Caring for patients with diabetes

by Lynne H. Slim, RDH, BSDH, MSDH
[email protected]

Mrs. Glukos enters my operatory for periodontal maintenance on a Monday morning. She is a 73-year-old-woman with early dementia and is assisted by her daughter, Lucy. She has poor chronic glycemic control, and her HbA1c is 8%. She uses a bronchodilator and steroids for chronic respiratory disease due to a lifetime of heavy smoking. She has Novolin 30/70, 26 units in the morning and 18 units in the afternoon. She has not eaten anything this morning.

My intuition is telling me that I should not proceed with my dental hygiene care plan. I am worried about a hypoglycemic event and I’m wishing my good friend, Cyndee Stegeman, EdD, RDH, RD, CDE, was here to advise me. Besides teaching dental hygiene, Cyndee is a registered dietitian and certified diabetes educator, and those credentials are not easy to come by. Certified Diabetes Educator (CDE) credentials require considerable experience, passage of a rigorous national exam, and maintaining continuing education courses. A dental hygienist has to be degreed as a registered dietitian (RD) before working toward CDE credentials. Other health professionals allowed to become CDEs include physicians, pharmacists, and nurses.

Let’s ask Cyndee for some advice on caring for my patient, and perhaps she’ll give us some additional tips on dealing with patients with diabetes.

Here’s what she had to say: Good job, Lynne, assessing the situation and being concerned about hypoglycemia before proceeding with the appointment. That is half the battle. My immediate concern for Mrs. Glukos is that she is on insulin and has not eaten anything all morning. Another question I would ask her is whether or not she is experiencing symptoms associated with hypoglycemia, such as changes in vision, hunger, shakiness, sweating, dizziness, fatigue, headache, mood swings, and trouble concentrating.

Next, determine her blood glucose level. If it is 70 mg/dl or lower, she needs to be treated with 10 to 15 grams of carbohydrates. Individuals with diabetes who take insulin or are on an oral agent in which hypoglycemia (i.e., sulfonylureas, meglitinides) is a side effect, will often carry carbohydrates in the event of an emergency such as jelly beans or raisins. If not, the office should have an emergency stash of carbohydrates such as three glucose tablets or one tube of glucose gel. Retest a patient after 15 minutes, and repeat if the blood glucose level remains under 70 mg/dl. If it is 50 mg/dl or lower, the patient should be treated with 20 to 30 grams of carbohydrates. Regardless of the blood glucose level, the patient should eat breakfast.

My next step would ideally be to reschedule the appointment. Our goal is to prevent a potential medical emergency. If the appointment proceeds, I would monitor the patient for signs and symptoms of hypoglycemia throughout the appointment. If it is a long appointment, I would stop in the middle to take her blood glucose level again and reassess the situation.

Now that we’ve gone beyond an emergency situation, let’s look at other aspects of Mrs. Glukos’ medical history. Her A1c level is 8%, which is a three-month average of 205 mg/dl. The American Diabetes Association defines uncontrolled diabetes as three consecutive readings of 200 mg/dl or above. This places her at risk for poor wound healing and at a increased risk of infection. In addition, the steroids may be a factor in the high blood glucose levels. A referral to her health-care provider is warranted.

Another important aspect for someone whose diabetes is uncontrolled is to schedule the appointment in the morning when blood glucose levels tend to be lower. A shorter appointment time is also more ideal for the patient. Stress can cause blood glucose levels to rise, so creating a calm environment is helpful.

For future appointments, I would flag Mrs. Glukos’ chart to indicate that special information should be relayed to her daughter prior to the appointment. Call her daughter the day before to remind her of her mother’s appointment, and ask her to bring her mother’s blood glucose monitoring system and have her mother eat her normal breakfast, as prescribed by her health-care provider. When Mrs. Glukos arrives for the appointment, check her blood glucose level.

Diabetes Care Considerations from Cyndee

• Not all patients with diabetes are at risk of developing dental/periodontal problems. In many cases, when blood glucose levels are controlled and they are treating their diabetes with diet, exercise and/or an oral agent that does not cause hypoglycemia, they can be treated like any other patient.
• I always obtain a blood glucose level on patients with diabetes right before I begin a procedure. Blood glucose levels are like blood pressure and body weight, and they change throughout the day. It is a snapshot of what the level is at the moment. I need to know what the blood glucose value is at that particular time. A reading obtained earlier in the day or the day before does not reflect what it might be when I begin the dental procedure.
• An A1c measures an average blood glucose level over a three-month period; therefore, it does not reflect what the glucose level is at the present moment. An A1c does not provide the exact information I need to proceed safely with treatment.

Lynne Slim, RDH, BSDH, MSDH, is an award-winning writer who has published extensively in dental/dental hygiene journals. Lynne is the CEO of Perio C Dent, a dental practice management company that specializes in the incorporation of conservative periodontal therapy into the hygiene department of dental practices. Lynne is also the owner and moderator of the periotherapist yahoo group: www.yahoogroups.com/group/periotherapist. Lynne speaks on the topic of conservative periodontal therapy and other dental hygiene-related topics. She can be reached at [email protected] or www.periocdent.com.