Diabetes

Question 1

what is diabetes mellitus?

Answer 1

• blood sugar levels too high
• body cannot take up glucose properly
• pancreas does not produce enough insulin
• OR body does not respond to insulin

Question 2

what is type 1 DM?

Answer 2

• insulin deficiency
• autoimmune destruction of pancreatic beta cells

Question 3

what does destruction of pancreatic beta cells lead to?

3

Answer 3

• hyperglycaemia
• ketoacidosis
• low c-peptide levels (indicating low insulin secretion)

Question 4

what is ketoacidosis?

Answer 4

• when body cells cannot access glucose due to a lack of insulin
• cells start to metabolise fat which results as ketones as end product

only occurs in T1DM

Question 5

what are the circulating antibodies present in T1DM?

3

Answer 5

• GAD - glutamic acid decarboxylase
• ICA - islet cell antibodies
• IAA - insulin autoantibodies

Question 6

what are the symptoms of DM?

4

Answer 6

• polyuria
• polydipsia
• tiredness
• unintentional weight loss

Question 7

what are the symptoms of diabetic ketoacidosis?

8

Answer 7

• polydipsia
• polyuria
• confusion
• blurred vision
• stomach pain
• nausea and vomiting
• sweet/fruity breath
• loss of consciousness

Question 8

how can you treat early signs of diabetic ketoacidosis (DKA)? what happens if it is not treated early?

Answer 8

• insulin and fluids
• if not treated early, sent to hospital urgently

Question 9

what is latent autoimmune diabetes (LADA)? which antibody is it associated with?

Answer 9

• diabetes onset in adults older than 30 years old
• GAD associated
• may masquerade as ‘non-obese’ type 2

Question 10

describe the natural history of beta cell loss in T1DM

Answer 10

• when beta cell function is high = normoglycaemia
• as cells are destroyed, pt transitions through impaired glucose tolerance (IGT)
• as beta function decreases further, pt enteres a diabetic category
• pt. enters a non-insulin requiring stage where they still have some functioning beta cells
• then enters a insulin for control stage
• and finally until they require insulin for survival as beta cell function is so low, not enough insulin is produced

Question 11

what is type 2 DM?

Answer 11

• insulin resistance
• diabetes associated with family history and social history
• transitions through impaired glucose tolerance

Question 12

what are the rarely acute presentations of T2DM?

Answer 12

• polyuria, polydipsia, tiredness
• unusual infections
• diabetic complications e.g. cardiovascular

Question 13

what are the effects of T2DM?

7

Answer 13

• impaired glucose tolerance (IGT)
• hyperinsulinaemia
• hypertension
• oesity with abdominal distribution
• dyslipidaemia (high LDL, low HDL)
• procoagulant epithelial markers
• early and accelerated atherosclerosis

Question 14

how would you be able to tell if T2DM was not well controlled?

Answer 14

the patient takes additional insulin medication with the oral medication when unable to maintain glycaemic control with:
* behavioural change
* body weight reduction
* oral hypoglycaemic agents

Question 15

what is insulin resistance?

Answer 15

• defect in insulin synthesis, secretion and action
• beta cell response to hyperglycaemia is inadequate
• results in elevated basal insulin levels
• failure of gluconeogenesis suppression
• insulin stimulated glucose uptake is impaired

Question 16

what is medication induced diabetes? what medications?

Answer 16

medicine which interferes with the **secretion of insulin or glucagon, or alters the uptake of glucose **
* corticosteroids (prednisolone, hydrocortisone)
* immune suppressants (cyclosporin)
* cancer medication (imatinib, nilotinib)
* antipsychotics (clozapine, olanzapine, quetiapine)
* antivirals (protease inhibitors)

Question 17

what other medical conditions are related to diabetes?

Answer 17

• endocrine diseases - Cushing’s, Acromegaly, Phaeochromocytoma (adrenaline tumour)
• pregnancy - gestational diabetes

Question 18

describe the four investigations for diabetes and the criteria for diagnosis of T2DM

Answer 18

• random sugar test - blood sugar tested at random time so no need to fast before - +11.1mmol/L on 2 occasions
• fasting sugar test - blood sugar tested after fasting - +7.0mmol/L
• glucose tolerance test - patient fasts before test then drinks glucose solution and blood glucose is measured - +11.1mmol/L
• HbA1C (glycated haemoglobin) - average blood sugar levels over previous 2-3 months - +48mmol/L

Question 19

what are the normal values for each of the investigations for T2DM?

