Transcribed by Leslie Afable 5/2/14

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Organ Systems Lecture 47 CCP VI: Diabetes by Dr. Marilyn J. Hammer

Slide 1 Diabetes
Dr. Hammer ...At the NYU College of Nursing I do research looking at associations
between blood glucose and immune function in patients with cancer, which I think
the blood glucose part is why I am sometimes asked to come give a talk on diabetes.
So we have a little bit of a technical glitch that on the slides the headings dont come
out but you have them so you dont have to worry about that.

Slide 2 Diabetes Statistics
Dr. Hammer So I always start off with a little bit of a statistics with diabetes.
Worldwide the prevalence is 347 million, so this is why its important to you as
dentists, you are going to be seeing a lot of patients, not just for their oral care but
they are going to come in with diabetes and have a lot of issues surrounding that. If
we look at the US alone, there are over 25 close to 26 million people with diabetes.
Its over 8% of the population at large. Most of them are diagnosed but we know
that there are at least 7 million people currently either with pre-diabetes or just
fully un-diagnosed. And if we look at age groups 20 years and older, its over 11%
of the population. Here is the breakdown by gender and then between Non-Hispanic
Whites and Blacks. You can see when we get into the older age range, over 65 years
old, really high percent almost 27% of that population, and thats a population that
is growing tremendously.

Slide 3 Diabetes Statistics
Dr. Hammer If we look at this just graphically, this is the same as from the slide
before just seeing the differences by age group. These stats are a little bit old, they
are still the most current posted on the NIH website. We have a little bit more
current information when we look at the incidence rates by age group. So this is
prevalence and this is incidence and the annual incidence rate is highest in this
age group from 45-64, but then people continue to live with the diabetes so theres
a very, very high prevalence rate with the older age group.

Slide 4 Diabetes Stats: Children
Dr. Hammer When we looked at it with children, its predominantly type 1
diabetes but then as kids get older we have a lot of childhood obesity and were
getting a lot more younger age groups showing signs of type 2 diabetes. Well talk a
little bit shortly about the difference between type 1 and type 2. So this is broken
down by ethnic group, this is all, Non-Hispanic White, Non-Hispanic Black, Hispanic,
Asian Pacific Islander, and American Indian.

Slide 5 Prevalence (Diagnosed) By Ethnic Group > 20 Years Old
Dr. Hammer If we look a little bit more closely at the prevalence of just those
diagnosed 20 years and older, we see a very high prevalence in American Indian
and Alaskan natives. Particularly among a group who live in Southern Arizona,
more than of their population. Then you can see the further breakdown of the
other groups.
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Slide 6 Diabetes by World Region
Dr. Hammer When we look at these stats worldwide, it gets pretty astounding. If
we compare rates from 2000 to whats projected to be in 2030, theyre going to
double. So worldwide is just tremendous. Then we can look at it by region. Here we
are in North America, they combine the Americas, really high rates, right now a little
bit smaller than the European region but were going to completely exceed the rates
in Europe by the year 2030.

Slide 7 More Worldwide Stats
Dr. Hammer So a little bit more on some worldwide stats, every 10 seconds 3
people develop diabetes. There are 4 and a half million deaths each year. It costs
approximately $465 billion US dollars annually. At least half of all people are
unaware of their condition. People with type 2 diabetes will die approximately 5-10
years before people without diabetes and its mostly due to the association with
cardiovascular disease.

Slide 8 Diabetes Facts
Dr. Hammer Among adults, diabetes is the leading cause of kidney failure, non-
traumatic lower-limb amputations, new cases of blindness. And again that major
risk for heart disease, stroke, the 7
th
leading cause of death in the US.

Slide 9 Dental Disease with Diabetes
Dr. Hammer With glycosylated hemoglobin A1C of greater than 9%. So A1C, Im
sure you know this already, but its the average of blood sugar over about a 2-3
month period. When it reaches a level of 9% of greater, theres almost a 3 fold
increased risk of periodontal disease. For those with diabetes who also smoke,
almost a 5 fold increased risk for periodontal disease. And of individuals with
diabetes have severe periodontal disease. So if you go into.. As a specialist with.. As a
periodontist, youre going to have a very, very busy practice just because of the high
prevalence of people with diabetes.

