Endocrine Disorders Flashcards
What is diabetes?
- Related to lack of beta cell pancreatic production of insulin
- Results in undernourished tissues which have multiple effects on systemic health
Insulin needed for sugar absorption into cells; a lack of insulin leads to increased serum glucose aka _____________________
hyperglycemia
What are the different types of diabetes?
- Type 1
- Type 2
- Gestational Diabetes occurs in 2-10% of pregnancies
What is type 1 diabetes?
- Aka juvenile diabetes
- Insulin dependent
- ~10-20% of diabetics
- Autoimmune disease
- Destruction of pancreatic β-cells → insulin deficiency
- Non-obese children and adults <40 years old
What are the microvascular effects of diabetes?
- Neuropathy – extremities, impotence, bladder dysfunction, gastroparesis
- Retinopathy – cataracts, blindness
- Nephropathy
What are the macrovascular effects of diabetes?
- Peripheral vascular disease, congestive heart failure – hypertension
- Myocardial infarction – diabetes accelerates atherosclerosis
- Stroke
What does diabetes do to wound healing and susceptibility to infection?
- Neutrophilic dysfunction, increased M1:M2 ratio
- Increased pro-inflammatory cytokines and increased MMPs
- Impaired angiogenesis and endothelial dysfunction
What is type 2 diabetes?
- Aka adult onset diabetes; non-insulin dependent diabetes
- Pancreas produces insulin but it is in low titers or it does not work properly
- ~80-90% of diabetics
What is the fasting glucose of someone who is…
normal
pre-diabetic
type 2 diabetes mellitus (important)
normal - <100 mg/dl
pre-diabetic - 100-125 mg/dl
type 2 diabetes mellitus - >126 mg/dl
What is the oral glucose tolerance test (2hr plasma glucose) of someone who is…
normal
pre-diabetic
type 2 diabetes mellitus (important)
normal - <140 mg/dl
pre-diabetic - 140-199 mg/dl
type 2 diabetes mellitus - >200 mg/dl
What is the hemoglobin A1C of someone who is…
normal (important)
pre-diabetic (important)
type 2 diabetes mellitus (important)
normal - <5.7%
pre-diabetic - 5.7-6.4%
type 2 diabetes mellitus - >6.5%
What is a hemoglobin A1C?
Measures the glycosylation of HbA aka HbA1C
*A stable measure not affected by QD glucose fluctuation
*Can be tested every 3 months
*Biannual testing is recommended
Higher prevalence of severe periodontal disease in poorly controlled ____________
diabetics
Can performing periodontal intervention help diabetes?
short-term reduction in HbA1c levels at 3-4 months after periodontal intervention, no confirmation that this is sustained long-term
Periodontitis + Diabetes →
more renal complications and cardiovascular complications
What treatments are used to increase insulin secretion?
important
- Sulfonylureas –glipizide, chlorpropamide and tolbutamide
- Glucagon-like peptide 1 (GLP1) receptor agonist – exenatide, liraglutide
What treatments are used to decrease gluconeogenesis?
important
- Biguanide – Metformin
- Insulin – rapid (lispro), short (regular -Novolin), long-acting (glargine)
What are other diabetes treatments besides increasing insulin secretion and decreasing gluconeogenesis?
he kinda said this wasn’t important
Sensitization to insulin
* Thiazolidinediones – pioglitazone
Decrease in glucagon secretion
* Dipeptidyl peptidase 4 (DPP4) – sitagliptin
* GLP1 receptor agonist – exenatide, liraglutide
Intestinal and renal absorption of glucose
* Sodium-glucose cotransporter-2 inhibitors – canagliflozin
* 𝛼-glucosidase inhibitor – acarbose
What are the oral symptoms of diabetes?
- Xerostomia/dry mouth
- Oral burning (different from burning mouth, secondary)
- Infections (bacterial, fungal, viral)
- Poor wound healing
- Increased caries
- Increased severity risk of periodontal disease
What are the dental concerns for someone with diabetes when considering poor would healing?
