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Diabetes mellitus

Mithileswer Kadiyala

Contents
Diabetes-Introduction Normal blood glucose levels Classification Diagnosis Pathophysiology Symptoms & Complications Oral manifestations Management & Emergency Treatment

Diabetes mellitus
Introduction
Diabetes mellitus is a metabolic disorder characterized by relative or absolute insufficiency of insulin, and resultant disturbances of carbohydrate metabolism. The major function of insulin is to make glucose available to various cells in the body & thus decrease blood glucose levels.

Normal blood glucose levels


normal blood glucose level :- 75-110mg/dl.. blood glucose level >180mg/dl..- HYPERGLYCEMIA.
(glucose spills in the urine)

blood glucose level <50mg/dl..(cerebral function is impaired)

HYPOGLYCEMIA.

Etiologic classification of DM
There are two types of Diabetes Mellitus:

Type 1, insulin-dependent or, juvenile-onset diabetes (IDDM) Type 2, non-insulin-dependent, adult-onset diabetes (NIDDM)

Type 1 (IDDM)
Autoimmune destruction of the insulin-producing beta cells of pancreas. 5-10% of DM cases. Mostly occurs in childhood and adolescence or any adolescence, age. Absolute insulin deficiency. High incidence of severe complications complications. Prone to autoimmune diseases (Graves, Addison, diseases. Hashimotos thyroiditis)

Type 2 (NIDDM)
Result from impaired insulin function. (insulin resistance) Constitutes 90-95% of DM Specific causes of this form are unknown. Risk factors : age, obesity, alcohol, diet, family history and lack of physical activity..etc.

Comparison
Clinical

Type 1
-onset <20 years -normal weight -decreased blood insulin -anti-islet cell antibodies

Type 2
-onset >30 years -obesity -normal or increased blood insulin -no anti-islet cell antibodies ketoacidosis rare No HLA association insulin resistance

Genetics

ketoacidosis common human leukocyte antigen (HLA)-D linked

Pathogenesis

autoimmunity, immunopathologic mechanisms severe insulin deficiency

relative insulin deficiency no insulitis focal atrophy and amyloid deposits mild beta-cell depletion

Islet Cells

insulitis early marked atrophy and fibrosis severe beta-cell depletion

Diagnosis
A Random plasma glucose(RBS) level of >=200 mg/dL with symptoms presented. Fasting plasma glucose level(FBS) of >=126. (Normal <110 mg/dL,) Oral glucose tolerance test (OGTT) value in blood of >=200 mg/dL. Glycosylated haemoglobin (HbA1c ) value >7%

Physiology of insulin hormone


intake of food carbohydrates digested in intestines converted to glucose insulin is produced by beta cells of pancreas in response to increased blood glucose levels. insulin promotes intake of glucose into the cells..thus decreasing blood glucose..

Pathophysiology of Diabetes
In type1:- -insulin is not secreted by beta cells -as a result,glucose doesnot enter into cells. -so cells are starved of glucose inspiteof its presence in plenty. In type2:-cells are resistant to insulin -hence though insulin is present, glucose is not taken by cells.

Pathophysiology of Diabetes(cont.)
Lack of insulin or insulin resistance, result in inability of insulin-dependent cells to use glucose. As a result cells utilize fats for energy Triglycerides broken down to fatty acids blood ketones diabetic ketoacidosis(diabetic coma). The chances of occurrence of ketoacidosis is more common in type1 diabetes..

Symptoms of Diabetes


As blood glucose levels become elevated (hyperglycemia), Glucose is excreted in the urine and excessive urination (polyuria) occurs because of osmotic diuresis. Increased fluid loss leads to dehydration and excessive thirst (polydipsia). Since cells are starved of glucose, the patient experiences increased hunger (polyphagia). Paradoxically, the diabetic patient often loses weight, since the cells are unable to take up glucose. These are the classic signs and symptoms of DM.

Complications of Diabetes
Many complications of diabetes are attributed to Microangiopathy caused by the disease Microangiopathy results in occlusion of small peripheral blood vessels, resulting in ischemia, which inturn predisposes to infection, gangrene, decreased wound healing Another factor for complications is impaired neutrophil chemotaxis making the host susceptable to infections..