Slide 10 Glucose Pathway
Dr. Hammer So lets just take a moment to look at normal blood sugar control. This
is an over-simplified graphic, but just as a reminder, I know that youve had diabetes
in some other lectures so hopefully some of this is an overview for you. You start off
with normal blood sugar level, you eat a meal with high/a lot of sugar or just right
after eating any meal, you get higher levels of blood sugar. This triggers the
pancreas, the beta cells in the islets of langerhan, sorry its cut off up here, but it
releases INSULIN. Insulin then acts on both the liver, converting glucose to glycogen
and proteins it stores it here and it also goes into muscle, which we cant see up
here. The muscle tissue utilizes it or it will also convert it for storage and that will
bring your blood glucose levels down back to normal. If you go a long period of time
without eating, you can have low blood glucose levels. The alpha cells now release
glucagon into the blood and thats going to convert the stored glycogen into glucose
that will raise your blood sugar levels up and youll be back to the homeostatic level.
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Slide 11 GLUT & Insulin Receptors
Dr. Hammer It takes a number of receptors on a cellular level for this to work. Both
insulin and these glucose transporters or GLUT receptors. So you need insulin to act
on an insulin receptor, which then does 2 things. It helps to INCREASE THE
EXPRESSION of these glut receptors on the cell surface and also has the glut
receptors then open in response to receive the glucose to bring the glucose into
the cell. Insulin also promotes glycogen synthesis, glycolysis and promotes fatty acid
synthesis.

Slide 12 GLUT4 & Insulin Receptors
Dr. Hammer Now this is a more fuller picture of what it looks like. The glut
receptors dont always have to be right next to the insulin receptors, sometimes
they are far apart on the membrane and you can see the complex pathways. In this
case, this is a muscle cell its a glut 4 receptor, of all of the different reactions that
take place with the insulin and glucose in combination to activate for energy
utilization in the cell. So memorize this for your quiz.. Im kidding sorry!

Slide 13 Glut & Insulin Receptors (Table)
Dr. Hammer And here are all the.. A list of just many different tissues and the
different glut receptors that live on them just for information for you.

Slide 14 Diabetes Pathway
Dr. Hammer So the diabetes pathway. At least this first box came out. So what
happens is with diabetes there is a decrease in insulin or there can be insulin in the
system but increased resistance for the cell to be able to utilize the insulin. The
tissue then does not uptake the glucose as it should so you get an INTRA-cellular
HYPOglycemia and an EXTRA-cellular HYPERglycemia. Intracellularly it then
triggers gluconeogenesis, glucogenesis. So just the formation of more glucose
because the cell is now hungry for glucose even though its floating around in the
blood. It will cause a breakdown of fats, increased ketones, can lead to diabetic
ketoacidosis. You are also then going to get to a state of decreased protein synthesis.
It can lead to cachexia, and all of these other symptoms here like increased risk for
infection. On the extracellular side, you get to a state of hyper-osmotic plasma
because there are more particles now outside of the cell so thats going to cause
cellular dehydration and eventually lead to a hyperglycemic coma. Also the blood
glucose level is going to exceed the renal threshold so this is where you get the
glucosuria where you get the high concentration of sugar in the urine. This leads to
osmotic diuresis and then you get these symptoms the polyuria, polydipsia, you get
low Ca and Na.. No excuse me low potassium and sodium.. Hypokalemia and
hyponatremia.

Slide 15 Normal Blood Glucose Levels
Dr. Hammer So normally our fasting blood glucose levels are around 80-100
mg/dL. If you take just any random blood sugar level, it should be somewhere
between 70-126 but when you do it fasting for at least 8 hours, it should be lower
around 80-100. If you look at blood sugar just following eating something, it should
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be less than 140 and the hemoglobin A1C levels should be less than 6.5 but even
this number is a little bit high. So what is hemoglobin A1c compared to just a
standard random blood sugar level? Heres a chart put out by the American Diabetes
Association. So around the level A1C of 6, thats 126 which really should be the
upper limit so you can see here at 6.5 youre actually in a little bit of a hyperglycemic
state.

