Diabetes Mellitus Flashcards
Define Diabetes Mellitus
describes diseases of abnormal carbohydrate metabolism that are characterized by hyperglycemia
It is associated with a relative or absolute impairment in insulin secretion, along with varying degrees of peripheral resistance to the action of insulin
type 1 can be immune mediated vs type 2 has many etiology: genetic defects, exocrine defects, drug induced, infectionetc
What are some CLINICAL feature of Diabetes Type 1
- Frequency
- Age of onset
- Body build
- Severity
- Insulin
- Plasma Glucagon
- Response to Oral hypoglycemic
Frequency : 5-10% Age of onset : 15 Body build: Normal or thin Severity : Extreme Insulin : Almost all Plasma Glucagon : High, suppressible Response to Oral hypoglycemic : Few respond
What are some CLINICAL feature of Diabetes Type 2
- Frequency
- Age of onset
- Body build
- Severity
- Insulin
- Plasma Glucagon
- Response to Oral hypoglycemic
Frequency : 90-95% Age of onset : 40 and up Body build: Obese Severity : Mild Insulin : 20-30% Plasma Glucagon : High, Resistant Response to Oral hypoglycemic : 50% respond
Clinical Features of type 1 Ketoacidosis Complications Rate of Clinical onset Stability Genetic locus HLA and abnormal autoimmune reactions Insulin receptor defects
Ketoacidosis: common
Complications : 90% in 20 years
Rate of Clinical onset : Rapid
Stability : Unstable
Genetic locus : Chrom 6
HLA and abnormal : autoimmune reactions : present
Insulin receptor defects : Usually not found
Clinical Feature of Type 2 Diabetes: Ketoacidosis Complications Rate of Clinical onset Stability Genetic locus HLA and abnormal autoimmune reactions Insulin receptor defects
Ketoacidosis : uncommon
Complications : less common
Rate of Clinical onset : Slow
Stability : Stable
Genetic locus : Chrom 2, 7, 12, 13 and 17
HLA and abnormal autoimmune reactions : Not present
Insulin receptor defects : Often found
What are Complications of DM
first 4
Metabolic disturbances
• ketoacidosis
•hyperosmolar nonketotic coma (T2diabetes)
Cardiovascular:
•accelerated atherosclerosis (coronary heart disease)
• high blood pressure
• Stroke
Eyes:
• retinopathy
• cataracts
• Blindness
Kidney:
• diabetic nephropathy
• renal failure
Complication of DM, last 3
Extremities:
• ulceration and gangrene of feet
• non–accident-related leg and foot amputations
Diabetic neuropathy: • dysphagia • gastric distention • Diarrhea and impotence • muscle weakness or cramps • numbness, tingling, deep burning pain
Early death:
most commonly caused by cardiovascular disease
What are the types of Insulin treatments available. Why is it important for us to know?
There are Rapid Acting Short Acting Intermediate Acting Long Acting Premixed combinations and Insulin pump
you don’t have to memorize the numbers but important for use to know, so ask patient and search it up to find out period of maximum effect of the medication so our pt does not develop hypoglycemia during the procedure
Ketoacidosis
Diabetic ketoacidosis (DKA) is a life-threatening problem that affects people with diabetes. It occurs when the body starts breaking down fat at a rate that is much too fast. The liver processes the fat into a fuel called ketones, which causes the blood to become acidic.
What could these symptoms in a diabetic pt be caused by: Hunger, Weakness, Tachycardia, Pallor, Sweating,
Insulin Shock, Mild Stage
treatment: giving the patient sweetened fruit juice or anything with sugar in it (e.g., cake icing) or intravenous glucose solution if in stage 3 ; glucagon or epinephrine may be used for transient relief.
What is Insulin Shock
Hypoglycemic reaction caused by an excess of insulin with 3 stages
• Etiology: overdose of insulin or an oral hypoglycemic agent particularly sulfonylurea drugs
What are the 3 stages of Insulin Shock
Mild Stage; Hunger, Weakness, Tachycardia, Pallor, Sweating
Moderate Stage; Incoherence , Uncooperativeness , Belligerence , Lack of judgment and Poor orientation
Severe Stage , Unconsciousness , Tonic or clonic movements, Hypotension , Hypothermia , Rapid, thread pulse
What is the treatment for insulin shock
Treatment: giving the patient sweetened fruit juice or anything with sugar in it (e.g., cake icing) or intravenous glucose solution if in stage 3 ; glucagon or epinephrine may be used for transient relief.
