Diabetes Mellitus patients in dental management

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Diabetes Mellitus patients in dental management

• Reporter ???
• Modulator Dr. ???

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Introduction

• Diabetes mellitus is a metabolic disorder
  characterized by relative or absolute
  insufficiency of insulin, and resultant
  disturbances of carbonhydrate 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.

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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
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Etiologic classification of DM

• There 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 types

JADA, Oct 2001
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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)

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Type 2 (NIDDM)

• Result from impaired insulin function. (insulin
  resistance)
• 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.

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Other specific types

• Genetic defects of beta-cell functions
• Decrease of exocrine pancreas
• Endocrinepathothies
• Drug or chemical usage
• Infections
• .

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Gestational diabetes mellitus (GDM)

• Defined as any degree of glucose intolerance with
  onset or first recognition during pregnancy.
• 4 of pregnancy in US.

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Pathophysiology

• Healthy 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 glycogen
• Fatty acid and amino acids converted to
  triglyceride and protein stores.

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Pathophysiology

• 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.

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Pathophysiology

• As 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.

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Complications

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

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Diagnosis

• A casual plasma glucose level of 200 mg/dL or
  greater with symptoms presented.
• Fasting plasma glucose level of 126 or
  greater.(Normal lt110 mg/dL,IGT,IFG)
• Oral glucose tolerance test (OGTT) value in blood
  of 200 mg or greater.
• ADA recommend gt45 y/o screened every 3 years.

Diabetes Care, 2000 National Institutes of
Health, Aug 2001
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Medical management

• Objective 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.

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Medical management

• Glycated hemoglobin assay (HbA1c ) reflects mean
  glycemia levels over the proceding 23 months.
  (normal lt 7)
• HbA1c also a predictor for development of chronic
  complications.

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Medical management

• Exercise and diet control
• Insulin rapid, short, intermediate, long
  acting.
• Oral antidiabetic agents

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Oral manifestations and complications

• No specific oral lesions associated with
  diabetes. However, there are a number of problems
  by present of hyperglycemia.
• 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.

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Oral manifestations and 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.

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Oral manifestations and complications

• Increased risk of infection
• Reasons unknown, but macrophage metabolism
  altered with inhibition of phagocytosis.
• Peripheral neuropathy and poor peripheral
  circulation
• Immunological deficiency
• High sugar medium
• Decrease production of Ab
• Candical infection are more common and adding
  effects with xerostomia

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Oral manifestations and complications

• Delayed healing of wounds
• Due to microangiopathy and ultilisation of
  protein for energy, may retard 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
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Dental management considerations

• To 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 levels
• Frequency of hypoglycemic episodes
• Medication, dosage and times.
• Consultation

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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. (lt70 mg/dL)
• Prophylactic antibiotics
• Established infection
• Pre-operation contamination wound
• Major surgery

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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 sensitivity? avoid aspirin.

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Emergency management

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

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Emergency management

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

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Emergency management

• Severe hyperglycemia
• A prolonged onset
• Ketoacidosis may develop with nausea, vomiting,
  abdominal pain and acetone odor.
• Difficult to different hypo- or hyper-.

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Emergency management

• Hyperglycemia need medication intervention and
  insulin administration.
• While emergency, give glucose first !
• Small amount is unlikely to cause significant
  harm.

JADA, Oct 2001
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Conclusion
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Thanks for ur attention !!
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1.Liver
glucose
glucose TG glycerol-po4 glyce
rol FA glycerol FAALB
2.Adipose

• ketone body
• ATPco2
• acetyl coA
• TG
• FA
• Glycerol-po4
• glucose
• glucose

3.Muscle
glucose
glucose