The Prevention and Treatment of Complications of Diabet...

The Prevention and Treatment of Complications of Diabetes Mellitus A Guide for Primary Care Practitioners

The Prevention and Treatment of Complications of Diabetes Mellitus A Guide for Primary Care Practitioners
wonder.cdc.gov

Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation
Publication date: 01/01/1991


--------------------------------------------------------------------------------

The Prevention and Treatment of Complications of Diabetes Mellitus A Guide for Primary Care Practitioners
Department of Health and Human Services, Public Health Service, Centers for Disease Control, National Center for Chronic Disease Prevention and Health Promotion, Division of Diabetes Translation
Publication date: 01/01/1991


--------------------------------------------------------------------------------

Table of Contents
Foreword


Preface


Psychosocial Problems
Prevention
Detection
Treatment
References


Acute Glycemic Complications
Diabetic Ketoacidosis; Background
Prevention
Guidelines for Sick Days
Record for Sick Days
Detection
Treatment
Hyperglycemic Hyperosmolar Nonketotic Coma
Prevention
Detection
Treatment
Hypoglycemia
Prevention
Detection
Treatment
Teaching Patients to Avoid Acute Glycemic Complications
References


Adverse Outcomes of Pregnancy
Pregestational and Gestational Diabetes; Background
Caring for the Patient With Pregestational Diabetes
Treatment
Caring for the Patient With Gestational Diabetes
Treatment
References


Disease
Prevention
Detection
Treatment
References


Eye Disease
Prevention of Diabetic Retinopathy
Detection and Monitoring of Diabetic Retinopathy
Treatment and Referral
References


Kidney Disease
Prevention
Detection
Treatment
References


Cardiovascular Disease
Prevention
Detection
Treatment
References


Neuropathy
Prevention
Detection
Differential Diagnosis
Treatment
References


Foot Problems
Prevention
Detection and Monitoring
Treatment
References


Appendix A, Office Guide


Acknowledgments


POINT OF CONTACT FOR THIS DOCUMENT:


Tables
Clinical Manifestations Of Eye Diseases
Example of An Office Guide


Figures
Natural History Of Diabetic Nephropathy In Persons With Insulin




--------------------------------------------------------------------------------

Foreword
The 1982 publication of The Prevention and Treatment of Five Complications of Diabetes: A Guide for Primary Care Practitioners was an initial attempt to provide straightforward and practical information that primary care practitioners could immediately apply in their practice in the diagnosis and prevention of complications of diabetes. In the eight years since that publication was released, over 200,000 copies have been distributed. The emphasis on early application of currently available preventive measures or treatments has resulted in the widespread use of the document.
The scope of the present revised edition has been broadened to cover nine complications of diabetes, and the recommendations for the previous five. We anticipate continued widespread use of this guide in assisting practitioners in the care of their patients with diabetes. The recommendations are clear, practical, and based upon scientific evidence, and they can be generally implemented in an office practice. We believe that they are conceptually consistent with the American Medical Association's new emphasis on practice parameters.

Although this publication is meant to provide freestanding and practical assistance in an office practice, the most appropriate use is in continuing education programs and workshops. In these settings, the practical application of the recommendations can be discussed and barriers to their application in individual practices overcome.

We congratulate the Centers for Disease Control in its efforts to update this guide and wish it the same success as the previous edition.

Charles M. Clark, Jr., M.D.
Indiana University School of Medicine
Indianapolis, Indiana



--------------------------------------------------------------------------------

Preface
This publication is designed to help the primary care practitioner in the day-to-day management of patients with diabetes. The recommendations relate to the prevention, detection, and treatment of the major complications of diabetes. The emphasis is on early application of currently available measures that, if systematically applied, may reduce the incidence or severity of these complications. Because of the need for brevity and practicality, we have neither discussed areas of controversy nor provided in-depth discussions of pathophysiology and the scientific rationale for treatment.
An office guide is included as an appendix. The office guide is a brief synopsis of the recommendations contained in the body of the text and is designed so that it may be photocopied and placed in the patient's medical record.

A companion publication entitled Take Charge of Your Diabetes: A Guide for Patients is available. It is written in nontechnical language and emphasizes the same preventive measures and treatments. The sequence of the chapters corresponds with the sequence in this document.

William H. Herman, M.D.
University of Michigan Medical Center
Ann Arbor, Michigan



--------------------------------------------------------------------------------

Psychosocial Problems
Background--
Description. Like other chronic illnesses, diabetes mellitus poses a wide range of problems for patients and their family members. These problems include pain, hospitalization, changes in lifestyle and vocation, physical disabilities, and threatened survival. Direct psychological consequences can arise from any one of these factors, making it harder for patients to treat their diabetes and live productive, enjoyable lives.

Populations at risk --

Diabetes itself does not cause changes in personality or psychiatric illness, but particular subgroups of the diabetic population appear to be at risk for developing psychosocial problems. Young people with insulin- dependent diabetes mellitus (IDDM) may have a higher prevalence of eating disorders, such as anorexia nervosa and bulimia, and adults with longstanding diabetes and major medical complications have a higher prevalence of symptoms of depression and anxiety. Elderly persons who have non-insulin-dependent diabetes mellitus (NIDDM) and other symptomatic medical conditions may also have a higher risk of developing psychological problems.

Patients with IDDM diagnosed before age 5 and older patients with NIDDM may have associated alterations in cognitive or intellectual functioning. The pathophysiology of these cognitive changes is not well understood. In the young patients, these cognitive changes may be linked to recurring episodes of severe hypoglycemia. In the older patients, both microvascular and artherosclerotic disease are possible factors.

Barriers to self-care.

Research has indicated that psychological and social factors can profoundly influence a patient's success at adhering to a prescribed regimen of self- care. Patients may fail to care for themselves if they have certain attitudes or beliefs, including the following:


Anticipating an early cure.
Believing that their self-care regimen is too difficult.
Believing that treatment is unlikely to improve or control their health problems.
Several other psychosocial factors can influence how well patients care for themselves:

Stressful events in the patient's life.
Development of a new complication.
The availability and quality of social support for the patient.
Psychiatric problems unrelated to the patient's diabetes.
The health care provider's approach to medical care.
Prevention
To help anticipate or identify psychosocial problems that could interfere with a patient's self-care regimen, the practitioner should strive to establish an ongoing, therapeutic alliance with the patient. The stronger the alliance, the more likely the patient is to share inner concerns and psychosocial issues. This leads to improved detection and permits more rapid institution of treatment.
This therapeutic alliance will take shape over time, through discussions identifying the patient's expectations of, and feelings about, treatment. Although the patient should not be forced to set particular goals, the practitioner may be able to broaden or refine existing objectives to include improving the patient's adjustment to having diabetes.