Oral findings in patients with uncontrolled diabetes most likely relate to:
- Excessive loss of fluids through urination (dry mouth more susceptible to infection)
- Altered response to infection and immune system (more prone to infection i.e. candidiasis)
- Microvascular changes
- Increased glucose concentrations in saliva.
What are oral consequences of vascular disease related to uncontrolled diabetes*****
Periodontal Disease
Pregnancy Gingivitis
Pregnancy Granuloma
These are also due to affect of reproductive hormones
What are oral consequences of immune dysfunction related to uncontrolled diabetes
Lichen Planus Oral Cancer Benign Migratory Glossitis Candidiasis* Vascular disease (periodontal disease, pregnancy gingivitis, pregnancy granuloma)
What are oral consequences of Candidiasis related to uncontrolled diabetes
Angular Cheilitis: is a common skin condition affecting the corners of your mouth. It leads to painful, cracked sores. People often confuse angular cheilitis with cold sores.
Denture Stomatitis : redness udner the denture caused by candidiasis
Median Rhomboid Glossitis : s the term used to describe a smooth, red, flat or raised nodular area on the top part (dorsum) of the middle or back of the tongue
Pseudomembranous or atrophic candidiasis of the mucosa
Oral side effects of drugs used to treat uncontrolled diabetes
- Lichenoid drug reaction
- Salivary Gland Dysfunction:
[which contributes to many other things due to low saliva/high glucose in salive]:
a. candidiasis
b. CARIES **
c. Fissured tongue
d. Burning tongue
Oral side effects of drugs to treat diabetes and peripheral neuropathy can lead to salivary gland dysfunction which can have the following consequences
- Parotid Gland enlargement
- Low Salivary flow and/or increased salivary glucose levels
[which contributes to many other things}
a. candidiasis
b. CARIES
c. Fissured tongue
d. Burning tongue]
What could these symptoms in a diabetic pt be caused by: Incoherence , Uncooperativeness , Belligerence , Lack of judgment and Poor orientation
Insulin Shock: Moderate Stage
Treatment: giving the patient sweetened fruit juice or anything with sugar in it (e.g., cake icing) or intravenous glucose solution if in stage 3 ; glucagon or epinephrine may be used for transient relief.
What are oral consequences of Peripheral Neuropathy related to uncontrolled diabetes
- Salivary Gland Dysfunction
2. Burning Tongue Sensation
list first half of Oral Manifestations in poor controlled diabetic patients
Mostly seen in poor controlled diabetic patients
- xerostomia: dry mouth
- low levels of salivary calcium, phosphate in saliva
- Elevated saliva glucose level
- bacterial, viral, and fungal infections (including candidiasis)
- poor or delayed wound healing
- increased incidence and severity of caries
list second half of Oral Manifestations in poor controlled diabetic patients***
- gingivitis and periodontal disease
- periapical abscesses
- burning mouth symptoms
- Diabetic neuropathy causing unusual numbness, tingling or pain in mouth
- higher percentage of oral lesions such as traumatic ulcers, and lichen planus
- *Metallic taste due to Metformin
Clinical Detection of Patients with Diabetes by History involves following questions
Are you diabetic?
• What medications are you taking?
• Are you being treated by a physician?
Clinical Detection of Patients with Diabetes by Establishment of severity of disease and degree of “control” involves following questions
- When were you first diagnosed as diabetic?
- What was the level of the last measurement of your blood glucose?
- What is the usual level of blood glucose for you?
- How are you being treated for your diabetes?
- How often do you have insulin reactions?
- How much insulin do you take with each injection, and how often do you receive injections? • How often do you test your blood glucose?
- When did you last visit your physician?
- Do you have any symptoms of diabetes at the present time?
Management of Patient with Undiagnosed Diabetes
- History of signs or symptoms of diabetes or its complications
- High risk for developing diabetes:
a. Presence of diabetes in a parent
b. Giving birth to one or more large babies (>9 lb)
c. History of spontaneous abortions or stillbirths
d. Obesity
e. Age older than 40 years - Referral or screening test for diabetes
Dental Management Considerations in the Patient With Diabetes
Patient evaluation and risk assessment;
Evaluate and determine whether diabetes exists
Obtain medical consultation
• if glycemic control is poor
•if signs and symptoms point to an undiagnosed problem
• if the diagnosis is uncertain
If diabetes is well controlled, all routine dental procedures can be performed without special precautions.