Slide 16 Diabetes Classifications
Dr. Hammer There are many classifications, so type 1 diabetes is IMMUNE
MEDIATED. Its destruction of the beta cells so it usually leads to ABSOLUTE
INSULIN DEFICIENCY. People with type I diabetes cannot produce insulin usually at
all. In type 2, its a progressive defect in the ability for the pancreas to secrete
insulin or its just decreasing the ability for the cells to utilize insulin, insulin
resistance. And there are a number of other types of classifications. Genetic defects
of the beta cells, you have defects in the insulin action, you have some diseases like
cystic fibrosis which can cause a diabetic state. Other endocrinopathies, can be drug
induced or from infections. Then we have GESTATIONAL DIABETES, this is
diagnosed during pregnancy and its not really overt diabetes and it usually goes
away from the patient after the baby is born but it still puts the women at risk for
type 2 diabetes later on.

Slide 17 Type 1 Diabetes
Dr. Hammer So lets take a look at type 1. Normally it occurs at a young age, you
can also have it diagnosed later in life. Its the most frequent chronic disease in kids.
It is an auto-immune disorder and a destruction of the beta cells. The destruction
rate is variable. There are some genetic predispositions that they have found linked
to this and also some linkages to human leukocyte antigens. They also think there
are a number of environmental factors involved probably a viral infection that might
contribute to the destruction of these cells.

Slide 18 Type 1 Diabetes (Figure)
Dr. Hammer So looking at it from a picture point of view, if you see this is a normal
cross section of pancreatic tissue. The blue cells being the beta cells here and you
can see them releasing insulin into the blood stream. Here these cells are not
functioning, they are dead and you see nothing going into the bloodstream.

Slide 19 Type 1 Diabetes
Dr. Hammer So a little bit closer up view of a cell. If you have diminished insulin,
its not getting to the receptors. The receptors arent then able to trigger the glucose
receptors to either form on the cell surface or be open to allow the glucose to come
in. So again, the pathway.. the pancreas is not producing insulin so you have too
much blood sugar that is still hanging out in the blood and then its not getting into
the cells and you get the protein breakdown trying to get the cells ..some energy so
that can lead to the ketoacidosis.

Slide 20 Type 1 Diabetes
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Dr. Hammer And just another picture starting from the digestion of food, getting
the sugar into the blood in the first place and then not being able to have it utilized
properly.

Slide 21 Type 1 Diabetes: Plasma Blood Glucose & A1C Goals for Type 1 Diabetes
by Age Group
So different goals for type 1 diabetes, because it predominantly occurs in kids and
depending on the age of the child theres going to be a different body surface area.
So there are different guidelines in terms of what is expected and what your goals
are for a kid with type 1 diabetes. The other thing that I dont have on this slide is
often with type I diabetes, many kids also end up with CELIAC DISEASE.

Slide 22 Type 2 Diabetes
Dr. Hammer So looking at type 2 diabetes, this is the majority of individuals with
diabetes. Its a much stronger genetic composition so you would think that type 1
diabetes would be more genetic because its a destruction of actual cells. But
actually they found more genes that are associated with type 2 diabetes and more
cases with type 1 where its just denovo, its just this onset where they dont see as
many patterns in families, they dont have a specific gene related to it. Although
there are some genes, and in type 2 diabetes you can see this fuller family history
along with a number of genes that they are finding more and more each day
associated with it. It can remain undiagnosed for years, its a much shorter/slower
onset. A lot of the abnormalities, the peripheral resistance to insulin, impaired
pancreatic secretion and increased glucose production in the liver because of it. The
pancreas may continue to produce insulin. A major risk factor is OBESITY. So
recommend lifestyle changes and then sometimes start patients on oral anti-
hyperglycemic agents and they may eventually need to take insulin, sometimes just
start them off early on with insulin. Ketoacidosis is more common in type 1 than
type 2 except in stressful situations people with type 2 can certainly get it.