Over time, this alliance may lead to better glycemic control by helping the patient address such self-care barriers as low motivation, preconceived judgments about treatment, and fears about diabetes.


Detection
The practitioner should be sensitive to possible psychosocial issues when diabetes is first diagnosed and when complications, however minor, first develop.
Some psychosocial barriers stem from personal, family, and cultural beliefs that may conflict with suggested treatment. A patient may resist following a prescribed diet, for instance, because of certain cultural beliefs about weight. Such beliefs should be given their due respect; patients respond best to advice that does not seem to prejudge their beliefs.

Certain medical conditions can be reliable indicators of Psychosocial barriers. Recurrent hypoglycemia, frequent episodes of diabetic ketoacidosis, and very high glycosylated hemoglobin levels should each be recognized as a possible sign of personal or family problems. Although brittle, or unstable, diabetes can sometimes have a metabolic basis, interrupted or erratic self-care is by far a more common cause--and psychosocial problems may underlie this cause.

To help uncover problem areas, the practitioner may want to conduct discussions along the following lines:


Ask patients to describe how they feel about the following issues of self-care:
The importance of glycemic control.
The feasibility of adhering to a prescribed diet.
The importance of self-monitoring of blood glucose.
The patient's susceptibility to developing complications.
The efficacy of treating complications.
The reasonableness of the practitioner's recommendations and expectations.
Ask patients to describe any stressful events or situations, such as changes in job, school, place of residence, and immediate family (for example, death or divorce). Ask whether any other events could be creating barriers to a self-care program.
Determine whether patients have adequate social and family support. Specifically, ask patients to whom they can turn for help in caring for themselves.
Ask about problems concerning mood, anxiety, and sense of well-being.
Ask young women who might be at risk for eating disorders whether they have skipped insulin doses, dieted excessively, eaten in binges, or vomited.
Ask specific questions about topics that patients may hesitate to talk about, such as sexual problems.
Determine how effectively patients use available information about diabetes. Ask whether they find it difficult to retain or add to such knowledge.
The practitioner may then be able to counsel patients and provide useful solutions.

Treatment
Try to actively engage the patient in determining as well as pursuing a course of treatment. Ask the patient both specific and open-ended questions. Open-ended questions may elicit information that can help detect problems as well as tailor the course of treatment. Such discussions may identify individual strengths and problem-solving strategies that have helped the patient successfully face previous challenges.
The practitioner will need to identify, for possible referral, mental health professionals who are knowledgeable about diabetes and who can serve as collaborators in treating the patient. If these individuals are not familiar with diabetes, they can be given materials (such as this guide) that provide basic information.

Refer the following persons:


Parents of children or adolescents in whom diabetes has recently been diagnosed. A single psychosocial evaluation of the family unit may be important to the overall educational process of raising a child who has diabetes.
Patients who in one year have had two or more episodes of severe hypoglycemia or diabetic ketoacidosis without obvious causes.
Patients whom you--the health care professional--find frustrating. The mental health professional may prove a valuable consultant for treating these patients.
Remember that diabetes is a chronic illness. Even if treatment activities fail to bring change within a short time, remaining involved with the patient and the patient's family and providing an accepting atmosphere may lead to increased motivation for change.
Encourage patients and their families to attend group sessions. Medical and psychosocial information can be given at these sessions, which can also provide a forum for discussion of personal concerns. These sessions can be led by health care professionals, including physicians, nurses, and dietitians, and may meet several times a year. Local diabetes organizations may sponsor or know of such groups.

Patient Education Principles:


Inform patients about the typical personal concerns that come with diabetes, about the problems faced in accepting the disease and adapting to it, and about the impact diabetes has on emotional and social functioning.
Involve families in treatment and education sessions.
Encourage parents to help their young children and adolescents who are having problems controlling their diabetes.
Encourage parents to give adolescents increasing responsibility for their diabetes--but not to force them to take these steps.
Encourage families to provide help for their older relatives, who may find insulin difficult or frightening to use or who may have trouble changing lifelong dietary habits.
Encourage families to ensure that school nurses and teachers are educated about the needs of children with diabetes and that nursing homes provide proper treatment to elderly patients with diabetes.
References
Bradley C. Psychological aspects of diabetes. In: Alberti KGMM, Krall LP, eds. The Diabetes Annual/1. New York: Elsevier, 1985.
Feste C. The Physician Within. Minneapolis: Diabetes Center, 1987.

Jacobson AM, Hauser ST. Behavioral and psychological aspects of diabetes. In: Ellenberg M, Rifkin H, eds. Diabetes Mellitus: Theory and Practice. 3rd ed. Vol. 2. New Hyde Park, New York: Medical Examination, 1983.



--------------------------------------------------------------------------------

Acute Glycemic Complications
Introduction--
In diabetes mellitus, severe hyperglycemia may result from absolute or relative insulin deficiency. In some patients, the condition may culminate in diabetic ketoacidosis or hyperglycemic hyperosmolar nonketotic coma. Profound hypoglycemia may result from a relative excess of insulin. Symptoms associated with acute hyperglycemia generally develop more slowly (over hours or days) than do symptoms associated with an acute fall in the level of blood glucose (over minutes).


Diabetic Ketoacidosis; Background
Definition. Diabetic ketoacidosis (DKA) develops when absolute insulin deficiency and excess contra-insulin hormones increase hepatic glucose production, decrease peripheral glucose utilization, and stimulate release of fatty acids from fat cells and production of ketones by the liver. These changes cause hyperglycemia, osmotic diuresis, volume depletion, and acidosis.
Occurrence. The annual incidence of DKA ranges from three to eight episodes per 1,000 persons with diabetes. It is much more common among persons with insulin-dependent diabetes mellitus (IDDM) than among those with non-insulin-dependent diabetes mellitus (NIDDM).

DKA may be the initial manifestation of previously unrecognized IDDM. More often, DKA develops in persons known to have diabetes. Patients with IDDM who fail to take insulin or who do not receive extra insulin during flulike illness, pneumonia, or myocardial infarction may develop DKA. Patients with NIDDM who experience severe stress may secrete more contra-insulin hormones; these further compromise limited insulin secretion, which may in turn lead to DKA.