*Morning appointments usually are best.
Definition of NOT Well controlled diabetes
• Fasting blood glucose <70 mg/dL (< 3.9 mmol/L)or >200 mg/dL (11.1 mmol/L)
Comorbidities • post-MI, • renal disease, • CHF, • symptomatic angina, • old age, • cardiac dysrhythmias, • cerebrovascular accident • Blood pressure >180/110 mm Hg
Diabetes Dental Management
Considerations for ANALGESICS
AVOID use of aspirin and other NSAIDs in patients taking **sulfonylureas* because they can worsen hypoglycemia
Diabetes Dental Management
Considerations for ANTIBIOTICS
NO NEED FOR Prophylactic antibiotics
Consider Ab if poor control diabetics (FPG > 200 mg/ dL) with poor oral hygiene in need of an invasive procedure
Manage infections aggressively by incision and drainage, extraction, pulpotomy, warm rinses, and antibiotics
What could be the cause of the following symptoms in your patient who has diabetes:
Unconsciousness , Tonic or clonic movements, Hypotension , Hypothermia , Rapid, thread pulse
Insulin Shock: Severe stage
Treatment: giving the patient sweetened fruit juice or anything with sugar in it (e.g., cake icing) or intravenous glucose solution if in stage 3 ; glucagon or epinephrine may be used for transient relief.
Diabetes Dental Management
Considerations for ANESTHESIA
No issues if diabetes is well controlled
General anesthesia should be avoided in poor control patient
Limit the number of cartridges containing 1 : 100,000 epinephrine to 2 For diabetic patients with:
1. concurrent hypertension or
2. history of recent MI or
3. with a cardiac arrhythmia
Diabetes Dental Management
Considerations for ANXIETY, ALLERGY, BREATHING, CHAIR POSITION
no issue
Diabetes Dental Management
Considerations for BLEEDING
Thrombocytopenia is a rare adverse effect associated with sulfonylureas. Avoid surgery of the DM is poor controlled. you can know by asking for most recent blood test (usually done by physician every 3-6 months)
Diabetes Dental Management
Considerations for BLOOD PRESSURE
Monitor blood pressure because diabetes is associated with hypertension.
*******Diabetes Dental Management
Considerations for CARDIOVASCULAR***
Confirm cardiovascular status.
BETA BLOCKERS can exacerbate hypoglycemia in patients taking SULFONYLUREAS
Diabetes Dental Management
Considerations for DEVICES
In patient with insulin Pump
• Ensure it is attached and working properly
• Antibiotic prophylaxis is not needed.
Diabetes Dental Management
Considerations for DRUGS
- Patient advised to take usual insulin dosage and normal meals on day of dental appointment; information confirmed with patient at appointment.
- Scheduling appointments in morning or mid- morning
Hypoglycemic agents—on rare occasions can cause aplastic anemia
sulfonylureas with NSAIDS or BB are BAAAD => hypoglycemia** on its own can RARELY cause thrombocytopenia
Diabetes Dental Management
Considerations for DRUG INTERACTIONS
1.
Aspirin and Oral hypoglycemic;*
Increased hypoglycemic effects.
RECOMMENDATION: Avoid interaction.
- GLINIDES (Repaglinide (Prandin) and Nateglinide (Starlix) And NSAIDs; increase risk of hypoglycemia
- Glinides (Repaglinide (Prandin) and Nateglinide (Starlix) with Azole (antifungal) and erythromycin; Metabolism may be inhibited so risk of hypoglycemia
- Sulfonylureas and Antigfungal (Azole group):Cincrease hypoglycemia
Diabetes Dental Management
Considerations for EQUIPMENT
Use office Glucometer to ensure good glucose control.
Diabetes Dental Management
Considerations for EMERGENCIES
Advise patient to inform dentist or staff if symptoms of insulin reaction occur during dental visit. Have glucose source (orange juice, soda, cake icing) available; give to the patient if symptoms of insulin reaction occur.
