Dental Management of Diabetic Patients

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Dental management of

diabetic patients

Presented by :Chitrang kolawale



Introduction Diabetes mellitus is a metabolic disordercharacterized by relative or absolute insufficiency of insulin, and resultant disturbances of carbonhydratemetabolism.

The major function of insulin is to counter theconcerted action of a number of hyperglycemia-generating hormones and to maintain low bloodglucose levels.



Epidemiology 6% (16million persons) of the general population in

the US have diabetes mellitus.

Almost 20% of adult older than 65 y/o haveDM.

A dental practice serving an adult population of 2,000can expect to encounter 40-80 persons with diabetes,about half of whom will be unaware of their condition.

National Institutes of Health, Aug 2001



Etiologic classification

of DM There are two types of DiabetesMellitus:

Type 1, insulin-dependent or, juvenile-onset diabetes(IDDM)

Type 2, non-insulin-dependent, adult-onset diabetes

(NIDDM)

Other specific types

J ADA, Oct 2001



Type 1 (IDDM)

Autoimmune destruction of the insulin-producingbeta cells of pancreas.

5-10% of DM cases. Common occurs in childhood and adolescence, or any

age.

Absolute insulin deficiency.

High incidence of severe complications. Prone to autoimmune diseases. (Graves, Addison,

Hashimotos thyroiditis)



Type 2 (NIDDM)

Result from impaired insulin function. (insulinresistance)

Constitutes 90-95% of DM

Specific causes of this form are unknown.

Risk factors : age, obesity, alcohol, diet, family Hx

and lack of physical activity..etc.



ComparisonComparison Type 1 Type 2

Clinical onset <20 years onset >30 years

normal weight obesity

decreased blood insulin normal or increased blood

insulin

anti-islet cell antibodies no anti-islet cell

antibodies

Genetics ketoacidosis common ketoacidosis rare

human leukocyte antigen

(HLA)-D linked

No HLA association

Pathogenesis autoimmunity,

immunopathologic

mechanisms

insulin resistance

severe insulin deficiency relative insulin deficiency

Islet Cells insulitis early no insulitis

marked atrophy and

fibrosis

focal atrophy and amyloid

deposits

severe beta-cell depletion mild beta-cell depletion



Other specific types

Genetic defects of beta-cell functions

Decrease of exocrine pancreas

Endocrinepathothies

Drug or chemical usage

Infections.



Gestational diabetes mellitus

(GDM)

Defined as any degree of glucose intolerance

with onset or first recognition during

pregnancy.

4% of pregnancy in US.



P

athophysiology Healthy people blood glucose level maintained

within 60 to 150 mg/dL.

Insulin synthesized in beta cells of pancreas andsecreted rapidly into blood in response to elevationsin blood sugar.

Promoting uptake of glucose from blood into cells

and its storage as glycogen Fatty acid and amino acids converted to triglyceride

and protein stores.



P

athophysiology Lack of insulin or insulin resistance, result in

inability of insulin-dependent cells to use

glucose.

Triglycerides broken down to fatty acids

blood ketones diabelic ketoacidosis.



P

athophysiology As blood sugar levels became elevated (hyperglycemia),

glucose is excreted in the urine and excessive of urinationoccurs due to osmotic diuresis (polyuria).

Increased fluid loss leads to dehydration and excess thirst(polydipsia).

Since cells are starved of glucose, the patient experiences

increased hunger (polyphagia).

Paradoxically, the diabetic patient often loss weight, since thecells are unable to take up glucose.



C

omplications People with DM have an increased incidence of both

microvascular and macrovascular complications.

Major organs/systems showing changes Long term complications

Cardiovascular system: heart,

brain, blood vessels

myocardial infarct; atherosclerosis;

hypertension; microangiopathy;

cerebral vascular infarcts; cerebral

hemorrhage

Pancreas islet cell loss; insulitis (Type 1); amyloid

(Type 2)

Kidneys nephrosclerosis; glomerulosclerosis;arteriosclerosis; pyelonephritis

Eyes retinopathy; cataracts; glaucoma

Nervous system autonomic neuropathy; peripheral

neuropathy

Peripherals peripheral vascular atherosclerosis;

infections; gangrene



Diagnosis A casual plasma glucose level of 200 mg/dL or

greater with symptoms presented.

