Cynthia R. Biron, RDH
Alocal Tallahassee dentist is credited with recognizing the signs of diabetes in two dental patients that he treated while in private practice. The dentist wishes to remain anonymous ,so he will be referred to as Dr. Sharp. The following two cases are described by Dr. Sharp:
Case 1
Several years ago, a young woman in her late twenties came into the office to initiate dental care. Her health history was unremarkable. She appeared to be healthy, and from all outward appearances, showed no signs of illness.
During the initial examination, I noticed that her breath smelled sweet as if she had been chewing "Juicy Fruit gum." As the examination continued, this sweet breath became a source of concern to me. I asked her if she ever had been diagnosed with diabetes, and she said she had not.
My concern was not assuaged. After the examination, I requested that she go to her physician`s office to have her blood drawn and tested. She said she would do it, so we called the physician`s office and arranged for the appointment.
Later in the day we called the office to find out the status of our patient. We were told that her glucose level exceeded 600 and she had been admitted into the local hospital. She was diagnosed with diabetes and, after sorting out her glucose levels and insulin demands, she was released.
Case 2
We had a long-standing relationship with a gentleman in his late forties. He was in the middle of extensive restorative care and was in the habit of coming into the office every one to two weeks. He was very faithful to his appointments, partly because of his desire for a healthy dentition, but also because he had a budding interest in our dental assistant. He never missed an appointment.
One day he was scheduled for an appointment just before the lunch hour, but he did not arrive or call to cancel. Knowing the man the way we did, we found this to be quite unusual. After some discussion among the staff, we determined that his not coming was significant, so we called his place of work. His coworkers said he was not at work. We called his house and there was no answer. This was a responsible gentleman, and missing appointments and not going to work were not at all typical of his behavior.
Since we were to see no other patients until after lunch, my assistant and I decided to go to his house. This is certainly out of the ordinary, but there were too many questions and no answers. When we arrived at his home, his car was in the drive way, but when we knocked on the door and called his name, no one answered. We pushed the door open and went in, calling out his name as we entered. No answer.
We wound our way to the back of the house into the bedroom. The gentleman lived alone. We found him in bed. We almost could not get him to arise. We had no idea what the problem was. We did learn that he had been in bed for several days. We got him dressed and drove him to the emergency room of the local hospital.
Since our lunch hour was just about over and our afternoon patients would be waiting, we were forced to leave him in the care of the emergency room staff. Some time later in the day, a hospital staff member called to tell us that the gentleman was diagnosed to be in a diabetic coma. If he had not been brought in that day, he would have died.
He spent about a week in the hospital and, after his insulin needs were determined, he was released. At no time was there any indication that the man was ill. His health history did not reveal any notion of diabetes. As time passed, we continued to see this man, and he commented on how much better he felt after he began to receive treatment for his diabetes.
Watching for signs of diabetes
It is not very common for a dentist to be the one to discover diabetes during his/her patient assessment, and it is extremely rare for a dentist to go to a patient`s home and save the patient`s life. Most of us will never be in that situation, but we will be in the situation of assessing the breath odors of our patients. We are quite familiar with the odor associated with periodontal disease, and, at times,we have been able to denote the smell of alcohol on a patient`s breath.
But we need to make it a point to sit down with our patients, while not wearing a face mask, and have a conversation to determine if there are unusual breath odors that could be indicative of other disease processes. Breath odors are also associated with gastrointestinal disorders, sinus, adenoid, and tonsil infections.
Because a diabetic coma comes on more gradually, patients experiencing it might not be aware of the changes, and signs and symptoms until they are quite immobilized. Patients who have been diagnosed with diabetes usually check their own glucose levels or see their physician regularly to have glucose levels monitored.
In addition to evaluating our patient`s breath odors, the medical history forms in a dental office should contain questions which reveal signs and symptoms of diabetes. Some of those questions are:
- How many times during the night do you get up to urinate?
