Diabetes mellitus (DM) is a syndrome

of chronic hyperglycaemia due to

relative insulin deficiency, resistance,
or both.
The glycosylated hemoglobin value
(HbA1c) is the primary target for glycemic
control

Diabetes Association recommends that the

blood test—which measures average levels
of glycemia over the preceding 2 to 3
months
The goal for patients in general is HbA1c
value of less than 7%, and the goal for each
individual patient is as close to normal (less
than 6%) as is possible without the
occurrence of clinically significant
hypoglycemia
Current Classification of Diabetes
 Type 1
Beta-cell destruction or defect in beta-cell function,
usually leading to absolute insulin deficiency
a. Immunemediated
Presence of islet cell or insulin antibodies that identify
the autoimmune process leading to beta-cell
destruction

b. Idiopathic
Type 2
Insulin resistance with relative insulin deficiency
Pathophysiology and
Complications
Glucose is the most important stimulus for
insulin secretion. Insulin remains in
circulation for only several minutes (half-
life [t½], 4 to 8 minutes); it then interacts
with target tissues and binds with cell
surface
insulin receptors.
Secondary intracellular messengers
are activated and interact with cellular
effector systems, including enzymes
and glucose transport proteins.
Lack of insulin or insulin action allows
glucose to accumulate in the tissue fluids
and blood
The mechanisms by which hyperglycemia
may lead to microvascular complications
include increased accumulation of polyols
through the aldose reductase pathway and
of advanced glycosylation end products.
The patient with uncontrolled
diabetes is deprived of insulin or its
action but will continue to use
carbohydrates at the usual rates in the
brain and nervous system because
these tissues do not require insulin.
However, other tissues in the
body are unable to take glucose
into the cells or to use it at a
normal rate.
Increased production of glucose from
glycogen, fat, and protein may occur; thus,
the rise in blood glucose in diabetic persons
results from a combination of
underutilization and overproduction
attained through glycogenolysis and fat
metabolism.
Hyperglycemia leads to glucose
excretion in the urine, which results in
increased urinary volume. The increase
in fluid loss through urine may lead to
dehydration and loss of electrolytes.
Lack of glucose utilization by many cells of
the body leads to cellular starvation. The
patient often increases intake of food but in
many cases still loses weight
The primary manifestations of
diabetes—hyperglycemia,
ketoacidosis, and vascular wall disease
—contribute to the inability of
patients with uncontrolled diabetes to
fight infection and prevent their
wounds from healing.
Complications of Diabetes
Mellitus
• Ketoacidosis
• Hyperosmolar nonketotic coma (type
2 diabetes)
• Diabetic retinopathy/blindness
• Cataracts
• Diabetic nephropathy/renal failure
• Accelerated atherosclerosis (coronary
heart disease )
• Ulceration and gangrene of feet
•Diabetic neuropathy (dysphagia,
gastric distention, diarrhea, impotence,
muscle weakness/cramps, numbness,
tingling, deep burning pain)
• Early death
Vessel changes include thickening of
the intima, endothelial proliferation,
lipid deposition, and accumulation of
para-aminosalicylic acid–positive
material.
These changes can be seen throughout the
body but have particular clinical
importance when they occur within the
retina and the small vessels of the kidney.
Criteria for the Diagnosis of
Diabetes Mellitus
1. Symptoms of diabetes plus casual plasma
glucose level of 200 mg/dL or greater

Casual is defined as any time of day without

regard to time since last meal Classic
symptoms of diabetes include polyuria,
polydipsia, and unexplained weight loss
2. Fasting plasma glucose of 126
mg/dL or greater

Fasting is defined as no caloric intake

for 8 hours or longer
3. 2-hour plasma glucose level of 200
mg/dL or greater during an oral glucose
tolerance test

The test should be performed using a glucose load

containing the equivalent of 75 g of anhydrous
glucose dissolved in water; this test is not
recommended for routine clinical use
Glycohemoglobin.
Measurement of HbA1c levels is of value in the
detection and evaluation of patients

HbA1c is an electrophoretically fast-moving

hemoglobin component found in normal persons; it
increases in the presence of hyperglycemia and may
reflect glucose levels in the blood over the 6 to 12
weeks preceding administration of the test.
Normally, patients should have 6% to 8% HbA1c. In
well-controlled diabetes cases, the level should stay
below 7%.