Fasting plasma glucose level of 126 orgreater.(Normal <110 mg/dL,IGT,IFG)

Oral glucose tolerance test (OGTT) value in blood of 200 mg or greater.

ADA recommend >45 y/o screened every 3 years.

Diabetes Care, 2000

National Institutes of Health, Aug 2001



Medical management Objective : maintain blood glucose levels as

close to normal as possible.

Good glycemic control inhibits the onset anddelay of type 1 DM, similar in type 2 DM.



Medical management Glycated hemoglobin assay (HbA1c ) reflects

mean glycemia levels over the proceding 2~3

months. (normal < 7%)

HbA1c also a predictor for development of chronic complications.



Medical management Exercise and diet control

Insulin : rapid, short, intermediate, long acting.

Oral antidiabetic agents



Oral manifestations and

complications No specific oral l esion s a ssociated with diabetes. H owever,

ther e ar e a number o f probl em s by pr esent o f hypergl ycemia.

Periodontal disease

Microangiopathy altering antigenic challenge.

Altered cell-mediated immune response and impaired of neutrophil

chemotaxis. Increased Ca+ and glucose lead to plaque formation.

Increased collagen breakdown.




complications Salivary glands

Xerostomia is common, but reason is unclear.

Tenderness, pain and burning sensation of tongue.

May secondary enlargement of parotid glands with sialosis.

Dental caries Increase caries prevalence in adult with diabetes. (xerostomia,

increase saliva glucose)

Hyperglycemia state shown a positive association with dental caries.




complications Increased risk of infection

Reasons unknown, but macrophage metabolism altered with inhibitionof phagocytosis.

Peripheral neuropathy and poor peripheral circulation

Immunological deficiency

High sugar medium

Decrease production of Ab

Candical infection are more common and adding effects withxerostomia




complications Delayed healing of wounds

Due to microangiopathy and ultilisation of protein for energy, mayretard the repair of tissues.

Increase prevalence of dry socket.

Miscellaneous conditions Pulpitis : degeneration of vascular.

Neuropathies : may affect cranial nerves. (facial) Drug side-effects : lichenoid reaction may be associated with

sulphonylurea. (chlopropamide)

Ulcers

New Zealand Journal, Jan 1985



Dental management

considerationsT o minimize the r isk o f an int rao perative emerg ency ,

cl inician s need t o con sider some issues bef or e initiating

dent al tx. Medical history :Assess glycemic control at initial appt.

Glucose levels

Frequency of hypoglycemic episodes

Medication, dosage and times.

Consultation



Dental management

considerations Scheduling of visits

Morning appt. (endogeneous cortisol) Do not coincide with peak activity.

Diet Ensure that the patient has eaten normally and taken medications as usual.

Blood glucose monitoring Measured before beginning. (<70 mg/dL)

Prophylactic antibiotics Established infection

Pre-operation contamination wound Major surgery



Dental management

considerations During treatment

The most complication of DM occur is hypoglycemia episode.

Hyperglycemia

After treatment

Infection control

Dietary intake

Medications : salicylates increase insulin secretion and sensitivityavoid aspirin.



Emergency management

Hypoglycemia

Initial signs : mood changes, decreased

spontaneity, hunger and weakness.

Followed by sweating, incoherence, tachycardia.

Consequenced in unconsiousness, hypotention,

hypothermia, seizures, coma, even death.




15 grams of fast-acting oral carbonhydrate.

Measured blood sugar.

Loss of conscious, 25-30ml 50% dextrose solution iv.over 3 min period.

Glucagon 1mg.




Severe hyperglycemia

A prolonged onset

Ketoacidosis may develop with nausea, vomiting,abdominal pain and acetone odor.

Difficult to differentiate between hypo- or hyper-.




Hyperglycemia need medication intervention andinsulin administration.

While emergency, give glucose first ! Small amount is unlikely to cause significant harm.

J ADA, Oct 2001



Conclusion



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Dental Management of Diabetic Patients