Diabetes

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Diabetes

• Normal Anatomy
• and
• Physiology

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Pancreas abdominal organ responsible for
exocrine secretion of digestive enzymes into the
gut And Endocrine secretion of hormones of
glucose control insulin and glucagon
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Pancreas Exocrine And Endocrine Islets of
Langerhans
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Glucose 6 carbon sugar that is the
principle source of energy for cellular
metabolism Glucose circulates in the blood and
is transported into cells for use as an
energy source
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Glucose concentration in the blood is normally
controlled between 3.6 and 11 mmol/L by various
hormonal influences including Insulin
and Glucagon
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Insulin peptide hormone released by beta cells
of the Islets of Langerhans in response to rising
levels of blood glucose Acts by increasing
cellular transport of glucose and increased
storage of glucose
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Glucagon peptide hormone released by alpha
cells of the Islets of Langerhans in response to
falling levels of blood glucose Acts by
increasing release of glucose from the liver by
breakdown of glycogen
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Alpha cells Glucagon Beta cells Insulin
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Diabetes mellitus A metabolic disease caused
by an absolute or relative lack of insulin
resulting in abnormalities in carbohydrate,
protein and lipid metabolism.
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Diabetes mellitus Prevalence 6 of the
population (estimate 30,000 in London
area) (120 diabetics in a 2,000 patient
practice)
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Diabetes mellitus Classfication Type 1
10 of diabetics (estimate 3,000 in London
area) Type 2 90 of diabetics (estimate
27,000 in London area)
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Pathophysiology

• Type 1 diabetes beta cells are immunologically
  destroyed, eventually no insulin is produced
• Type 2 diabetes insulin secretion is reduced,
  target cells become relatively insulin resistant
  ( receptors and post-receptor activity

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Comparison of type 1 and 2

• Type 1
• 10 of diabetics
• Age of onset young
• Severe
• Requires insulin
• Normal build
• Little genetic component
• Autoimmune

• Type 2
• 90 of diabetics
• Age of onset 40
• Mild
• May require insulin, usually diet or oral
  hypoglycemics
• Obese
• Strong genetic component

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Diabetes is characterized by Hyperglycemia Lo
ss of glucose (and water) in the urine
Paradoxical cellular starvation
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Symptoms of diabetes

• Polyuria (increased urination)
• Polydipsia (increased drinking)
• Weight loss
• Weakness
• Increased infections and impaired healing
• Blurred vision

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Lab tests - diagnosis

• Normal range of fasting blood glucose
• 3.9 to 6.1 mmol/L
• Diagnosis of DIABETES is based on
• Random glucose
• gt11.0 mmol/L symptoms
• or
• Fasting glucose
• gt6.9 mmol/L on 2 occasions

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Medical management

• The tighter the glycemic control, the fewer
  complications BUT the more risk of getting
  hypoglycemic
• IDEAL management
• Fasting glucose 4.0 7.0 mmol/L
• Infection, stress, pregnancy, surgery will all
  disturb control

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Treatment Type 1

• Diet and physical acitivity plus
• Insulin usual starting dose about 20 units/day
• (OD, BID, multiple, continuous infusion pump)
• Testing 2-5 x/day
• ACE inhibitors (captopril / ramipril) to control
  nephropathy
• Cholesterol lowering drugs

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Treatment Type 2

• Diet and physical activity only (testing
  2x/month)
• /- Oral hypoglycemics (increase insulin
  secretion, receptors or post-receptor activity)
• Sulphonylureas (glyburide Diabeta)
• (can induce hypoglycemia)
• Biguanides (metformin Glucophage)
• Gamma-glucosidase inhibitor (acarbose
  Prandase
• /- Insulin

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Lab tests - monitoring

• Daily (or more) finger pick and glucometer
  readings
• Hb A1c (Normal 4.0 to 6.0)
• A long term (3 month) measure of diabetic control
  (glycosylated Hb)
• Good lt7.0
• Fair 7.0 to 8.9
• Poor gt9.0

