Hypoglycemia is a common emergency that occurs during the dental treatment of patients who have diabetes. Dentists are trained to recognize and treat hypoglycemia; its common warning signs are confusion, agitation, tremors, tachycardia, diaphoresis, dizziness, unconsciousness and, if treated improperly, death.¹ The best treatment for hypoglycemia is prevention.^2,3

Advances in biomedical technology now give people who have diabetes improved control over their daily lives. As new forms of insulin, methods of insulin delivery and monitoring of blood glucose have become available, people who have diabetes are able to maintain their blood-glucose levels at more satisfactory and safer levels.

Because of the ongoing biodigital revolution and the importance of continuing to deliver quality oral health care to patients, we present a discussion and update of the basic medical sciences as they relate to diabetes, as well as their integration into clinical dentistry.

	STRESS AND THE PHYSIOLOGY OF HYPOGLYCEMIA

TOP ABSTRACT STRESS AND THE PHYSIOLOGY... DENTAL APPOINTMENTS AND THE... TECHNOLOGICAL ADVANCES IN CARE... CONCLUSION REFERENCES

 
"Stress," "anxiety" and "fear" are words that many patients associate with visits to their dentists. A common and important misconception of dentists is that the acute stress of a dental visit in an anxious patient who has diabetes causes hypoglycemia.⁴

Instead, the major glycemic effect of stress is an increase in blood-glucose levels, which causes the release of catecholamines, primarily epinephrine, into the bloodstream.⁵ Different types of stress—including anxiety, fear, exercise, pain and trauma, as well as hypoxia, hypothermia, hypotension and hypoglycemia—stimulate this release. Acute stress, such as that occurring during a dental visit, stimulates the sympathetic splanchnic nerves that induce the release of large amounts of catecholamines (primarily epinephrine) from the adrenal medulla. This sympathetic-adrenergic system prepares the body for "flight or fight," the acute stress reactions.⁶ In people who do not have diabetes, the alpha and beta cells, in turn, exert negative feedback on each other to maintain normal blood sugar levels and to prevent hypoglycemia.

Clinicians can prevent hypoglycemic attacks from occurring in the dental office by talking with patients who have type 1 diabetes mellitus about their insulin intake before dental appointments.

In all people, a stress-induced catecholamine increase prepares the body for "fight or flight," inducing the release of glucose by stimulating glycogenolysis, increasing lipolysis and inhibiting peripheral glucose uptake. In patients who have IDDM, however, no insulin is produced by the beta cells of the pancreas. Since insulin is not available in these patients to antagonize the alpha cell’s release of glucagon, the alpha cells are down-regulated owing to the islet cells’ paracrine action and, therefore, produce less glucagon.⁷

Catecholamine release due to stress, thus, becomes a major counter-regulatory mechanism to the exogenous insulin taken by the patient who has diabetes. It can be seen, then, that the release of catecholamines in a stressed patient who has diabetes causes blood sugar levels to increase.^8,9

Patients who have type 1 diabetes mellitus develop hypoglycemia during stressful dental visits for the same reason that it develops at any time—because there is an excess amount of exogenous insulin relative to blood glucose.² Excess insulin stimulates glycogenesis and simultaneously stops the production of new glucose, which results in a decrease in blood glucose even in the presence of catecholamines.⁶ A patient who has diabetes, therefore, first will have an increase in blood sugar levels, caused by the influences of stress-induced catecholamine release. This is followed by a steep drop in blood-glucose levels, precipitated by excess exogenous insulin.

	DENTAL APPOINTMENTS AND THE DAWN PHENOMENON

TOP ABSTRACT STRESS AND THE PHYSIOLOGY... DENTAL APPOINTMENTS AND THE... TECHNOLOGICAL ADVANCES IN CARE... CONCLUSION REFERENCES

 
Clinicians can prevent hypoglycemic attacks from occurring in the dental office by talking with patients who have type 1 diabetes mellitus about their insulin intake before dental appointments.

Clinicians usually schedule patients who have diabetes for morning appointments and instruct them to eat their usual breakfasts and take their insulin.^4,10 These instructions, however, do not apply to all patients who have IDDM. People have different lifestyles, and patients who have type 1 diabetes mellitus are no exception. They tailor their meals, insulin administration, and work and exercise routines in many different ways with the guidance of their physicians and dietitians. Many patients who have diabetes and are on strict control regimens choose not to eat breakfast and are able to adjust their insulin dosages accordingly and successfully. There are variations in the types of insulin a patient may administer, including onset, peak time and duration of action. Insulin administration methods also vary from subcutaneous insulin injections to the increasing use of insulin pumps.¹¹ To instruct every patient who has type 1 diabetes mellitus to eat a meal and administer insulin before morning dental appointments does not conform to current technology. Clinicians need to have a solid understanding of the basic medical sciences as they apply to diabetes mellitus so they can advise a patient properly regarding special preparations before a dental appointment.

