Diabetes MellitusDiabetes Mellitusforfor

DentistDentist

Diabetes MellitusDiabetes Mellitus A constellation of abnormalities caused by A constellation of abnormalities caused by

lack of insulin or insulin resistance lack of insulin or insulin resistance characterized by:characterized by:

PolyuriaPolyuria PolydipsiaPolydipsia PolyphagiaPolyphagia Weight loss or weight gain, hyperglycemia, Weight loss or weight gain, hyperglycemia,

glucosuria, ketosis, acidosis and comaglucosuria, ketosis, acidosis and coma

= Hyperglycemia, with secondary damage to:= Hyperglycemia, with secondary damage to: KidneysKidneys ESRD ESRD Eyes Eyes Blindness Blindness NervesNerves Peripheral sensory and Autonomic Peripheral sensory and Autonomic

neuropathyneuropathy Blood vesselsBlood vessels Extremities Amputation Extremities Amputation

EpidemiologyEpidemiology 6 – 15 %6 – 15 % of the general population have DM. of the general population have DM. Almost Almost 20% of adult20% of adult older than 65 years have older than 65 years have

DM.DM. Develops in people of all ages but most Develops in people of all ages but most

diabetics are 45 years and older diabetics are 45 years and older Sixth most common cause of death Sixth most common cause of death Leading cause of :Leading cause of :

Blindness Blindness 25-50 % End Stage Renal Disease25-50 % End Stage Renal Disease

Constant blood glucose level is maintained Constant blood glucose level is maintained (70-110 mg/dl)(70-110 mg/dl)

Diabetes Mellitus Diabetes Mellitus ClassificationClassification

Type 1 DiabetesType 1 Diabetes : : Absolute insulin deficiency, Absolute insulin deficiency, autoimmune disease autoimmune disease

Insulin-Dependent Diabetes Mellitus (IDDM) 5-10%Insulin-Dependent Diabetes Mellitus (IDDM) 5-10%

Type 2 DiabetesType 2 Diabetes : Insulin Resistance: Insulin Resistance (Relative, (Relative, progressive insulin deficiency; non-autoimmune etiology) progressive insulin deficiency; non-autoimmune etiology)

Non-Insulin-Dependent Diabetes Mellitus (NIDDM) 85-90%Non-Insulin-Dependent Diabetes Mellitus (NIDDM) 85-90%

GestationalGestational (Occurrence only during pregnancy); at (Occurrence only during pregnancy); at increased risk for developing type 2 diabetes later in life (increased risk for developing type 2 diabetes later in life (4%4% of of pregnancy ).pregnancy ).

Impaired Fasting Glucose : Impaired Fasting Glucose : MModerate elevation of oderate elevation of blood glucose; have high risk of developing diabetes & CADblood glucose; have high risk of developing diabetes & CAD

Secondary Diabetes Secondary Diabetes ( Drugs & other endocrine ( Drugs & other endocrine disorders ).disorders ).

Type 1 (IDDM)Type 1 (IDDM)

Autoimmune destructionAutoimmune destruction of the insulin-produ of the insulin-producing beta cells of pancreas.cing beta cells of pancreas.

5-10%5-10% of DM cases < 40 years. of DM cases < 40 years. Common occurs in Common occurs in childhood and adolescencechildhood and adolescence, ,

or any age.or any age. Absolute insulinAbsolute insulin deficiency. deficiency. High incidence of severe complications ( DKA ).High incidence of severe complications ( DKA ). Prone to Prone to autoimmune diseasesautoimmune diseases. (Grave’s, Addi. (Grave’s, Addi

son, Hashimoto’s thyroiditis)son, Hashimoto’s thyroiditis) Treated with Treated with InsulinInsulin

Type II: (NIDDM )Type II: (NIDDM ) Non-autoimmune ( Unknown specific cause )Non-autoimmune ( Unknown specific cause ) 85-90% of cases > 40 years85-90% of cases > 40 years Does not cause ketoacidosisDoes not cause ketoacidosis Treated with Hypoglycaemic agents ± Treated with Hypoglycaemic agents ±

InsulinInsulin Two metabolic defects:Two metabolic defects:

Decreased insulin secretionDecreased insulin secretion Inability of tissues to respond to insulin due to a Inability of tissues to respond to insulin due to a

receptor defectreceptor defect Risk factors :Risk factors : age, obesity, alcohol, diet, family age, obesity, alcohol, diet, family

History and lack of physical activity.History and lack of physical activity.