Slide 23 Hyperglycemia & Oxidative Stress
Dr. Hammer There is an association with OXIDATIVE STRESS and IMPAIRMENT
OF THE IMMUNE SYSTEM. So if we look at this cross section of just a graphic of a
cell and particularly the mitochondria, this is a cross section of the mitochondria.
Normally a molecule of glucose goes to the tricarboxylic acid cycle, creates ATP, you
get some oxygen kicked off that then connects with nearby hydrogen. It just makes
some water molecules and thats our normal system. If there is too much glucose,
superoxide is formed. This is broken down by the enzyme, SUPEROXIDE
DISMUTASE, but that creates hydrogen peroxide. Now this is broken down and just
becomes water and oxygen which seems fine. But the process of this breakdown
causes an overabundance of reactive oxygen species or oxidative stress and this
impairs cells signaling and particularly on immune cells it then will impair the
ability for the immune cell to detect a foreign microorganism and take care of it. Or
it can stop the detection of an abnormally forming cell. But if you think about it in
terms of infection, its why people with diabetes have such high rates of infection,
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poor wound healing because it is this pathway thats now impairing their immune
function.

Slide 24 Diagnosing Type 2 Diabetes
Dr. Hammer So how do we diagnose type 2 diabetes? So these are ADA criteria.
A1C greater than 6.5, fasting plasma glucose (FPG) above 126 or if you do an oral
glucose tolerance test the blood sugar gets above 200. Or someone can be
symptomatic with a random plasma glucose (PG) over 200. They all have these
asterisks in the absence of unequivocal hyperglycemia. So if this is unclear then you
want to confirm with a RE-TEST.

Slide 25 Oral Glucose Tolerance
Dr. Hammer Sugar on forward and you get this purple line here, a bit of a bump up
over an hour of time. It will peak and then insulin will come in and take care of it, it
will decrease it. Actually, it will go for a short period below the norm and then come
back up to a nice normal level. If someone has impaired glucose tolerance, it starts
off when you ingest the glucose at a bit of a higher level. It will follow pretty much
the same pattern though but just stay at a higher level. With diabetes what happens
is you start off at a much higher level. It increases and then it has trouble, it doesnt
really regulate back because you dont have that insulin to take care of it. There are a
couple of diseases where you have very odd findings off of this chart here so
something like MYXOEDEMA leaves you with an overall LOW level of blood sugar
no matter how much you take in. Then with HYPERTHYROIDISM, you get this
IMMEDIATE spike and this huge dip and then it comes back to regulate. So different
conditions can cause different reactions with the glucose tolerance test.

Slide 26 Comparisons Between Type 1 & 2
Dr. Hammer So comparison between type 1 and type 2. So generally type 1 is a
younger group. Onset is mostly diagnosed under the age of 30. Normally a more thin
or normal stature, more common among white people. Type 2 is generally later
onset but again with childhood obesity its becoming younger and younger. Anyone
with obesity is at risk. A number of ethnic groups are more susceptible. The onset is
going to be ABRUPT with type 1 and SLOWER type 2. Its with type 1,
autoimmune beta cell destruction. With type 2 you have the insulin resistance,
impaired secretion, increased production. Very importantly, so type 1 you have little
or predominantly NO production of insulin but in type 2 diabetes it can be
decreased, it can be normal, it can even be elevated. So you can read in the literature
that people with type 2 diabetes having hyper-insulinemia because the pancreas can
still be functioning but you might just have a high level of insulin resistance. So with
the extra sugar, the pancreas can be trying to get a lot of insulin out. So you can see
any of these levels with type 2 diabetes whereas type 1 you see little to no
production. So thats a key difference. Higher susceptibility to ketoacidosis with type
1 and then with type 1 you have to take insulin and also the diet and exercise. For
type 2, again diet and exercise. You might have to take insulin and if you cant
control it with diet and exercise youll probably have to take oral agents.

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Slide 27 Gestational Diabetes
So just a word on the gestational diabetes, to screen for it you can perform the
glucose tolerance test and the patients fasting blood sugar is above 92 mg/dL and
in an hour it bumps up to 180 and then in 2 hours 153. Thats probably someone
that will have gestational diabetes.

Slide 28 Prediabetes
Dr. Hammer So theres a prediabetes phase. So this is above normal but not quite
at the diagnosis of diabetes yet. The impaired fasting blood glucose will be around
100-125 or with a 2 hour glucose tolerance test it will get up to the 140-199 range.
Above 200 it would be the diagnosis for diabetes. So this is a group that is high at
risk for developing diabetes and if you catch someone at this range, you can get
them to do some drastic lifestyle changes, you can get them back down to normal
and not hit the level of diabetes. Just a note that the World Health Organization
criteria calls this upper limit at 110 mg/dL. So these criteria are from the
American Diabetes Association. You will see differences among different
organizations out there in terms of the guidelines.

