Dental Management of Patients With Diabetes Mellitus

1
Dental Management of Patients With Diabetes
Mellitus

• Donald Falace, DMD
• Professor and Division Chief
• Oral Diagnosis and Oral Medicine
• University of Kentucky College of Dentistry

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Diabetes Mellitus

• A constellation of abnormalities caused by lack
  of insulin and characterized by
• Polyuria
• Polydipsia
• Polyphagia
• Weight loss or weight gain, hyperglycemia,
  glycosuria, ketosis, acidosis and coma
• Do not confuse diabetes mellitus with diabetes
  insipidus
• Diabetes insipidus is a pituitary disorder due to
  a deficiency of vasopressin (ADH) that is
  characterized by the excretion of excessive
  quantities of urine. It is unrelated to diabetes
  mellitus.

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Epidemiology of Diabetes

• Affects about 18 million individuals in the
  United States 5 million are unaware of their
  disease
• 41 million adults between the ages of 40-74 have
  prediabetes which puts them at increased risk to
  develop type 2 diabetes obesity is a major risk
  factor
• Develops in people of all ages but most diabetics
  are 45 years and older 1 in 5 over age 65 has
  diabetes
• African Americans, Hispanics, American Indians
  and Alaskan Natives are 2-3 times more likely to
  have diabetes than Caucasians
• Sixth most common cause of death in the United
  States in 2002 (73,000 deaths)
• Leading cause of blindness and chronic renal
  failure

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Basic Defect of Diabetes Mellitus

• There is either an absolute lack (type 1) or a
  relative lack (type 2) of insulin production
• And, in addition, with type 2 diabetes, there is
  an insensitivity or resistance to insulin by
  insulin receptors on target tissues

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Insulin

• One of the two principle hormones produced and
  secreted by the pancreas (the other is glucagon)
• Insulin is produced by the beta cells and
  glucagon is produced by the alpha cells in the
  islets of Langerhans
• Insulin promotes the entry of glucose into most
  cells of the body and thus controls the rate of
  carbohydrate metabolism glucose can then be used
  immediately for energy or it will be stored in
  the form of glycogen or fat

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Pathophysiology of Diabetes Mellitus
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Diabetes Mellitus Classification

• Previously used terms of insulin dependant or
  juvenile diabtes, and non-insulin dependant
  or adult diabetes have been replaced by
• Type 1 Diabetes (absolute insulin deficiency,
  autoimmune disease)
• Type 2 Diabetes (relative, progressive insulin
  deficiency non-autoimmune etiology)
• Gestational (occurrence only during pregnancy)
  at increased risk for developing type 2 diabetes
  later in life
• Impaired glucose homeostasis (prediabetes)
  moderate elevation of blood glucose have high
  risk of developing diabetes

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Comparison of Type 1 and Type 2 Diabetes
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Symptoms of Type 1 Diabetes

• Cardinal symptoms
• Polydipsa (increased thirst)
• Polyuria (increased urination)
• Polyphagia (increased hunger)
• Weight loss
• Loss of strength

• Other symptoms
• Skin infections
• Irritability
• Headache
• Drowsiness
• Malaise
• Dry mouth

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Symptoms of Type 2 Diabetes

• Cardinal symptoms are uncommon
• Weight gain (or loss)
• Night time urination
• Genital fungal infections

• Blurred vision
• Decreased vision
• Paresthesias
• Impotence
• Postural hypotension

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Laboratory Diagnosis of Diabetes Mellitus (DM)

• Random blood glucose (by itself is not reliable
  for diagnosis but can provide information on real
  time blood glucose for monitoring purposes)
• Normal fasting blood glucose is lt100 mg/dl
• Diagnostic criteria for DM
• Fasting blood glucose ? 126 mg/dl, or,
• Symptoms of DM (polyuria, polydipsia, wt. loss)
  plus casual blood glucose that is ? 200 mg/dl,
  or,
• Two hour post-prandial blood glucose ? 200 mg/dl
• Glycosylated hemoglobin (HbA1c gt7 measures
  blood glucose past 2-3 months
• Urinalysis - not reliable

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Complications of Diabetes Mellitus(more common
and severe with type I)

