Diabetes mellitus and its relation to dentistry .pptx

Diabetes mellitus and its relation to dentistry by Ali Bahaa

1. Diabetes mellitus By : Ali Bahaa Kadhim

2. Overview Diabetes mellitus characterized by high blood glucose level and inability to produce / use insulin. More than 240 million person in the world have diabetes mellitus. It's one of the leading cause of death in United State. Dentist should recognize diabetic patient by history, clinical signs and symptoms and laboratory tests and refer it to physician when needed.

3. Insulin Glucose level in blood is increased after food intake. Insulin is released from beta cells in pancreas and released into the blood. This hormone bind to specific receptors in body cells and help absorption of glucose into these cells, which then, glucose level in blood normalize. However diabetic patient have problem in secreting insulin, or there is cellular resistance to insulin or both. This lead to high blood glucose level that lead to many symptoms and complications.

4. Classification Diabetic patient can be classified into: Type 1 (less common - 10% - usually younger than 30 yrs ): beta cells in pancreas are destroyed and there is no insulin secretion. Type 2 (most common - 90% -usually obese and older): There is partial insulin deficiency and cellular insulin resistance. Gestational: which occur in 5-7% of all pregnancies and results in loss of fetus. In case of surviving fetuses, they usually overweight. When pregnancy over, mother glycemic control return to normal but these women are at risk of developing diabetes in the next 5-10 years.

5. Classification Continued: • Other specific types: include more than 56 disease that cause destruction of beta cells such as genetic, inflammation, cancer, surgery, endocrine conditions such as hyperpituitarism , hyperthyroidism, or could be drug induced.

6. Clinical Signs and Symptoms Patient with type 1 diabetes: the onset of symptoms is sudden and acute. Patient usually non-obese child or young adult younger than 40 years old, but could occur at any age. Signs and symptoms include: polydipsia, polyuria, polyphagia, weight loss, loss of strength, marked irritability, recurrence of bed wetting drowsiness, malaise, and blurred vision. Patient also may develop ketoacidosis which characterized by symptoms of vimitting , abdominal pain, nausea, tachypnea, paralysis and loss of consciousness.

7. Clinical Signs and Symptoms Patient with type 2 diabetes: usually affect obese individuals older than 40 years old. Symptoms usually develop gradually and less common. Symptoms include: polydipsia, polyuria, polyphagia, weight loss, loss of strength. Other symptoms related to complications of diabetes type 1 and 2 includes: skin lesions, cataracts, blindness, hypertension, chest pain, and anemia.

8. Clinical Signs and Symptoms Feature Type 1 Type 2 Frequency 5-10% 90-95% Age of onset 15 yrs 40 yrs and over Body Build Normal or thin Obese Severity severe Mild Insulin requirement Almost All patient 25 – 30 % Ketoacidosis Common Uncommon Rate of clinical onset Rapid Slow

9. Diabetes Complications Generally, Patient with poorly controlled or uncontrolled diabetes mellitus is at risk of: Infection Poor wound healing Complications of diabetes includes: Metabolic distrubances : (ketoacidosis) Cardiac: atherosclerosis, hypertension, congestive heart failure, and myocardial infarction. Eyes: retinopathy, cataracts and blindness. Kidney: nephropathy and renal failure. Limbs: ulceration and gangrene of feet, which lead to foot amputation. Neuropathies: dysphagia, gastric distention, diarrhea, muscle weakness and cramp, numbness, burning pain.

10. Diabetes Complications Diabetes mellitus (DM) is the seventh leading cause of death in US, mostly due to cardiovascular complications associated with it.

