ENDOCRINOPATHIES

DIABETES MELLITUS

MODERATOR

DR.ASHISH SHRESTHA

DR.VINAY MARLA

DEPARTMENT OF ORAL PATHOLOGY AND HISTOLOGY

PRESENTER

ROSHAN KUMAR SHAH

BDS: 3RD YEAR(2011)

ROLL NO:496

CONTENTS

INTRODUCTION

CLASSIFICATION

PATHOPHYSIOLOGY

CLINICAL FEATURES

DIAGNOSIS

ORAL MANEFESTATION

DENTAL MANAGEMENT OF DIABETIC

PATIENT

DIABETES MELLITUS

A clinically and genetically heterogenous metabolic disordercharacterized by abnormally elevated blood glucose level (hyperglycemia) and dysregulation of carbohydrate, protein, and lipid metabolism.

Results from either a defect in insulin secretion from pancreas or resistance of body’s cells to insulin action, or both.

Affects almost all tissues in the bodY

Associated with significant complications of multiple organ system, including eyes, nerves, kidneys, and blood vessels.

CLASSIFICATION

Etiological Classification of DM by the

American Diabetes Association (1997)

Type 1 diabetes mellitus

Type 2 diabetes mellitus

Other specific types of diabetes

Mellitus

Gestational diabetes mellitus

TYPE 1 DIABETES MELLITUS

Autoimmune destruction of the insulin-producing beta cells of pancreas.

5-10% of DM cases.

Common occurs in childhood and adolescence, or any age.

Absolute insulin deficiency.

High incidence of severe complications.

TYPE 2 DIABETES MELLITUS

Result from impaired insulin function. (insulin

resistance)

Constitutes 90-95% of DM

Specific causes of this form are unknown.

Risk factors : age, obesity, alcohol, diet,

family History and lack of physical activity,

etc.

THE PANCREAS

PANCREAS – ENDOCRINE PART

Accounts for only 2% of the pancreatic mass

Nests of cells - islets of Langerhans

Four major cell types

Alpha (A) cells secrete glucagon

Beta (B) cells secrete insulin

Delta (D) cells secrete somatostatin

F cells secrete pancreatic polypeptide

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY CONTD…..

Normal blood glucose level to be maintained within 60 to 150 mg/dL.

As blood sugar levels became elevated, glucose is excreted in the urine and causes excessive urination occurs due to osmotic diuresis.

Increased fluid loss leads to dehydration and excess thirst.

Since cells are starved of glucose, the patient experiences increased hunger.

RISK FACTORS

CLINICAL PRESENTATIONS

polyuria polydipsia

polyphagia

Weight loss

weakness

Delayed wound healing

Obesity

0RAL MANIFESTATIONS

In people with diabetes, the first signs and

symptoms of a medical condition can

develop in the mouth.• oral conditions include xerostomia,

burning sensations, overgrowth of gum tissue, tooth decay, periodontal disease (6th complication)fungal infections, fruity (acetone) breath,A WARNING SIGN increased thickness of saliva

PERIODONTITIS

Periodontal tissues frequently manifest these changes because of chronic bacterial infections.

Recent epidemiologic evidence shows that the prevalence of diabetes in patients with periodontitis is significantly greater (by two times) than in people without periodontitis.

Given that diabetes may be present for a number of years before it is diagnosed, dentist may be the first health professional to detect a patient’s diabetes.

PERIODONTITIS AS A RISK FACTOR FOR DIABETES MELLITUS

Diabetes has long been believed to be a risk factor for periodontal disease. Results of new studies show that the reverse might also be true.

In individuals with periodontitis :

Increase in local and systemic expression of inflammatory cytokines, such as TNF-alpha and IL-6

Both TNF-alpha and IL-6 have been shown to impair intracellular insulin signaling, which may lead to

insulin resistance

In a longitudinal study of patients with type 2 DM:

Increased risk of worsening glycemic control seen in patients who had severe periodontitisover a period of time which led to various complications.

( Taylor GW,Burt BA Becker MP et al,1996)

These trials often examined the effects of scaling and root planing on glycemic control, either alone or in combination with adjunctive systemic tetracycline therapy.