The level of hyperglycemia as indicated by the HbA1c

may reach as high as 20% in some uncontrolled cases.
Drug treatment
Oral Antidiabetic (Hypoglycemic) Drugs
SULFONYLUREAS (ENHANCE INSULIN
SECRETION)
Chlorpropamide

BIGUANIDES (REDUCE HEPATIC GLUCOSE

PRODUCTION)
Metformin
GAMMA-GLUCOSIDASE INHIBITORS (DELAY
CARBOHYDRATE DIGESTION)
Acarbose

THIAZOLIDINEDIONES (ENHANCE INSULIN

SENSITIVITY)
Rosiglitazone
Insulin Preparations Classified According to
Their Pharmacodynamic Profiles

RAPID-ACTING
Insulin lispro 5h

SHORT-ACTING
Regular 5-8h
 INTERMEDIATE-ACTING

NPH (Neutral Protamine Hagedorn) (Isophane)

14-24h
Lente (insulin zinc suspension

LONG-ACTING
Ultralente 20-36h
 PREMIXED COMBINATIONS
50% NPH, 50% regular 14-24h
70% NPH, 30% regular 14-24h
70% NPA, 30% aspart 14-24h
(Neutral protamine aspart)
Signs and Symptoms of Insulin
Reaction
MILD STAGE

• Hunger
• Weakness
• Tachycardia
• Pallor
• Sweating
• Paresthesias
 MODERATE STAGE

• Uncooperativeness
• Belligerence
• Lack of judgment
• Poor orientation
 SEVERE STAGE

• Unconsciousness
• Tonic or clonic movements
• Hypotension
• Hypothermia
• Rapid thready pulse
Detection of the Patient With
Diabetes
 KNOWN DIABETIC PERSON

1. Detection by history:

a. Are you diabetic?
b. What medications are you taking?
c. Are you being treated by a physician?
2. Establishment of severity of disease and
degree of “control”

a. When were you first diagnosed as diabetic?

b. What was the level of the last measurement of
your blood glucose?
c. What is the usual level of blood glucose for
you?
d. How are you being treated for your diabetes?

e. How often do you have insulin reactions?

f. How much insulin do you take with each

injection, and how often do you receive
injections?
g. Do you test your urine for glucose?

h. When did you last visit your physician?

i. Do you have any symptoms of diabetes at

the present time?
UNDIAGNOSED DIABETIC PERSON
1. History of signs or symptoms of
diabetes or its complications

2. High risk for developing diabetes

a. Parents who are diabetic
b. History of spontaneous abortions or

stillbirths
c. Obesee.
d. Over 40 years of age

3. Referral or screening test for diabetes

Dental Management of the
Patient With Diabetes
 1. Non–insulin-dependent patient:

If diabetes is well-controlled, all dental

procedures can be performed without
special precautions.
 2. Insulin-controlled patient:

• If diabetes is well-controlled, all dental

procedures can be performed without special
precautions.

• Morning appointments are usually best.

• Patient advised to take usual insulin dosage
and normal meals on day of dental
appointment; information confirmed when
patient comes for appointment.

• Advise patient to inform dentist or staff if

symptoms of insulin reaction occur during
dental visit
• Glucose source (orange juice, soda,
Glucola) should be available and given
to the patient if symptoms of insulin
reaction occur.
 3. If extensive surgery is needed:

• Consult with patient's physician concerning

dietary needs during postoperative period.

