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Diabetes Mellitus for Dentist

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

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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 or insulin resistance 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. Epidemiology • 6 – 15 % of the general population have DM. • Almost 20% of adult older than 65 years 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 (70-110 mg/dl)

  4. Diabetes Mellitus Classification • Type 1 Diabetes : Absolute insulin deficiency, autoimmune disease • Insulin-Dependent Diabetes Mellitus (IDDM) 5-10% • Type 2 Diabetes: Insulin Resistance(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 Fasting Glucose : Moderate elevation of blood glucose; have high risk of developing diabetes & CAD • Secondary Diabetes ( Drugs & other endocrine disorders ).

  5. 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

  6. 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 History and lack of physical activity.

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

  8. 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)

  9. Comparing IDDM and NIDDM

  10. Comparing IDDM and NIDDM

  11. 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

  12. Mucormycosis: • Rare , Occurs in DKA • Deep fungal infection with Mucorales • Signs and symptoms: • Nasal obstruction • Bloody nasal discharge • Facial pain and swelling • Visual disturbances • Later, blindness, seizers, and death

  13. 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

  14. Diagnosing DM • Normal: 70-110 mg/dl • Symptomatic :1 Reading • Asymptomatic :2 Readings • Diabetes (one of the 3): • Random: ≥ 200 mg/dL • Fasting glucose ≥126 mg/dL • OGTT ≥ 200 mg/dL

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

  16. 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

  17. Multiple Systemic Complications: Nephropathy Retinopathy Accelerated atherosclerosis Neuropathy Skin lesions Delayed wound healing Increased susceptibility to infection Cataract Subgingival microflora Periodontitis has been described as the sixth complication of diabetes mellitus

  18. Pathophysiological Mechanisms • Impaired neutrophil function • Decreased phagocytosis • Decreased leukotaxis • Increased bone loss • Tobacco use increases risk

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

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

  21. 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

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

  23. DKA vs. HHNS

  24. 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

  25. 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

  26. 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

  27. 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

  28. Oral Hypoglcemics

  29. 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

  30. 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

  31. 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.

  32. Precautions when treating the IDDM pt. • Brief morning appointments. Decrease stress. • Patient 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.

  33. 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.

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