Slide 29 Signs & Symptoms of Diabetes
Dr. Hammer So the classic signs and symptoms. The polyphagia, polydypsia,
polyurea, blurred vision, dark rough patches of skin, dry mouth, a lot of dryness and
excessively dry skin, fatigue, unexplained loss of weight. So here is where someone
is obese and they start to lose weight and they might be very happy about that but if
its unexplained and its over kind of a short period of time, its a reason for concern.
Normally when that happens, the first thing that people start to look at is the
THYROID but with someone obese we think that it might be diabetes if theyre not
already diagnosed. You can also have like the neuropathy symptoms, the tingling or
pain in the feet or legs, wounds that aren't healing, you can have sexual dysfunction.

Slide 30 Case Study
Dr. Hammer So were going to talk about a case study kind of threaded throughout
this. JT was a patient who actually came into the clinic here I think about 5-6 years
ago. He was at that time a 48 year old African American male. He came to the College
of Dentistry for routine dental care. He was referred to the nurse practitioner clinic
by admissions after they found a blood pressure of 164/122 but he was
asymptomatic with this. He had no chest pain or discomfort or visual changes, no
shortness of breath or headache. He had no primary care provider. His past physical
exam had been in 2002 and he reported that his blood pressure was about 140/95
at the time. He had no insurance and he also reports having gained about 60 lbs of
weight over the past 6 years due to stress. Then he notes that hes been getting up a
lot in the night to urinate and hes thirsty. He says I like to drink a lot of water.

Slide 31 Prediabetes Testing Criteria
Dr. Hammer So keep JT in mind as we go through some of these other criteria. So
prediabetes testing criteria, if a patient is physically INACTIVE, if they have relatives
particularly first degree, if they fit into one of the ethnic groups, women with
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gestational diabetes or who have just delivered a baby weighing more than 90 lbs.
Hypertension, remember theres that association with cardiovascular disease, also
with high cholesterol levels and then women with polycystic ovary syndrome. So
they found that a number of women with type 2 diabetes have multiple cysts on
their ovaries and high androgen levels. So they have come up with this polycystic
ovary syndrome scenario with these symptoms and also the diabetes as well. The
high A1c levels and then there are conditions such as severe obesity and this
acanthosis nigricans, we will talk about that in a moment, and anything with
cardiovascular disease. So if someone appears to be in pretty good shape but they
are at least 45 years old, they should first be screened. If theyre fine, then you can
screen them every 3 years. If they start to have some of these risk factors then you
might want to start screening them every year.

Slide 32 Diabetes Related Complications
Dr. Hammer So complications. Microvascular the retinopathies, nephropathies,
and all the neuropathies. Macro-vascular with the coronary heart disease and
cerebrovascular peripheral arterial disease. And then psychosocial problems and
then there is your category, dental disease, highly associated with diabetes.

Slide 33 Dermal Manifestations
Dr. Hammer So the acanthosis nigricans, you get these dark patches on the skin.
Sometimes the neck or under the arms. They think that its either some trigger from
insulin or an insulin-like growth factor that is triggering these keratinocytes to
produce these marks on the skin. But its a classic sign with someone with diabetes.
Not all people with diabetes have it but people that you see this on you would
suspect that they would have diabetes.

Slide 34 Case Study: JT
Dr. Hammer So lets get back to JT. He has hypertension and a sedentary lifestyle.
They did a urine glucose test and they found that theres a lot of sugar in his urine.
They then did a random blood sugar test and found it to be 372 mg/dL. His A1C was
9.2. They repeated the sugar and it was down to 138 but its still high. Importantly,
his BMI is body mass index is 29 which is in the category of MORBIDLY OBESE.

Slide 35 Body Mass Index & Diabetes
Dr. Hammer So what is obesity have to do? Here are some stats on risk factors. So
at a category of 25 to 29.9, overweight. Here are the risks for males and females for
having diabetes, its up to 30% in males and 35% in females. When you hit this
obese range, 30-34.9, it goes up substantially and then when you get above 35,
morbidly obese, its like our patient JT it really gets up there, the risk for diabetes.

