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DENT :D > Diabetes Mellitus > Flashcards

Diabetes Mellitus Flashcards

1
Q

Define Diabetes Mellitus

A

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

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2
Q

What are some CLINICAL feature of Diabetes Type 1

  • Frequency
  • Age of onset
  • Body build
  • Severity
  • Insulin
  • Plasma Glucagon
  • Response to Oral hypoglycemic
A 
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
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3
Q

What are some CLINICAL feature of Diabetes Type 2

  • Frequency
  • Age of onset
  • Body build
  • Severity
  • Insulin
  • Plasma Glucagon
  • Response to Oral hypoglycemic
A 
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
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4
Q 
Clinical Features of type 1
Ketoacidosis
Complications
Rate of Clinical onset
Stability 
Genetic locus 
HLA and abnormal autoimmune reactions 
Insulin receptor defects
A

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

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5
Q 
Clinical Feature of Type 2 Diabetes: 
Ketoacidosis
Complications
Rate of Clinical onset
Stability 
Genetic locus 
HLA and abnormal autoimmune reactions 
Insulin receptor defects
A

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

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6
Q

What are Complications of DM

first 4

A

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

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7
Q

Complication of DM, last 3

A

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

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8
Q

What are the types of Insulin treatments available. Why is it important for us to know?

A 
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

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9
Q

Ketoacidosis

A

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.

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10
Q

What could these symptoms in a diabetic pt be caused by: Hunger, Weakness, Tachycardia, Pallor, Sweating,

A

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.

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11
Q

What is Insulin Shock

A

Hypoglycemic reaction caused by an excess of insulin with 3 stages
• Etiology: overdose of insulin or an oral hypoglycemic agent particularly sulfonylurea drugs

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12
Q

What are the 3 stages of Insulin Shock

A

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

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13
Q

What is the treatment for insulin shock

A

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.

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14
Q

Oral findings in patients with uncontrolled diabetes most likely relate to:

A
  1. Excessive loss of fluids through urination (dry mouth more susceptible to infection)
  2. Altered response to infection and immune system (more prone to infection i.e. candidiasis)
  3. Microvascular changes
  4. Increased glucose concentrations in saliva.
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15
Q

What are oral consequences of vascular disease related to uncontrolled diabetes*****

A

Periodontal Disease
Pregnancy Gingivitis
Pregnancy Granuloma

These are also due to affect of reproductive hormones

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16
Q

What are oral consequences of immune dysfunction related to uncontrolled diabetes

A 
Lichen Planus
Oral Cancer
Benign Migratory Glossitis
Candidiasis*
Vascular disease (periodontal disease, pregnancy gingivitis, pregnancy granuloma)
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17
Q

What are oral consequences of Candidiasis related to uncontrolled diabetes

A

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

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18
Q

Oral side effects of drugs used to treat uncontrolled diabetes

A
  1. Lichenoid drug reaction
  2. 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
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19
Q

Oral side effects of drugs to treat diabetes and peripheral neuropathy can lead to salivary gland dysfunction which can have the following consequences

A
  1. Parotid Gland enlargement
  2. 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]
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20
Q

What could these symptoms in a diabetic pt be caused by: Incoherence , Uncooperativeness , Belligerence , Lack of judgment and Poor orientation

A

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.

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21
Q

What are oral consequences of Peripheral Neuropathy related to uncontrolled diabetes

A
  1. Salivary Gland Dysfunction

2. Burning Tongue Sensation

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22
Q

list first half of Oral Manifestations in poor controlled diabetic patients

A

Mostly seen in poor controlled diabetic patients

  1. xerostomia: dry mouth
  2. low levels of salivary calcium, phosphate in saliva
  3. Elevated saliva glucose level
  4. bacterial, viral, and fungal infections (including candidiasis)
  5. poor or delayed wound healing
  6. increased incidence and severity of caries
23
Q

list second half of Oral Manifestations in poor controlled diabetic patients***

A
  1. gingivitis and periodontal disease
  2. periapical abscesses
  3. burning mouth symptoms
  4. Diabetic neuropathy causing unusual numbness, tingling or pain in mouth
  5. higher percentage of oral lesions such as traumatic ulcers, and lichen planus
  6. *Metallic taste due to Metformin
24
Q

Clinical Detection of Patients with Diabetes by History involves following questions

A

Are you diabetic?
• What medications are you taking?
• Are you being treated by a physician?