Symptoms of Type I Diabetes Symptoms of Type I Diabetes (IDDM)(IDDM)

Common Common symptoms:symptoms: PolydipsiaPolydipsia

PolyuriaPolyuria

PolyphagiaPolyphagia

Weight lossWeight loss

Loss of strengthLoss of strength

Other symptoms:Other symptoms: Skin infectionsSkin infections

Marked irritabilityMarked irritability

HeadacheHeadache

DrowsinessDrowsiness

MalaiseMalaise

Dry mouthDry mouth

Symptoms of Type II Diabetes Symptoms of Type II Diabetes (NIDDM)(NIDDM)

Common Symptoms:Common Symptoms: Same as IDDM but Same as IDDM but

uncommonuncommon Genital fungal infectionsGenital fungal infections

Gain or loss of weightGain or loss of weight

Urination at nightUrination at night

Blurred/decreased visionBlurred/decreased vision

Parasthesias / loss of Parasthesias / loss of sensationsensation

ImpotenceImpotence

Postural hypotensionPostural hypotension

Comparing IDDM and NIDDMComparing IDDM and NIDDM

IDDM NIDDM% of diabetics 5-10% 85-90%

age at onset 15 y.o 40+ y.o.

body build normal/thin obese

severity severe mild

Insulindependency

almost all 25-30%

oralhypoglycemics

few respond 50% respond

Comparing IDDM and NIDDMComparing IDDM and NIDDM

IDDM NIDDMketoacidosis common uncommon

onset of disease rapid slow

complications 90% in 20 yrs. Less common

stability unstable stable

family history common more common

insulin receptordefects

uncommon common

Oral Manifestations of DMOral Manifestations of DM None are PathognomonicNone are Pathognomonic Commonly associated Commonly associated

conditions:conditions: XerostomiaXerostomia Parotid glands Parotid glands

enlargementenlargement Burning mouth/tongueBurning mouth/tongue Altered tasteAltered taste InfectionsInfections CandidiasisCandidiasis MucormycosisMucormycosis Periodontal diseasePeriodontal disease Abnormal eruption Abnormal eruption

patternpattern Increased caries riskIncreased caries risk Impaired healingImpaired healing

Mucormycosis:Mucormycosis:

Rare , Occurs in DKARare , Occurs in DKA Deep fungal infection with MucoralesDeep fungal infection with Mucorales Signs and symptoms:Signs and symptoms:

Nasal obstructionNasal obstruction Bloody nasal dischargeBloody nasal discharge Facial pain and swellingFacial pain and swelling Visual disturbancesVisual disturbances Later, blindness, seizers, and deathLater, blindness, seizers, and death

Oral Red FlagsOral Red Flags(Suggest the need for (Suggest the need for medical evaluation for medical evaluation for

possible diabetes)possible diabetes) Multiple or recurrent periodontal Multiple or recurrent periodontal

abscessesabscesses Extensive periodontal bone loss Extensive periodontal bone loss

(especially in a younger individual or (especially in a younger individual or with a lack of etiologic factors)with a lack of etiologic factors)

Rapid alveolar bone destructionRapid alveolar bone destruction Delayed healingDelayed healing

Diagnosing DMDiagnosing DM Normal: 70-110 mg/dlNormal: 70-110 mg/dl Symptomatic :1 ReadingSymptomatic :1 Reading Asymptomatic :2 ReadingsAsymptomatic :2 Readings Diabetes (one of the 3):Diabetes (one of the 3):

Random: ≥ 200 mg/dLRandom: ≥ 200 mg/dL Fasting glucose ≥126 mg/dLFasting glucose ≥126 mg/dL OGTT ≥ 200 mg/dLOGTT ≥ 200 mg/dL

Glycosylated (glycated) Glycosylated (glycated) HaemoglubinHaemoglubin

4-6%4-6% Normal Normal <7.5%<7.5% Good Good

controlcontrol 7.6-8.9%7.6-8.9% Moderate Moderate

controlcontrol >9%>9% Poor Poor

controlcontrol

Blood Glucose Testing : Blood Glucose Testing :

Glucometer TestingGlucometer Testing Purchase a glucometer for the dental clinicPurchase a glucometer for the dental clinic Ask your patients to bring their glucometers Ask your patients to bring their glucometers

to your clinicto your clinic Obtain a blood glucose reading/sObtain a blood glucose reading/s

– Is the patient’s diabetes well – Is the patient’s diabetes well controlled/not?controlled/not?