• I. Macrovascular (large vessel) disease
• (accelerated atherosclerosis)
• Heart CHD, congestive heart failure
• Cerebrovascular stroke
• Peripheral gangrene
• II. Microvascular (small vessel) disease
• (thickened capillary basement membrane)
• Nephropathy kidney failure
• Retinopathy blindness

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• IV. Neuropathy (gt50 of all diabetics)
• Impotence
• Bladder dysfunction
• Paresthesias
• Neuropathic pains (diabetic neuropathy,
• including burning mouth)
• V. Neuromuscular dysfunction
• Muscle weakness
• Muscle cramps
• VI. Decreased resistance to infection

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Metabolic Complications of Diabetes Mellitus

• Hyperglycemia (deficient insulin, diabetic
  ketoacidosis) chronic, slowly progressive
• Hypoglycemia (excess insulin, excess exercise,
  stress, poor diet) acute, rapidly progressive
• most likely problem to be encountered in
  the dental office

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Hyperglycemia (Ketoacidosis)

• Disorientation
• Rapid, deep breathing
• Hot, dry skin
• Acetone breath
• Hypotension
• Coma (blood glucose 300 to 600 mg/dl)

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Hypoglycemia

• It is unlikely that hypoglycemic symptoms will
  occur if blood glucose levels are gt than 45 mg/dl
• CNS/Adrenergic Effects Headache, mental
  confusion, somnolence, sweating, tachycardia,
  tremors, nervousness (40 mg/dl or less)
• Disorientation (30 mg/dl or less)
• Seizures/Coma (25 mg/dl or less)

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Medical Management of DM

• Diet (both type 1 and 2)
• Exercise (both type 1 and 2)
• Medications
• Oral hypoglycemics (type 2 only)
• Insulin (type 1 and 2)
• Injectable
• Inhaled (avail. 2006)
• Pancreatic transplant
• Pancreas
• Pancreas and kidney
• Beta cells

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Oral Hypoglycemics

• Drugs That Increase Insulin Supply
• Sulfanylureas - enhance secretion of insulin from
  pancreas (requires functional ß cells)
• First Generation
• Tolbutamide (Orinase)
• Acetohexamide (Dymelor)
• Tolazamide (Tolinase)
• Chlorpropamide (Diabenase)
• Second Generation
• Glimipride (Amaryl)
• Glyburide (DiaBeta Micronase)
• Glipizide (Glucotrol)
• Other Secretagogues
• Nateglinide (Starlix)
• Repaglinide (Prandin)

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Oral Hypoglycemics

• Drugs That Decrease Insulin Resistance or Improve
  Insulin Effectiveness
• Biguanides - decrease glucose secretion by liver
  and enhance the uptake of glucose in cells
• Metformin (Glucophage)
• Alpha-Glucosidase Inhibitors - slows uptake of
  CHO from gut
• Acarbose (Precose)
• Miglitol (Glyset)
• Thiazolidinediones - increases cellular
  responsiveness to insulin
• Pioglitazone (Actos)
• Rosiglitazone (Avandia)

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Progression of Type 2 Diabetes(Ann Int Med
1998128165-175)

• Many patients with type 2 diabetes will
  eventually need a second oral drug or will need
  insulin ?-cell failure is progressive

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Types of Insulin

• Rapid acting 5-15min Lispro Aspart
• Short acting 30-60min Regular
• Intermediate 2-4h NPH Lente
• Long acting 6-10h Ultralente
  Glargine
• Premixed 30-60min 70NPH/30 regular

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Examples of Common Insulin Regimens
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Insulin Pump for Continuous Infusion

• Battery-driven external pump
• Subcutaneous injection of short or rapid acting
  insulin
• Basal rate delivered throughout the day
• Bolus delivered just before meals

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Inhaled Insulin (Exubera)

• The first inhaled insulin to get FDA approval.
• Exubera delivers short-acting insulin via an
  inhaler. It offers adults with type 1 or type 2
  diabetes an alternative to the insulin injections
  they need to control their blood sugar.
• The Exubera device isn't as small as an asthma
  inhaler. Folded up, it's the size of a standard
  flashlight. A retractable inhaler tube comes out
  from the body of the device when extended it
  reaches from the chest to the mouth. A blister
  pack of insulin then must be inserted before the
  device is triggered.

