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Diabetes Mellitus for Dentist

Diabetes Mellitus for Dentist. Diabetes Mellitus. A constellation of abnormalities caused by lack of insulin and characterized by: Polyuria Polydipsia Polyphagia Weight loss or weight gain, hyperglycemia, glucosuria, ketosis, acidosis and coma = Hyperglycemia, with secondary damage to:

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Diabetes Mellitus for Dentist

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  1. Diabetes MellitusforDentist

  2. Diabetes Mellitus • A constellation of abnormalities caused by lack of insulin and characterized by: • Polyuria • Polydipsia • Polyphagia • Weight loss or weight gain, hyperglycemia, glucosuria, ketosis, acidosis and coma • = Hyperglycemia, with secondary damage to: • Kidneys ESRD • Eyes  Blindness • Nerves Peripheral sensory and Autonomic neuropathy • Blood vessels Extremities Amputation

  3. Diabetes Mellitus • Disease complex resulting from lack of insulin • Low output of insulin from pancreas • Unresponsiveness of peripheral tissues to insulin • Metabolic component: • Increased blood glucose from lack of insulin. • Changes in lipid protein metabolism • Vascular component: • Atherosclerosis • Microangiopathy affecting the kidneys and eyes

  4. Epidemiology • 6 – 15 % of the general population have diabetes mellitus. • Almost 20% of adult older than 65 y/o have DM. • Develops in people of all ages but most diabetics are 45 years and older • Sixth most common cause of death • Leading cause of : • Blindness • 25-50 % End Stage Renal Disease • Constant blood glucose level is maintained (65-110 mg/dl) • Blood glucose rises and falls in response to meals

  5. Diabetes Mellitus Classification • Type 1 Diabetes(Absolute insulin deficiency, autoimmune disease) • Insulin-Dependent Diabetes Mellitus (IDDM) 5-10% • Type 2 Diabetes(Relative, progressive insulin deficiency; non-autoimmune etiology) Non-Insulin-Dependent Diabetes Mellitus (NIDDM) 85-90% • Gestational(occurrence only during pregnancy); at increased risk for developing type 2 diabetes later in life (4% of pregnancy ). • Impaired glucose homeostasis (prediabetes);moderate elevation of blood glucose; have high risk of developing diabetes • Secondary Diabetes ( Drugs & other endocrine disorders.

  6. Type 1 (IDDM) • Autoimmune destruction of the insulin-producing beta cells of pancreas. • 5-10% of DM cases < 40 years. • Common occurs in childhood and adolescence, or any age. • Absolute insulin deficiency. • High incidence of severe complications ( DKA ). • Prone to autoimmune diseases. (Grave’s, Addison, Hashimoto’s thyroiditis) • Treated with Insulin

  7. Type II: (NIDDM ) • Non-autoimmune ( Unknown specific cause ) • 85-90% of cases > 40 years • Does not cause ketoacidosis • Treated with Hypoglycaemic agents ± Insulin • Two metabolic defects: • Decreased insulin secretion • Inability of tissues to respond to insulin due to a receptor defect • Risk factors : age, obesity, alcohol, diet, family Hx and lack of physical activity.

  8. Pathophysiology of Diabetes Mellitus

  9. Diabetes Mellitus • Results from a deficiency of insulin Due to: • Low output of insulin from the pancreas OR BY • Peripheral tissues being unresponsive to the insulin

  10. Common symptoms: Polydipsia Polyuria Polyphagia Weight loss Loss of strength Other symptoms: Bed wetting Skin infections Marked irritability Headache Drowsiness Malaise Dry mouth Symptoms of Type I Diabetes (IDDM)

  11. Common Symptoms: Same as IDDM but uncommon Genital fungal infections Gain or loss of weight Urination at night Blurred/decreased vision Parasthesias / loss of sensation Impotence Postural hypotension Symptoms of Type II Diabetes (NIDDM)

  12. Comparing IDDM and NIDDM

  13. Comparing IDDM and NIDDM

  14. Oral Manifestations of DM • None are Pathognomonic • Commonly associated conditions: • Xerostomia • Parotid glands enlargement • Burning mouth/tongue • Altered taste • Infections • Candidiasis • Mucormycosis • Periodontal disease • Abnormal eruption pattern • Increased caries risk • Impaired healing

  15. 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 factors) • Rapid alveolar bone destruction • Delayed healing

  16. Diagnosing DM • Normal: 70-110 mg/Dl • Symptomatic :1 Reading • Asymptomatic :2 Readings • Diabetes (one of the 3): • Random: ≥ 200 mg/dL • 110-200 mg/dL has Impaired Glucose Tolerance • Fasting glucose ≥126 mg/dL • 110-126 mg/dL has Impaired Fasting Glucose • OGTT ≥ 200 mg/dL • 140-200 mg/dL has Impaired Glucose Tolerance

  17. Glycosylated (glycated) Haemoglubin • 4-6% Normal • <7.5% Good control • 7.6-8.9% Moderate control • >9% Poor control

  18. Blood Glucose Testing : Glucometer Testing • Purchase a glucometer for the dental clinic • Ask your patients to bring their glucometers to your clinic • Obtain a blood glucose reading/s – Is the patient’s diabetes well controlled/not? – Consult with the physician • Consider referral to a physician for further evaluation

  19. Host response Subgingival microflora Collagen metabolism Vascularity Heredity patterns Periodontitis has been described as the sixth complication of diabetes mellitus Pathophysiological Mechanisms Impaired neutrophil function Decreased phagocytosis Decreased leukotaxis Increased bone loss Tobacco use increases risk Diabetes May Cause Alterations in….