Diabetes Dental Management
Considerations for FOLLOW-UP
Routine and periodic follow-up evaluation
Inspect for oral lesions as a way to monitor for disease progression. Poor periodontal health is associated with poor glycemic control.
Dental Management Considerations in the Patient With Diabetes in need of extensive surgery
If extensive surgery is needed:
• Consult with patient’s physician concerning dietary needs
during postoperative period.
Dental Management Considerations in the Patient With UNCONTROLLED Diabetes in need of surgery
If diabetes is not well controlled;
• Provide appropriate emergency care only.
• Request referral for medical evaluation, management, and risk factor modification.
• If pt is symptomatic, seek IMMEDIATE referral
• If patient is asymptomatic, request routine referral.
special precaution is needed for patients with complication of the diabetes, renal disease or heart disease
Protocol for Diabetic IV
sedation
• fasting before the
appointment (i.e.,nothing by mouth after midnight)
• using only half the usual insulin dose (consult with physician)
• Supplementing with intravenous glucose during the procedure. ( not that hypoglycemic stage is more dangerous than the hyperglycemic phase)
Note:
• Patients with well-controlled diabetes may be given general anesthesia if necessary. However, management with local anesthetics is preferable, especially in outpatient office setting
OVERALL Dental Management Considerations in the Patient With Diabetes
- Prevent insulin shock during the dental appointment.
- Be sure they take their usual insulin dosage
- eat normal meals before the appointment
- Confirm the patient has taken insulin and has eaten breakfast
- Patients should be instructed to tell the dentist whether at any time during the appointment they are experiencing symptoms of an insulin reaction.
- A source of sugar such as orange juice, cake icing, or non-diet soft drink must be available in the dental office to be given to the patient if symptoms of an insulin reaction develop
Question 1 Which of the following conditions may develop as result of juvenile diabetes mellitus? 1. Ataxia. 2. Aphasia. 3. Deafness. 4. Blindness. 5. Motorparalysis.
Blindness
juvenile = same as TYPE 1
A 45 year old with insulin-dependent diabetes mellitus has a morning dental appointment. During the examination, the patient complains of being lightheaded and weak. Sweating is observed. The patient is most likely experiencing
A. hyperglycemia. B. hypoglycemia. C. syncope. D. hyperventilation. E. cerebrovascular accident.
hypoglycemia
Question 3
Which of the following statements about the nutritional management of diabetes is correct?
a. A diet planned according to Canada’s Food Guide to Healthy Eating must be modified for a person with diabetes.
b. TheGlycemicIndexoffoodsshouldbeusedwhenplanningthediet.
c. The fat content of the diet should be 30-35% of energy intake.
d. Sucroseupto10%oftotaldailyenergyintake(e.g.50%of2000 kcal/day) is acceptable
glycemic index?
a or b
Question 4
Diabetes mellitus is the result of
• A. hypersecretion of the posterior pituitary.
• B. atrophy of the islands of Langerhans.
• C. destruction of the adrenal cortex.
• D. destruction of the posterior pituitary or associated hypothalamic centres.
atrophy of islets of langerhans
Question 5
A 50 year old obese patient was diagnosed with type 2 diabetes last year and has recently started taking an oral hypoglycemic. He frequently skips meals in order to reduce his weight. During his 8:30 a.m. appointment, his speech becomes slurred and he is less alert than usual. Which of the following is the most appropriate management?
a) Have him drink 175ml of diet cola.
b) Give him 15g of glucose as tablets or in a solution.
c) Have him eat a chocolate bar.
d) Dismiss the patient and advise him to eat
15g ** remember this number it is standard amount to give to patient
Question 6 Untreated diabetes mellitus characteristically demonstrates a) hypoglycemia. b) hyperglycemia. c) hypophagia d) hyperlipidemia e) dysuria
hyperglycemia
Question 7 All of the following are oral complications of uncontrolled diabetes mellitus EXCEPT for a) periodontal bone loss. b) delayed healing. c) hairy leukoplakia. d) oral candidiasis.
hairy leukoplakia
What are drugs that have a BAD interaction with Sulfonylureas
- what are other drugs that react poorly with hypoglycemic drugs? (glinidines)
AVOID interactions with sulfonylureas AND:
- Beta Blockers
- NSAIDS
- Antifungals (azole)
these interactions lead to hypoglycemia**
for Glinides, avoid interactions with: NSAIDS, azole, and erythromycin*
