DIABETES AND ITS ORAL MANIFESTATIONS.pptx

this seminar summerizes the oral manifestations that can occur in patients with diabetes

1. 21-12-2020 /38 1

2. DIABETES AND ITS ORAL MANIFESTATIONS BY Dr. Advaitha Anand Department of conservative dentistry and endodontics M.D.S 1 st year 2020 21-12-2020 /38 2

3. Introduction The word ‘diabetes’, derived from the Greek meaning ‘siphon’ or ‘pass through’, was first used by Aretaeus of Cappadocia in the 2nd century AD. Diabetes mellitus is a syndrome of impaired carbohydrate, fat, and protein metabolism caused by either lack of insulin secretion or decreased sensitivity of the tissues to insulin. The World Health Organization estimates that as many as 346 million people suffer from diabetes worldwide, with India and China being the largest contributors to the world’s diabetic load 21-12-2020 /38 3

4. History of Diabetes Diagnosis, epidemiology and pathogenesis of diabetes mellitus: an update for psychiatrists RICHARD I. G. HOLT BRITISH JOURNAL OF PSYCHIATRY (2004) 21-12-2020 /38 4

5. Diagnosis, epidemiology and pathogenesis of diabetes mellitus: an update for psychiatrists RICHARD I. G. HOLT BRITISH JOURNAL OF PSYCHIATRY (2004) 21-12-2020 /38 5

6. Diagnosis According to the ADA and WHO, diagnostic criteria for diabetes include: A fasting plasma glucose ≥ 126 mg/dL, A random plasma glucose ≥ 200 mg/dL 2-hour plasma glucose ≥ 200 mg/dL during an oral glucose tolerance test (OGTT) with a loading dose of 75 gm, and A glycated hemoglobin (HbA1C) level ≥ 6.5% Guyton and Hall Textbook of Medical Physiology 12 th edition(2011) 21-12-2020 /38 6

7. Classification (as per American Diabetes Association, 2007) TYPE 1 DIABETES MELLITUS (10%) (earlier called Insulin-dependent, or juvenile-onset diabetes) TYPE 2 DIABETES MELLITUS (80%) (earlier called non-insulin-dependent, or maturity-onset diabetes) OTHER SPECIFIC TYPES OF DIABETES (10%) GESTATIONAL DIABETES MELLITUS (4%) Type IA DM: Immune-mediated Type IB DM: Idiopathic Essential Pathology for Dental Students by harsh mohan 5 th edition(2017) 21-12-2020 /38 7

8. PATHOGENESIS Hyperglycemia may result from the following: Reduced insulin secretion Decreased glucose use by the body Increased glucose production Essential Pathology for Dental Students by harsh mohan 5 th edition(2017) 21-12-2020 /38 8

9. Pathogenesis of Type 1 DM Robbins and Cotran Pathologic Basis of Disease 9 th edition (2015) 21-12-2020 /38 9

10. Robbins and Cotran Pathologic Basis of Disease 9 th edition (2015) 21-12-2020 /38 10

11. Pathogenesis of Type 2 DM 21-12-2020 /38 11

12. 21-12-2020 /38 12

13. Development of type 2 diabetes Robbins and Cotran Pathologic Basis of Disease 9 th edition (2015) 21-12-2020 /38 13

14. Endodontic disease in diabetic patients Lima et al. International Endodontic Journal 2013 21-12-2020 /38 14

15. Clinical Features of Diabetes Type 1 DM Early age (<35 yrs ) Abrupt onset of symptoms Polyuria, polyphagia, polydipsia present Not obese but have generally progressive weight loss Prone to develop metabolic complications such as ketoacidosis and hypoglycemic episodes. 21-12-2020 /38 15

16. Type 2 DM Occurs in middle aged or older (>40) Onset of symptoms is slow and insidious Generally asymptomatic or may present with polyuria and polydipsia. Frequently obese and have unexplained weight loss and weakness. Metabolic complications such as ketoacidosis are infrequent. 21-12-2020 /38 16

17. Pathophysiology of basic signs and symptoms Robbins and Cotran Pathologic Basis of Disease 9 th edition 2015 21-12-2020 /38 17

