1. Diabetes Mellitus for Dentist

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

3. Epidemiology 6 – 15 % of the general population have DM. 6 – 15 % of the general population have DM. Almost 20% of adult older than 65 years 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 Develops in people of all ages but most diabetics are 45 years and older Sixth most common cause of death Sixth most common cause of death Leading cause of : Leading cause of : Û Blindness Û 25-50 % End Stage Renal Disease Û Constant blood glucose level is maintained (70-110 mg/dl)

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

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

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

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

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

9. Comparing IDDM and NIDDM

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

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

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

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

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

16. Blood Glucose Testing : Glucometer Testing Purchase a glucometer for the dental clinic Purchase a glucometer for the dental clinic Ask your patients to bring their glucometers to your 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 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 Consider referral to a physician for further evaluation

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

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

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

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

23. 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: 1.Administer oral glucose source 2.Monitor vital signs 3.IV D50, 50ml or glucagon 1mg 4.Consult physician Severe S & S: 1.IV D50, 50ml or glucagon 1mg 2.Prepare to ER 3.Monitor vital signs 4.Give O 2 Hypoglycemia Hypoglycemia

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

25. DKA vs. HHNS

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

27. Complications of Diabetes Mellitus I. Macrovascular (large vessel) disease I. Macrovascular (large vessel) disease (Accelerated Atherosclerosis) Heart: CHD, congestive heart failure Heart: CHD, congestive heart failure Cerebrovascular: stroke Cerebrovascular: stroke Peripheral: gangrene Peripheral: gangrene II. Microvascular (small vessel) disease (Thickened capillary basement membrane) Nephropathy: kidney failure Nephropathy: kidney failure Retinopathy: blindness Retinopathy: blindness Neuropathy : Pain & Ulcers Neuropathy : Pain & Ulcers

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

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

31. Oral Hypoglcemics

32. 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

33. 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

34. 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.

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

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