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• Diabetic complications
• Related to the strictness of
• glycemic control and are
• characterized as
• Macrovascular complications
• atherosclerosis
• Microvascular complications
• eye and kidney

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Complications

• Macrovascular
• Stroke (2-5 X increased risk)
• MI (2-5 X increased risk)
• Cutaneous ulcers (PVD)
• Amputation (40 X increased risk)

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Complications

• Microvascular
• Retinopathy blindness
• (20 X increased risk)
• Cataracts (5 X risk)
• Nephropathy renal failure
• (25 X increased risk)

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Complications

• Neuropathy numbness, tingling, pain, glove and
  stocking sensory deficits
• Autonomic involvement
• Infections secondary to impaired vascularity and
  PMN defects
• Decreased duration and quality of life

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Emergencies ketoacidosis

• In type 1 patients only
• Marked hyperglycemia (high serum glucose) causes
  osmotic diuresis
• Patient loses excess water, Na, K, and ketones
  released from the liver cause a metabolic
  acidosis
• Precipitated by an infection, insulin error or
  omission, or occurs in a previously undiagnosed
  patient

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Emergencies ketoacidosis

• Treated with insulin, fluid replacement, K
• replacement
• Type 2 diabetics can have a much less serious
  variant of this called
• Hyperglycemic hyperosmolar nonketotic state
  secondary to dehydration

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Emergencies hypoglycemia

• May occur with an overdose of insulin / oral
  medication or a missed meal
• Only some oral medications cause hypoglycemia
  (Sulfonylureas) Glyburide, Glicazide,
  Chlorpropamide
• Patient gets diaphoretic, weak, shaky,
  palpitations, difficulty thinking, aggressive,
  vision changes and may lose consciousness

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Emergencies hypoglycemia

• Patient needs glucose a glass of juice, a
  candy, or if comatose, IV 50 glucose solution or
  IM glucagon (1 mg)
• Some patients are totally unaware of their
  hypoglycemia until they lose consciousness

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Dental management

• Assess control / severity / compliance (CSC)
• Treatment plan modification (based on CSC)
• Possibly None
• AM appointments
• Normal meds and diet pre-op
• Limit treatment duration
• Antibiotic coverage???
• Post-op diet instructions
• Hospitalization / GA and NPO status
• Consultation with the MD

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Dental management

• Assess control / severity /compliance
• When were they first diagnosed
• Type 1 vs Type 2
• What medications are they taking (or diet only)
• How much insulin do they use / how frequently
• How often do they measure their glucose and
• what are their usual measurements

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Dental management

• Assess control / severity / compliance
• Frequency of hypoglycemic reactions (can they
  feel them coming on?)
• Complications brain, eye, heart, kidney, toes
• How often and when last did they see their MD
• Did they take meds and have meals today
• Be alert to changes in control

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Dental management

• Assess control / severity / compliance
• BRITTLENESS poor control of diabetes
• as a function of the nature of the disease
• or other complicating factors such as
• infection (?dental abscess?)
• COMPLIANCE an indication of the patients
• willingness or ability to manage his/her
• medications or diet for optimal control

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Dental conerns

• Hypoglycemia during a procedure
• Oral surgeries that will prevent the patients
  from getting their usual caloric requirements
• Brittle diabetics (extreme fluctuations of
  hypo/hyperglycemia) usually occurs after years
  of high dose insulin therapy

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Dental conerns

• Acute oral infections that precipitate
  hyperglycemia
• Be more aggressive with antibiotics in patients
  with high sugars

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Oral complications

• Xerostomia secondary to dehydration
• Mucosal fungal infection candidiasis
• Increased caries and periodontal disease

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Oral complications

• Poor post surgical wound healing
• Burning mouth syndrome diabetic neuropathy
• Consult MD in suspicious patients

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Questions?