- If 2hr after meal glucose or fasting glucose reading < 70 or > 200 mg/dl or HbA1c > 8.0%
— Defer elective treatment
— If emergency/active infection, consider referral to hospital/specialized setting
— Send medical consultation - If patient not being closely followed by physician (> 6 months), refer
- Prophylactic antibiotics
What do you do with a patient with diabetes if they are not being closely followed by a physician (> 6 months)?
refer
What do you do with a patient with diabetes if 2hr after meal glucose or fasting glucose reading < 70 or > 200 mg/dl or HbA1c > 8.0%?
- Defer elective treatment
- If emergency/active infection, consider referral to hospital/specialized setting
- Send medical consultation
What comoribidities and drug interactions do dentists need to consider when treating diabetes?
- HTN
- HLD (hyperlipidemia)
- Other cardiovascular disease (angina, MI, CHF, stroke)
- Renal impairment
What drugs do dentists need to avoid for patients with diabetes?
- Tetracyclines (including doxycycline) with insulin– hypoglycemia
- fluoroquinolones ciprofloxacin (Cipro), levofloxacin (Levaquin), etc. with insulin– hypoglycemia
- Aspirin with sulfonylureas– hypoglycemia
What do you need to worry about when a patient with diabetes has an early morning appointment?
- Eat normal meal and take medication(s) prior to appointment
- Be aware of and have patient communicate symptoms of hypoglycemia
- Have high-concentration sugar products readily available (orange juice, cake icing, soft drinks (non-diet, non-zero)
Gestational diabetes occurs in ____% of pregnancies
2-10%
When does gestational diabetes present itself?
midterm
24-28 weeks
Dental procedures could harm the developing fetus through the effects of…
➢Ionizing Radiation
➢Drugs - continues post-partum from transmission of drugs via breast milk
➢Stress
What are common pregnancy discomforts/symptoms?
➢Nausea and vomiting - hormonal imbalances, stress (physical and emotional) and hyperacidity
➢Indigestion - difficulties digesting foods rich in fats, sugars, acids can lead to nausea and vomiting
➢Headaches
➢Polyuria
➢Lumbar pain
➢Perspiration
➢Breast tenderness
Avoid elective dental care during the _____ trimester
first
_________ trimester is the best time to perform dental treatment on a pregnant patient
Second
After the middle of the third trimester, elective dental care is best __________
postponed
What is important to know about dental treatment on pregnant people?
- Maintain optimal oral health
- Avoid elective dental care during the first trimester
- Avoid drugs known to be harmful to the fetus
- Lack of proper oral health care during pregnancy could harm the developing fetus and affect the time of delivery
True/False
Dental treatment can be safely performed in all trimesters
True
- but it is a little controversial
Radiographs and pregnancy… is it ok?
- yea it is fine (but people don’t like it)
The gonadal/fetal dose incurred with 2 periapical images when a Pb apron is used is 700 times less than that for 1 day exposure to natural background radiations in the US
What are the UMKC SOD radiograph rules for new and recall pregnant patients?
- Radiographs should be postponed until post-partum
- long term benefit to the health of the mother from new patient or recall exam radiographs
- BUT no benefit to the health of developing child
- unborn child faces greater risks from the radiation exposure than the mother, without any benefit to their health
- National Council on Radiation Protection and Measurements recommends different radiation exposure thresholds for pregnant radiation workers than non-pregnant radiation workers
— radiation exposure thresholds for pregnant radiation workers is lowered to the same thresholds as the general population - SoD Dental Radiography recommendation guidelines for Pregnant Patients mirrors these NCRP recommendations.
What are the UMKC SOD radiograph rules for emergency pregnant patients?
- necessary radiographs are part of the standard of care to treat and diagnose a condition that threatens the health of the mother and the unborn child
- lack of radiographs compromises the emergency care diagnosis and treatment,
— this will directly impact the health of the unborn child. - primary beam is not directed toward the child-bearing area.
When can emergency dental treatment be provided to pregnant people?
any time during pregnancy
Pain control and elimination of __________ should be performed. These can stress mother and endanger the fetus.
infections
Emergency dental treatment may require a consult with the _____________, if there is a concern about medications or effect of emergency treatment on the fetus.
obstetrician
Untreated dental infections may pose a risk to the developing fetus such as…
Fever and sepsis may precipitate a spontaneous abortion
In advanced stages of pregnancy, avoid the supine position for long periods because…
Supine hypotension syndrome
Patient can rotate to their side to allow venous return to recover. Studies indicated that the LEFT side is the best.
