Diabetes Mellitus patients in dental management shabeel pn

IntroductionDiabetes mellitus is a metabolic disorder characterized by relative or absolute insufficiency of insulin, and resultant disturbances of carbohydrate metabolism.

The major function of insulin is to counter the concerted action of a number of hyperglycemia-generating hormones and to maintain low blood glucose levels.

Epidemiology 6% (16 million persons) of the general population in the US have diabetes mellitus. Almost 20% of adult older than 65 y/o have DM.A dental practice serving an adult population of 2,000 can 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 DMThere are two types of Diabetes Mellitus:

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

Type 2, non-insulin-dependent, adult-onset diabetes (NIDDM)

Other specific typesJADA, Oct 2001

Type 1 (IDDM)Autoimmune destruction of the insulin-producing beta 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. (insulin resistance)Constitutes 90-95% of DMSpecific causes of this form are unknown.Risk factors : age, obesity, alcohol, diet, family Hx and lack of physical activity..etc.

ComparisonType 1Type 2Clinicalonset 30 yearsnormal weightobesitydecreased blood insulinnormal or increased blood insulinanti-islet cell antibodiesno anti-islet cell antibodiesGeneticsketoacidosis commonketoacidosis rarehuman leukocyte antigen (HLA)-D linkedNo HLA associationPathogenesisautoimmunity, immunopathologic mechanismsinsulin resistancesevere insulin deficiencyrelative insulin deficiencyIslet Cellsinsulitis earlyno insulitismarked atrophy and fibrosisfocal atrophy and amyloid depositssevere beta-cell depletionmild beta-cell depletion

Other specific typesGenetic defects of beta-cell functionsDecrease of exocrine pancreasEndocrinepathothiesDrug or chemical usageInfections.

Gestational diabetes mellitus (GDM)Defined as any degree of glucose intolerance with onset or first recognition during pregnancy.4% of pregnancy in US.

PathophysiologyHealthy people blood glucose level maintained within 60 to 150 mg/dL.Insulin synthesized in beta cells of pancreas and secreted rapidly into blood in response to elevations in blood sugar.Promoting uptake of glucose from blood into cells and its storage as glycogenFatty acid and amino acids converted to triglyceride and protein stores.

PathophysiologyLack 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.

PathophysiologyAs blood sugar levels became elevated (hyperglycemia), glucose is excreted in the urine and excessive of urination occurs 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 the cells are unable to take up glucose.

ComplicationsPeople with DM have an increased incidence of both microvascular and macrovascular complications.

Major organs/systems showing changesLong term complicationsCardiovascular system: heart, brain, blood vesselsmyocardial infarct; atherosclerosis; hypertension; microangiopathy; cerebral vascular infarcts; cerebral hemorrhagePancreasislet cell loss; insulitis (Type 1); amyloid (Type 2)Kidneysnephrosclerosis; glomerulosclerosis; arteriosclerosis; pyelonephritisEyesretinopathy; cataracts; glaucomaNervous systemautonomic neuropathy; peripheral neuropathyPeripheralsperipheral vascular atherosclerosis; infections; gangrene

DiagnosisA casual plasma glucose level of 200 mg/dL or greater with symptoms presented.Fasting plasma glucose level of 126 or greater.(Normal 45 y/o screened every 3 years.Diabetes Care, 2000National Institutes of Health, Aug 2001

Medical managementObjective : maintain blood glucose levels as close to normal as possible.

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

Medical managementGlycated 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 managementExercise and diet controlInsulin : rapid, short, intermediate, long acting.Oral antidiabetic agents

Oral manifestations and complicationsNo specific oral lesions associated with diabetes. However, there are a number of problems by present of hyperglycemia.

Periodontal diseaseMicroangiopathy altering antigenic challenge.Altered cell-mediated immune response and impaired of neutrophil chemotaxis.Increased Ca+ and glucose lead to plaque formation.Increased collagen breakdown.

Oral manifestations and complicationsSalivary glandsXerostomia is common, but reason is unclear.Tenderness, pain and burning sensation of tongue.May secondary enlargement of parotid glands with sialosis.

Dental cariesIncrease caries prevalence in adult with diabetes. (xerostomia, increase saliva glucose)Hyperglycemia state shown a positive association with dental caries.

Oral manifestations and complicationsIncreased risk of infectionReasons unknown, but macrophage metabolism altered with inhibition of phagocytosis.Peripheral neuropathy and poor peripheral circulation Immunological deficiencyHigh sugar mediumDecrease production of Ab

Candical infection are more common and adding effects with xerostomia

Oral manifestations and complicationsDelayed healing of woundsDue to microangiopathy and ultilisation of protein for energy, may retard the repair of tissues.Increase prevalence of dry socket.

Miscellaneous conditionsPulpitis : degeneration of vascular.Neuropathies : may affect cranial nerves. (facial)Drug side-effects : lichenoid reaction may be associated with sulphonylurea. (chlopropamide)UlcersNew Zealand Journal, Jan 1985

Dental management considerationsTo minimize the risk of an intraoperative emergency, clinicians need to consider some issues before initiating dental tx.Medical history : take hx and assess glycemic control at initial appt.Glucose levelsFrequency of hypoglycemic episodesMedication, dosage and times.Consultation

Dental management considerationsScheduling of visitsMorning appt. (endogeneous cortisol)Do not coincide with peak activity.DietEnsure that the patient has eaten normally and taken medications as usual.Blood glucose monitoringMeasured before beginning. (

Dental management considerationsDuring treatmentThe most complication of DM occur is hypoglycemia episode.Hyperglycemia

After treatmentInfection controlDietary intakeMedications : salicylates increase insulin secretion and sensitivity avoid aspirin.

Emergency managementHypoglycemiaInitial signs : mood changes, decreased spontaneity, hunger and weakness.Followed by sweating, incoherence, tachycardia.Consequenced in unconsiousness, hypotention, hypothermia, seidures, coma, even death.

Emergency management15 grams of fast-acting oral carbonhydrate.Measured blood suguar.Loss of conscious, 25-30ml 50% dextrose solution iv. over 3 min period.Glucagon 1mg.911, 119

Emergency managementSevere hyperglycemiaA prolonged onsetKetoacidosis may develop with nausea, vomiting, abdominal pain and acetone odor.Difficult to different hypo- or hyper-.

Emergency managementHyperglycemia need medication intervention and insulin administration.While emergency, give glucose first ! Small amount is unlikely to cause significant harm.JADA, Oct 2001

Conclusion

Thanks for ur attention !!

1.Liver ketone body ATP+co2 acetyl coA TG FAGlycerol-po4 glucose

glucose glucose glucose

TG glycerol-po4

glycerol +FA

glycerol FA+ALB

2.Adiposeglucoseglucose3.Muscle