Diabetes

Question 1

What is the epidemiology of diabetes mellitus?

Answer 1

Estimated 5 million ppl with diabetes in UK by 2025.
Estimated 850,000 ppl in UK undiagnosed
12.3 million at risk of type 2 DM

Question 2

A patient contacts you to update their medication list prior to an appointment for a dental extraction next week. In addition to his usual Metformin, he is now taking Gliclazide. He asks whether or not this will affect his dental treatment.

Does this patient suffer from type 1 or type 2 diabetes mellitus?

Answer 2

Type 2

Question 3

Identify two differences between diabetes mellitus type 1 and 2.

Answer 3

age of onset: type 1 = younger
prevalence: type 2 more prevalent
aetiology: type 1 = autoimmune type 2 = insulin resistance/B cell dysfunction
Initial presentation: type 1 = loss of weight/polyuria/DKA: type 2 = hyperglycaemia, diabetic complications
association with BMI: usually reduced BMI in T1. Increased BMI in T2

Question 4

Name two oral complications of diabetes mellitus (5)

Answer 4

1. oral infections
2. periodontal disease
3. poor healing
4. xerostomia
5. neuropathic changes/changes in sensation.

Question 5

Identify the main actions of metformin on the liver and muscle.

Answer 5

Decreases hepatic gluconeogenesis
Increases glucose uptake and utilisation in skeletal muscle
Increases sensitivity to insulin

Question 6

A patient contacts you to update their medication list prior to an appointment for a dental extraction next week. In addition to his usual Metformin, he is now taking Gliclazide. He asks whether or not this will affect his dental treatment.

Can the extraction for this patient still go ahead as originally planned?

Answer 6

Yes

Question 7

Give two treatment measures that are used in the management of hypoglycaemia in the dental setting.

Answer 7

Glucagon
Lucozade, or any other suitable example of high sugar substance
Hypostop

Question 8

What is normal blood glucose?

Answer 8

fasting: 4.0-6.0 mmol/L
Post prandial (2hrs after meal) <7.8mmol/L

Question 9

What does each cell type release in the islets of langerhans?

Answer 9

Alpha cells - glucagon
Beta cells - insulin
Delta cells - somatostatin

Question 10

When is insulin released?

What does insulin cause in 1) liver and muscle cells 2) fat cells 3) liver and kidney cells?

Answer 10

High blood sugars (e.g. after a meal) stimulate insulin release from pancreas.

1) liver and muscle cells
> incr storage of glucose as glycogen
> amino acid production from proteins

2) fat cells
> formation of fats from fatty acids + glycerol

3) liver and kidney cells
> inhibition of making glucose (gluconeogenesis)

overall, insulin increases storage of glucose, fat, amino acids
therefore, reducing concentration in circulating blood stream

Question 11

When is glucagon released?

What does glucagon cause in 1) liver and muscle 2) liver and kidney cells?

Answer 11

Low blood sugars (e.g. fasting) stimulate glucagon release form the pancreas.

1) LIVER AND MUSCLE CELLS
> breakdown of glycogen to release glucose (glycogenolysis)

2) LIVER AND KINDEY CELLS
> stimulate gluconeogenesis

Overall, glucagon stimulates release of glucose form body stores to increase concentration in bloodstream.

Question 12

What does insulin deficiency or resistance cause?

Answer 12

> Cells unable to absorb glucose despite high levels in blood.Glucagon release stimulated to try and increase glucose levels.Increased release of glucose from storage + gluconeogenesisIncreases blood sugars further but cells still unable to take up and use.

Question 13

What does high levels of blood sugar in diabetic pts cause?

Answer 13

> Increased filtration of glucose by kidneysExcess glucose in renal tubules causes loss of water by osmosisResults in excess glucose being excreted in urine, with polyuriaPolydipsia results because of vol loss + due to osmotic effects stimulating thirst receptors.

Question 14

What is polyuria?

Answer 14

Lots of urine

Question 15

What is polydipsia?

Answer 15

Very thirsty

Question 16

What are symptoms of diabetes mellitus? (7)

Answer 16

1) Polyuria
2) Polydipsia
3) Weight loss
4) Sx + signs of diabetic ketoacidosis
5) Lethargy
6) Blurred vision
7) Recurrent infections

Question 17

How do you diagnose diabetes?