Complications of Diabetes
Major organs/systems showing changes Cardiovascular system

Long term complications


myocardial infarct; atherosclerosis; hypertension; microangiopathy; cerebral vascular infarcts; cerebral hemorrhage

Pancreas Kidneys Eyes Nervous system Peripherals

islet cell loss; insulitis (Type 1); amyloid (Type 2) nephrosclerosis; glomerulosclerosis; arteriosclerosis; pyelonephritis retinopathy; cataracts; glaucoma autonomic neuropathy; peripheral neuropathy peripheral vascular atherosclerosis; infections; gangrene

Oral manifestations of Diabetes


A number of oral conditions have been associated with DM, particularly in patients with poor disease control. Oral manifestations can be grouped as follows
Periodontal disease Ulcers and irritation fibromas Fungal infections Faster alveolar bone resorption Salivary gland dysfunction Oral burning and taste disturbances Lichen planus and lichenoid reactions. Dental caries Delayed wound healing (remember as PUFF SOLDD)

Oral manifestations of Diabetes


Periodontal disease

Microangiopathy altering antigenic challenge. Altered cell-mediated immune response and impaired of neutrophil chemotaxis. Increased Ca+ and glucose lead to plaque formation. Increased collagen breakdown Xerostomia is common, but reason is unclear. Tenderness, pain and burning sensation of tongue. May secondary enlargement of parotid glands with sialosis.

Salivary glands

Oral manifestations of Diabetes


Dental caries
--Increase caries prevalence in adult with diabetes. (xerostomia, increase saliva glucose) --Hyperglycemia state shown a positive association with dental caries.

Oral burning and taste disturbances


--The burning may be due to peripheral neuropathy, xerostomia or candidiasis. Good glycemic control may alleviate the burning sensation. --some diabetic patients have a mild impairment of the sweet taste sensation. This may be related to xerostomia or disordered glucose receptors.

Oral manifestations of Diabetes


Fungal infections
an increased predisposition to manifestations of oral candidiasis, including median rhomboid glossitis, denture stomatitis and angular cheilitis. This predisposition may be due to xerostomia, increased salivary glucose levels or immune dysregulation. Mucormycosis is a rare but serious systemic fungal infection that may occur in patients with uncontrolled DM. Oral involvement usually appears as palatal ulceration or necrosis.

Oral manifestations of Diabetes


Lichen planus and lichenoid reactions The prevalence of oral lichen planus is significantly higher in diabetic patients than in control subjects. However, this may be a side effect of oral hypoglycemic agents or antihypertensive medications. Grinspan Syndrome is triad of lichenplanus , diabetes mellitus & vascular hypertension. Faster alveolar bone resorption Diabetic patients show increased alveolar bone compared to non-diabetic patients..

Oral manifestations of Diabetes


Traumatic ulcers and irritation fibromas
People with type 1 DM have a higher prevalence of oral traumatic ulcers and irritation fibromas. These findings may be related to altered wound healing patterns in these patients.

Delayed healing of wound


-Due to microangiopathy and ultilisation of protein for energy, may retard the repair of tissues. -Increase prevalence of dry socket.

Medical management
Exercise and diet control Insulin : rapid, short, intermediate, long acting. Oral antidiabetic agents

Management of Diabetic patient


To minimize the risk of an intraoperative emergency, clinicians need to consider some issues before initiating dental treatment

Medical history : take history and assess glycemic control at initial appt.
Glucose levels Frequency of hypoglycemic episodes Medication, dosage and times. Consultation

Management of Diabetic patient


Scheduling of visits Morning appt. (endogeneous cortisol) Do not coincide with peak activity. Diet Ensure that the patient has eaten normally and taken medications as usual. Blood glucose monitoring Measured before beginning. Prophylactic antibiotics Established infection Pre-operation contamination wound Major surgery

Emergency management
Hypoglycemia(Insulin shock):Initial signs: weakness; dizziness pale ; moist skin headache ; altered consciousness management: . i.v. injection of 50% dextrose sol. . i.m. injection of glucagon. .administration of oral forms of sugars.

Emergency management
Hyperglycemia(Ketosis):

Initial signs:

dry, warm skin ; kussmauls breathing; acetone breath; rapid weak pulse; headache ; altered consciousness management: . i.v. injection of 50% dextrose sol. .careful administration of i.m. insulin by monitering blood glucose levels. .administration of oxygen..

After treatment..
Patients with poorly controlled DM are at greater risk of developing infections and may demonstrate delayed wound healing. Therefore, antibiotic coverage may be necessary for patients with overt oral infections or for those undergoing extensive surgical procedures.

Conclusion
It is important for dentists to be familiar with the medical management of patients with DM, and to recognize the signs and symptoms of undiagnosed or poorly controlled disease. By taking an active role in the diagnosis and treatment of oral conditions associated with DM, dentists also may contribute to the maintenance of optimum health in patients with this disease.