25
Q

Clinical Detection of Patients with Diabetes by Establishment of severity of disease and degree of “control” involves following questions

A
  • 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?
26
Q

Management of Patient with Undiagnosed Diabetes

A
  1. History of signs or symptoms of diabetes or its complications
  2. 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
  3. Referral or screening test for diabetes
27
Q

Dental Management Considerations in the Patient With Diabetes

A

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.

28
Q

Definition of NOT Well controlled diabetes

A

• 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
29
Q

Diabetes Dental Management

Considerations for ANALGESICS

A

AVOID use of aspirin and other NSAIDs in patients taking **sulfonylureas* because they can worsen hypoglycemia

30
Q

Diabetes Dental Management

Considerations for ANTIBIOTICS

A

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

31
Q

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

A

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.

32
Q

Diabetes Dental Management

Considerations for ANESTHESIA

A

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

33
Q

Diabetes Dental Management

Considerations for ANXIETY, ALLERGY, BREATHING, CHAIR POSITION

A

no issue

34
Q

Diabetes Dental Management

Considerations for BLEEDING

A

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)

35
Q

Diabetes Dental Management

Considerations for BLOOD PRESSURE

A

Monitor blood pressure because diabetes is associated with hypertension.

36
Q

*******Diabetes Dental Management

Considerations for CARDIOVASCULAR***

A

Confirm cardiovascular status.

BETA BLOCKERS can exacerbate hypoglycemia in patients taking SULFONYLUREAS

37
Q

Diabetes Dental Management

Considerations for DEVICES

A

In patient with insulin Pump
• Ensure it is attached and working properly
• Antibiotic prophylaxis is not needed.

38
Q

Diabetes Dental Management

Considerations for DRUGS

A
  • 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

39
Q

Diabetes Dental Management

Considerations for DRUG INTERACTIONS

A

1.
Aspirin and Oral hypoglycemic;*
Increased hypoglycemic effects.
RECOMMENDATION: Avoid interaction.

  1. GLINIDES (Repaglinide (Prandin) and Nateglinide (Starlix) And NSAIDs; increase risk of hypoglycemia
  2. Glinides (Repaglinide (Prandin) and Nateglinide (Starlix) with Azole (antifungal) and erythromycin; Metabolism may be inhibited so risk of hypoglycemia
  3. Sulfonylureas and Antigfungal (Azole group):Cincrease hypoglycemia
40
Q

Diabetes Dental Management

Considerations for EQUIPMENT

A

Use office Glucometer to ensure good glucose control.

41
Q

Diabetes Dental Management

Considerations for EMERGENCIES

A

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.

42
Q

Diabetes Dental Management

Considerations for FOLLOW-UP

A

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.

43
Q

Dental Management Considerations in the Patient With Diabetes in need of extensive surgery

A

If extensive surgery is needed:
• Consult with patient’s physician concerning dietary needs
during postoperative period.

44
Q

Dental Management Considerations in the Patient With UNCONTROLLED Diabetes in need of surgery

A

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

45
Q

Protocol for Diabetic IV

sedation

A

• 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

46
Q

OVERALL Dental Management Considerations in the Patient With Diabetes

A
  • 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
47
Q 
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.
A

Blindness

juvenile = same as TYPE 1

48
Q

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.
A

hypoglycemia

49
Q

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

A

glycemic index?

a or b

50
Q

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.

A

atrophy of islets of langerhans

51
Q

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

A

15g ** remember this number it is standard amount to give to patient

52
Q 
Question 6
Untreated diabetes mellitus characteristically demonstrates a) hypoglycemia.
b) hyperglycemia.
c) hypophagia
d) hyperlipidemia e) dysuria
A

hyperglycemia

53
Q 
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.
A

hairy leukoplakia

54
Q

What are drugs that have a BAD interaction with Sulfonylureas

  • what are other drugs that react poorly with hypoglycemic drugs? (glinidines)
A

AVOID interactions with sulfonylureas AND:

  • Beta Blockers
  • NSAIDS
  • Antifungals (azole)

these interactions lead to hypoglycemia**

for Glinides, avoid interactions with: NSAIDS, azole, and erythromycin*

DENT :D (7 decks)

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