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Diabetes Mellitus

Mohammad Kazim Razi

Definition

Latin word: Diabetes = Pass through, Mellitus = sweetened with honey Simply defined as a common endocrine disorder that occurs as a result of a deficiency of insulin or resistance to insulin. It is characterized by impairment of carbohydrate, protein, and lipid metabolism. Primary feature of this disorder is the elevation in blood glucose levels (hyperglycemia), resulting from either a defect in insulin secretion from the pancreas, a change in insulin action, or both.

Classification

Type 1 (previously called insulin dependent diabetes mellitus (IDDM) or juvenile onset diabetes) Type 2 (previously called non-insulin dependent diabetes mellitus, NIDDM, or adult-onset diabetes) Gestational Diabetes Mellitus (Pregnancy) Other types : Genetic defects affecting beta-cell function or insulin action Pancreatic diseases or injuries (pancreatic cancer, pancreatitis, traumatic injury, cystic fibrosis, pancreatectomy) Infections (congenital rubella, Cytomegalovirus infection) Drug-induced diabetes (steroid hormones [glucocorticoids], thyroid hormone) Endocrine disorders (hyperthyroidism, Cushings syndrome, glucagonoma, acromegaly, pheochromocytoma) Other genetic syndromes (with associated diabetes) Diabetes Insipidus (False Diabetes) When the pituitary gland fails to secrete adequate amount of antidiuretic hormone or Kidney fails to respond to ADH.

Epidemiology and Prevalence

It is estimated that approximately 194 million people have diabetes in the adult population in the International Diabetes Federation (IDF) Regions. This is an increase from the 1995 global estimation of 135 million which was published in a World Health Organization study in 1998. The IDF conducted a study in 2010 in the UAE and the results of this study where that 12.2% of the population between the ages of 20 to 79 had Diabetes, about 425,000 people. This percentage will increase to about 21.4 % in 20 years according to IDF. The ministry of health in association with the World Health Organization has established an independent body of local scientists and experts to draw up strategies and national programs to increase public awareness of Diabetes as a first step to control the disease

Etiology

Type I diabetes usually begins in childhood (before the age of 30) and individuals suffering from this type need insulin treatments because their bodies produce very little insulin by themselves. Causes:

Genetic predisposition. Environmental exposure: virus, toxin, stress. Autoimmune reaction: beta-cells that produce insulin in the pancreas are destroyed. When 80-90% of the beta-cells are destroyed, overt symptoms occur.

Type II diabetes is commonly associated with obesity. It does not usually occur until after the age of 30. Causes:

Insulin resistance: unable to utilize insulin that the body makes because of cellreceptor defect; glucose is unable to be absorbed into cells for fuel. Decreased insulin secretion: pancreas does not secrete enough insulin in response to glucose levels. Excess production of glucose from the liver: result of defective insulin secretory response; dawn phenomenon

Etiology

Gestational Diabetes Mellitus: It develops during the third trimester and significantly increases perinatal morbidity and mortality Causes: Genetic predisposition Insulin resistance due to pregnancy. Most patients with gestational diabetes return to a normoglycemic state after labor; however, about 30 to 50% of women with a history of gestational diabetes will develop type 2 diabetes within 10 years. The proper diagnosis and management of gestational diabetes improves pregnancy outcomes.

Signs and Symptoms

Polydipsia (excessive thirst) Polyuria (excessive urination) Polyphagia (excessive hunger) Unexplained weight loss Changes in vision Weakness, malaise Irritability Nausea Dry mouth Ketoacidosis*

Diagnosis

Diagnosed by the casual glucose, fasting glucose level and oral glucose tolerance test (OGTT).

Presence of diabetes symptoms plus casual (nonfasting) plasma glucose 200 mg/dL (casual glucose may be drawn at any time of day without regard to time since last meal) Fasting plasma glucose* 126 mg/dL (fasting is defined as no caloric intake for at least 8 hours) Two-hour postprandial glucose 200 mg/dL during an oral glucose tolerance test using a glucose load containing the equivalent of 75 g of anhydrous glucose dissolved in water. (This method is not recommended for routine use as it can lead to Cardiovascular disease).

Other tests: Glycated hemoglobin assay (HbA1 test and HbA1c test), Fructosamine test and SBGM (Glucometers)

Compliations

Retinopathy
1. 2.

Vision changes Blindness

Nephropathy (renal failure) Neuropathy Sensory


1. 2. 3.

Loss of sensation in hands and feet (other areas may be affected as well) Impotence Other sensory dysfunction

Autonomic
1. 2. 3.

Gastroparesis (affects stomach emptying and other gastrointestinal functions) Changes in cardiac rate, rhythm, conduction Other autonomic dysfunction

Macrovascular disease (accelerated atherosclerosis)


1. 2. 3.

