Bhatia Yashpreetsingh A.IV BDS

ROLL NO : 3

Diabetes Mellitus and its Diabetes Mellitus and its Oral ManifestationsOral Manifestations

IntroductionIntroduction

Diabetes mellitus is a metabolic disease characterized by abnormally elevated blood glucose levels (hyperglycemia) and dysregulation of carbohydrate, protein, and lipid metabolism.

EpidemiologyEpidemiology

• Prevalence is similar in both males and females.

• Incidence rises as the population ages and prevalence of obesity increases.

• An “average” medical practice will have between 60 and 70 diabetic individuals for every 1000 patients and 50% of these will be undiagnosed.

- US prevalence data

ClassificationClassification CharacteristicsCharacteristics

Type 1 DM (Insulin-Type 1 DM (Insulin-dependant DM, formerly dependant DM, formerly

juvenile diabetes)juvenile diabetes)

Beta cell destruction, leading to absolute insulin deficiency.Immune mediated.Idiopathic.

Type 2 DM (Non insulin-Type 2 DM (Non insulin-dependant DM, formerly dependant DM, formerly

adult-onset diabetes)adult-onset diabetes)

Insulin resistance with relative insulin deficiency.

Other specific types of DM Other specific types of DM

Heterogeneous group in which etiology is estb. or partially known.Genetic defects of beta cell function Genetic defects in insulin action Diseases of exocrine pancreasEndocrinopathiesDrugs or chemically induced, etc.

Gestational DMGestational DMAny degree of glucose intolerance with onset or 1st recognition during pregnancy.

PathophysiologyPathophysiology

Type 1 Diabetes mellitusType 1 Diabetes mellitus

Diabetic KetoacidosisDiabetic Ketoacidosis

Glucose can’t enter cells and remains in bld. stream.

Fat lipolysis(to meet cellular demands)

Glycerol and free fatty acids released.

Glucose Ketones

Increased Ketones in body fluids & decreased H+ ion

Electrolyte loss,dehydration, alteration in HCO3-

buffer system

Diabetic Ketoacidosis

Coma and Death.

Converted to

If untreated

Type 2 DMType 2 DM

Clinical presentationClinical presentation

Diagnostic CriteriaDiagnostic Criteria

NormalImpaired Fasting

Diabetes Mellitus

Fasting Glucose

<110 mg/dl

110- 126 mg/dl

>= 120 mg/dl

2 hr post prandial plasma glucose

<140 mg/dl

140 – 200 mg/dl

>= 200 mg/dl

OGTT

Plasma glucose at 2 hr >=

200 mg/dl

Complications of DMComplications of DM

Site Presentation

EyesEyesRetionopathy, cataracts,

blindness.

KidneyKidney Neuropathy, Renal failure

Nervous systemNervous system

Sensory: Peripheral neuropathy, cranial neuropathy affecting cranial nerves III, IV, VI & VII.Autonomic: Gastroparesis, changes in cardiac rate rhythm & dysfunction ; postural hypotension ; GI neuropathy; urinary bladder atony ; impotence.

Skin and oral mucosaSkin and oral mucosaUnusal infections, delayed wound healing

PeriodontiumPeriodontiumGingivitis and periodontal

diseases

Cardio vascular systemCardio vascular system

Macro vascular diseases( accelerated atherosclerosis) leading to peripheral vascular diseases, coronary artery disease and cerebro- vascular disease, ischeamic ulcers, gangrenous feet.

ManagementManagement

Oral hypoglycemic agents Oral hypoglycemic agents

Agent Generic name

Sulfonylurea/ 1st generation

Chlorpropamide, Tolazamide, Tolbutamide,

acetohexamide,

Sulfonylurea/ 2nd generation

Glyburide, glipizide, glimeperide

Meglitinides Repaglinide, Nateglinide

Biguanide Metformin

Thiazolidinediones Rosiglitazone, pioglitazone

A – glucosidase inhibitors.

Acarbose, miglitol

Oral manifestations of DMOral manifestations of DM

Mucosal conditions : oral dysesthesia including

burning mouth, altered wound healing , increase

incidence of infection and candidial infections

(particularly acute pseudomembranous candidiasis

of the tongue, buccal mucosa, gingiva.

Xerostomia (mostly side effect of OHA) and bilateral

generalised salivary gland enlargement or

sialadenitis.