18. Chronic Complications of Diabetes Diabetic macrovascular disease damage induced in large- and medium-sized muscular arteries causes accelerated atherosclerosis among diabetics, resulting in increased risk of myocardial infarction, stroke, and lower extremity ischemia. Diabetic microvascular disease damage induced in small vessels effects are most profound in the retina, kidneys, and peripheral nerves, resulting in diabetic retinopathy, nephropathy, and neuropathy Robbins and Cotran Pathologic Basis of Disease 9 th edition (2015) 21-12-2020 /38 18

19. Robbins and Cotran Pathologic Basis of Disease 9 th edition (2015) 21-12-2020 /38 19

20. Oral manifestations of Diabetes Mellitus. A systematic review Elisabet Mauri-Obradors , 1   Albert Estrugo-Devesa , 2   Enric Jané-Salas , 2   Miguel Viñas , 3  and  José López-López Med Oral Patol Oral Cir Bucal . 2017 21-12-2020 /38 20

21. Diabetes and Periodontal Disease considered the sixth complication of DM Increased Ca + and glucose lead to plaque formation. Increased collagen breakdown. Altered cell-mediated immune response and impaired of neutrophil chemotaxis Oral manifestations of Diabetes Mellitus. A systematic review Elisabet Mauri-Obradors , 1   Albert Estrugo-Devesa , 2   Enric Jané-Salas , 2   Miguel Viñas , 3  and  José López-López Med Oral Patol Oral Cir Bucal . 2017 21-12-2020 /38 21

22. Diabetes and Periapical Pathology higher prevalence of periapical lesions in patients with poorly controlled diabetes. The dental pulp of diabetic patients may have limited dental collateral circulation, impaired immune response, and an increased risk of infection or pulp necrosis. The special characteristics of periapical lesions in patients with diabetes provide evidence that the treatment objectives and definition of success should be different for these patients.   Oral manifestations of Diabetes Mellitus. A systematic review Elisabet Mauri-Obradors , 1   Albert Estrugo-Devesa , 2   Enric Jané-Salas , 2   Miguel Viñas , 3  and  José López-López Med Oral Patol Oral Cir Bucal . 2017 21-12-2020 /38 22

23. Diabetes and Dental Caries  studies have found a higher incidence of dental caries in patients with DM which could be explained by the decrease of salivary secretion suffered by diabetics. Arrieta-Blanco  et al.  in a study of 144 patients (70 diabetic and 74 non-diabetic) found no significant difference in mean caries between the two groups. Oral manifestations of Diabetes Mellitus. A systematic review Elisabet Mauri-Obradors , 1   Albert Estrugo-Devesa , 2   Enric Jané-Salas , 2   Miguel Viñas , 3  and  José López-López Med Oral Patol Oral Cir Bucal . 2017 21-12-2020 /38 23

24. Diabetes and Oral Mucosa DM Patients may have a higher prevalence of mucosal disorders possibly associated with chronic immunosuppression, delayed healing, and/or salivary hypofunction. These alterations include: oral fungal infections such as oral candidiasis; fissured tongue, irritation fibroma, traumatic ulcers and lichen planus Oral manifestations of Diabetes Mellitus. A systematic review Elisabet Mauri-Obradors , 1   Albert Estrugo-Devesa , 2   Enric Jané-Salas , 2   Miguel Viñas , 3  and  José López-López Med Oral Patol Oral Cir Bucal . 2017 21-12-2020 /38 24

25. Diabetes and Xerostomia In a study conducted by Chavez  et al. , a tendency for salivary flow to decrease was observed when HbA1c values increased. DM can cause xerostomia and there may be a significant correlation between the degree of xerostomia and glucose levels in saliva. increased salivary glucose promotes the proliferation and colonization of bacteria in the oral cavity, and glucose is the basis for Candida development and decreases the activity of neutrophils Oral manifestations of Diabetes Mellitus. A systematic review Elisabet Mauri-Obradors , 1   Albert Estrugo-Devesa , 2   Enric Jané-Salas , 2   Miguel Viñas , 3  and  José López-López Med Oral Patol Oral Cir Bucal . 2017 21-12-2020 /38 25

26. Diabetes and Burning Mouth Syndrome Burning mouth syndrome (BMS) is characterized by a burning sensation in the oral mucosa and an absence of clinical signs. Its etiology includes systemic, local, and psychological factors (stress, anxiety and depression).   Patients with diabetes often have burning mouth syndrome, but a clear relationship between DM and BMS has not been identified Oral manifestations of Diabetes Mellitus. A systematic review Elisabet Mauri-Obradors , 1   Albert Estrugo-Devesa , 2   Enric Jané-Salas , 2   Miguel Viñas , 3  and  José López-López Med Oral Patol Oral Cir Bucal . 2017 21-12-2020 /38 26