What is supine hypotension syndrome?
Due to compression inferior vena cava of the that results in impaired venous return to the heart.
What does supine hypotension syndrome manifest as…
- Fall in blood pressure
- Bradycardia
- Sweating
- Nausea
How can a patient recover from supine hypotension syndrome?
Patient can rotate to their side to allow venous return to recover. Studies indicated that the LEFT side is the best.
______ drugs should be avoided during pregnancy, if possible. Benefit should outweigh potential risks.
All
What type of drugs should you avoid for pregnant people?
- Avoid aspirin and other NSAIDs
- Opioids should be avoided
- Some antibiotics
- Tetracycline and doxycycline are CONTRAINDICATED
What is the analgesic of choice for pregnant people?
Acetaminophen
Why should pregnant people avoid aspirin and NSAIDS?
- Closure of the ductus arteriosus
- Risk of post-partum hemorrhage and delayed labor
When can pregnant people use opioids?
Only when absolutely necessary and in consultation with the physician – codeine with acetaminophen (APAP) is usually the preferred agent
What are the antibiotics that pregnant people can take?
Amoxicillin
clindamycin
azithromycin
metronidazole
erythromycin
Can sedation be used on pregnant people?
Yes but no pharmacologic sedation is preferred
If absolutely necessary for a pregnant patient, nitrous oxide may be used for < ___ min and with at least 50% oxygen
30
Pregnant patient should not have multiple appointments or extended appointment with ________________ sedation as cumulative effects are a point for concern.
nitrous oxide
Avoid sedation during _______ trimester. As always, appropriate oxygenation after nitrous is necessary to avoid diffusion hypoxia.
first
If plan is to proceed with any type of sedation, even nitrous, what is necessary?
consultation with the physician is necessary
What sedation should be avoided with pregnant people?
Benzodiazepines
Women of child-bearing age should not be chronically exposed to nitrous in occupational capacity for more than _______________ without scavenging equipment.
3 hours/week
What can happen if a pregnant/women of child-bearing age has more than 3 hours/week of nitrous exposure?
Risk for decreased fertility and greater rates of spontaneous abortion
Pregnant radiation workers should wear/shall be given personal dosimeter monitoring devices to monitor occupational dose limits and assure that the annual effective dose is….
<1mSv/yr
What is the maximum permissible dose?
That amount of ionizing radiation which in the light of present knowledge will not produce any serious, harmful, or deleterious effects on the individual receiving it.
What is the occupational maximum permissible dose?
1 mSv/yr
What is important to know for lactating mothers and dentistry?
- Most drugs are of little pharmacologic significance to lactation
- Do not prescribe drugs known to be harmful
- Medications should be taken just after breast feeding
How can the periodontium change during pregnancy?
- can range from mild inflammation to
severe overgrowth - hormonal increase can exaggerate the gum tissue’s response to bacterial plaque
- Tooth mobility may be present
Gingivitis is the most common oral condition in pregnancy, _____% of pregnant women.
60-75%
Pregnancy Gingivitis and Exacerbated Periodontitis affected by:
- Lack of attention to Oral Hygiene
- Increased systemic fluid levels from increased progesterone and estrogen exacerbate any existing gingival/periodontal condition
What is a pyogenic granuloma/epulis gravidarum?
- not an actual granuloma
- forms submucosally and takes the shape a nodular growth
- in pregnancy, it is an exacerbated response to plaque and bacteria precipitated by the changes in progesterone and estrogen hormonal levels
Gestational diabetes occurs in _____% of pregnancies
2-10%
When does gestational diabetes present?
midterm (24-28 weeks)
What are the things you need to consider about gestational diabetes?
- high blood sugar affecting pregnant women who have insufficient insulin production relative to metabolic needs
- In some instances, it may also be insulin resistance
- Generally asymptomatic
Gestational diabetics are at higher risk of developing type ____ diabetes later in life
2
What are the risks to the fetus with gestational diabetes?
- Fetus can have excess weight gain
- Affects lung development
- Delivery may require cesarean section
What are the treatments for gestational diabetes?
*daily blood sugar monitoring
*healthy diet
*exercise
*monitoring the baby
… if those don’t work then,
* Medical intervention like the intervention for Type 2 diabetes is indicated
— IM - Insulin
— PO - Metformin