– Consult with the physician– Consult with the physician Consider referral to a physician for further Consider referral to a physician for further

evaluationevaluation

Multiple Systemic Multiple Systemic Complications:Complications:

NephropathyNephropathy RetinopathyRetinopathy Accelerated atherosclerosisAccelerated atherosclerosis NeuropathyNeuropathy Skin lesionsSkin lesions Delayed wound healingDelayed wound healing Increased susceptibility to infectionIncreased susceptibility to infection CataractCataract Subgingival microfloraSubgingival microflora Periodontitis has been described as the sixth Periodontitis has been described as the sixth

complication of diabetes mellituscomplication of diabetes mellitus

Pathophysiological Pathophysiological MechanismsMechanisms

Impaired neutrophil functionImpaired neutrophil function Decreased phagocytosisDecreased phagocytosis Decreased leukotaxisDecreased leukotaxis

Increased bone lossIncreased bone loss Tobacco use increases riskTobacco use increases risk

Acute complications of Acute complications of diabetesdiabetes

Hypoglycemia! Hypoglycemia! * * Most likely problem to Most likely problem to be encountered in the dental clinicbe encountered in the dental clinic

Diabetic ketoacidosisDiabetic ketoacidosis Marked hyperglycemia (>500 mg/dL)Marked hyperglycemia (>500 mg/dL) DehydrationDehydration Nausea, vomiting, respiratory difficulties Nausea, vomiting, respiratory difficulties

Hyperosmolar nonketotic comaHyperosmolar nonketotic coma

Emergency management:Emergency management:

Hypoglycemia:Hypoglycemia: Sugar orallySugar orally Glucose IVGlucose IV Glucagon IMGlucagon IM

Hyperglycemia:Hyperglycemia: Transfer to hospitalTransfer to hospital

If in doubt, assume hypoglycemia not If in doubt, assume hypoglycemia not hyperglycemiahyperglycemia

Terminate all Terminate all ProceduresProcedures

Mild S & S:Mild S & S:1.Administer oral 1.Administer oral

glucose sourceglucose source2.Monitor vital signs2.Monitor vital signs3.Consult physician3.Consult physician4.Intake before next 4.Intake before next

visitvisit

Moderate S & S:Moderate S & S:1.1. Administer oral Administer oral

glucose sourceglucose source2.2. Monitor vital Monitor vital

signssigns3.3. IV D50, 50ml or IV D50, 50ml or

glucagon 1mgglucagon 1mg4.4. Consult physicianConsult physician

Severe S & S:Severe S & S:1.1. IV D50, 50ml or IV D50, 50ml or

glucagon 1mgglucagon 1mg2.2. Prepare to ERPrepare to ER3.3. Monitor vital Monitor vital

signssigns4.4. Give OGive O22

HypoglycemiHypoglycemiaa

Hyperosmolar Hyperglycemia Non Ketotic Coma

(HHNS) Hyperglycemia

Hypernatremia

Ketones are negative

Dehydration

Coma

DKA vs. HHNSDKA vs. HHNS

Long-Term Complications of Long-Term Complications of DiabetesDiabetes

After 15-20 years; Responsible for morbidity After 15-20 years; Responsible for morbidity and mortalityand mortality

Vascular:Vascular: Accelerated atherosclerosis with Accelerated atherosclerosis with MI, PVD, renal atherosclerosisMI, PVD, renal atherosclerosis

Ocular:Ocular: Retinopathy, Cataract, Glaucoma , Retinopathy, Cataract, Glaucoma , BlindnessBlindness

Kidney:Kidney: Glomerular, Vascular, Glomerular, Vascular, Pyelonephritis , ESRDPyelonephritis , ESRD

NeuropathyNeuropathy Increased sensibility to infectiousIncreased sensibility to infectious Poor wound healingPoor wound healing DisabilityDisability