Morbidity and mortality. Before insulin was available, patients with diabetes often died of DKA; now, the mortality rate associated with DKA is less than 5%. However, persons who develop DKA experience pain and suffering, lose time from school or work, have increased hospitalization rates, and have high medical costs. Serious medical sequelae include cerebral edema (in young people), aspiration pneumonia, and adult respiratory distress syndrome.


Prevention
Why DKA occurs. Ultimately, DKA results from lack of insulin. Early recognition of metabolic disarray, by monitoring glucose and ketones and by properly using exogenous insulin and fluids, can prevent further decompensation. Thus, DKA should be considered preventable. Said differently, when DKA occurs, a breakdown in care has occurred that should have been prevented.
Three general circumstances may allow DKA to develop:


Low index of suspicion.
Inappropriate cessation of insulin therapy.
Mismanagement of intercurrent illness, often due to inadequate education.
Index of suspicion. Many people may not know the signs and symptoms of diabetes. At times, even when a person seeks medical help, a health care provider may fail to recognize the warning signs of hyperglycemia--particularly when the patient is very young (an infant), is very old (such as an octogenarian), or has unusual symptoms (such as mental deterioration without nausea or vomiting).
Therefore, to prevent DKA or to minimize its extent, the health care provider must have a high index of suspicion for DKA. In emergency rooms, clinics, and physicians' offices, routine use of a glucose/ketone urine dipstick may allow for early identification of decompensating diabetes.

Inappropriate cessation of insulin therapy. Under circumstances such as those described below, insulin therapy may be inappropriately discontinued.


Adolescents with diabetes may not adhere to a prescribed program, and their parents may not provide appropriate supervision.
Patients with major emotional or psychosocial problems may fail to adhere to their usual medical program.
Intercurrent illness. Both patients and health care providers may incorrectly assume that when no food or fluid is consumed, no insulin should be taken. However, when ill or stressed, the patient with diabetes should promptly test the glucose level in blood and/or urine and test the urine for ketones. The patient should follow a sick-day protocol and consult with the health care provider. Both patients and providers must understand the proper management of diabetes during intercurrent illness. (See "Guidelines for Sick Days".)
Analysis and referral. For the patient who has experienced DKA, the health care provider should do the following:


Determine why DKA occurred.
Assess the patient's self-care practices.
Modify individual guidelines (as appropriate).
Implement preventive measures to prevent subsequent episodes.
When recurrent episodes of DKA occur, the practitioner should determine the medical and psychosocial components of the episodes. Patients with difficult-to-manage IDDM should be referred to a diabetologist. Patients with underlying psychosocial problems should be referred to a mental health professional.
The guidelines and record for sick days on the following page are adapted from Take Charge of Your Diabetes: A Guide for Patients. Review these guidelines and discuss them with patients before illness occurs. Explain how to keep a record, and stress the importance of self-monitoring.


Guidelines for Sick Days
Keep a daily record of your sick days by following the guidelines below. If you feel too sick to follow any of these guidelines, ask a family member or a friend to help you. By following these instructions and by keeping a diary, you can work with your health care provider to feel better.
Health care provider's name:

Health care provider's telephone number:

1. If you feel too sick to eat normally, call your health care provider right away. Describe in detail how you feel. 2. Keep taking insulin when you feel sick. Don't stop taking insulin even if you can't eat. Your health care provider may change your insulin dose or may tell you to drink liquids that have sugar in them.
3. Weigh yourself every day and write down your weight. 4. Take your temperature every morning and evening. Write down the readings. (For small children or for someone who is breathing through the mouth, use a rectal thermometer.) If your temperature is above normal (99 F), drink extra liquids.
5. If you weigh 80 pounds or more, try to drink at least 12 eight- ounce glasses of liquid per day. Write down how much you drink. If you throw up, call your health care provider right away. You may need to go to the hospital or have special medical treatment. 6. Every 4 hours or before every meal, measure the glucose level in your blood. Write down the results. If the level is less than 60 mg/dL or consistently higher than 240 mg/dL, call your health care provider. Every 4 hours or each time you pass urine, test your urine for ketones and write down the results.
7. If you start to have trouble breathing, call your health care provider (or have someone do it for you) or go to a nearby emergency room. 8. Every 4 to 6 hours, write down whether you feel awake or sleepy. If you feel very sleepy or can't concentrate, have someone call your health care provider right away.
9. If your health care provider asks you to, call every day to describe your daily record (see "Record for Sick Days" below). Your health care provider may adjust your daily insulin dosage.



Record for Sick Days
How often Question Answer
Every day How much do you weigh
today? _____ pounds
Every evening How much did you drink
today? _____ glasses
Every morning What is your temperature? AM ______
and every evening PM ______
Every 4 hours How much medication Time Dose
or before did you take? ______ ______
every meal ______ ______
______ ______
______ ______
______ ______
______ ______

Every 4 hours What is the level of Time Level
or before glucose in your blood? ______ ______
every meal ______ ______
______ ______
______ ______
______ ______
______ ______

Every 4 hours What is the level of Time Level
or each time ketones in your urine? ______ ______
you pass urine ______ ______
______ ______
______ ______
______ ______
______ ______

Every 4 to How are you Time Condition
6 hours breathing? ______ ______
______ ______
______ ______
______ ______
______ ______
______ ______


If you feel unusually sleepy or can't concentrate, have someone call your health care provider or take you to an emergency room.


Detection
Symptoms. Suspect diabetes and DKA in any person at any age who has symptoms compatible with hyperglycemia and ketosis, including:

Altered mental status.
Fatigue.
Weight loss.
Blurred vision.
Thirst.
Excessive urination.
Enuresis.
Abdominal pain.
Nausea or vomiting.
Results of a simple glucose/ketone urine dipstick may give guiding information about the presence of diabetes or DKA. If glucose or ketones are present in the urine, the blood glucose level must be measured.
Monitoring. All patients with IDDM should be taught to prevent DKA. Encourage patients to monitor their blood glucose level and advise them to monitor the urine for ketones when the blood glucose level is 240 mg/dL or more and/or acute illness develops.

Insist that patients contact you promptly when the blood glucose level remains at 240 mg/dL or more, ketonuria develops, or acute illness persists.

Periodically assess how proficient patients are with self- monitoring and reassess their understanding of self-care during acute illness. (See "Guidelines for Sick Days".)


Treatment
Identify the causes of DKA by taking a thorough history, performing a physical examination, and requesting appropriate laboratory tests. In adult patients, an electrocardiogram should be performed to rule out a silent acute myocardial infarction. Treatment should be initiated while this information is being collected.
If DKA is mild and the patient is quickly responding to therapy, replacement of fluids, electrolytes, and insulin may occur in the emergency room. If DKA is more severe, hospitalize the patient at once to ensure adequate treatment and monitoring of the clinical state until recovery ensues. An intensive care unit is the preferred site for the treatment of severe DKA.