- Are you thirsty throughout the day?
- Have you or has anyone in your family been diagnosed with diabetes?
- Have you experienced changes in your weight without altering your dietary intake?
- Have you had any changes in your vision?
- Have you had problems healing from cuts, wounds or infections?
- Have you had any kidney disorders?
- Have you had abnormal blood pressure? (Take the patient`s blood pressure)
- Have you been diagnosed with any heart condition or heart problems?
- Have you ever had chest pain?
- Have you had any neurological problems?
- Have you had any problems with circulation, including numbness and tingling of extremities?
In the Harvard Health Letter of April 1996, the following information is noted:
__ Diabetes is the leading cause of new cases of blindness, end-stage kidney disease, and lower limb amputations in the United States.
__ Thirty to 70 percent of people with diabetes have nerve damage that may be severe.
__ Type II (non-insulin dependent ) diabetes:
* affects roughly 14 million Americans, about half of whom are unaware that they have the disease.
* is diagnosed in 625,000 people in the United States each year.
* is three times as common today as it was in 1960.
* is more likely to develop in people who are over 40, obese, sedentary, have a family history of diabetes, or are of African-American, Mexican, or Native-American descent.
* more than doubles the risk for a stroke or heart disease.
Treatment of diabetes
With these statistics on diabetes in our country, we need to be more astute at recognizing signs and symptoms of the disease so that we can refer these patients to physicians for proper care.
The increase in the number of cases of Type II non-insulin dependent diabetes mellitus (NIDDM) has brought about an advance in the treatment of Type II diabetes mellitus. The American Diabetes Association (ADA) has developed glycemic goals for these patients. The ADA recommends that the first line of treatment for Type II diabetes should be diet and exercise.
If the glycemic goals are not met within three months, drug therapy is appropriate while maintaining dietary guidelines and exercise regimens prescribed by physicians. The sulfonylureas drugs can cause weight gain. However, newer drugs with different mechanisms of action that do not cause weight gain have been approved by the U.S. Food and Drug Administration (FDA).
Sulfonylureas drugs, such as glyburide or glipizide, stimulate the pancreas to increase insulin production and can cause hypoglycemia. The new drugs that are being prescribed for Type II diabetes are metformin (Glucophage) and acarbose (Precose). The newest drug that is available is troglitazone(Rezulin), a thiazolidinedione.
Metformin (Glucophage) - Metformin is classified as a biguanide and was approved by the FDA in 1995. Unlike sulfonylures, metformin does not increase insulin secretion. It inhibits hepatic gluconeogenesis which decreases glucose output by the liver. Metformin usually decreases a patient`s appetite. The ensuing weight loss results in a reduction in the insulin requirement. Metformin does not cause hypoglycemia.
Several drugs compete with metformin for renal excretion and could result in toxicity. These antibiotics are sulfamethoxazole (Bactrim, Septra), vancomycin (Vancocin), and trimethoprim (Proloprim, Trimpex). Other drugs include procainamide (Procan SR, Pronestyl), quinidine gluconate, cimetidine (Tagamet), ranitidine (Zantac), digoxin, furosemide, and triamterene.
Acarbose (Precose) - Acarbose is classified as an alpha-glucosidase inhibitor. Acarbose delays carbohydrate metabolism by inhibiting enzymes in the small intestines which are responsible for the digestion of carbohydrates. Acarbose does not cause hypoglycemia by itself. But when it is used in combination with a sulfonylureas, the hypoglycemia that can occur cannot be treated by fruit juices or any other complex carbohydrates as the acarbose delays the absorption of the complex carbohydrate.
If a patient taking acarbose-sulfonylureas drug therapy demonstrates signs and symptoms of hypoglycemia, dental professionals should be prepared to provide glucose tablets, liquid, or glucagon injections to treat the hypoglycemia.