Slide 36 Risk of Heart Disease
Dr. Hammer Then the association with the risk for heart disease. So having just one
risk factor can actually double the chance of heart disease and theres a synergistic
effect between the hypertension, the dyslipidemia, and glucose intolerance.
Remember JT has these multiple risk factors.
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Slide 37 JTs Risk Factors
Dr. Hammer So he has some NON-modifiable risk factors: his age, his gender, his
family history and his race. But he does also have a number of modifiable: the
psychosocial issues, he can work on the stress, and then his lifestyle behaviors,
nutrition and exercise are modifiable.

Slide 38 Treatment Algorithm for T2D
Dr. Hammer So this is a treatment algorithm for type 2 diabetes. Were not going to
go through this point by point but just to show that when its diagnosed you always
start with lifestyle interventions and then you can follow this algorithm
depending on what their A1C level is and are they responding to different meds. You
can just go through the pathway.

Slide 39 Pharmacology Options for T2D
Dr. Hammer So the pharmacological options for this, we have the oral agents and
insulin at both basal and bolus levels. Just as an example here, BIGUANIDE is a
metformin, a very popular oral agent. What it does is that it decreases the hepatic
glucose output so that will decrease the blood sugar level. It is pretty potent. You
can expect a decrease in the A1C level by at least 2 percent but there are side effects,
particularly GI and you can get lactic acidosis. So with someone with a new onset,
they will usually get a little bit of initiation of insulin therapy and then be put on one
of these or more of the agents either a higher dose for a bolus level and then
regulate down to a basal level.

Slide 40 Insulin
Dr. Hammer I just have a few slides on different types of insulin just so that youre
familiar with them. The different levels of rapid, short acting, intermediate acting
and long acting. So this shows you the speed of onset of when they take it, how long
after. So if someone is about to eat a meal, you want to know when to take the
insulin so that it would effect and keep their blood sugar normal, when it peaks and
how long it will last for.


Slide 41 Pre-Mixed Insulin
There is also pre-mixed insulins which is a combination of short acting and
intermediate acting.

Slide 42 Oral Agents
Dr. Hammer Then many different oral agents, so I have just a couple of tables here.
This is just for your information. All of the different classes and the agents that are
part of those classes, how they work, and then some comments on them. Mostly they
talk about side effects here. Some of the new ones like the bile acid sequestrants, so
theyre not exactly sure how it works in terms of controlling blood sugar but the
positive side is that it decreases the LDLs and may complement a statin if the patient
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is on it. But look at this huge list of side effects. Possible contraindications or things
to look out for.

Slide 43 Other Agents
Dr. Hammer Here are a few more agents. There are newer ones every day.

Slide 44 Goals for Decreased CVD Risk with T2D
Dr. Hammer So the goals to decrease the cardiovascular risk, you want to get the
A1C below 7 and blood pressure down to 13-140/80. Controlling the cholesterol,
for the smokers its really essential for them to quit smoking, increase physical
activity, and make healthy food choices, and then of course you always want to send
them to a healthcare facility with both a dental provider and a primary healthcare
provider.

Slide 45 Preventing Complications in Patients with T2D
Dr. Hammer So preventing complications, again trying to get that glucose below a
level of 7 for the A1C, controlling their blood pressure, lipids, and all this preventive
care: eyes, kidneys, feet, teeth and gums are really essential.

Slide 46 Diabetes & Periodontal Disease
Dr. Hammer So diabetes and periodontal disease. They looked at people from the
Nhanes data, 3,000 individuals without diabetes and they found that among those
with periodontal disease, so now looking at it from the other direction, 93% with
periodontal disease were at risk for diabetes compared to 63% who did not have
periodontal disease.

Slide 47 Diabetes & Periodontal Disease
Dr. Hammer So also through the Nhanes looking at this they came up with some
guidelines for screening, this 45 years of age with the high BMI or under 45 but a
high BMI with at least one additional risk factor. They did find that those at risk with
periodontal disease, that only a little bit more than had seen a dentist in the past
6 months, half in the past year, and over 60% in the past 2 years. So you need to get
them to see you more frequently.

Slide 48 Diabetes & Periodontal Disease
Dr. Hammer So there is this relationship with periodontal disease is a risk for
diabetes and diabetes is a risk for periodontal disease. So just be aware of that.