11. Diabetes Diagnosis in Dental Office Most common type of diabetes is type 2. Dentist should be able to recognize diabetic symptoms and interpret screening tests. However, referral to physician for definitive diagnosis and treatment is important. Patient is diagnosed with diabetes when one of these tests is confirmed: Fasting blood glucose level ≥ 126 mg/ dL Random blood glucose + (symptoms) ≥ 200 mg/ dL Oral glucose tolerance test ≥ 200 mg/ dL HbA1C ≥ 6.5%

12. Treatment Plan for Minor Oral Procedures Patient with uncontrolled or poorly controlled diabetes should be send to physician for treatment. Patient with controlled type 1 diabetes: in case of non-invasive dental procedure, patients can be treated just like non-diabetic patients, however, be aware of patient's susceptibility to infection and poor wound healing. In invasive dental procedure: after consultation with patient physician, blood glucose level is taken. If it is between 70-200 mg/ dL then dental procedure can be done. If it is ≥ 200 mg/ dL , then elective dental procedure should be deferred until glucose level normalize.

13. Treatment Plan for Minor Oral Procedures Patient with controlled type 2 diabetes: No treatment modification required. Be cautious of patient's susceptibility to infection and impaired wound healing. For diabetes type 1 and 2, major surgical procedure with general anesthesia require special management other than what described above. These guidelines are for diabetic patient who suffers only from diabetes mellitus without any other complications. Medically compromised diabetic patient who suffer from diabetic complications (such as hypertension, renal impairment, etc..) require special attention and treatment plan modification.

14. Insulin Shock When patient take their insulin and do not eat, this results in hypoglycemia that called insulin shock. It also occur when they eat but take insulin overdose, or oral hypoglycemic medication overdose. The initial signs and symptoms include: hunger, weakness, trembling, tachycardia, pallor, and sweating. If left undetected it can lead to sever symptoms (hypotension, hypothermia, tonic clonic movements) and loss of consciousness. Dentist should instruct the patient to take their usual meal and insulin injection before coming to the clinic. Morning appointment is preferred.

15. Dentist's Instruction Prior to Dental Visit Patient should eat normal meals before appointment and take their medication. Take a morning appointment Have their medication and glucose (juice, non-diet cola, etc..) available at dental visit. Inform the dentist about any insulin reaction when they first occur. After dental appointment, patient should keep his eating routine and medications. They should keep good oral hygiene and restrict to dentist's instruction to prevent infection and impaired wound healing, dry socket, and osteomylitis from happening.

16. In Case of Acute Infection • Antibiotic prophylaxis for patient after dental procedure is not required unless patient suffer from infection and/or systemic symptoms of infection (lymphadenopathy, fever). • In case of patient with infection, patient's insulin dosage should be altered with consultation, and infection is treated locally.

17. In Case of Acute Infection Insulin dosage guidelines: Oral hypoglycemic-controlled patients: may require insulin, consult with physician. Insulin-controlled patient: may need increased insulin dosage, consult with physician. Patient with brittle diabetes (fluctuating, too high and too low) and patient receiving high dose of insulin: culture is taken from infected area for antibiotic sensitivity test. Culture is sent to testing, and antibiotic therapy is initiated with penicillin or its alternatives in case of allergies. If patient condition did not response to medication, antibiotic is selected from test result and therapy is initiated.

18. In Case of Acute Infection In all cases, infection should be treated locally with: Warm intra-oral rinses Incision and drainage  Pulpotomy , endodontics, or extraction And antibiotic

19. Oral Manifestations of Diabetes Patient with uncontrolled diabetes mellitus may suffer from: Xerostomia Poor wound healing infection Oral ulceration and lesions candidiasis Burning pain in the mouth Periapical abscess caries These are due to excessive loss of tissue fluid, altered response to infection, microvascular changes, and increased glucose level in saliva.

20. Oral Manifestations of Diabetes Patient with diabetes has increased inflammatory response, reduced wound healing, and microvasculature changes which contribute to: Periodontal diseases Gingival diseases and proliferation Periodontal abscess

21. Dental Management Follow what have been discussed earlier regarding management and treatment planning for such patient. Analgesia: avoid aspirin and NSAIDs in patient taking sulfonylureas, because it can worsen the hypoglycemia Antibiotics: antibiotic prophylaxis is not required unless there is an infection or brittle diabetes. Anesthesia: usual dose. However, in patient with cardiac symptoms, limit dose to 2 cartridge containing 1:100,000 epinephrine. Blood pressure: monitor blood pressure, because diabetes is associated with hypertension.

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