Complications of Diabetes Complications of Diabetes MellitusMellitus

I. Macrovascular (large vessel) I. Macrovascular (large vessel) disease disease

(Accelerated Atherosclerosis)(Accelerated Atherosclerosis) Heart: CHD, congestive heart failureHeart: CHD, congestive heart failure Cerebrovascular: strokeCerebrovascular: stroke Peripheral: gangrenePeripheral: gangrene

II. Microvascular (small vessel) II. Microvascular (small vessel) diseasedisease

(Thickened capillary basement (Thickened capillary basement membrane)membrane)

Nephropathy: kidney failureNephropathy: kidney failure Retinopathy: blindnessRetinopathy: blindness Neuropathy : Pain & UlcersNeuropathy : Pain & Ulcers

Neuropathy (>50% of all diabetics)Neuropathy (>50% of all diabetics) ImpotenceImpotence Bladder dysfunctionBladder dysfunction ParesthesiasParesthesias Neuropathic pains (diabetic neuropathy, Neuropathic pains (diabetic neuropathy,

including burning mouth)including burning mouth)

Neuromuscular dysfunctionNeuromuscular dysfunction Muscle weaknessMuscle weakness Muscle crampsMuscle cramps

Decreased Resistance to InfectionDecreased Resistance to Infection

Medical Management of DMMedical Management of DM

Diet (both type 1 and Diet (both type 1 and 2)2)

Exercise (both type 1 Exercise (both type 1 and 2)and 2)

MedicationsMedications Oral hypoglycemics Oral hypoglycemics

(Type 2)(Type 2) Insulin (type 1 and 2)Insulin (type 1 and 2)

Rapid & Short ActingRapid & Short Acting Intermediate action Intermediate action Long ActingLong Acting InjectableInjectable Inhaled (avail. 2006)Inhaled (avail. 2006)

Pancreatic transplantPancreatic transplant

Oral HypoglcemicsOral Hypoglcemics

Dental Management of the Dental Management of the Diabetic PatientDiabetic Patient

Determine the status of the diabetic Determine the status of the diabetic patient.patient.

Thorough medical historyThorough medical history Type of diabetesType of diabetes MedicationsMedications ? How they monitor their glucose ? How they monitor their glucose

levelslevels Results of last medical evaluationResults of last medical evaluation

Dental Management of the NIDDM Dental Management of the NIDDM PatientPatient

All dental procedures can be done.All dental procedures can be done.

For dental treatment, no special precautions For dental treatment, no special precautions needed unless symptoms of diabetes are needed unless symptoms of diabetes are present.present.

Take normal dosage of oral hypoglycemics Take normal dosage of oral hypoglycemics for outpatient proceduresfor outpatient procedures

Dental management of the IDDM Dental management of the IDDM PatientPatient

Depends on how well their disease is Depends on how well their disease is controlled.controlled.

If well controlled, routine treatment should If well controlled, routine treatment should be well tolerated using precautions.be well tolerated using precautions.

If poorly controlled IDDM patient, do If poorly controlled IDDM patient, do medical consult.medical consult.

Precautions when treating the Precautions when treating the IDDM pt.IDDM pt.

Brief morning appointments. Decrease stress. Brief morning appointments. Decrease stress. Patient should take normal insulin dosage and Patient should take normal insulin dosage and

eat normal breakfast. Confirm this with patient.eat normal breakfast. Confirm this with patient. Consult physician if procedure will affect the Consult physician if procedure will affect the

patient’s ability to eat. Physician may alter the patient’s ability to eat. Physician may alter the insulin therapy/diet for patient.insulin therapy/diet for patient.

Minimize risk of infection: consider antibiotic Minimize risk of infection: consider antibiotic coverage after surgery and treatment. in coverage after surgery and treatment. in presence of suppuration.presence of suppuration.

Have a source of sugar available.Have a source of sugar available. Consider adjunctive sedation.Consider adjunctive sedation.

If the patient has an Acute Oral If the patient has an Acute Oral Infection:Infection:

Treat aggressively with definitive Treat aggressively with definitive therapy such as:therapy such as:

Incision &DrainageIncision &Drainage ExtractionExtraction PulpectomyPulpectomy

Indicated Indicated == Antibiotic therapy, culture, Antibiotic therapy, culture, and medical consultation.and medical consultation.

InfectionInfection, causing alteration of blood , causing alteration of blood glucose control, can necessitate change in glucose control, can necessitate change in insulin therapy and hospitalization.insulin therapy and hospitalization.