FOCUS | ISSUE 6 | 2010
ALLIED HEALTH Glucometer use as a “Standard of Care”
Reduced immune capacity in people with diabetes translates into compromised periodontal healing, dry mouth, increased caries susceptibility and increased risks of systemic infection
THE DENTAL TEAM by Ed Kendrick, DDS PRACTICE PEARLS
The “finger extraction”—with 2 X 2 gauze—of an extremely mobile #32 in a 65-year-old male with poorly controlled diabetes seemed so easy and quick.
Yet, his subsequent hospitalization for a life-threatening blood borne infection, and further discovery in hospital lab tests that his blood glu- cose levels were over 300, brought home a lesson about screening for blood glucose (BG) levels that I’ve known for years—but did not practice.
IN YOUR PRACTICE RULES & REGULATIONS
to climb. Since 1987, the death rate due to diabetes has increased by 45 percent, while the death rates due to cancer, heart disease and stroke have declined.
Prudence would direct that we have an understanding of our patients’ immune capacity in the context of blood glucose levels, especially because we are responsible for out- comes of healing from our interven- tions.
Reduced immune capacity in people with diabetes, especially in poorly controlled cases, presents increased risks of infection, delayed healing and non-optimal healing. For dentists, this translates into a patient with compromised periodontal healing, dry mouth, increased caries susceptibility and increased risks of systemic infection.
Advanced bone loss and highly inflamed gingiva in this 46 year-old Hispanic female should trigger suspicion of uncontrolled diabetes condition. The BG reading of 477 is dangerously high. The severe nature of pain, which also contributes to elevation of BG levels, combined with Grade III+ mobility led to a decision to place her on antibiotics immediately, extract the tooth with non-epinephrine containing Citanest by mandibular block and place hemostatic gauze dusted with tetracycline in the socket. The patient was seen by a physician immediately following extraction and placed on oral glycemic medication.
BY THE NUMBERS
We must know our patients’ blood glucose status as surely as we monitor blood pres- sures. Screening for blood glucose levels—at a minimum asking the patient about their own BG levels and, better still, knowing the last A1C level—can reduce untoward effects, morbidity and even unnecessary deaths.
No doubt your initial health history form asks the patient to “check” if she has been diag- nosed with diabetes. When you learn your patient has diabetes do you ask about:
• The most recent BG reading? • The most recent A1C result? • Are BG readings are regularly taken?
• Has the patient eaten on the day of the appointment?
• Are there wide swings of BG levels, includ- ing hypoglycemic events?
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Every dental office should own and use a blood glucose meter. Pre-surgical (extraction, root planing, etc.) testing—or at minimum, docu- menting patient reports of their BG levels—is a standard of care as our profession recognizes the integral nature of oral and systemic health.
It is safe to say that dentists treat quite a num- ber of patients who have undiagnosed diabetes conditions and certain genetic groups are much more susceptible to diabetes. According to the American Diabetes Association:
• Nearly 24 million children and adults in the U.S. have diabetes.
• Another 57 million Americans have prediabetes and are at risk for developing type 2 diabetes.
• One out of every 3 children (and 1 in 2 minority children) born in the U.S. today will face a future with diabetes if current trends continue.
• The death rate from diabetes continues
PATIENT ASSESSMENT, TESTING, MONITORING
Patients presenting to dentists with symptoms of marked hyperglyce- mia, including polyuria, polydipsia, weight loss (sometimes with poly- phagia) and blurred vision, should receive screening for blood glucose levels, as should those with potential complications of diabetes such as fluctuant gingival tissues, periodon-
tal abscess, rapid and aggressive periodontitis- associated alveolar bone loss, mucosal disorders as well as oral fungal infections. In addition, patients who have been in pain, and who may not have eaten, are susceptible to hypogly- cemic episodes that can present as in-office emergencies needing prompt emergency help. Several different types of blood glucose tests are used, including:
Fasting blood sugar (FBS) measures blood glucose after one has not eaten for at least right hours. It is often the first test done to check for prediabetes and diabetes. In general, up to 100 milligrams per deciliter (mg/dL) is considered normal for a fasting blood glucose test. Persons with levels between 100 and 125 mg/dL have impaired fasting glucose, or pre- diabetes. These levels are considered to be risk factors for type 2 diabetes and its complica- tions. Diabetes is diagnosed in persons with fasting blood glucose levels that are 126 mg/ dL or higher.
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