( Tetracyclines decrease the production of matrix metalloproteinase such as collagenase )

In a more recent evaluation of scaling and root planing combined with systemic doxycycline therapy for 2 wks ,diabetic pts showing improvement in periodontal health also had significant improvement in glycemiccontrol and vice versa.

When researchers performed scaling and root planing but did not administer adjunctive antibiotic therapy, some studies showed significant improvement in glycemic control after treatment, while others showed no significant improvement in glycemic control despite improvements in patients’ periodontal health.

Multiple periodontal abscesses

SALIVARY GLAND DYSFUNCTION

Dry mouth (xerostomia) and salivary hypofunction is common in patients with diabetes.

When the normal environment of the oral cavity is altered because of a decrease in salivary flow or alteration in salivary composition, a healthy mouth becomes susceptible to dental caries and tooth deterioration.

DIABETES AND CANDIDIASIS

Contributing factors for oral candidiasis in patients with diabetes salivary dysfunction

compromised immune function

salivary hyperglycemia that provides a potential substrate for fungal growth

Oral lesions associated with candidiasis include median rhomboid glossitis

atrophic glossitis

denture stomatitis

angular cheilitis

Amphotericin B, nystatin, clotrimazole, miconazole, ketoconazole, fluconazole, itraconazole

ACUTE ORAL INFECTIONS

Recurrent bouts of herpes simplex virus,

periodontal abscesses or palatal ulcers are

common in patients with diabetes.

Published reports of life-threatening deep

neck infection from a periodontal abscess

and fatal palatal ulcers are available.

DIAGNOSIS

COMPLICATIONS

Microvascular

Retinopathy, cataract

Nephropathy

Peripheral Neuropathy

Foot disease

Macrovascular

MI

Stroke

Ischemia

DENTAL CONSIDERATIONS

KNOWN DIABETIC PATIENTS

inquire about the medication, the type, severity and control of diabetes, the physician treating the patient and the date of last visit

The dentist should be aware of the patient’s recent glycated hemoglobin values.

HbA1c values of less than 8% indicate relatively good glycemic control; greater than 10% indicate poor control

When the level of control of diabetes is not known, consult patients physician .

KNOWN DIABETIC PATIENTS

Patients, receiving good medical management without serious complications such as renal disease, hypertension, or coronary atherosclerotic heart disease, can receive any indicated dental treatment

Local anesthesia is preferred, but such patients can even be safely treated in general anesthesia

Morning appointments should be preferred because this is the time of high glucose and low insulin activity

This reduces the risk of hypoglycemic episodes during the dental procedures

KNOWN DIABETIC PATIENTS

a source of glucose such as an orange juice must be available in the dental office to avoid hypoglycemic attacks

Prophylactic antibiotics for patients taking high doses of insulin to prevent post-operative infection are recommended

It's best to do surgery when blood sugar levels are within normal range

KNOWN DIABETIC PATIENTS

To avoid hyperglycemia use anxiety reduction protocol

Emotional stresses and painful conditions increase the amount of cortisol and epinephrine secretion which induce hyperglycemia so pre-treatment anxiety should be reduced by

sedation pain during procedures can be avoided by a

potent anesthesia

INSTRUCTIONS TO BE GIVEN TO A DIABETIC

diabetic patients should be strongly motivated to maintain a good oral hygiene by brushing after every meal

using floss daily

keeping their dentures clean

patients should be frequently recalled for dental examinations

prophylactic measures, such as topical fluorides should be applied

The patients should be encouraged to quit smoking as it greatly increases the risk of periodontal disease in diabetic patients

Diabetics should be informed that they are more likely to catch dental diseases than the normal ones because awareness and knowledge increases the tendency to seek preventive dental care, and improves chances of maintaining healthy mouth

REFERENCES

Davidson’s principles and practice of

Medicine 21st Edition

Burket’s oral medicine 11th Edition

Medical emergencies in dental office, Stanley

F Malamed 4th Edition

Medical problems in dentistry C. Scully & R.

A. Cawson 4th Edition

Carranza’s clinical periodontology 11th edition

THANK YOU