Diabetes

• Fourth year dentistry students
• General medicine
• Diabetes mellitus


  A chronic condition characterized by high blood sugar levels due to the body's inability to produce or use insulin effectively

  
• 1st and 2nd lectures
• By Asst. professor Ahmed Almerzoug
• Objectives


  • Understand definition, clinical picture, diagnosis, complications and general management of DM
  • Oral manifestations of DM
  • Oral complications in DM patients
  • Considerations in dental management of dm patients
• Risk Factors for T2DM

  • Genetics
  • Lifestyle
  • Environment
  • Social Determinants
  • Family history
  • Race or ethnicity
  • Weight gain/obesity
  • Physical inactivity
  • Poor sleep
  • Smoking
  • Acculturation
• Obesity


  Abnormal or excessive fat accumulation that presents a risk to health
• Body mass index (BMI)


  A screening tool, but it does not diagnose body fatness or health

  
• In Asians, Overweight: ≥23 kg/m2

  
• Symptoms of Type 1 Diabetes

  • Polydipsa (increased thirst)
  • Polyuria (increased urination)
  • Polyphagia (increased hunger)
  • Weight loss
  • Loss of strength
  • Skin infections
  • Irritability
  • Headache
  • Drowsiness
  • Malaise
  • Dry mouth

  
• Symptoms of Type 2 Diabetes

  • Weight gain (or loss)
  • Night time urination
  • Genital fungal infections
  • Blurred vision
  • Decreased vision
  • Paresthesias
  • Impotence
  • Postural hypotension
• Diagnostic criteria for DM

  • Random blood glucose (by itself is not reliable for diagnosis but can provide information on real time blood glucose for monitoring purposes)
  • Fasting blood glucose ≥ 126 mg/dl
  • Symptoms of DM (polyuria, polydipsia, wt. loss) plus casual blood glucose that is ≥ 200 mg/dl
  • Two hour post-prandial blood glucose ≥ 200 mg/dl
  • Glycosylated hemoglobin (HbA1c gt7 measures blood glucose past 2-3 months)
  • Urinalysis - not reliable

  
• Acute Complications of Diabetes

  • Hypoglycemia
  • Diabetes Ketoacidosis (DKA)
  • HHNS, which is also called hyperglycemic hyperosmolar nonketotic coma or hyperglycemic hyperosmolar syndrome
• Hyperglycemia (Ketoacidosis)


  • Disorientation
  • Rapid, deep breathing
  • Hot, dry skin
  • Acetone breath
  • Hypotension
  • Coma (blood glucose 300 to 600 mg/dl)
• HYPERGLYCEMIC HYPEROSMOLARNONKETOTIC SYNDROME


  Hyperglycemia predominate, with alterations of the sensorium (sense of awareness). At the same time, ketosis is minimal or absent. The basic biochemical defect is lack of effective insulin (ie, insulin resistance). The patients persistent hyperglycemia causes osmotic diuresis, resulting in losses of water and electrolytes. To maintain osmotic equilibrium, water shifts from the intracellular fluid space to the extracellular fluid space. With glucosuria and dehydration, hypernatremia and increased osmolarity occur.

  
• Hypoglycemia


  • Hypoglycemia symptoms will unlikely occur if blood glucose levels are gt than 45 mg/dl
  • CNS/Adrenergic Effects Headache, mental confusion, somnolence, sweating, tachycardia, tremors, nervousness (40 mg/dl or less)
  • Disorientation (30 mg/dl or less)
  • Seizures/Coma (25 mg/dl or less)

  
• HYPOGLYCEMIA (INSULIN REACTIONS)


  The blood glucose falls to less than 50 to 60 mg/dL (2.7 to 3.3 mmol/L). It can be caused by too much insulin or oral hypoglycemic agents, too little food, or excessive physical activity. It often occurs before meals, especially if meals are delayed or snacks are omitted.

  
• Complications of Diabetes Mellitus

  • Macrovascular (large vessel) disease (accelerated atherosclerosis)
  • Microvascular (small vessel) disease (thickened capillary basement membrane)
  • Neuropathy (gt50 of all diabetics)
  • Decreased resistance to infection

  
• Macrovascular complications


  • Heart CHD, congestive heart failure
  • Cerebrovascular stroke
  • Peripheral gangrene
• Microvascular complications


  • Nephropathy kidney failure
  • Retinopathy blindness
• Neuropathy complications


  • Impotence
  • Bladder dysfunction
  • Paresthesias
  • Neuropathic pains (diabetic neuropathy, including burning mouth)
  • Neuromuscular dysfunction
  • Muscle weakness
  • Muscle cramps
• Management of DM


  • Life style modifications: control body weight
  • Regular sport
  • Dietary modifications: decrease refined sugar and avoid fatty meals, increase vegetable consumption and whole grain diet which must be rich in fibers
• Insulin


  One of the two principle hormones produced and secreted by the pancreas (the other is glucagon). Insulin is produced by the beta cells and glucagon is produced by the alpha cells in the islets of Langerhans. Insulin promotes the entry of glucose into most cells of the body and thus controls the rate of carbohydrate metabolism glucose can then be used immediately for energy or it will be stored in the form of glycogen or fat.