Health care providers whose experience with DKA is episodic and infrequent should not hesitate to arrange for the patient's prompt referral to a specialist experienced in the care of patients with DKA. A detailed summary of the treatment of DKA is available in the American Diabetes Association's Physician's Guide to Insulin- Dependent (Type 1) Diabetes.

Note: See "Patient Education Principles".


Hyperglycemic Hyperosmolar Nonketotic Coma
Background--
Definition. Hyperglycemic hyperosmolar nonketotic coma (HHNKC) is characterized by severe hyperglycemia (glucose level typically greater than 600 to 800 mg/dL), dehydration, and altered mental status -- in the absence of ketosis. In HHNKC, hyperglycemia causes glycosuria. Osmotic diuresis results in volume contraction and a reduction in both the glomerular filtration rate and glucose excretion. Worsening hyperglycemia causes further extracellular hypertonicity and intracellular dehydration.

Central nervous system dysfunction in persons with HHNKC is probably due to hyperosmolarity. The absence of ketosis has not been entirely explained but may be due to the secretion of insulin in amounts sufficient to suppress ketogenesis.

Occurrence. HHNKC occurs most often among persons over 60 years of age. Most persons with HHNKC have a history of NIDDM, but in a sizable minority, NIDDM is undiagnosed or untreated. When persons who are chronically ill, debilitated, or institutionalized have mild renal insufficiency and lack normal thirst mechanisms or access to water, they are at risk of developing HHNKC. Acute illnesses (stroke, myocardial infarction, or pneumonia), drugs (diuretics or glucocorticoids), surgery, and, occasionally, large glucose loads (through enteral or parenteral nutrition or peritoneal dialysis) may precipitate HHNKC.

Severity. The mortality rate for HHNKC has been reported to be as high as 50%, primarily because of the age of the population most at risk and the acute precipitating causes.


Prevention
Be alert to the elderly patient who:

Has a history of NIDDM.
Has an altered level of consciousness.
Takes diuretics or glucocorticoids.
Lacks free access to drinking water.
Has a poor support system at home or lives in a nursing home.
Is receiving enteral or parenteral nutrition.
For persons with several of these characteristics, periodically monitor the glucose level in the urine or blood. (Monitoring blood glucose is preferred.) If the fasting blood glucose level is above 200 mg/dL, monitor the glucose level more frequently and initiate or adjust hypoglycemic medications as necessary.
Early diagnosis of diabetes or early identification of worsening hyperglycemia will permit appropriate therapy that will prevent the development of HHNKC.


Detection
The patient with HHNKC has severe hyperglycemia and azotemia without ketoacidosis. The intravascular volume is contracted, and the patient shows signs and symptoms of hypovolemia and severe dehydration. Both diffuse and focal central nervous system deficits may occur. These may include hallucinations, aphasia, nystagmus, hemianopsia, hemiplegia, hemisensory deficits, and focal or grand mal seizures. Coma may ensue.

Treatment
Therapy is primarily directed at replacement of fluid and electrolytes while supportive care is given. Insulin therapy is designed to slowly --over 24 to 48 hours--return the blood glucose level to a near normal range.
When therapy is successful, the patient may be significantly sensitive to further insulin. Ultimately, the patient may achieve metabolic control through diet and/or oral agents.

Note: See "Patient Education Principles".


Hypoglycemia
Background--
Occurrence. Any person with diabetes who takes an oral hypoglycemic agent or insulin may experience low blood glucose. Severe hypoglycemia occurs more often in patients who are following an intensified insulin therapy protocol (with the target glucose level near the normal range), whose diet and activity vary widely, who have a long duration of diabetes, and/or who have autonomic neuropathy. Patients with a history of severe hypoglycemia are at increased risk for future episodes. Often the cause is multifactorial. A delay or decrease in food intake, vigorous physical activity, and alcohol consumption all may contribute.


Prevention
Patient education and self-monitoring of blood glucose are the best approaches to preventing hypoglycemia.
By emphasizing the relation between hypoglycemia and delayed or decreased food intake or increased physical activity, you may help patients anticipate and avoid the condition. If patients regularly and correctly monitor their blood glucose level, impending hypoglycemia may be avoided. Patients who know how to treat hypoglycemia can reduce its impact and severity.

To minimize the risk of hypoglycemia, cooperation is required between the patient, family members, other persons close to the patient (including friends, teachers, and colleagues), and health care providers. Stress the importance of such persons knowing the signs and symptoms of hypoglycemia and how to treat it.


Detection
Clinical hypoglycemia (blood glucose level below approximately 60 mg/dL) is associated with adrenergic symptoms (apprehension, tremors, sweating, or palpitations) and neuroglycopenic symptoms (fatigue, headache, confusion, coma, or seizure). Usually, the symptoms of low blood glucose are mild, related to catecholamine release, and easily treated by the patient.
Severe hypoglycemia occurs when the patient ignores, inappropriately treats, lacks, or does not recognize the early warning signs or when glucose counterregulation fails to return the blood glucose level to normal.


Treatment
Guidelines for treating hypoglycemia are as follows:

Person Action
_________________________________________________________________________

Patient Eat 10 to 15 grams of rapidly absorbable carbohydrate (3 to
5 pieces of hard candy, 2 to 3 packets of sugar, or 4 ounces
of fruit juice) to abort the episode. Repeat in 15 minutes,
as necessary.

Friend or If the patient is unable to treat himself or herself,
family administer oral carbohydrate. If the patient is unable to
member swallow, administer glucagon subcutaneously or
intramuscularly. For children younger than 3 years of age,
give 0.5 mg glucagon; for children 3 years of age and older
and for adults, give 1.0 mg.

Practitioner If the patient shows signs and symptoms of severe
hypoglycemia, administer glucagon or inject 25 grams of
sterile 50% glucose intravenously.

Analyze the cause of the episode. Often, a modest reduction
in the insulin dosage should be advised. Reeducate the
patient about preventing hypoglycemia by discussing the
timing of meals and physical activity, the use of alcohol,
and the frequency of self-monitoring of blood glucose.

Those patients who develop hypoglycemia while taking oral
hypoglycemic agents should be closely monitored for at least
48 to 72 hours to prevent a possible recurrence.