Slide 49 Oral Neuropathies
Dr. Hammer There are oral neuropathies so there arent any specific oral lesions
associated with diabetes but a number of concerns or things you might see in
patients with diabetes like burning mouth syndrome or burning tongue, TMJ issues,
depapillation and fissuring of the tongue.

Slide 50 Oral Complications
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Problems with the salivary glands, xerostomia. They dont exactly know why.
Tenderness, pain, burning, they have secondary enlargement of parotid glands, and
then a lot of dental caries. So this one makes more sense, the increased dental
caries because the bacteria love sugar, right? So the oral cavity without uncontrolled
sugar might have a lot of areas of high sugar and it can lead to these dental
problems.

Slide 51 Oral Complications
Dr. Hammer Other complications, again you have immune system breakdown so
you can have alteration of the flora, you can have candida, cheilosis.

Slide 52 Oral Complications
Dr. Hammer Cracking of the oral mucosa. You can have increased incidence of
enamel hypoplasia, increased tooth sensitivity.

Slide 53 Increased Risk of Infection
Dr. Hammer Again that increased risk of infection, they still say the main reasons
are unknown but I think its that pathway that I showed you earlier that leads to the
impairment of the immune system. In the oral area, in particular, macrophage
metabolism is altered and you can get a thickening of the vascular endothelium. You
can have a lot of the peripheral neuropathies and poor circulation. Someone with
immunological deficiency will be at increased risk in the oral area, high sugar
medium. You will also have a decreased production of antibodies because of that
immune dysfunction. You find more candidial infections with the xerostomia.

Slide 54 Other Oral Complications
Dr. Hammer Other complications, so delayed healing of wounds. The
microangiopathy and the utilization of protein for energy can impair the tissue
healing. You can have more cases of dry socket. Also you might find more people
with pulpitis, other neuropathy cranial nerve problems, and then different drug side
effects. You might see more oral ulcers.

Slide 55 Gingivitis
Dr. Hammer Gingivitis, high risk of developing gingivitis with diabetes. Its nearly
twice that of those without diabetes. In 2000.. Late 1990s early 2000s, they
categorized this diabetes mellitus-associated gingivitis. Now this has been re-termed
type 2 diabetes so I dont know if they have renamed this condition. But there is an
associated gingivitis thats specifically gingival disease in patients with diabetes. So
really trying to normalize their blood sugar, good glycemic control, may actually
significantly reduce the risk of gingivitis in patients with diabetes.

Slide 56 Periodontitis
Dr. Hammer Then back to the periodontitis. So you have the systemic
inflammation with insulin sensitivity. The periodontal disease can induce or
perpetuate this chronic inflammatory state so youre gonna see higher levels of C-
reactive protein, the pro-inflammatory cytokines like interleukin-6, and tumor
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necrosis factor alpha. You will see increased fibrinogen levels and you might just
have this whole systemic inflammatory response that then will further exacerbate
the insulin resistance.


Slide 57 Periodontitis & Glycemic Control
Dr. Hammer So just graphically, if someone is obese they have periodontal disease
you have these increased pro-inflammatory cytokines leading to more insulin
resistance.

Slide 58 Untitled Slide w/ Figure

Dr. Hammer This just shows it another way. All of the different contributing factors
from obesity, high glucose diet, and the different problems leading to this
inflammatory expression that then acts on the liver and eventually you get to the
diabetes, the atherosclerosis, heart disease, and stroke.

Slide 59 Glycemic Control Studies
Dr. Hammer So they did a number of glycemic control studies and they had mixed
findings. They found that treating periodontal disease MAY improve glycemic
control. Other studies found maybe not as great results. I think its probably more
the other way, if you can control the blood sugar, you might have less periodontal
disease. But again they do work both ways.

Slide 60 Treatment Strategies
Dr. Hammer The treatment strategy is to really encourage your patients to eat a
healthy diet, be physically active, control their blood sugar, of course foot care with
patients with diabetes, and adhering to their medication. This actually.. it can be
quite challenging for either cardiovascular disease/hypertension.. ..the patients
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dont like the side effects of different medications so medication adherence is
sometimes your biggest challenge. And then stress reduction.