27. Dental management considerations for the diabetic patient Consult with patient’s physician to assess diabetes control Update medical history and medications and review systems at each appointment Confirm that patient has eaten and taken medications before initiating treatment Anticipate and be prepared to manage hypoglycemia Diagnosis, Management, and Dental Considerations for the Diabetic Patient Aaron Miller, Aviv Ouanounou ,J Can Dent Assoc. 2020;86:k8 21-12-2020 /38 27

28. Prevent, treat and eliminate infections promptly Do not use or recommend aspirin-containing compounds Achieve profound local anesthesia Ensure excellent oral hygiene and provide profound preventive care Reinforce regular diet and medication regimen before and after dental appointments Take glucometer reading if patient is high risk, on insulin or having surgery Diagnosis, Management, and Dental Considerations for the Diabetic Patient Aaron Miller, Aviv Ouanounou ,J Can Dent Assoc. 2020;86:k8 21-12-2020 /38 28

29. Diagnosis, Management, and Dental Considerations for the Diabetic Patient Aaron Miller, Aviv Ouanounou ,J Can Dent Assoc. 2020;86:k8 21-12-2020 /38 29

30. Dental management considerations 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 appointment. Ask patient about recent blood glucose level and frequency of hypoglycemic episodes. Medication, dosage and times of administration. Diagnosis, Management, and Dental Considerations for the Diabetic Patient Aaron Miller, Aviv Ouanounou ,J Can Dent Assoc. 2020;86:k8 21-12-2020 /38 30

31. Scheduling of visits: Morning appointment is preferred due to high cortisol levels. Appointments should not coincide with peak insulin activity since risk of hypoglycaemia is maximum during this time. Diet : Ensure that the patient has eaten normally and taken medications as usual. Blood glucose monitoring : blood glucose is measured before beginning the procedure; in case blood glucose is <70mg/dL the patient is asked to take a rich carbohydrate meal. 21-12-2020 /38 31

32. During treatment : Most common complication is hypoglycemic episode. Initial signs : mood changes, decreased spontaneity, hunger and weakness. Followed by sweating, incoherence, tachycardia . Results in unconsciousness, hypotension, hypothermia, seizures, coma, even death. 21-12-2020 /38 32

33. Emergency management  15 grams of fast-acting oral carbohydrate. Such as glucose tables, gel , candy etc. Measure blood sugar level to confirm the diagnosis If patient is unable to swallow or get unconscious 25-30ml 50% dextrose solution iv. Or 1 mg glucagon should be administered intravenously. 21-12-2020 /38 33

34. Severe hyperglycemia : Ketoacidosis may develop with nausea, vomiting, abdominal pain and acetone odor Definitive management of hyperglycemia requires medical intervention and insulin administration. It is difficult to differentiate between hypoglycemia and hyperglycemia. Clinician should measure blood glucose after immediate treatment. 21-12-2020 /38 34

35. After treatment Antibiotic coverage is essential for patients with overt oral infections and those undergoing extensive surgical procedures. Aspirin or aspirin containing compounds should be avoided for patients with diabetes mellitus. 21-12-2020 /38 35

36. Conclusion Diabetes may have significant impact on delivery of dental care. It is important for dentists to be familiar with the medical management of DM, and to diagnose the signs and symptoms of undiagnosed or poorly controlled disease. 21-12-2020 /38 36

37. References Guyton and Hall Textbook of Medical Physiology 12 th edition Essential Pathology for Dental Students by harsh mohan 5 th edition Robbins and Cotran Pathologic Basis of Disease 9 th edition Diagnosis, epidemiology and pathogenesis of diabetes mellitus: an update for psychiatrists RICHARD I. G. HOLT BRITISH JOURNAL OF PSYCHIATRY (2004) Diagnosis, Management, and Dental Considerations for the Diabetic Patient Aaron Miller, Aviv Ouanounou ,J Can Dent Assoc. 2020;86:k8 Oral manifestations of Diabetes Mellitus. A systematic review Elisabet Mauri-Obradors , 1   Albert Estrugo-Devesa , 2   Enric Jané-Salas , 2   Miguel Viñas , 3  and  José López-López Med Oral Patol Oral Cir Bucal . 2017 21-12-2020 /38 37

38. 21-12-2020 /38 38