Teaching Patients to Avoid Acute Glycemic Complications
Thorough and repetitive patient education is essential to preventing the development of acute glycemic complications. In particular, teach patients how to care for themselves when they are ill and how to monitor themselves.
Patient Education Principles:
For patients with diabetic ketoacidosis--


Be sure your patients with diabetes know the following:
If they are at risk for DKA.
When they are most susceptible to DKA.
What they can do to prevent DKA.
When they should contact you.
For patients with hyperglycemic hyperosmolar nonketotic coma--

Remind persons responsible for the elderly, the infirm, or the chronically ill to look for the signs and symptoms of diabetes when their patients do not thrive. Recommend that a blood glucose screening test be performed at the bedside.
For patients with hypoglycemia--

Ensure that patients who use oral hypoglycemic agents or insulin understand the signs and symptoms, causes, and treatment of hypoglycemia.
Instruct patients who use oral hypoglycemic agents or insulin to wear a bracelet or necklace that identifies them as having diabetes and to carry sugar or some other source of simple carbohydrate that can be used to promptly treat hypoglycemia.
Advise persons with diabetes to tell close friends, teachers, or colleagues about their diabetes, how to recognize hypoglycemia, and what to do if an emergency occurs.
Ensure that patients particularly prone to hypoglycemia who are treated with insulin have glucagon available and that family members and friends know how to administer it.
Instruct patients with diminished awareness of the signs and symptoms of hypoglycemia to monitor their blood glucose levels at frequent intervals so that unexpected episodes can be recognized early and more severe hypoglycemia forestalled.
Consider changing the level of diabetes control in the following patients:
Those who do not or cannot recognize the early warning signs of hypoglycemia.
Those who do not understand the educational details of avoiding or treating hypoglycemia.
Those whose lifestyle makes them vulnerable to life-threatening episodes of hypoglycemia.
References
Bergenstal RM. Diabetic ketoacidosis. Postgraduate Medicine. 1985;77:151-161.
Butts DE. Fluid and electrolyte disorders associated with diabetic ketoacidosis and hyperglycemic hyperosmolar nonketotic coma. Nursing Clinics of North America. 1987;22:827-836.

Carroll P, Matz R. Uncontrolled diabetes in adults. Diabetes Care. 1983;6:579-585.

Casparie AF, Elzing LD. Severe hypoglycemia in diabetic patients. Diabetes Care. 1985;8:141-145.

Consensus statement of self-monitoring of blood glucose. Diabetes Care. 1987;10:95-99.

The DCCT Research Group. Diabetes Control and Complications Trial (DCCT): results of feasibility study. Diabetes Care. 1987;10:1-19.

Foster DW, McGarry JD. The metabolic derangements and treatment of diabetic ketoacidosis. New England Journal of Medicine. 1983;309:159-169.

Keller U. Diabetic ketoacidosis: current views on pathogenesis and treatment. Diabetologia. 1986;29:71-77.

Kitabchi AE, Matteri R, Murphy MB. Optimal insulin delivery in diabetic ketoacidosis and hyperglycemic, hyperosmolar nonketotic coma. Diabetes Care. 1982;5(suppl 1):78-87.

Physician's Guide to Insulin-Dependent (Type I) Diabetes: Diagnosis and Treatment. Alexandria, Virginia: American Diabetes Association, 1988.

Physician's Guide to Non-Insulin-Dependent (Type II) Diabetes: Diagnosis and Treatment. 2nd ed. Alexandria, Virginia: American Diabetes Association, 1988.

Sperling MA. Diabetic ketoacidosis. Pediatric Clinics of North America. 1984;31:591-610.



--------------------------------------------------------------------------------

Adverse Outcomes of Pregnancy
Introduction--
When a woman who is known to have diabetes becomes pregnant, she is said to have pregestational diabetes. When a woman develops diabetes during pregnancy or is first recognized as having this condition during pregnancy, she is said to have gestational diabetes. Each year, approximately 10,000 infants are born to women with pregestational diabetes, and 60,000 to 90,000 infants are born to women with gestational diabetes.

The factor most important to the outcome of pregnancy is how well the mother's glucose level is controlled before and during pregnancy. When women with diabetes receive optimal care, the perinatal mortality rate for their offspring approaches the corresponding rate for the general population. However, when pregnant women with diabetes do not receive expert treatment, the perinatal mortality rate for their offspring more than doubles.


Pregestational and Gestational Diabetes; Background
Metabolic changes. Normal pregnancy is characterized by increasing insulin resistance, which is probably due to human placental lactogen, a growth-hormone-like protein secreted by the placenta. Although pregnant women develop compensatory hyperinsulinemia, postprandial glucose levels increase significantly throughout pregnancy. During late pregnancy, fasting glucose levels fall because of increased glucose consumption by the placenta and the fetus.
Human placental lactogen reaches its peak late in pregnancy; during the third trimester, insulin requirements rise. Gestational diabetes most often appears during this period of maximum insulin resistance, and ketoacidosis may be seen -- particularly in patients with insulin-dependent diabetes mellitus who do not increase their insulin dose appropriately.

Effect on the fetus. Because glucose crosses the placenta by facilitated diffusion, maternal hyperglycemia produces fetal hyperglycemia. Fetal hyperinsulinemia occurs in response to this abnormal metabolic environment. Hyperinsulinemia, combined with hyperglycemia, leads to excessive fetal growth. It may also contribute to intrauterine fetal death, delayed fetal pulmonary maturation, and neonatal hypoglycemia.

The incidence of major congenital malformations is increased approximately fourfold among infants of women with pregestational diabetes. Approximately 9% of pregnancies complicated by pregestational diabetes result in the birth of infants with central nervous system, cardiac, renal, skeletal, and other malformations. Major malformations may occur in 20% to 25% of infants born to women with very poor glycemic control during organogenesis, as evidenced by markedly elevated glycosylated hemoglobin levels during the first trimester.

Other factors that may increase the risk for fetal anomalies include early age at onset of maternal diabetes and microvascular disease in the mother. The earlier the age at onset of pregestational diabetes, the worse the prognosis is for successful pregnancy.

Effect on the mother. Pregnancy may be associated with exacerbation of diabetic eye disease, especially in women with unrecognized or untreated proliferative diabetic retinopathy. Diabetic women with nephropathy and hypertension are at greater risk for preeclampsia and fetal growth retardation than are women without nephropathy. Death has been reported among pregnant women with diabetes and coronary artery disease.


Caring for the Patient With Pregestational Diabetes
Prevention --
The outcome of pregnancy complicated by pregestational diabetes is improved when care begins before conception. Each visit with a woman of childbearing age who has diabetes should be considered a preconceptional visit. Discuss family planning and ask the patient her thoughts about a future pregnancy.

