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Dental Management of Patients With Diabetes Mellitus


Symptoms of Type 1 Diabetes. Cardinal symptoms. Polydipsa (increased thirst) ... Symptoms of Type 2 Diabetes. Cardinal symptoms are uncommon. Weight gain (or loss) ... – PowerPoint PPT presentation

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Title: Dental Management of Patients With Diabetes Mellitus

Dental Management of Patients With Diabetes
  • Donald Falace, DMD
  • Professor and Division Chief
  • Oral Diagnosis and Oral Medicine
  • University of Kentucky College of Dentistry

Diabetes Mellitus
  • A constellation of abnormalities caused by lack
    of insulin and characterized by
  • Polyuria
  • Polydipsia
  • Polyphagia
  • Weight loss or weight gain, hyperglycemia,
    glycosuria, ketosis, acidosis and coma
  • Do not confuse diabetes mellitus with diabetes
  • Diabetes insipidus is a pituitary disorder due to
    a deficiency of vasopressin (ADH) that is
    characterized by the excretion of excessive
    quantities of urine. It is unrelated to diabetes

Epidemiology of Diabetes
  • Affects about 18 million individuals in the
    United States 5 million are unaware of their
  • 41 million adults between the ages of 40-74 have
    prediabetes which puts them at increased risk to
    develop type 2 diabetes obesity is a major risk
  • Develops in people of all ages but most diabetics
    are 45 years and older 1 in 5 over age 65 has
  • African Americans, Hispanics, American Indians
    and Alaskan Natives are 2-3 times more likely to
    have diabetes than Caucasians
  • Sixth most common cause of death in the United
    States in 2002 (73,000 deaths)
  • Leading cause of blindness and chronic renal

Basic Defect of Diabetes Mellitus
  • There is either an absolute lack (type 1) or a
    relative lack (type 2) of insulin production
  • And, in addition, with type 2 diabetes, there is
    an insensitivity or resistance to insulin by
    insulin receptors on target tissues

  • 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

Pathophysiology of Diabetes Mellitus
Diabetes Mellitus Classification
  • Previously used terms of insulin dependant or
    juvenile diabtes, and non-insulin dependant
    or adult diabetes have been replaced by
  • Type 1 Diabetes (absolute insulin deficiency,
    autoimmune disease)
  • Type 2 Diabetes (relative, progressive insulin
    deficiency non-autoimmune etiology)
  • Gestational (occurrence only during pregnancy)
    at increased risk for developing type 2 diabetes
    later in life
  • Impaired glucose homeostasis (prediabetes)
    moderate elevation of blood glucose have high
    risk of developing diabetes

Comparison of Type 1 and Type 2 Diabetes
Symptoms of Type 1 Diabetes
  • Cardinal symptoms
  • Polydipsa (increased thirst)
  • Polyuria (increased urination)
  • Polyphagia (increased hunger)
  • Weight loss
  • Loss of strength
  • Other symptoms
  • Skin infections
  • Irritability
  • Headache
  • Drowsiness
  • Malaise
  • Dry mouth

Symptoms of Type 2 Diabetes
  • Cardinal symptoms are uncommon
  • Weight gain (or loss)
  • Night time urination
  • Genital fungal infections
  • Blurred vision
  • Decreased vision
  • Paresthesias
  • Impotence
  • Postural hypotension

Laboratory Diagnosis of Diabetes Mellitus (DM)
  • Random blood glucose (by itself is not reliable
    for diagnosis but can provide information on real
    time blood glucose for monitoring purposes)
  • Normal fasting blood glucose is lt100 mg/dl
  • Diagnostic criteria for DM
  • Fasting blood glucose ? 126 mg/dl, or,
  • 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

Complications of Diabetes Mellitus(more common
and severe with type I)
  • I. Macrovascular (large vessel) disease
  • (accelerated atherosclerosis)
  • Heart CHD, congestive heart failure
  • Cerebrovascular stroke
  • Peripheral gangrene
  • II. Microvascular (small vessel) disease
  • (thickened capillary basement membrane)
  • Nephropathy kidney failure
  • Retinopathy blindness

  • IV. Neuropathy (gt50 of all diabetics)
  • Impotence
  • Bladder dysfunction
  • Paresthesias
  • Neuropathic pains (diabetic neuropathy,
  • including burning mouth)
  • V. Neuromuscular dysfunction
  • Muscle weakness
  • Muscle cramps
  • VI. Decreased resistance to infection

Metabolic Complications of Diabetes Mellitus
  • Hyperglycemia (deficient insulin, diabetic
    ketoacidosis) chronic, slowly progressive
  • Hypoglycemia (excess insulin, excess exercise,
    stress, poor diet) acute, rapidly progressive
  • most likely problem to be encountered in
    the dental office

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

  • It is unlikely that hypoglycemic symptoms will
    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)