  
• Types of Insulin


  • Rapid acting 5-15min Lispro Aspart
  • Short acting 30-60min Regular
  • Intermediate 2-4h NPH Lente
  • Long acting 6-10h Ultralente Glargine
  • Premixed 30-60min 70NPH/30 regular

  
• Diabetic macrovascular complications


  Result from changes in the medium to large blood vessels. Blood vessel walls thicken, sclerose, and become occluded by plaque that adheres to the vessel walls. Eventually, blood flow is blocked.
• Myocardial infarction


  Twice as common in diabetic men and three times as common in diabetic women. Coronary artery disease may account for 50- 60 of all deaths in patients with diabetes. Patients may not experience the early warning signs of decreased coronary blood flow and may have silent myocardial infarctions. These silent myocardial infarctions may be discovered only as changes on the electrocardiogram. This lack of ischemic symptoms may be secondary to autonomic neuropathy.
• Cerebrovasculer complications


  Cerebral blood vessels are similarly affected by accelerated atherosclerosis. Occlusive changes or the formation of an embolus elsewhere in the vasculature that lodges in a cerebral blood vessel can lead to transient ischemic attacks and strokes. People with diabetes have twice the risk of developing cerebrovascular disease, and studies suggest there may be a greater likelihood of death from cerebrovascular disease in patients with diabetes.
• Diabetic Macrovascular Complications


  Signs and symptoms of peripheral vascular disease include diminished peripheral pulses and intermittent claudication (pain in the buttock thigh, or calf during walking). The severe form of arterial occlusive disease in the lower extremities is largely responsible for the increased incidence of gangrene and subsequent amputation in diabetic patients.
• Retinopathy


  The eye pathology referred to as diabetic retinopathy is caused by changes in the small blood vessels in the retina, the area of the eye that receives images and sends information about the images to the brain. Nearly all patients with type 1 diabetes and more than 60 of patients with type 2 diabetes have some degree of retinopathy after 20 years.
• Diabetic foot


  Foot ulcers are one of the main complications of DM, with a 15 lifetime risk for foot ulcers in all diabetic patients. With damage to the nervous system, a person with diabetes may not be able to feel his or her feet properly. Normal sweat secretion and oil production that lubricates the skin of the foot is impaired. These factors together can lead to abnormal pressure on the skin, bones, and joints of the foot during walking and can lead to breakdown of the skin of the foot. Sores may develop. Damage to blood vessels and impairment of the immune system from diabetes make it difficult to heal these wounds. Bacterial infection of the skin, connective tissues, muscles, and bones can then occur. These infections can develop into gangrene.
• Salivary gland dysfunction and xerostomia

  Dry mouth complaints (xerostomia) and salivary hypofunction noticed in patients with diabetes, which may be due to polyuria, or an underlying metabolic or endocrine problem. When the normal environment of the oral cavity is altered because of a decrease in salivary flow or alteration in salivary composition, a healthy mouth can become susceptible to dental caries and tooth deterioration. Dry, atrophic and cracking oral mucosa is the eventual complication from insufficient salivary production. Accompanying mucositis, ulcers and desquamation, as well as an inflamed, depapillated tongue, are also common problems.
• Diabetes Mellitus and Periodontal Disease


  While the exact relationship between DM and periodontal disease remains unclear, the bulk of evidence suggests that periodontal disease is more prevalent and severe among diabetics than among non-diabetics.

  
• Candidiasis


  Oral candidiasis is an opportunistic fungal infection commonly associated with hyperglycemia and is thus a frequent complication of marginally controlled or uncontrolled diabetes. Oral lesions associated with candidiasis include median rhomboid glossitis (central papillary atrophy), atrophic glossitis, denture stomatitis, pseudomembraneous candidiasis (thrush) and angular cheilitis. Candida albicans is a constituent of the normal oral microflora that rarely colonizes and infects the oral mucosa without predisposing factors. These include immunologically compromised conditions (for example, AIDS, cancer or diabetes), the wearing of dentures in conjunction with poor oral hygiene and the long-term use of broad-spectrum antibiotics.
• Oral Manifestations of DM

  • xerostomia
  • enlargement of parotid glands
  • burning mouth/tongue
  • altered taste
  • candidiasis
  • mucormycosis
  • periodontal disease
  • increased caries risk
• ORAL COMPLICATIONS OF DIABETES

  • Gingivitis and periodontal disease
  • Patients with type 1 diabetes and chronic, marginal metabolic control of the disease have more extensive and severe periodontal disease than do patients who maintain rigorous control of their diabetes. Patients with type 1 diabetes and retinopathy tend to exhibit more loss of periodontal attachment by the fourth and fifth decades of life.

  
• Dental Management Considerations


  • Screening/identification
  • Prevention of hypoglycemia
  • Planning dental treatment and surgery
  • Infection management
  • Antibiotic prophylaxis
  • Oral manifestations
• Prevention of Hypoglycemia(Insulin Reaction)

  • Make sure pt has normal meals along with insulin
  • AM appointments best - avoids peak insulin action
  • Watch for hypoglycemic symptoms Mood change, hunger, anxiety, tremor, headache, lightheadedness, sweating, nausea, tachycardia
  • Tell patient to advise you at first onset of symptoms
  • Check with glucometer if patient becomes symptomatic
  • Treatment oral CHO (sugar, OJ, cola, candy, cake icing) do not give oral CHO if unconscious!

  
• Dental Treatment Guidelines


  • A well controlled, stable diabetic, whether diet controlled, on oral hypoglycemics, or taking insulin, requires little or no modification for routine dental care, including surgery
  • Make sure patient has normal meals and continues normal insulin administration
  • For poorly controlled, uncontrolled or symptomatic diabetics, defer elective treatment and consult with physician to determine stability and control of their disease
• Following Oral Surgery


  • If the patient is unable to eat a normal diet as a result of the surgery, encourage alternate dietary intake such as a liquid dietary supplement (e.g. Ensure)
  • Insulin may need to be decreased if food intake is decreased
  • Presence of infection may temporarily increase the insulin requirement
  • Postoperative antibiotics are not necessary if diabetes is well controlled may be indicated for poorly controlled diabetic, especially if oral/dental infection present