Title: Diabetes Mellitus patients in dental management
1Diabetes Mellitus patients in dental management
- Reporter ???
- Modulator Dr. ???
2Introduction
- Diabetes mellitus is a metabolic disorder
characterized by relative or absolute
insufficiency of insulin, and resultant
disturbances of carbonhydrate metabolism. - The major function of insulin is to counter the
concerted action of a number of
hyperglycemia-generating hormones and to maintain
low blood glucose levels.
3Epidemiology
- 6 (16 million persons) of the general population
in the US have diabetes mellitus. - Almost 20 of adult older than 65 y/o have DM.
- A dental practice serving an adult population of
2,000 can expect to encounter 40-80 persons with
diabetes, about half of whom will be unaware of
their condition.
National Institutes of Health, Aug 2001
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5Etiologic 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) - Other specific types
JADA, Oct 2001
6Type 1 (IDDM)
- Autoimmune destruction of the insulin-producing
beta cells of pancreas. - 5-10 of DM cases.
- Common occurs in childhood and adolescence, or
any age. - Absolute insulin deficiency.
- High incidence of severe complications.
- Prone to autoimmune diseases. (Graves, Addison,
Hashimotos thyroiditis)
7Type 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 Hx and lack of physical activity..etc.
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9Other specific types
- Genetic defects of beta-cell functions
- Decrease of exocrine pancreas
- Endocrinepathothies
- Drug or chemical usage
- Infections
- .
10Gestational diabetes mellitus (GDM)
- Defined as any degree of glucose intolerance with
onset or first recognition during pregnancy. - 4 of pregnancy in US.
11Pathophysiology
- Healthy people blood glucose level maintained
within 60 to 150 mg/dL. - Insulin synthesized in beta cells of pancreas and
secreted rapidly into blood in response to
elevations in blood sugar. - Promoting uptake of glucose from blood into cells
and its storage as glycogen - Fatty acid and amino acids converted to
triglyceride and protein stores.
12Pathophysiology
- Lack of insulin or insulin resistance, result in
inability of insulin-dependent cells to use
glucose. - Triglycerides broken down to fatty acids ?blood
ketones? ? diabelic ketoacidosis.
13Pathophysiology
- As blood sugar levels became elevated
(hyperglycemia), glucose is excreted in the urine
and excessive of urination occurs due to osmotic
diuresis (polyuria). - Increased fluid loss leads to dehydration and
excess thirst (polydipsia). - Since cells are starved of glucose, the patient
experiences increased hunger (polyphagia). - Paradoxically, the diabetic patient often loss
weight, since the cells are unable to take up
glucose.
14Complications
- People with DM have an increased incidence of
both microvascular and macrovascular
complications.
15Diagnosis
- A casual plasma glucose level of 200 mg/dL or
greater with symptoms presented. - Fasting plasma glucose level of 126 or
greater.(Normal lt110 mg/dL,IGT,IFG) - Oral glucose tolerance test (OGTT) value in blood
of 200 mg or greater. -
- ADA recommend gt45 y/o screened every 3 years.
Diabetes Care, 2000 National Institutes of
Health, Aug 2001
16Medical management
- Objective maintain blood glucose levels as
close to normal as possible. - Good glycemic control inhibits the onset and
delay of type 1 DM, similar in type 2 DM.
17Medical management
- Glycated hemoglobin assay (HbA1c ) reflects mean
glycemia levels over the proceding 23 months.
(normal lt 7) - HbA1c also a predictor for development of chronic
complications.
18Medical management
- Exercise and diet control
- Insulin rapid, short, intermediate, long
acting. - Oral antidiabetic agents
19Oral manifestations and complications
- No specific oral lesions associated with
diabetes. However, there are a number of problems
by present of hyperglycemia. - 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.
20Oral manifestations and complications
- Salivary glands
- Xerostomia is common, but reason is unclear.
- Tenderness, pain and burning sensation of tongue.
- May secondary enlargement of parotid glands with
sialosis. - Dental caries
- Increase caries prevalence in adult with
diabetes. (xerostomia, increase saliva glucose) - Hyperglycemia state shown a positive association
with dental caries.
21Oral manifestations and complications
- Increased risk of infection
- Reasons unknown, but macrophage metabolism
altered with inhibition of phagocytosis. - Peripheral neuropathy and poor peripheral
circulation - Immunological deficiency
- High sugar medium
- Decrease production of Ab
- Candical infection are more common and adding
effects with xerostomia
22Oral manifestations and complications
- Delayed healing of wounds
- Due to microangiopathy and ultilisation of
protein for energy, may retard the repair of
tissues. - Increase prevalence of dry socket.
- Miscellaneous conditions
- Pulpitis degeneration of vascular.
- Neuropathies may affect cranial nerves.
(facial) - Drug side-effects lichenoid reaction may be
associated with sulphonylurea. (chlopropamide) - Ulcers
New Zealand Journal, Jan 1985
23Dental management considerations
- To minimize the risk of an intraoperative
emergency, clinicians need to consider some
issues before initiating dental tx. - Medical history take hx and assess glycemic
control at initial appt. - Glucose levels
- Frequency of hypoglycemic episodes
- Medication, dosage and times.
- Consultation
24Dental management considerations
- 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. (lt70 mg/dL)
- Prophylactic antibiotics
- Established infection
- Pre-operation contamination wound
- Major surgery
25Dental management considerations
- During treatment
- The most complication of DM occur is hypoglycemia
episode. - Hyperglycemia
- After treatment
- Infection control
- Dietary intake
- Medications salicylates increase insulin
secretion and sensitivity? avoid aspirin.
26Emergency management
- Hypoglycemia
- Initial signs mood changes, decreased
spontaneity, hunger and weakness. - Followed by sweating, incoherence, tachycardia.
- Consequenced in unconsiousness, hypotention,
hypothermia, seidures, coma, even death.
27Emergency management
- 15 grams of fast-acting oral carbonhydrate.
- Measured blood sugua.
- Loss of conscious, 25-30ml 50 dextrose solution
iv. over 3 min period. - Glucagon 1mg.
- 911, 119
28Emergency management
- Severe hyperglycemia
- A prolonged onset
- Ketoacidosis may develop with nausea, vomiting,
abdominal pain and acetone odor. - Difficult to different hypo- or hyper-.
29Emergency management
- Hyperglycemia need medication intervention and
insulin administration. - While emergency, give glucose first !
- Small amount is unlikely to cause significant
harm.
JADA, Oct 2001
30Conclusion
31Thanks for ur attention !!
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331.Liver
glucose
glucose TG glycerol-po4 glyce
rol FA glycerol FAALB
2.Adipose
- ketone body
- ATPco2
- acetyl coA
- TG
- FA
- Glycerol-po4
-
- glucose
-
- glucose
3.Muscle
glucose
glucose