Peripheral vascular disease Cardiovascular (coronary artery disease) Cerebrovascular (stroke)

Alterations in wound healing

Oral Manifestations

Xerostomia Oral Candidiasis Lichen Planus Lichenoid drug reactions Dental Caries Enlargement of Parotid Glands Gingivitis Periodontitis Burning Mouth Syndrome (Glossodynia)

Pseudomembranous candidiasis

Xerostomia

Lichen Planus

Parotid Enlargement

Gingivitis

Periodontitis

Burning Mouth Syndrome

Treatment
Diabetes

is an incurable disease and the only treatment for it is by management of the disease depending on the type of the disease and by achieving blood glucose levels that are as close to the normal level as possible as well as preventing the aforementioned diabetic complications.

Type 1
Insulin (Ultralente )by injection with syringes or pumps [Hypoglycemia] Diet Exercise Education Monitoring

Type 2

Diet/weight management Exercise/increase physical activity Oral hypoglycemic/antihyperglycemic agents (Mentformin), insulin sensitizers, or insulin Education Monitoring Treatment of comorbid conditions (e.g., hypertension, lipid abnormalities)

Gestational Diabetes
Diet: provide adequate calories without hyperglycemia or ketonemia Exercise: program that does not cause fetal distress, contractions, or hypertension (>140/90 mmHg). Insulin: if unable to consistently maintain blood glucose <95 mg/dl fasting (<5.3 mmol/l) and <140 mg/dl (<7.8 mmol/l) 1 hour postprandial and <120 mg/dl (<6.7 mmol/l) 2 hours postprandial.

Dental Management

Establish adequate diabetic control at least 2-3 days before operation If taking Mentformin stop 24-48 hrs before surgery Timed treatment to avoid disturbance of routine insulin administration or meals, so perform operation as early as possible in the morning On the morning of surgery omit usual insulin or oral anti-diabetic drug and check blood glucose electrolytes, urea and creatinine Consultation of anesthesiologist well in advance is advisable Use local anesthesia for routine dentistry the amount of adrenaline (epinephrine) in local anesthetic solutions has no significant effect on the blood sugar Sedation can be given if required Dental operations under general anesthesia should only be carried out in hospital under expert supervision Deal with any diabetic complications Manage hypoglycemic coma (Always have a source of glucose available)

Insulin

Insulin is classified as rapid, short, intermediate or long-acting. Each category induces variable onset of peak activity and duration. Insulin injections are timed so that peak plasma levels coincide with peak postprandial glucose levels. It is important for the practitioner to know the medication regimen being used by the patient, and any surgical therapy should be timed to avoid peak insulin activity and possible hypoglycaemic crisis

Complications that can affect Dental Management


Susceptibility to infection, particularly candidosis Diabetic coma Hypoglycemic coma Ischaemic heart disease Acceleration of periodontal disease if control is poor Dry mouth secondary to polyuria and dehydration Oral lichenoid reactions due to oral hypoglycemic drugs Sialadenosis

Diabetic Coma
Intravenous fluids to restore water to dehydrated tissues Potassium, sodium or phosphate supplements to help the cells function correctly Insulin to help the tissues absorb glucose again Treatment for any underlying infections

Hypoglycemic Coma

Patients often aware of what is happening and able to warn the Dentist. Before consciousness is lost, give glucose tablets or powder, or sugar (at least four lumps) as a sweetened drink, repeated if symptoms not completely relieved Ideally, if consciousness is lost, give sterile intravenous glucose (up to 50 mL of a 50% solution) If sterile glucose not available give subcutaneous glucagon (1 mg) then give sugar by mouth during the brief recovery period. Hypostop, a gel containing glucose, may provide sufficient glucose absorbed through the oral mucosa to combat declining consciousness

Antibiotic Prophylaxis

Insulin-dependent diabetic patients, particularly those with poorly controlled disease, are vulnerable to infections. Therefore, antibiotic coverage for invasive dental procedures is recommended in patients with poorly controlled or uncontrolled diabetes, but is generally not required for those in whom the disease is well-controlled or for those who are not dependent on insulin therapy.

Antibiotic Prophylaxis

Type 1 Management
Early in the morning establish IV infusion of 500 ml 10% dextrose + 20mmol K+ given at a rate of 100ml/hr Check blood glucose using blood glucose meter or strip 2-4 hourly and adjust content of infusion to maintain values within the range 5-11 mmol/l

Type 2 Management

Minor Surgery:
Constant Monitoring : measure blood glucose frequently

Glucose/Potassium/Insulin IV if necessary postoperatively Early in the morning establish IV infusion of 500 ml 10% dextrose + 20mmol K+ given at a rate of 100ml/hr Check blood glucose using blood glucose meter or strip 2-4 hourly and adjust content of infusion to maintain values within the range 5-11 mmol/l

Major Surgery:

Sources

Burkets Oral Medicine Diagnosis and Treatment , 10th Edition Tyldesley's Oral Medicine, 5th Edition Davidsons Principles & Practice of Medicine, 20th Edition The Prevention of Oral Disease, 4th Edition Cawsons Essentials of Oral Pathology and Oral Medicine, 7th Edition

Shetty V, Bertolami C. The physiology of wound healing.


http://www.diabetes.org http://www.diabetesjournals.org/ http://www.idf.org/ http://jama.ama-assn.org/ http://jada.ada.org