  20. Multiple Systemic Complications: • Nephropathy • Retinopathy • Accelerated atherosclerosis • Neuropathy • Skin lesions • Delayed wound healing • Increased susceptibility to infection • Cataract

  21. Acute complications of diabetes • Hypoglycemia! * Most likely problem to be encountered in the dental clinic • Diabetic ketoacidosis • Marked hyperglycemia (>500 mg/dL) • Dehydration • Metabolic ketoacidosis (nausea, vomiting, respiratory difficulties) • Hyperosmolar nonketotic coma

  22. Hypoglycaemia: < 50 mg / dl • Very serious emergency • Signs and symptoms: • Warm sweaty skin • Rapid bounding pulse • Dilated (reacting) pupils • Anxiety, tremor, aggression • Confusion • Tingling sensation around the mouth • Loss of consciousness

  23. Hypoglycemia

  24. Manifestation of Acute Hypoglycemia

  25. Hyperglycaemia: • Less serious than hypoglycemia • Signs and symptoms: • Vomiting • Hyperventilation • Acetone breath • Dehydration • Hypotension • Tachycardia • Dry mouth and skin

  26. Hyperglycemia (Ketoacidosis)

  27. Emergency Management: • Hypoglycemia: • Sugar orally • Glucose IV • Glucagon IM • Hyperglycemia: • Transfer to hospital • If in doubt, assume hypoglycemia not hyperglycemia

  28. Terminate all Procedures Mild S & S: 1.Administer oral glucose source 2.Monitor vital signs 3.Consult physician 4.Intake before next visit • Moderate S & S: • Administer oral glucose source • Monitor vital signs • IV D50, 50ml or glucagon 1mg • Consult physician • Severe S & S: • IV D50, 50ml or glucagon 1mg • Prepare to ER • Monitor vital signs • Give O2 • Hypoglycemia

  29. Emergency management :Hyperglycemia • Severe : A prolonged onset • Ketoacidosis may develop with nausea, vomiting, abdominal pain and acetone odor. • Difficult to different hypo- or hyper-. • Hyperglycemia need medication intervention and insulin administration. • While emergency, give glucose first ! • Small amount is unlikely to cause significant harm.

  30. Hyperosmolar Hyperglycemia Non Ketotic Coma(HHNS) • Hyperglycemia • Hypernatremia • Ketones are negative • Dehydration • Coma

  31. DKA vs. HHNS

  32. Long-Term Complications of Diabetes • After 15-20 years; Responsible for morbidity and mortality • Vascular: Accelerated atherosclerosis with MI, PVD, renal atherosclerosis • Ocular: Retinopathy, Cataract, Glaucoma , Blindness • Kidney: Glomerular, Vascular, Pyelonephritis , ESRD • Neuropathy • Increased sensibility to infectious • Poor wound healing • Disability

  33. Complications of Diabetes Mellitus 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 • Neuropathy : Pain & Ulcers

  34. Neuropathy (>50% of all diabetics) • Impotence • Bladder dysfunction • Paresthesias • Neuropathic pains (diabetic neuropathy, including burning mouth) Neuromuscular dysfunction • Muscle weakness • Muscle cramps Decreased Resistance to Infection

  35. Medical Management of DM • Diet (both type 1 and 2) • Exercise (both type 1 and 2) • Medications • Oral hypoglycemics (Type 2) • Insulin (type 1 and 2) • Rapid & Short Acting • Intermediate action • Long Acting • Injectable • Inhaled (avail. 2006) • Pancreatic transplant • Pancreas • Pancreas and kidney • Beta cells

  36. Oral Hypoglcemics

  37. Dental Management of the Diabetic Patient • Determine the status of the diabetic patient. • Thorough medical history • Type of diabetes • Medications • ? How they monitor their glucose levels • Results of last medical evaluation

  38. Dental management of the NIDDM patient • All dental procedures can be done. • For dental treatment, no special precautions needed unless symptoms of diabetes are present. • Take normal dosage of oral hypoglycemics for outpatient procedures

  39. Dental management of the IDDM patient • Depends on how well their disease is controlled. • If well controlled, routine treatment should be well tolerated using precautions. • If poorly controlled IDDM patient, do medical consult.

  40. Precautions when treating the IDDM pt. • Brief morning appointments. Decrease stress. • Pt. should take normal insulin dosage and eat normal breakfast. Confirm this with patient. • Consult physician if procedure will affect the patient’s ability to eat. Physician may alter the insulin therapy/diet for patient. • Minimize risk of infection: consider antibiotic coverage after surgery and treatment. in presence of suppuration. • Have a source of sugar available. • Consider adjunctive sedation.

  41. If the patient has an Acute Oral Infection: • Treat aggressively with definitive therapy such as: • Incision &Drainage • Extraction • Pulpectomy • Indicated = Antibiotic therapy, culture, and medical consultation. • Infection, causing alteration of blood glucose control, can necessitate change in insulin therapy and hospitalization.

  42. Indications for Periodic Screening for DM • Those people who have/are: • Showing signs or symptoms of diabetes or its complications • Diabetic relatives • Obese individuals • Over 40 years old • Delivered large babies • Spontaneous abortions or stillbirths

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