Medical Management of DM
  • Diet (both type 1 and 2)
  • Exercise (both type 1 and 2)
  • Medications
  • Oral hypoglycemics (type 2 only)
  • Insulin (type 1 and 2)
  • Injectable
  • Inhaled (avail. 2006)
  • Pancreatic transplant
  • Pancreas
  • Pancreas and kidney
  • Beta cells

Oral Hypoglycemics
  • Drugs That Increase Insulin Supply
  • Sulfanylureas - enhance secretion of insulin from
    pancreas (requires functional ß cells)
  • First Generation
  • Tolbutamide (Orinase)
  • Acetohexamide (Dymelor)
  • Tolazamide (Tolinase)
  • Chlorpropamide (Diabenase)
  • Second Generation
  • Glimipride (Amaryl)
  • Glyburide (DiaBeta Micronase)
  • Glipizide (Glucotrol)
  • Other Secretagogues
  • Nateglinide (Starlix)
  • Repaglinide (Prandin)

Oral Hypoglycemics
  • Drugs That Decrease Insulin Resistance or Improve
    Insulin Effectiveness
  • Biguanides - decrease glucose secretion by liver
    and enhance the uptake of glucose in cells
  • Metformin (Glucophage)
  • Alpha-Glucosidase Inhibitors - slows uptake of
    CHO from gut
  • Acarbose (Precose)
  • Miglitol (Glyset)
  • Thiazolidinediones - increases cellular
    responsiveness to insulin
  • Pioglitazone (Actos)
  • Rosiglitazone (Avandia)

Progression of Type 2 Diabetes(Ann Int Med
  • Many patients with type 2 diabetes will
    eventually need a second oral drug or will need
    insulin ?-cell failure is progressive

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

Examples of Common Insulin Regimens
Insulin Pump for Continuous Infusion
  • Battery-driven external pump
  • Subcutaneous injection of short or rapid acting
  • Basal rate delivered throughout the day
  • Bolus delivered just before meals

Inhaled Insulin (Exubera)
  • The first inhaled insulin to get FDA approval.
  • Exubera delivers short-acting insulin via an
    inhaler. It offers adults with type 1 or type 2
    diabetes an alternative to the insulin injections
    they need to control their blood sugar.
  • The Exubera device isn't as small as an asthma
    inhaler. Folded up, it's the size of a standard
    flashlight. A retractable inhaler tube comes out
    from the body of the device when extended it
    reaches from the chest to the mouth. A blister
    pack of insulin then must be inserted before the
    device is triggered.

Pancreas/Kidney-Pancreas Transplant
Primary problem with these and any transplant
patient is the need for lifelong
immunosuppression which puts them at increased
risk for infection while probably not required,
antibiotic prophylaxis for invasive dental
procedures should be discussed with the physician
Islet Cell Transplantation(experimental)
  • Islet cell transplantation is a process whereby
    isolated islet cells from donor (cadaver)
    pancreases are injected into the liver of
    patients with Type 1 diabetes (Edmonton Protocol)
  • Once in the liver, the transplanted cells develop
    a blood supply and begin producing insulin.
  • The transplant is carried out under local
    anesthetic and does not involve major surgery
  • Most patients require islets from more than one
    donor pancreas, and therefore require more than
    one transplant procedure.
  • As with any other organ or tissue transplant,
    patients require immunosuppressive therapy in
    order to prevent rejection of the new cells

Dental Management Considerations
  • Screening/identification
  • Prevention of hypoglycemia
  • Planning dental treatment and surgery
  • Infection management
  • Antibiotic prophylaxis
  • Oral manifestations

Screening, Identification and Risk Assessment for
  • Type 1 or 2?
  • Severity of their disease?
  • Oral hypoglycemics or insulin (type, dose)?
  • Degree and ease of control?
  • Past insulin reactions?

Glucometer Testing/Screening(ask patient to
bring their glucometer with them)
  • Random blood glucose (glucometer)
  • Random blood glucose testing is variable (45-130
  • Fasting blood glucose
  • lt 126 mg

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
  • Check with glucometer if patient becomes
  • 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

Oral Manifestations of DM
  • None are pathognomonic
  • Commonly associated conditions
  • xerostomia
  • enlargement of parotid glands
  • burning mouth/tongue
  • altered taste
  • candidiasis
  • mucormycosis
  • periodontal disease
  • increased caries risk

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

Oral Red Flags(Suggest the need for medical
evaluation for possible diabetes)
  • Multiple or recurrent periodontal abscesses
  • Extensive periodontal bone loss (especially in a
    younger individual or with a lack of etiologic
  • Rapid alveolar bone destruction
  • Delayed healing

Carotid Atheromas and Type 2 Diabetes
(Friedlander, JADA,133Nov 2002)
  • Study of 46 patients with type 2 diabetes
  • 34 men 12 women
  • Age range 62-77
  • Presence of carotid artery calcifications on
    panoramic films
  • On insulin 36
  • Not on insulin 24
  • Non-diabetic controls 4