Results of a glycosylated hemoglobin test provide overall assessment of glycemic control. Pregnancy should be deferred until excellent glycemic control is achieved, as indicated by a normal or near normal glycosylated hemoglobin level. Counsel patients about nutrition and teach them how to monitor their blood glucose levels and how to adjust their insulin treatment.

For patients who are planning to become pregnant, establish baseline data that can be used to assess maternal and perinatal risk, including the following:


History of diabetic ketoacidosis and severe hypoglycemia.
Blood pressure measurement.
Eye examination.
Quantitative assessment of renal function and urinary protein or albumin excretion.
Electrocardiogram (if indicated).
Patients whose pregnancy is complicated by diabetes often experience significant emotional and financial stresses. Assess the patient's emotional or psychosocial support and financial resources through discussion with the patient, her partner, and her family.
Emphasize the dangers of smoking and of consuming alcohol when pregnant.


Treatment
Health care team. An experienced health care team is required to care for a patient with pregestational diabetes. The team should include the following persons:

An obstetrician or a specialist in maternal-fetal medicine.
An internist or diabetologist.
A pediatrician or neonatologist.
A diabetes educator.
A dietitian.
A social worker.
Every effort should be made to refer patients to medical centers that can provide comprehensive support. If such referral is not possible, members of the health care team should frequently consult with each other by telephone.
Glucose level. Excellent control of maternal diabetes is a critical objective both before and during pregnancy. During normal pregnancy, mean maternal plasma glucose levels rarely exceed 120 mg/dL and range from fasting levels of 60 mg/dL to 2-hour postprandial levels of 120 mg/Dl. Use these values as the therapeutic objective for patients whose pregnancies are complicated by pregestational diabetes.

Diet. During the latter half of pregnancy, the patient with pregestational diabetes needs to eat approximately 35 kilocalories per kilogram of her ideal prepregnancy body weight each day, or approximately 2200 to 2400 calories per day. A weight gain of 24 to 28 pounds is recommended for most patients; however, for obese patients with noninsulin-dependent diabetes mellitus, the preferred daily dietary intake is 25 kilocalories per kilogram of ideal prepregnancy body weight, or approximately 1600 to 1800 calories per day.

The calories should be derived as follows: approximately 50% from complex carbohydrates, 30% from fats, and 20% from proteins. Patients will require three meals and up to three snacks each day. A bedtime snack is particularly important to decrease the risk of nocturnal hypoglycemia.

Monitoring. Patients with insulin-treated diabetes should monitor their blood glucose levels at least four times a day -- either before or 2 hours after each meal and at bedtime. Before breakfast, patients should test for ketones in their urine. Ask patients to record results in a log book and to note any changes in diet and exercise and any problems with hypoglycemia.

Measure the glycosylated hemoglobin level at least once each trimester to assess overall glycemic control.

Insulin therapy. Patients treated with oral hypoglycemic agents should be switched to insulin before they become pregnant. Human insulin should generally be used. Patients with insulin-treated diabetes require an individualized insulin regimen based on their exercise plan and blood glucose levels.

Most patients will require at least two injections a day of a mixture of intermediate-acting (NPH or lente) and short-acting (regular) insulin. Selected patients may be treated with multiple daily injections (that is, regular insulin before each meal and an injection of intermediate- or long-acting ultralente| insulin at bedtime). For some patients, continuous subcutaneous insulin infusion is an option, but it appears to offer no significant advantage over multiple daily injections. Patients who prefer the flexibility offered by the pump may be started on such therapy, and those who have used a pump before pregnancy may continue to do so.

Fetal assessment. Maintain a program of fetal assessment throughout pregnancy. Measure the maternal serum alpha-fetoprotein level at 16 weeks of gestation to screen for neural tube defects and other fetal anomalies. Perform a detailed ultrasonographic examination at 16 to 18 weeks of gestation. If indicated, assess the fetal cardiac structure by echocardiography at 20 weeks of gestation. When performed by experienced professionals, such tests allow detection of most major fetal malformations. If an anomaly is found, skilled counseling must be provided for the patient.

During the third trimester, assessment of fetal growth and well- being becomes most important. Fetal growth may be evaluated by serial ultrasonographic examination every 4 to 6 weeks. Fetal well-being may be determined by a variety of techniques, including the following:


Maternal monitoring of fetal activity.
Antepartum heart rate testing by using the nonstress or contraction stress test.
Biophysical profile that includes an ultrasonographic evaluation of fetal activity, fetal breathing movements, fetal tone, and amniotic fluid volume.
Although these tests may be initiated at 28 weeks of gestation, they are most often begun at 32 weeks and performed once or twice a week until delivery.
Delivery. If the patient maintains excellent glucose control, if her blood pressure is normal, and if antepartum fetal testing shows no evidence of fetal compromise, delivery may occur at term. If delivery is planned before term, assess fetal pulmonary maturation by measuring the ratio of amniotic fluid lecithin to sphingomyelin (L/S) and the level of acidic phospholipid phosphatidyglycerol. If ultrasound suggests excessive fetal size, delivery by cesarean section may be elected.

Delivery must take place where expert maternal and neonatal care are available. Breast-feeding should be encouraged.

Postpartum care. In the immediate postpartum period, reassess the patient's meal plan and adjust her treatment program. Maternal insulin requirements fall significantly, usually to- or even below- prepregnancy levels.

During the patient's postpartum follow-up visit, encourage her to diet, if necessary, to achieve her ideal body weight. Contraception should be discussed. Low-dose oral contraceptives or a progestin-only pill may be offered to patients who have no evidence of hypertension or vascular disease. For patients with hypertension or vascular disease, a barrier method of contraception, such as a diaphragm, is preferred. If the patient has completed her family or if she has serious vascular disease, sterilization should be discussed.


Caring for the Patient With Gestational Diabetes
Detection --
Screening. All pregnant women should be screened for gestational diabetes. If only those patients with recognized historical or clinical risk factors are screened, a significant number of cases of gestational diabetes will be missed.