Answer 19

• HbA1C - 41mmol/L and below
• fasting glucose - 6.0mmol/L and below
• 2 hour plasma glucose - 7.7mmol/L and below

Question 20

what is the group inbetween diabetes and normal when investigating blood sugar levels? what are the values?

Answer 20

impaired or pre-diabetes

Question 21

what are the differences between T1DM and T2DM?

Answer 21

Question 22

how would you manage diabetes mellitus generally?

Answer 22

• structured education - make appropriate to patient’s needs
• healthy living advice - dietary advice, living interventions, personalised diabetes plan
• blood glucose management - explain targets and the need to maintain them
• consider prevention to reduce risk from associated disease - antiplatelets, statins, antihypertensives

Question 23

what are the different insulin regimes?

Answer 23

• basal-bolus: more injections so better control
• split-mixed: fewer injections so poorer control

Question 24

how would you manage T1DM?

Answer 24

• nutrition - carbohydrate counting
• exercise - planned activity, understand individual response to exercise
• monitoring - initially need regular checks until pt is familiar with their personal response to food and exercise
• insulin - subcutaneous injection with different preparations and time to act

Question 25

how would you manage T2DM?

Answer 25

* **lifestyle** - weight loss, diet, exercise * **medication** - biguanides, DDP-4 inhibitors, GLP-1 mimetics, sulphonylureas * **surgery** - gastric vertical banding - bariatric surgery

Question 26

what does metformin (biguanides) do?

Answer 26

* enhance cell insulin sensitivity * reduce hepatic gluconeogenesis

Question 27

what are some acute diabeteic complications? | 3

Answer 27

* hypoglycaemia * hyperglycaemia * ketoacidosis

Question 28

what are some chronic diabetic complications?

Answer 28

* cardiovascular disease * peripheral vascular disease * increased risk of infection * retinopathy * neuropathy * nephropathy

Question 29

when does hypoglyaemia occur? what should you do when someone has a hypoglycaemic episode?

Answer 29

* blood glucose **below 4mmol/L** * give them something to **eat or drink** that will increase blood sugar * if someone becomes unconscious, give **glucagon injection** then **food/drink** when consciousness regained

Question 30

what are the macrovascular complications with diabetes?

Answer 30

* coronary artery disease * peripheral ischaemia (PVD) * stroke * hypertension

Question 31

what are the microvascular complications with diabetes?

Answer 31

* nephropathy (renal disease) * retinopathy (eye disease) * neuropathy (nerves)

Question 32

what are the infection complications with diabetes?

Answer 32

* UTI * pneumonia * skin/soft tissue infections * fungal infections - candida

Question 33

how do diabetic ulcers form?

Answer 33

* **sustained hyperglycaemia** leads to **increased glycated haemoglobin** and the formation of **advanced glycation end products** (AGEs) * AGEs increase **oxidant stress** and lead to the production of **free radicals** which cause **tissue damage** i.e. diabetic ulcers * they also bind to **cell surface receptors** (RAGEs) and cause **increased permeability** and **increased adhesion molecule expression** of endothelial cells, **increased chemotaxis** and **increased production of TNFa and IL-6** from macrophages, and **increased production of MMPs** and **reduced collagen formation** by fibroblasts

Question 34

what occurs with diabetic neuropathy?

Answer 34

* **general sensation** - 'glove and stocking' = numbness, tingling or pain in hands or feet * **motor neuropathy** - weakness and wasting of muscels * **autonomic regulation** - hyperglycaemia awareness lost, postural reflexes, bladder and bowel dysfunction

Question 35

what are the problems with surgery for diabetic people?

Answer 35

* **fasting is a problem** - need insulin to prevent ketoacidosis, need carboydrates to prevent hypoglycaemia * **metabolic changes associated with surgery** - hormone changes aggravate diabetes (adrenaline, cortisol, GH), more glucose production and less muscle uptake, metabolic acidosis more likely

Question 36

what are the oral manifestations with DM? | 8

Answer 36

* dry mouth * burning mouth * fungal infections * enlarged salivary glands * periodontal disease * impaired wound healing * halitosis * taste alteration

Question 37

what should you be aware of when treating a diabetic person as a dentist?

Answer 37

* **timing of dental treatment** - morming visit after breakfast, bring snack * risk of **hypoglycaemia** * **reduce stress** - increases *adrenaline*, which interferes with *insulin activity* and may cause a *hypoglycaemic event* * be aware of **diabetic complications** - neuropathy, dehydration, retinopathy * be aware of **increased infection risk** * be aware of **poor wound healing** * link between **DM and periodontal disease**