Answer 17

Random glucose >11.1 mmol/L
Fasting glucose >7.0 mmol/L
2 hr postprandial >11.1 mmol/L

HbA1c >4.8 mmol/mol

only pregnant use glucose tolerance test.
normally use HbA1c

Question 18

What are the types of diabetes? (5)

Answer 18

1. Type I DM –> failure to produce insulin
2. Type II DM –> resistance to insulin
3. Gestational DM –> pregnant women who have never had diabetes before but who have high glucose levels during pregnancy.
4. MODY –> genetic defects leading to DM.

5. Secondary diabetes
> pancreatic disease e.g. cystic fibrosis, pancreatomy
> endocrine e.g. Cushings. Acromegaly 
> drug induced e.g. steroids
> genetic

Question 19

What are the differences btw type 1 and type 2 DM?

Answer 19

Age of onset: T1DM = younger T2DM = older
UK prevalence T2DM = more prevalent
Aetiology T1DM = autoimmune T2DM = insulin resistance, beta cells destruction + beta cell dysfunction.
Initial presentation: T1DM = polyuria, polydipsia, weight loss, ketoacidosis. T2DM = hyperglycaemic symptoms, diabetic complications.
Appearance; T1DM = low BM1 T2DM = increased BMI

Question 20

Describe T2DM

Answer 20

Usually insidious onset
Often have developed complications by time of diagnosis
More likely to have additional risk factors e.g. hypertension, hyperlipidaemia.
Lifestyle an important factor

Question 21

What are the risk factors of T2DM?

Answer 21

> Obesity
> Lack of exercise
> Ethnicity - south asian, african, african-carribean, middle eastern
> History of gestational diabetes
> Impaired glucose tolerance
> Diabetes
> Polycystic ovary syndrome
> Family history

Question 22

What are the goals of treatment of type 2 diabetes?

Answer 22

keep patient feeling well
prevention of hypoglycaemia (low blood sugar)
delay onset + progression of microvascular + macrovascular complications
65% patients with diabetes die from heart disease + stroke.

Question 23

What are diabetic complications?

Answer 23

stroke
heart attack
peripheral artery disease
diabetic retinopathy
cataracts
glaucoma
diabetic foot
diabetic + peripheral neuropathy

Question 24

What are the treatment options for T1DM and T2DM?

Answer 24

T1DM = only option is insulin
T2DM = multiple options

Question 25

What are the 2 types of insulin regime?

Answer 25

Basal-bolus regime Basal = long acting background insulin Bolus = short acting insulin taken with meals Twice daily insulin = mixture of shirt and intermediate insulin - less flexibility

Question 26

All different types of insulin has similar mechanism of action. How does insulin differ? (3)

Answer 26

1. Rate of absorption 2. Peak onset of action 3. Duration

Question 27

How is insulin given? | Where on the body?

Answer 27

Subcutaneously delivered via pen devices ``` rotate site of injection: : upper outer arm : abdomen : buttocks : upper outer thigh ```

Question 28

What type of diabetes can have insulin delivered via insulin pump therapy?

Answer 28

only type I unopened supplies of insulin in refrigerator. Insulin in use an be kept at room temp. needles dispose in sharps bin.

Question 29

What are the different therapies for T2DM? (4)

Answer 29

Metformin, sulphonylureas (e.g. gliclazide), SGLT2 inhibitors (e.g. dapaglifozin), Incretin hormones (GLP)

Question 30

How does metformin work?

Answer 30

It increases insulin sensitivity Decreases hepatic gluconeogenesis Increases glucose uptake and utilisation in skeletal muscle

Question 31

How does sulphonylureas work?

Answer 31

Increase insulin release, risk of hypoglycaemia

Question 32

How do SGLT2 inhibitors (e.g. dapaglifozin) work?

Answer 32

Reduce glucose absorption in the kidney | therefore increase glucose excreted in urine

Question 33

How to incretin hormones work? (GLP)

Answer 33

``` GLP-1 agonists - act on GLP receptors, s/c injections. DPP4 inhibitors (gliptins) - prevent GLP breakdown ``` GLP: : stimulates release of insulin only in presence of glucose : reduces appetite + promote satiety - feeling fed : delay gastric emptying : reduces hepatic glucogenesis

Question 34

What is hypoglycaemia?

Answer 34

Refers to any episode of low blood glucose <4mmol/L Occurring in patients taking insulin or sulphonylureas Symptoms can be divided into two stages.

Question 35

What are the 2 stage hypoglycaemia can be divided into?

Answer 35

1. AUTONOMIC: - due to activation of autonomic nervous systems (sweating, tremor, anxiety, palpitations, etc) WARNING SYMPTOMS) 2. NEUROGLYCOPAENIC - due to reduced glucose delivery to the brain (poor concentration, odd behaviour, dizziness, blurred vision etc.) if left untreated, leading to coma + death

Question 36

What causes hypoglycaemia?

Answer 36

``` missing or delaying a meal not having carbohydrate at last meal exercise taking more insulin than you need drinking alcohol on an empty stomach unknown ```

Question 37

How do you treat hypoglycaemia?

