Diabetes for dentists

Question 1

Diagnosis

Answer 1

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

Question 2

Presenting features of diabetes

Answer 2

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)

Question 3

Clinical features of newly diagnosed type 1 diabetes

Answer 3

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

Question 4

Clinical features of type 1 diabetes

Answer 4

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

Question 5

Prevalence of type 1 diabetes

Answer 5

Relatively rare (prevalence of 3/1000 among children and adolescents)
250,000 in the UK

Question 6

Aims of treatment of type 1 diabetes

Answer 6

Initially to achieve a normal weight
Relieve symptoms and prevent ketoacidosis
Prevent microvascular and macrovascular complications
Avoid hypoglycaemia

Question 7

Microvascular complications

Answer 7

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

Question 8

Treatment of type 1 diabetes

Answer 8

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)

Question 9

Symptoms of hypoglycaemia

Answer 9

Glucose too low –> release of adrenaline

• shaky
• sick
• hot
• dizzy
• heart racing
• frightened
• increases BR
• irritable
• weakness/ fatigue
• impaired vision

Question 10

Neuropathy type 1 diabetes

Answer 10

Longest nerves spine to feet

• can’t feel pain
• ulcers, infections, can lead to amputations

Question 11

Benefits and risks of tight glucose control

Answer 11

Good glucose control –> very low chances of retinopathy and vice versa
Tight glucose control –> higher risk of hypoglycaemia and vice versa

Question 12

The dilemma for those with type 1 diabetes

Answer 12

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

Question 13

Conclusions - type 1 diabetes

Answer 13

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

Question 14

Type 2 diabetes

Answer 14

Perhaps greatest non-infective threat to global health
Disease of ‘western industrialised lifestyle’
-obesity
-lack of physical exercise

Question 15

Type 2 diabetes prevalence

Answer 15

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

Question 16

Pathogenesis of type 2 diabetes

Answer 16

> thrombogenesis
Early hyperinsulinaemia
Abnormal lipids (low HDL cholesterol hypertriglyceridaemia)
Hypertension
Central obesity
Insulin resistance
Hyperglycaemia

–>major CV risk (x3-4)

Question 17

Complications in type 2 diabetes

Answer 17

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

Question 18

Pathogenesis of raised blood glucose in Type 2 diabetes

Answer 18

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

Question 19

Treatment in Type 2 diabetes

Answer 19

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

Question 20

Typical treatment pathway in pts with type 2 diabetes

Answer 20

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

Question 21

Other possible medications

Answer 21

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

Question 22

Conclusions - type 2 diabetes

Answer 22

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

Question 23

Diabetic ketoacidosis: definition

Answer 23

Hyperglycaemia (use capillary sample but confirm with lab test)
Venous bicarbonate < 15 mmol/l
Ketones
Usually only type 1 diabetes

Question 24

Causes of diabetic ketoacidosis

Answer 24

Infections
Omission of insulin
New diagnosis

Question 25

Mortality of diabetic ketoacidosis

Answer 25

1-5%
Elderly
-associated co-morbidity and late diagnosis
Young
-severe DKA recognised late
-rare and poorly understood condition of cerebral oedema in children

Question 26

Hyperosmolar Hyperglycaemic State (HHS) or Hyperosmolar Non-Ketotic Coma (HONK) definition

Answer 26

Hyperglycaemia (blood glucose usually >50 mmol/l)
Hyperosmolality (osmolality usually >350 mosmoles/l)
Accompanied by dehydration
Type 2 diabetes

Question 27

Those at risk of HHS or HONK

Answer 27

Poorly controlled Type 2 diabetes

Newly diagnosed Type 2 diabetes patients, often elderly

Question 28

Symptoms and signs of hypoglycaemia

Answer 28

Autonomic
-sweating
-tremor
-palpitations
Neuroglycopenic
-loss of conc.
-drowsiness
-anger/ sadness
-confusion

Question 29

Hypo management: pt conscious

Answer 29

Oral glucose –> check blood glucose after 10 mins (further PO glucose if needed) –> identify cause, re-educate, adopt measures to avoid hypos

Question 30

Hypo management: pt unconscious

Answer 30

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

Question 31

Monitoring diabetes

Answer 31

Venous blood glucose
-normal range 4-7
HbA1c
Capilliary blood glucose
Blood ketones
Urinary ketones

Question 32

Diabetes and dentristry

Answer 32

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)