The ADA has issued a consensus statement reviewing the use of combination therapy for Type II diabetes. It indicates that nonpharmacologic therapy that does not achieve glycemic goals should then call for monotherapy in the order of a sulfonylurea, a biguanide, an alpha-glucosidase inhibitor, or insulin. If monotherapy does not achieve goals, combination therapy should follow with a sulfonylurea plus one of the following: biguanide, insulin, or alphaglucosidase inhibitor. Combinations of three drugs or combinations of alpha-glucosidase inhibitor plus insulin are infrequently used and/or are less well studied, according to the ADA.
Troglitazone (Rezulin) - Troglitazone enhances glycemic control to reduce insulin levels and also improves dyslipidemia and hypertension associated with insulin resistance. It is used in patients with Type II diabetes on insulin whose hyperglycemia is not adequately controlled.
In addition to recognizing signs and symptoms of diabetes, dental professionals should be aware of possible dental drug interactions with antidiabetic agents and the prevention and management of medical emergencies associated with diabetes. Basic life support, including supplemental oxygen is always indicated for the diabetic patient in emergency distress.
Insulin has no place in a medical emergency drug kit. If there is confusion as to whether a patient is experiencing hypoglycemia or hyperglycemia, always give carbohydrate - never give insulin. Additional carbohydrate given to a hyperglycemic patient is not going to cause severe changes to the patient`s immediate condition. However, giving insulin to a hypoglycemic patient could be catastrophic. A hypoglycemic patient who has been given carbohydrate will improve rapidly. The hyperglycemic patient who has been given carbohydrate will not demonstrate improvement or noticeable worsening.
Emergency-trained dental professionals may choose to differentiate hypoglycemia from hyperglycemia by performing blood glucose tests with commercial test kits.
To the Dr. Sharp professionals who go above and beyond the call of duty in patient assessment and care, thank you for elevating the reputation of all dental health professions. You have shown us that treating the whole patient - and not just their oral conditions - can keep us filled with sense of purpose and eagerness to practice with extraordinary dedication to our patients.
References
- American Diabetes Association. Consensus statement. The pharmacological treatment of hyperglycemia in NIDDM. Diabetes Care 1995;18:1510-8.
- Baliga BA, Fonseca VA. Recent advances in the treatment of type II diabetes mellitus. American Family Physician 1997; 55: 817-824.
- Chaisson JL, Josse RG, Hunt JA, Palmason C, Rodger NW, Ross SA, et al. The efficacy of acarbose in the treatment of patients with non-insulin-dependent diabetes mellitus: a multicenter controlled clinical trial. Ann Intern Med 1994;121:928-35.
- Crofford OB. Metformin (Editorial). N Engl J Med 1995;333-588-9.
- Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-86.
- Iwamoto Y, Kosaka K, Kuzuya T, Akanuma Y, Shigeta Y, Kaneko T. Effects of troglitazone. A new hypoglycemic agent in patients with NIDDM poorly controlled by diet therapy. Diabetes Care 1996;19:151-6.
- Krentz AJ, Ferner RE, Bailey CJ. Comparative tolerability profiles of oral antidiabetic agents. Drug Saf 1994;11:223-41.
- Nathan D, Dinsmoor R. Novel drugs for type II diabetes. Harvard Health Letter, April 1996:4-6.
- Turner R, Cull C, Holman R. United Kingdom Prospective Diabetes Study 17: a 9-year update of a randomized, controlled trial on the effect of improved metabolic control on complications in non-insulin-dependent diabetes mellitus. Ann Intern Med 1996;124(1Pt 2):136-45.
Cynthia R. Biron, RDH, is chair of the dental hygiene program at the Tallahassee Community College. She is also a certified emergency medical technician.
Diabetes Associated Emergencies
(without differential diagnosis):
Provide basic life support - summon emergency medical assistance.
V
Administer oral carbohydrate only to conscious patients.
V
Unconscious patients may be given glucagon injections
V
Always administer supplemental oxygen
V
Monitor vital signs