Timing. Screen for gestational diabetes at approximately 24 to 28 weeks of gestation. Screening may be indicated before 24 weeks if the patient has a history of any of the following:


Polydipsia or polyuria.
Recurrent vaginal and/or urinary tract infections.
Glycosuria of 1+ or greater on two or more occasions or 2+ or greater on one occasion.
Hydramnios.
Having given birth to an infant who was large for gestational age.
Gestational diabetes.
Method for screening. Patients need not be fasting when the screening test is performed. Use a 50-gram oral glucose load and measure the patient's glucose level after one hour. If the venous plasma glucose is 140 mg/dL or higher, schedule a 100-gram oral glucose tolerance test (see next paragraph).
Method for diagnosis. In pregnancy, the oral glucose tolerance test should be performed as follows:


Perform the test in the morning, after at least 3 days of unrestricted diet (more than 150 grams of carbohydrate per day) and unrestricted physical activity and after an overnight fast of at least 8 hours but not more than 14 hours.
Ask the patient to remain seated. If she smokes, ask her not to do so during the test.
Administer a 100-gram oral glucose load.
Measure venous plasma glucose when the patient is fasting and at 1, 2, and 3 hours after administering the glucose load.
Diagnose gestational diabetes when two or more of the following concentrations are met or exceeded.
___________________________________________________________________________

Time of Glucose
Test Concentration
___________________________________________________________________________
Fasting 105 mg/dL
After glucose
1 hour 190 mg/dL
2 hours 165 mg/dL
3 hours 145 mg/dL
___________________________________________________________________________




If the initial glucose tolerance test is normal but the patient is thought to be at high risk for gestational diabetes, or if one concentration is met or exceeded, consider repeating the glucose tolerance test at 32 weeks of gestation.
Although blood glucose measurements using glucose-oxidase-impregnated test strips are useful for monitoring treatment, they are not sufficiently precise for diagnostic purposes. Glycosuria and glycosylated hemoglobin tests are also not sensitive enough to be used to diagnose gestational diabetes.

Treatment
Most women with gestational diabetes can be cared for as outpatients. The patient should be seen at 1- to 2-week intervals to assess glucose control, weight gain, and blood pressure. The patient may need to be hospitalized if she does not maintain acceptable glucose control or if she develops hypertension or an infectious complication such as pyelonephritis.
Diet. Dietary therapy is the mainstay of treatment for patients with gestational diabetes. The daily dietary plan should contain approximately 2000 to 2400 calories distributed among three meals and a bedtime snack.

Monitoring. Ideally, the efficacy of the diet is assessed by daily self-monitoring of blood glucose. Weekly measurements of fasting and postprandial glucose levels are also an acceptable method of monitoring.

Pharmacologic therapy. If the fasting plasma glucose level exceeds 105 mg/dL and/or the 2-hour postprandial value exceeds 120 mg/dL, treatment with human insulin should be initiated. Patients who require insulin should be instructed in glucose self-monitoring.

Oral hypoglycemic agents should not be used during pregnancy.

Fetal assessment. Patients with insulin-treated gestational diabetes require a program of fetal surveillance identical to that recommended for patients with pregestational diabetes (see the earlier discussion). Begin fetal surveillance by 34 weeks of gestation for patients with non-insulin-treated gestational diabetes who develop preeclampsia or have a history of intrauterine death. Begin fetal surveillance at 40 weeks of gestation for patients with uncomplicated non-insulin-treated gestational diabetes who have not delivered.

Postpartum care. All patients with gestational diabetes should undergo a 75-gram oral glucose tolerance test at 6 to 8 weeks postpartum to determine whether abnormal carbohydrate metabolism has persisted.

The glucose tolerance test should be performed as follows:


Perform the test in the morning, after at least 3 days of unrestricted diet (more than 150 grams of carbohydrate per day) and unrestricted physical activity and after an overnight fast of between 8 and 14 hours.
Ask the patient to remain seated. If she smokes, ask her not to do so during the test.
Administer a 75-gram oral glucose load.
Measure the venous plasma glucose when the patient is fasting and 30, 60, 90, and 120 minutes after administering the glucose load.
Diagnose abnormal glucose tolerance according to the following criteria:
__________________________________________________________________________
Glucose Concentration
__________________________________________________________________________
Normal Impaired
Time of Glucose Glucose Diabetes
Test Tolerance Tolerance Mellitus
___________________________________________________________________________

Fasting <115 mg/dL <140 mg/dL >140 mg/dL
and and or
After glucose <200 mg/dL 1 value >200 1 value>200
(30, 60, and mg/dl mg/dL mg/dL
90 minutes) and and and
120 minutes <140 mg/dL >140 mg/dL >200 mg/dL
but <200
mg/dL
--------------------------------------------------------------------------

Encourage patients to achieve their ideal body weight to decrease their likelihood of developing non-insulin-dependent diabetes mellitus. Patients with a history of gestational diabetes should be annually evaluated for onset of diabetes.

For contraception, patients may use low-dose oral contraceptive pills, progestin-only pills, or barrier methods.

Patient Education Principles:
For patients with pregestational diabetes


Emphasize the importance of prepregnancy care.
Work with the patient, her partner, her family, and other health care providers to improve the patient's nutrition, exercise program, and glucose control.
Recommend that conception be delayed until the patient's blood glucose control is excellent and the glycosylated hemoglobin level is normal or near normal.
Explain the risks of birth defects and adverse perinatal outcomes and the need for fetal surveillance.
Recommend that the patient's vascular condition be thoroughly evaluated before she becomes pregnant. Explain that pregnancy may exacerbate advanced diabetic retinopathy but generally does not permanently worsen diabetic nephropathy.
Explain that, overall, pregnancy does not shorten the life expectancy of a woman with diabetes but does increase her risk for hypoglycemia and ketoacidosis and for associated mortality.
Inform patients with coronary atherosclerosis that their risks for morbidity or mortality may be greater during pregnancy.
Discuss the emotional and financial demands of pregnancy with the patient, her partner, and her family.
Inform patients about lifestyle elements--such as drinking alcoholic beverages and smoking--that increase the risk for a poor outcome of pregnancy. Emphasize that patients will need to modify such behaviors before becoming pregnant.
For patients with gestational diabetes --

Work with the patient, her partner, her family, and other health care providers to improve the patient's nutrition, exercise program, and glucose control.
Explain the risks of adverse perinatal outcomes and the need for fetal surveillance.
Inform patients that they are at increased risk both for developing gestational diabetes during future pregnancies and for developing overt diabetes later in life.
Encourage physical activity and postpartum weight loss to decrease the likelihood of developing diabetes later in life.
Recommend an evaluation at 6 to 8 weeks postpartum, and annually thereafter, for detecting the development of diabetes.
For patients with a history of gestational diabetes--

Recommend screening for overt diabetes before subsequent pregnancies.
Recommend early screening for the onset of carbohydrate intolerance during subsequent pregnancies.
References
Freinkel N, Dooley SL, Metzger BE. Care of the pregnant woman with insulin-dependent diabetes mellitus. New England Journal of Medicine. 1985;313:96-101.
Freinkel N, Gabbe SG, Hadden DR, et al. Summary and recommendations of the Second International Workshop-Conference on Gestational Diabetes Mellitus. Diabetes. 1985 ;34(suppl 2):123-126.

