Diabetes for dentists Flashcards
Diagnosis
Symptoms and random plasma glucose > 11.1 mmol/l
Fasting plasma glucose > 7 mmol/l
HbA1c > 48 mmol/mol
No symptoms - OGTT (75g glucose) fasting > 7 or 2h value > 11.1 mmol/l
Presenting features of diabetes
Thirst -osmotic activation of hypothalamus Polyuria -osmotic diuresis Weight loss and fatigue -dehydration -lipid and muscle loss Pruritis vulvae and balanitis -vaginal candidiasis Hunger Blurred vision -altered acuity due to uptake of glucose/water into lens Respiratory -Kussmaul breathing (hyper-ventilation)
Clinical features of newly diagnosed type 1 diabetes
Weight loss
Short history (weeks) of severe symptoms
Moderate or large urinary ketones
Any 2 of these three features indicate Type 1 diabetes and are an indication for immediate insulin treatment at ANY age
Clinical features of type 1 diabetes
Commonest age at diagnosis, 5-15y , but can occur at any age
An insulin deficiency disease (autoimmune destruction of the beta cell)
Treatment consists of restoring appropriate insulin concentrations
Prevalence of type 1 diabetes
Relatively rare (prevalence of 3/1000 among children and adolescents) 250,000 in the UK
Aims of treatment of type 1 diabetes
Initially to achieve a normal weight
Relieve symptoms and prevent ketoacidosis
Prevent microvascular and macrovascular complications
Avoid hypoglycaemia
Microvascular complications
Around 30% in UK will develop diabetic nephropathy
- CV mortality with no nephropathy x2, but with nephropathy x30
- those with nephropathy tend to develop proliferative retinopathy and severe neuropathy with major effect on QoL
Treatment of type 1 diabetes
To restore physiology of the beta cell
Insulin treatment
-2x daily mixture of short/medium acting insulin
-basal bolus, (once or 2x daily medium acting insulin plus pre meal quick acting insulin)
Ability to judge carbohydrate intake
Awareness of blood glucose lowering effect of exercise
All combined to keep blood glucose close to normal (and so prevent diabetic complications)
Symptoms of hypoglycaemia
Glucose too low –> release of adrenaline
- shaky
- sick
- hot
- dizzy
- heart racing
- frightened
- increases BR
- irritable
- weakness/ fatigue
- impaired vision
Neuropathy type 1 diabetes
Longest nerves spine to feet
- can’t feel pain
- ulcers, infections, can lead to amputations
Benefits and risks of tight glucose control
Good glucose control –> very low chances of retinopathy and vice versa
Tight glucose control –> higher risk of hypoglycaemia and vice versa
The dilemma for those with type 1 diabetes
Setting higher glucose targets will < risk of hypoglycaemia but > risk of diabetic complications
Setting lower glucose targets will < risk of complications but > risk of hypoglycaemia
Conclusions - type 1 diabetes
2/3 of all pts can expect reasonable life expectancy with minor complications
Tight glucose control will > proportion but often at expense of hypoglycaemia & weight gain
Challenge is to engage most pts in the management of their own disease
Type 2 diabetes
Perhaps greatest non-infective threat to global health
Disease of ‘western industrialised lifestyle’
-obesity
-lack of physical exercise
Type 2 diabetes prevalence
7% prevalence in Sheffield
2.7 million in the UK, i.e., ~1 in 20
Medications cost the NHS ~£1000 million / y
Currently affects > 360 million worldwide
Pathogenesis of type 2 diabetes
> thrombogenesis Early hyperinsulinaemia Abnormal lipids (low HDL cholesterol hypertriglyceridaemia) Hypertension Central obesity Insulin resistance Hyperglycaemia
–>major CV risk (x3-4)
Complications in type 2 diabetes
Macrovascular affect majority and often advanced at diagnosis
-MI, stroke, peripheral vascular diagnosis
Microvascular affect 20-25% at diagnosis and are modified by underlying vascular disease
Life expectancy shortened at diagnosis by ~5-10 years