The hyperglycemic reaction known as the "dawn phenomenon" is the physiological basis for scheduling a morning dental appointment for patients who have type 1 diabetes mellitus. The dawn phenomenon is morning hyperglycemia without an antecedent hypoglycemia. It is an event exclusive to patients who have type 1 diabetes mellitus and usually occurs between 5 a.m. and 9 a.m. It is caused by the rise of nocturnal growth hormone secretion with the subsequent stimulation of gluconeogenesis by the liver.¹² Therefore, on waking, patients who have type 1 diabetes mellitus have relative hypoinsulinemia with expected increases in blood glucose. Significant early morning blood-glucose elevations generally occur owing to a combination of the dawn phenomenon and normally high morning levels of endogenous cortisol. These dawn elevations may be treated with combinations of insulin or by adjusting the basal rates and times of an insulin pump. The dawn phenomenon is a major physiological rationale behind scheduling patients who have IDDM for morning appointments. The principle that cannot be stressed enough, however, is that having patients who have type 1 diabetes mellitus follow their "normal routines" is essential in the prevention of hypoglycemia.

	TECHNOLOGICAL ADVANCES IN CARE OF PEOPLE WHO HAVE DIABETES

TOP ABSTRACT STRESS AND THE PHYSIOLOGY... DENTAL APPOINTMENTS AND THE... TECHNOLOGICAL ADVANCES IN CARE... CONCLUSION REFERENCES

 
Little has been written in the dental literature about the treatment of patients who have IDDM and use insulin infusion pump therapy. The insulin pump is a beeper-sized device that delivers insulin to the patient through an indwelling subcutaneous catheter (Figure 1 and Figure 2). The catheter is changed three to four times each week and is inserted with the help of a penlike insertion device (Figure 3). The Diabetes Control and Complications Trial, or DCCT, of 1993 proved that intensive therapy (insulin infusion pump therapy or three to four insulin injections daily) showed significant reductions in the long-term complications of diabetes mellitus, including retinopathy, nephropathy and neuropathy.⁹

View larger version (102K): [in this window] [in a new window]   Figure 1. A typical insulin pump is a beeper-sized device usually worn at the patient’s belt line. The buttons that control the action of the pump can be seen clearly and are accessed easily by the patient.

View larger version (104K): [in this window] [in a new window]   Figure 2. A catheter delivers the insulin from the infusion pump into the patient.

View larger version (105K): [in this window] [in a new window]   Figure 3. Insertion of the indwelling catheter is accomplished using a penlike injecting device.

There are 1 million people who have type 1 diabetes mellitus in the United States, and approximately 200,000 of them use insulin pumps (Oral communication, Ray Hoese, director of marketing communications, Medtronic MiniMed, Northridge, Calif., March 2002). Practitioners need to be familiar with the way the insulin pumps work and understand their advantages and disadvantages (Box). They also must be aware of the increased incidences of hypoglycemia caused by intensive therapy and know how to treat hypoglycemic patients who have diabetes. The emergency treatment of patients using different insulin delivery systems requires constant updating.

Dental practitioners need to be familiar with insulin pump therapy to deal effectively with complications that may arise in their patients who have IDDM and who use the pump. One of the major risks of infusion pump therapy is the development of hyperglycemia caused by pump failure or a kink in the infusion line. Although current pumps have built-in alarms to safeguard against kinks in the lines, cases of ketoacidosis have occurred relatively quickly in pump users because the pump is the sole source of insulin.¹⁴ Practitioners need to know the signs and symptoms of hyperglycemia and how to treat it. Practitioners must be certain that their patients who have diabetes bring their glucometers with them to every appointment and take their blood-glucose level readings before dental treatment or more frequently if indicated. Cases of severe hypoglycemia also have been reported with pump users, especially when patients first switch to pump therapy. This is due to the fact that insulin is being infused constantly at a preprogrammed rate. If the patient has not eaten enough or if the basal rate of insulin is set too high, the patient will become hypoglycemic rapidly.

If office emergencies arise that involve patients who have diabetes and are receiving infusion pump therapy, the clinician needs to quickly determine the nature of the emergency (that is, hypoglycemia vs. hyperglycemia). Since the majority of these emergencies will be cases of hypoglycemia, the clinician or patient should always place the insulin pump on "suspend" mode immediately. This will prevent more insulin from being pumped into the patient. A quick blood-glucose level check with the patient’s glucometer then can be performed to verify the diagnosis. The dentist or patient then needs to check the pump’s function after glucose levels return to normal. In instances of an unconscious patient who has hypoglycemia, the dentist must immediately suspend the flow of insulin into the patient and quickly administer glucagon subcutaneously (a solution of intravenous 50 percent dextrose also is acceptable if an intravenous line is already in place). A properly equipped in-office emergency kit should include a disposable glucagon injection set for unconscious patients who have diabetes.²

	CONCLUSION

TOP ABSTRACT STRESS AND THE PHYSIOLOGY... DENTAL APPOINTMENTS AND THE... TECHNOLOGICAL ADVANCES IN CARE... CONCLUSION REFERENCES

 
Dental practitioners treating patients who have IDDM need to have a solid foundation in both the basic medical sciences and emerging biomedical technology as they relate to diabetes mellitus. This will enable practitioners to provide quality oral health care in a safe and monitored environment. Both medical and dental treatment must be customized for the needs of each patient who has diabetes.

As more patients who have type 1 diabetes mellitus will be using intensive therapy and insulin pump infusion, dentists also need to familiarize themselves with insulin infusion pump therapy and its advantages and disadvantages. Clinicians may find themselves encountering unfamiliar medical emergencies caused by the use of infusion pumps. It is essential that practitioners remain current regarding the basic medical science and biomedical technology of diabetes care. Patients and the profession demand it.