Fuhrmann K, Reiher H, Semmler K, Fischer F, Fischer M, Glockner E. Prevention of congenital malformations in infants of insulin- dependent diabetic mothers. Diabetes Care. 1983;6:219-223.

Gabbe SG. Management of diabetes mellitus in pregnancy. American Journal of Obstetrics and Gynecology. 1985;153:824-828.

Greene MF, Hare JW, Cloherty JP, et al. First-trimester hemoglobin A(1) and risk for major malformation and spontaneous abortion in diabetic pregnancy. Teratology. 1989;39:225-231.

Landon MB, Gabbe SG. Glucose monitoring and insulin administration in the pregnant diabetic patient. Clinical Obstetrics and Gynecology. 1985;28:496-506.

Mills JL, Knopp RH, Simpson JL. et al. Lack of relation of increased malformation rates in infants of diabetic mothers to glycemic control during organogenesis. New England Journal of Medicine. 1988;318:671-676.

Mills JL, Simpson JL, Driscoll SG, et al. Incidence of spontaneous abortion among normal women and insulin-dependent diabetic women whose pregnancies were identified within 21 days of conception. New England Journal of Medicine. 1988;319:1617-1623.

Schwartz R. The infant of the diabetic mother. In: Davidson JK, ed. Clinical Diabetes Mellitus. New York: Thieme. 1986.

Steel JM. Prepregnancy counseling and contraception in the insulin- dependent diabetic patient. Clinical Obstetrics and Gynecology. 1985;28:553-566.



--------------------------------------------------------------------------------

Disease
Background
Definition. The term periodontal disease describes a group of localized infections that affect the tissue surrounding and supporting the teeth.

The two most common forms of periodontal disease are gingivitis and periodontitis. Gingivitis, an early and reversible condition, is an inflammation of the soft tissues surrounding the teeth. Persons with gingivitis have tender, edematous, red gums that may bleed upon gentle pressure, such as from toothbrushing.

Periodontitis is a progressive inflammatory condition that destroys periodontal ligament fibers and alveolar bone and can eventually cause tooth loss. Although gingivitis usually precedes periodontitis, not all gingivitis progresses to periodontitis.

For all persons, the keys to preventing periodontal disease are good oral hygiene and regular dental care. A third element crucial to persons with diabetes is good glycemic control; poorly controlled diabetes can invite or promote periodontal disease.

Occurrence. disease is widely prevalent. Forty to 50% of U.S. adults report gingival bleeding, and over 80% of adults have objective evidence of previous periodontal disease. The prevalence and severity of periodontal disease increase markedly with age. Eight percent of adults younger than age 65 and 34% of adults 65 and older have evidence of advanced periodontal destruction.

Among children and adolescents with poorly controlled insulin- dependent diabetes mellitus and among adults with poorly controlled non-insulin-dependent diabetes mellitus, the prevalence of periodontal disease is considerably greater than it is among their nondiabetic peers. The severity of periodontal disease is also usually greater among persons with diabetes.

Pathophysiology. disease is initiated by the toxic

metabolic products of bacteria in dental plaque. Other associated factors include smoking, vitamin C deficiency, dental restorations, and prostheses.

disease appears to be aggravated by increased levels of blood glucose and by other conditions associated with poor glycemic control. Altered microbial flora, impaired immunity, vascular changes, and abnormal collagen metabolism may contribute to the development and severity of periodontal disease among persons with diabetes.


Prevention
Effective self-care is essential to periodontal health. To ensure that patients with diabetes are aware of the importance of maintaining good glycemic control as well as an effective regimen of oral hygiene, the health care provider should do the following:

Inform patients of their increased risk of developing periodontal disease.
Inform patients of the association between poor glycemic control and periodontal disease.
Explain that severe periodontal disease and other oral infections may adversely affect glycemic control.
Motivate patients to care for their teeth and gums.
Explain how dental plaque contributes to periodontal disease.
Inform patients that they can partly remove plaque by brushing and flossing their teeth at least twice a day.
Explain that teeth lost to periodontal disease may be difficult to replace. Dentures often fit poorly over gums damaged by periodontitis; the resulting discomfort may limit a patient's dietary choices and may thus impede diabetes management.
To ensure that patients receive the regular professional dental care critical to preventing periodontal disease, the health care provider should do the following:

Instruct patients to see a dentist at least every 6 months. Patients with periodontal disease will need to schedule more frequent appointments.
Provide a list of recommended dentists or local dental clinics if the patient does not have a dentist.
Urge patients to inform their dentist that they have diabetes. If possible, ask for the dentist's name and telephone number; you may need to alert this person to the special problems of treating a person with diabetes.
Efficient brushing and flossing removes the more superficial supragingival dental plaque. Subgingival plaque, as well as calculus (hard deposits of plaque, also called tartar), will require professional removal. For some patients, the dentist may prescribe antiplaque rinses, such as chlorhexidene.
To evaluate personal oral hygiene, the dentist or dental hygienist should ask patients to demonstrate how they remove plaque. Patients can then be shown, if necessary, how to more effectively care for their teeth.


Detection
To determine whether a patient is at increased risk for developing periodontal disease, the health care provider should ask about the patient's oral hygiene habits. Does the patient brush and floss twice daily? Does the patient use any other devices for cleaning teeth? When did the patient last see a dentist? Is the patient experiencing any of the following: bad taste in the mouth, bad breath, sore gums, swollen or red gums, bleeding gums, difficulty chewing, loose teeth, or oral pain?
The health care provider should inspect the patient's mouth for the following signs of dental disease:


Puffy, red gums.
A buildup of plaque.
Obviously decayed teeth.
The characteristic bad breath of periodontitis.
Patients showing these possible indicators of periodontal disease should be referred to a dentist.
Severe periodontal disease can be present without obvious inflammation. A complete dental examination, including periodontal probing of gum pockets, is necessary to determine the presence and severity of periodontal infection.


Treatment
The health care provider can treat periodontal disease by helping the patient achieve good glycemic control. Further measures fall to the dental health professional, who initially treats periodontal disease by removing plaque from infected areas of the patient's mouth. If infection or destruction has progressed too far, the dentist may prescribe antibiotic treatment, perform restorative procedures, perform surgery, or extract teet