral health of the patient, but also to help control their diabetes. Those with diabetes are at an increased risk for developing exaggerated tissue responses to inflammatory factors. Document a gingival statement with each visit for monitoring, and inform the patient of any noted changes, educating them on influencing factors. Any changes in blood pressure should be followed up with their primary care provider, as it could be a sign of disease progression. Advise those who have diabetes against drinking alcohol, drug use, and smoking. Also, take note of a patient’s demeanor. Stress, sickness, and anxiety can trigger fluctuations in blood glucose levels in some people with type 1 diabetes or completely insulin-dependent type 2 diabetes. Pharmacological interactions can occur with some of the medications used to protect vital organs in people with diabetes when combined with some NSAIDs or epinephrine, so be sure to check drug interactions before making any recommendations.
Medical emergencies can arise.
If your patient with type 1 diabetes, or completely insulin-dependent type 2 diabetes, begins to act lethargic, pale, tremble, develop a sudden headache, slurs their words, becomes belligerent, drowsy, or otherwise begins to act impaired, stop the appointment. Then, sit the patient up, and ask them to assess their blood glucose level. If lower than 70mg/dL, administer a source of glucose such as juice, crackers, and glucose tablets and wait 15 minutes. Do not administer insulin if blood glucose levels are low. If the blood glucose level has stabilized, you may continue the appointment. If the patient becomes unresponsive or begins to have a seizure, place the patient in a supine position and activate emergency response protocols. The dentist, or the patient’s caregiver, may administer glucagon. Protect the patient’s airway and supply supportive oxygen. Record all actions taken and inform the patient of the situation once they regain consciousness, as they are not likely to remember the event.
If your patient has an abnormally high blood glucose reading, over 180mg/dL, consider postponing non-emergency treatment, as they are at an increased risk for infections. A high blood glucose reading is not typically a medical emergency until the patient is in diabetic ketoacidosis. Some symptoms of DKA include fever, irritability, respiratory distress, xerostomia, urination frequency, bed wetting, or inability to hold urine. If you suspect your patient may be in diabetic ketoacidosis, immediately refer them to their endocrinologist, primary care provider, or emergency room for evaluation.
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