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Pancreas/Kidney-Pancreas Transplant
Primary problem with these and any transplant
patient is the need for lifelong
immunosuppression which puts them at increased
risk for infection while probably not required,
antibiotic prophylaxis for invasive dental
procedures should be discussed with the physician
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Islet Cell Transplantation(experimental)

• Islet cell transplantation is a process whereby
  isolated islet cells from donor (cadaver)
  pancreases are injected into the liver of
  patients with Type 1 diabetes (Edmonton Protocol)
• Once in the liver, the transplanted cells develop
  a blood supply and begin producing insulin.
• The transplant is carried out under local
  anesthetic and does not involve major surgery
• Most patients require islets from more than one
  donor pancreas, and therefore require more than
  one transplant procedure.
• As with any other organ or tissue transplant,
  patients require immunosuppressive therapy in
  order to prevent rejection of the new cells

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Dental Management Considerations

• Screening/identification
• Prevention of hypoglycemia
• Planning dental treatment and surgery
• Infection management
• Antibiotic prophylaxis
• Oral manifestations

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Screening, Identification and Risk Assessment for
DM

• Type 1 or 2?
• Severity of their disease?
• Oral hypoglycemics or insulin (type, dose)?
• Degree and ease of control?
• Past insulin reactions?

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Glucometer Testing/Screening(ask patient to
bring their glucometer with them)

• Random blood glucose (glucometer)
• Random blood glucose testing is variable (45-130
  mg/dl)
• Fasting blood glucose
• lt 126 mg

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Prevention of Hypoglycemia(Insulin Reaction)

• Make sure pt has normal meals along with insulin
• AM appointments best - avoids peak insulin action
• Watch for hypoglycemic symptoms Mood change,
  hunger, anxiety, tremor, headache,
  lightheadedness, sweating, nausea, tachycardia
• Tell patient to advise you at first onset of
  symptoms
• Check with glucometer if patient becomes
  symptomatic
• Treatment oral CHO (sugar, OJ, cola, candy,
  cake icing) do not give oral CHO if unconscious!

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Dental Treatment Guidelines

• A well controlled, stable diabetic, whether diet
  controlled, on oral hypoglycemics, or taking
  insulin, requires little or no modification for
  routine dental care, including surgery
• Make sure patient has normal meals and continues
  normal insulin administration
• For poorly controlled, uncontrolled or
  symptomatic diabetics, defer elective treatment
  and consult with physician to determine stability
  and control of their disease

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Following Oral Surgery

• If the patient is unable to eat a normal diet as
  a result of the surgery, encourage alternate
  dietary intake such as a liquid dietary
  supplement (e.g. Ensure)
• Insulin may need to be decreased if food intake
  is decreased
• Presence of infection may temporarily increase
  the insulin requirement
• Postoperative antibiotics are not necessary if
  diabetes is well controlled may be indicated
  for poorly controlled diabetic, especially if
  oral/dental infection present

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Oral Manifestations of DM

• None are pathognomonic
• Commonly associated conditions
• xerostomia
• enlargement of parotid glands
• burning mouth/tongue
• altered taste
• candidiasis
• mucormycosis
• periodontal disease
• increased caries risk

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Diabetes Mellitus and Periodontal Disease

• While the exact relationship between DM and
  periodontal disease remains unclear, the bulk of
  evidence suggests that periodontal disease is
  more prevalent and severe among diabetics than
  among non-diabetics

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Oral Red Flags(Suggest the need for medical
evaluation for possible diabetes)

• Multiple or recurrent periodontal abscesses
• Extensive periodontal bone loss (especially in a
  younger individual or with a lack of etiologic
  factors)
• Rapid alveolar bone destruction
• Delayed healing

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Carotid Atheromas and Type 2 Diabetes
(Friedlander, JADA,133Nov 2002)

• Study of 46 patients with type 2 diabetes
• 34 men 12 women
• Age range 62-77
• Presence of carotid artery calcifications on
  panoramic films
• On insulin 36
• Not on insulin 24
• Non-diabetic controls 4

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Angle
Hyoid