Pathogenesis of raised blood glucose in Type 2 diabetes
Insulin resistance (probably inherited) which demands increased production of insulin to maintain normal glucose levels before the development of diabetes Progressive failure of insulin secretion
Treatment in Type 2 diabetes
Ideally consists of weight loss and exercise (improve insulin resistance) which if substantial will reverse hyperglycaemia
but most of those with T2 diabetes have been making ‘wrong’ lifestyle choices all their lives
At present, management usually consists of medication to control BP, blood glucose and lipids
Tight control of BP and lipids has a greater effect in < risk of macrovascular disease (and < microvascular complications) and is usually easier to achieve than blood glucose control
Typical treatment pathway in pts with type 2 diabetes
Diet: ‘Eat less’ and < refined CHO (glucose)
Metformin: biguanide which < blood glucose by improving glucose uptake without > body weight and also reduces CV disease in the longterm
-now initial treatment of choice for all those with T2 diabetes
-s/e of abdo pain and diarrhoea limit dose
Sulphonylurea: Act by stimulating release of insulin from pancreatic beta cells so can cause weight gain and hypoglycaemia, examples gliclazide, glibenclamide
Insulin: Insulin secretion declines progressively in Type 2 diabetes, > 50% will need insulin
Other possible medications
Or possibly pioglitazone,
Or a DPPIV inhibitor, e.g., sitagliptin
Or a gliflozin, e.g., empagliflozin
Or a incretin mimetic (injection), e.g., exenatide or liraglutide
Conclusions - type 2 diabetes
The ‘best’ treatment, weight loss and increased exercise is rarely achieved
Needs multiple medications, many of which are probably not taken
The challenge is to engage the patient in the management of their own condition
This is not ‘mild’ diabetes - high risk of premature vascular death and other vascular complications
Diabetic ketoacidosis: definition
Hyperglycaemia (use capillary sample but confirm with lab test)
Venous bicarbonate < 15 mmol/l
Ketones
Usually only type 1 diabetes
Causes of diabetic ketoacidosis
Infections
Omission of insulin
New diagnosis
Mortality of diabetic ketoacidosis
1-5%
Elderly
-associated co-morbidity and late diagnosis
Young
-severe DKA recognised late
-rare and poorly understood condition of cerebral oedema in children
Hyperosmolar Hyperglycaemic State (HHS) or Hyperosmolar Non-Ketotic Coma (HONK) definition
Hyperglycaemia (blood glucose usually >50 mmol/l)
Hyperosmolality (osmolality usually >350 mosmoles/l)
Accompanied by dehydration
Type 2 diabetes
Those at risk of HHS or HONK
Poorly controlled Type 2 diabetes
Newly diagnosed Type 2 diabetes patients, often elderly
Symptoms and signs of hypoglycaemia
Autonomic -sweating -tremor -palpitations Neuroglycopenic -loss of conc. -drowsiness -anger/ sadness -confusion
Hypo management: pt conscious
Oral glucose –> check blood glucose after 10 mins (further PO glucose if needed) –> identify cause, re-educate, adopt measures to avoid hypos
Hypo management: pt unconscious
glucogon 1 mg (IM) or IV glucose (100 mls 10% dextrose) –> check blood glucose after 10 mins (further IV glucose if needed) –> identify cause, re-educate, adopt measures to avoid hypos
Monitoring diabetes
Venous blood glucose -normal range 4-7 HbA1c Capilliary blood glucose Blood ketones Urinary ketones
Diabetes and dentristry
Increased rates of gingivitis / periodonitis (2-5 fold) / dental caries / candidiasis / endocarditis
Stress – both physical & emotional raises blood glucose levels
Beware of hypoglycaemic medications
Type 1 diabetes is autoimmune process, therefore Sjorgrens is more likely
Some studies suggest improvements in glycaemic control after periodontal intervention
Dentists can help in the early recognition of T2DM (and rarely T1DM)