• Antibiotic prophylaxis can be considered for

patients with brittle diabetes and those taking
high doses of insulin who also have chronic states
of oral infection.
A major goal in the dental management of
patients with diabetes who are being
treated with insulin is to prevent insulin
shock during the dental appointment
Dental Management of the Patient With
Diabetes and Acute Oral Infection

1. Non–insulin-controlled patients may

require insulin; consultation with physician
required

2. Insulin-controlled patients usually require

increased dosage of insulin; consultation with
physician required
3. Patient with brittle diabetes or receiving
high insulin dosage should have culture(s)
taken from the infected area for antibiotic
sensitivity testing

 a. Culture sent for testing

 b. Antibiotic therapy initiated

 c. In cases of poor clinical responses to
the first antibiotic, a more effective
antibiotic is selected according to
sensitivity test results
4. Infection should be treated with the use of
standard methods
a. Warm intraoral rinses
b. Incision and drainage
c. Pulpotomy, pulpectomy, extractions, etc.
d. Antibiotics
The risk for infection in patients with
diabetes is directly related to fasting blood
glucose levels.

If fasting blood glucose level is below 206

mg/100 mL, no increased risk is present
If fasting blood glucose level rises to
above 230 mg/100 mL, an 80% increase
has occurred in the risk of infection.
Local Anesthetics and Epinephrine
For most patients with diabetes,
routine use of local anesthetic with

1 : 100,000 epinephrine should be

tolerated well.
Epinephrine has a pharmacologic
effect that is opposite that of insulin,
so blood glucose could rise with the
use of epinephrine
In diabetic patients with
hypertension, post myocardial
infarction, cardiac arrhythmia caution
may be indicated with epinephrine.
Guidelines for these patients are
similar to those for patients with
cardiovascular conditions
Oral Complications and
Manifestations
Oral complications of poorly controlled
diabetes mellitus
Xerostomia
 bacterial, viral, and fungal infections
(including candidiasis)
poor wound healing
Increased incidence and severity of caries
Gingivitis and periodontal disease
 Periapical abscesses; and burning mouth
symptoms.
Oral findings in patients with uncontrolled
diabetes most likely relate to
a. excessive loss of fluids through urination,
b. altered response to infection,
c. microvascular changes, and
d. possibly, increased glucose concentrations in
saliva
The parotid saliva of persons with
uncontrolled diabetes has been reported to
contain a slightly increased amount of
glucose
severe, progressive periodontitis.
Periodontal disease is clearly a
complication of type 1 diabetes.

The increased risk of periodontal disease is

particularly significant when hyperglycemia
is poorly controlled
Patient with cellulitis
Periodontal abscess
Lesion involving the palate in a
patient with diabetes.
A significantly higher percentage of oral
lesions, especially
a. candidiasis, b. traumatic ulcers,
c. lichen planus, d. delayed healing,
has been noted in individuals with type 1
diabetes, as compared with a control
population.
Diabetic neuropathy may lead to oral
symptoms of paresthesias and tingling,
numbness, burning, or pain caused by
pathologic changes involving nerves in
the oral region.
Diabetes has been associated with oral
burning symptoms.

 Early diagnosis and treatment of diabetes

may allow for regression of these
symptoms, but in long-standing cases, the
changes may be irreversible
Management of the patient with
diabetes
Insulin Dependent diabetes
1. Defer surgery until diabetes is well
controlled

2. Schedule an early morning appoinment;

avoid lengthy appointment.
3. Use anxiety reduction protocol

4. Monitor vital signs

5. Maintain verbal contact with

patients during procedur
6. If the patient unable to eat after
surgery then consult the patient
physician to alter the dose of insulin
(give 5% dextrose to maintain blood
glucose levels)
( No regular or NPH insulin)
.
7. If allowed to take normal diet after
surgery…… normal breakfast , take
normal dose of regular insulin and half
dose of NPH
8. Resume normal insulin doses until they
are able to return to usual caloric intake
and activity level

9. Watch for the sign of hypoglycemia

 Non –insulin diabetes mellitus.
Protocols.

 ANY

 ?
 Questions