Slide 61 Dental Management
Dr. Hammer And dental management. Medical history if the patient has diabetes
looking at their glucose levels, it can actually get more episodes of hypoglycemia
than hyperglycemia. So being cautious with the medication and dosage, consulting
when needed. And think about prediabetes. PE meaning physical exam and not
pulmonary embolism in this case. Have they had an exam in the past 12 months? Do
they have a regular healthcare provider? No, you know we always have to plug
refer them here as we refer to you.

Slide 62 Dental Management Considerations
Dr. Hammer Scheduling a visit, so somebody has diabetes you have to think about
their risk for having either hypoglycemia or hyperglycemia but particularly
hypoglycemia. So its better for them to come in in the morning trying not to
coincide with their peak activity. Make sure that theyve eaten and taken their usual
medications before working on them. Monitoring their blood sugar and then if they
have something that is going on they might need prophylactic antibiotics. Certainly
if they have an infection, if theyre going to have some kind of oral surgery or a
major surgery.

Slide 63 Dental Management Considerations: During & After Treatment
Dr. Hammer During treatment, again hypoglycemia is the most common
complication so you might see somebody in your chair with some symptoms. We
will go through those in a moment. They could also have hyperglycemia. So if they
think they are going to be in a dental chair for a while, they might eat an over
abundance of, you know, theyll come in and eat a few donuts and NOT take their
insulin just thinking that they dont want to be hypoglycemic and then they end up
with a hyperglycemic episode. So after treatment, infection control, making sure
that they do eat carefully and take their medication.

Slide 64 Periodontal Tx & Diabetes
So treating periodontal disease with diabetes, make sure that theyve taken their
insulin followed by a meal. Again with the morning appointments you want to
monitor their vital signs and their blood sugar if you can. Just think about whats
going to happen after them, if they cant eat for several hours after whatever work
you do on them, how that might affect their blood sugar, what they might be able to
ingest if they can have some kind of drink with sugar in it if they need it following.
This one, tissues should be handled atraumatically as possible, I hope you do that for
ALL patients. Then epinephrine should NOT be used in concentrations greater than
1:100,000 parts and thats because epinephrine induces gluconeogenesis. So just
by using epinephrine youre going to bump up their blood sugar. Diet
recommendations should maintain their proper glucose balance and then good oral
care at home should be stressed.

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Slide 65 Hypoglycemia S&S
Dr. Hammer So signs and symptoms of hypoglycemia. Early stage, some
diminished cerebral function, you can see someone have a mood change, hunger,
nausea, headache. When it gets more severe, they can start sweating and have
tachycardia and be a bit anxious and have some bizarre behavioral patterns. Then
later on they can actually become unconscious, have a seizure, become hypotensive
or hypothermic, can lead to coma and even death. So if you have someone with
hypoglycemia that you are working on you will start to see these early stage signs
and be able to take care of them.

Slide 66 Drugs Causing Hypoglycemia
Dr. Hammer Many drugs cause hypoglycemia. This one might surprise you, you
might think alcohol is full of sugar. It initially bumps up blood sugar and then it
causes a blood sugar drop.

Slide 67 Hyperglycemia S&S
Dr. Hammer Then hyperglycemia with increased thirst, frequent urination. So its
signs of someone at risk for diabetes. Its the same for hyperglycemia.

Slide 68 Drugs Causing Hyperglycemia
Dr. Hammer And many different drugs can also cause hyperglycemia so they are
just listed here for you.

Slide 69 Dental Implants & Diabetes
Dr. Hammer Dental implants. So years ago they said dental implants were
contraindicated in someone with diabetes. Since 1998 theyve come out with
statements saying no, its perfectly safe to put an implant in someone with diabetes.

Slide 70 Case Study: JT Today
Dr. Hammer So JT, where is he today? He is taking metformin, a statin,an aspirin,
an ACE inhibitor, and hydrochlorothiazide. Hes doing self care monitoring his blood
sugar. Hes exercising to lose weight and hes educating himself about diets and his
blood pressure is controlled. His blood sugar levels are getting better and he is
seeing good dental care for his periodontal disease here in this clinic.

Slide 71 Conclusions
Dr. Hammer So we know that its commonly encountered, a complete medical
history is really important. Be aware of hypoglycemic events and , you know,
continue our shared partnership with patients between the clinic here and your
dental clinic.

Slide 72 Questions
Dr. Hammer So a couple of minutes to spare, any questions?