Dry mucosal surfaces caused by insufficient salivary

output are easily irritated, causing minor mucosal

ulcerations, oral burning sensations, increased

likelihood of fungal infections.

High incidence and severity of dental caries in DM patients have been associated with xerostomia, increased GCF glucose levels, increase in dental plaque accumulation.

Prevalence and severity of gingivitis, periodontitis and gingival inflammation, alteration of periodontal wound healing.

Vascular changes seen in retina, glomerulus are also seen in periodontium.

Progressive destructive periodontitis is more common in patients with poor glycemic control.

Poor oral hygiene and smoking contribute to the ^ incidence & severity of periodontitis in DM.

General Management General Management ConsiderationsConsiderations Access level of glycemic control.

Refer patients with signs and symptoms suggestive

of undiagnosed or uncontrolled DM to physicians for

diagnosis and treatment.

Obtain medical consultation if systemic

complications are present.

Use a glucometer to help avoid emergencies related

to diabetes.

Treat aggressively acute oral infections.

Place patients on frequent recall visits to monitor

and treat oral complications and maintain optimal

oral hygiene and diet.

Appointment schedulingAppointment scheduling

Drug Peak Activity

Lispro insulin 30-90 mins.

Regular insulin 2-3 hrs.

NPH / Lente insulin

4-10 hrs.

Oral Sulfonylureas

Depends on individual drug

taken.

Specific Management Specific Management GuidelinesGuidelines

• Use of Epinephrine: Stress epinephrine and cortisol production increases Bld. Glucose level increases. So, pain control and stress reduction are essential. Epinephrine is not contraindicated in these patients as it helps promote better dental anaesthesia and significantly lowers amounts of endogenous epinephrine released.

• Oral Candidiasis : Signifies uncontrolled DM & can manifest in presence of salivary hypofunction. Treatment is similar except that topical antifungal medications should be sugar free. If topical antifungal therapy is not successful after 7 – 10 days, systemic antifungal agents may be required.

Management of Recurrent HSV Infection: Oral Acyclovir, famciclovir, or valacyclovir can be used.

Management of Burning moth syndrome: Xerostomia and Candidiasis can contribute to the symptoms associated with burning mouth. Amitriptyline can be used.

Surgical considerations : Well controlled DM patient = Normal patient. Antibiotics may be given for orofacial infections and oral surgical procedures in poorly controlled DM patient.

Periodontal Management: Nonsurgical debridement and systemic antibiotics(tetracycline, doxycycline) is the treatment.

Oral diseases management with Corticosteroids: They increase glucose levels so physician should be consulted and adjustment of dosage of drugs is required.

Managing Diabetic Managing Diabetic Emergency(Hypoglycemic Emergency(Hypoglycemic Shock)Shock)Hypoglycemia is a potentially life threatening

situation.Signs and symptoms: Confusion, sweating,

tremors, agitation, anxiety, diziness, tingling or numbness, and tachycardia. Seizure or loss of consciousness may occur.

Bld. Glucose is checked with glucometer(15 sec) and glucose is administerd to patient. Patient recovers within 10-15 minutes and is observed for 30 to 60 mins.

Hyperglycemia is less likely to occur and develops more slowly. Emergency medical system is activated, opening of airway and administration of O2.

Factors that increase risk of Factors that increase risk of HypoglycemiaHypoglycemia

Skipping or delaying food intake.Injection of too much insulin.Injection of insulin into tissue with high bld. flow.Increasing exercise level without adjusting insulin

or sulfonylurea dose.Alcohol consumption.Inability to recognise symptoms of hypoglycemia.Anxiety, stress.Denial of warning signs or symptoms.Past history of hypoglycemia.Hypoglycemia unawareness.

Treatment of Hypoglycemia in Treatment of Hypoglycemia in dental office.dental office.

Patient Condition Treatment

Patient is awake and able to take food by

mouth.

Give 15 gm oral carbohydrate.

125 -175 ml fruit juice or soda.

3-4 tablespoon sugar.Hard candy.

Cake frosting.

Patient is unable to take food by mouth

and IV line is in place.

Give 25-30 ml D50 (50 % dextrose solution) or

1 mg glucagon.

Patient is unable to take food by mouth and IV line is not in

place.

Give 1 mg glucagon Subcutaneously or IM at

almost any body site.

ReferencesReferencesBurket’s – Oral Medicine (11th edition).

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