Answer 37

if able to have oral intake: - 3 glucose or dextrose tables - 5 jelly babies - small glass of a sugary drink - small carton of pure fruit juice - tube of glucose gel If unable to swallow - IM glucagon - IV glucose Recheck BM 10-15 mins after treating Then have 15-20 g of a slower acting CHO: - sandwich, fruit, cereal, milk

Question 38

What is diabetic ketoacidosis (DKA)? MEDICAL EMERGENCY

Answer 38

only type II Due to insulin deficiency Cells unable to use glucose so breakdown Fatty acids instead Leads to ketone formation. Acidosis develop. Sever dehydration.

Question 39

What are common risk factors diabetes?

Answer 39

obesity, physical activity, diet | influence both oral health and diabetes risk

Question 40

What are the oral manifestations of diabetes?

Answer 40

1. Increased prevalence, extent + severity of periodontitis 2. Periodontal abscesses 3. Poor healing 4. Recurrent infections 5. Medication side effects e.g. gingival overgrowth from calcium channel blockers. 6. Dry mouth - increased risk of caries, candida injection + chronic mouth ulcers.

Question 41

How are diabetes and periodontitis linked?

Answer 41

Diabetics are 2-4x more susceptible to gum disease due to poor blood glucose control > Gum infection further decreases blood glucose control and increases insulin resistance and hyperglycaemia (an excess of glucose in the bloodstream) > High blood glucose levels make fighting infections more difficult and causes more severe gum disease > Severe gum disease can then increase blood glucose levels further, contributing to increased periods of time with high blood sugar > cycle round

Question 42

What is the link btw gum disease & diabetes? (4)

Answer 42

1. Diabetic control: gum disease is linked to blood glucose control. People with poor blood sugar control get gum disease more often, more severely and they lose more teeth. 2. Blood vessel changes: blood vessel deliver oxygen and nourishment to body tissues, including mouth, and carry away the tissues' waste products. Diabetes causes blood vessels to thicken, which slows the flow of nutrients and the removal of harmful wastes, increasing the risk of gum injection. 3. Bacteria: many kinds of bacteria thrive on sugars, including glucose - the sugar linked to diabetes. when diabetes is poorly controlled, high glucose level in saliva enable gums to grow and set the stage for gum disease 4. Smoking: a smoker with diabetes, age 45 or older, is 20x more likely to get severe gum disease.

Question 43

What links periodontitis to diabetes? (slides)

Answer 43

3-4x increased prevalence of severe periodontitis Severity of perio is associated with poor glycaemic control Adverse outcomes in diabetes are more likely in the of periodontitis. Successful treatment of periodontitis can lead to improvements in glycaemic control. Studies have shown consistently a 0.4 reduction in HbA1c with treatment of periodontitis. Every 1% reduction in HbA1c is associated with a reduced risk of diabetes complications.

Question 44

What considerations do you need to make with a diabetic patient undergoing a procedure?

Answer 44

For procedures with LA and no requirement to be NBM (nil by mouth), then generally no changes will be needed. However if a pt has had (or will) reduced oral intake due to procedure, then may have to make alterations to meds to avoid hypoglycaemia (insulin, gliclazide) Alterations to meds depend on likely starvation period + what meds taking. Ideally planned procedure. Seek advice from diabetes team if unsure. Infection + stress cause hyperglycaemia Hypoglycaemia may occur if reduced oral intake.

Question 45

What are the implications of diabetes for dental practice?

Answer 45

a) risk of hypoglycaemia whilst attending the dental surgery b) higher risk of oral disease, particularly if diabetes is poorly controlled c) undiagnosed diabetes may be present at the dental surgery d) pts with diabetes may experience some improvement in their glycaemic control following successful periodontal treatment.