diabetes mellitus & its oral manifestations
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Oral Manifestations Of Diabetes Mellitus
By: Md Khateeb Khan
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Introduction
Diabetes mellitus is a metabolic disorder characterized by relative or absolute insufficiency of insulin and resultant disturbances of carbohydrate metabolism.
The major function of insulin is to counter the concerted action of a number of hyperglycemia-generating hormones and to maintain low blood glucose levels.
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Epidemiology
Almost 20% of adult older than 65 year old have DM.
A dental practice serving an adult population of 2,000 can expect to encounter 40-80 persons with diabetes, about half of whom will be unaware of their condition.
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Etiologic classification of DM
There are two types of Diabetes Mellitus:
Type 1, insulin-dependent or juvenile-onset diabetes (IDDM)
Type 2, non-insulin-dependent or adult-onset diabetes (NIDDM)
Other specific types
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Type 1 (IDDM) Autoimmune destruction of the insulin-producing beta
cells of pancreas.
5-10% of DM cases.
Commonly occurs in childhood and adolescence.
Absolute insulin deficiency.
High incidence of severe complications.
Prone to autoimmune diseases (Grave’s, Addison, Hashimoto’s thyroiditis).
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Pathogenesis of Type I DM
Environment ?Environment ?
Viral infection ?Viral infection ?Genetic Genetic
HLA-DR3/DR4HLA-DR3/DR4
Severe Insulin deficiencySevere Insulin deficiency
ß cell Destructionß cell Destruction
Type I DMType I DM
Autoimmune Insulitis Autoimmune Insulitis
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Type 2 (NIDDM)
Result from impaired insulin function (insulin resistance).
Constitutes 90-95% of DM cases.
Specific causes of this form are unknown.
Risk factors : age, obesity, alcohol, diet, family history and lack of physical activity, etc.
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Pathogenesis of Type II DM
EnvironmentEnvironment
Obesity ?Obesity ?ß cell defectß cell defect
GeneticGenetic
ß cell ß cell
exhaustionexhaustion Type II DMType II DM
Insulin resistanceInsulin resistance
Relative Insulin DeficiencyRelative Insulin Deficiency
IDDMIDDM
Abnormal SecretionAbnormal Secretion
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ComparisonComparison Type 1 Type 2
Clinical onset <20 years onset >30 years
normal weight obesity
decreased blood insulin normal or increased blood insulin
anti-islet cell antibodies no anti-islet cell antibodies
Genetics ketoacidosis common ketoacidosis rare
human leukocyte antigen (HLA)-D linked
No HLA association
Pathogenesis autoimmunity, immunopathologic mechanisms
insulin resistance
severe insulin deficiency relative insulin deficiency
Islet Cells insulitis early no insulitis
marked atrophy and fibrosis
focal atrophy and amyloid deposits
severe beta-cell depletion mild beta-cell depletion
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Other specific types
Genetic defects of beta-cell functions
Decrease of exocrine pancreas
Endocrinopathies
Drug or chemical usage
Infections
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Gestational diabetes mellitus (GDM)
Defined as any degree of glucose intolerance with onset or first recognition during pregnancy.
4% of pregnancy.
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Pathophysiology Healthy people blood glucose level maintained within 60
to 150 mg/dL.
Insulin synthesized in beta cells of pancreas and secreted rapidly into blood in response to elevations in blood sugar.
Promoting uptake of glucose from blood into cells and its storage as glycogen
Fatty acid and amino acids converted to triglyceride and protein stores.
Lack of insulin or insulin resistance, result in inability of insulin-dependent cells to use glucose.
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Pathophysiology Triglycerides broken down to fatty acids blood
ketones↑ diabetic ketoacidosis.
As blood sugar levels became elevated (hyperglycemia), glucose is excreted in the urine and excessive of urination occurs due to osmotic diuresis (polyuria).
Increased fluid loss leads to dehydration and excessive thirst (polydipsia).
Since cells are starved of glucose, the patient experiences increased hunger (polyphagia).
Paradoxically, the diabetic patient often loses weight, since the cells are unable to take up glucose.
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Factors Causing
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Complications People with DM have an increased incidence of both
microvascular and macrovascular complications.
Major organs/systems showing changes Long term complications
Cardiovascular system: heart, brain, blood vessels
Myocardial infarction; atherosclerosis; hypertension; microangiopathy; cerebral vascular infarcts; cerebral hemorrhage
Pancreas Islet cell loss; insulitis (Type 1); amyloid (Type 2)
Kidneys Nephrosclerosis; glomerulosclerosis; arteriosclerosis; pyelonephritis
Eyes Retinopathy; cataracts; glaucoma
Nervous system Autonomic neuropathy; peripheral neuropathy
Peripherals Peripheral vascular atherosclerosis; infections; gangrene
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Diagnosis
A casual plasma glucose level of 200 mg/dL or greater with symptoms presented.
Fasting plasma glucose level of 126 or greater.(Normal <100 mg/dL)
Oral glucose tolerance test (OGTT) value in blood of 200 mg or greater.
ADA recommend >45 year old screened every 3 years.
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Interpretation of the glucose tolerance testA 75 gram oral glucose tolerance test (OGTT) is used to follow up people with equivocal results who may have Diabetes, Impaired Fasting Glucose or Impaired Glucose Tolerance.
Fastingmmol/L
2 hours post load mmol/L
Normal < 5.5 and < 7.8
IFG 6.1 – 6.9 and < 7.8
IGT < 7.0 and 7.8 – 11.0
Diabetes mellitus ≥ 7.0 and/or ≥ 11.1
GDM ≥ 5.5 and/or ≥ 9.0
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Medical management
Objective : Maintain blood glucose levels as close to normal as possible.
Good glycemic control inhibits the onset and delay of type 1 DM, similar in type 2 DM.
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Medical management Exercise and diet control
Insulin : rapid, short, intermediate, long acting.
Oral antidiabetic agents
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Oral manifestations and complications
No specific oral lesions associated with diabetes. However,
there are a number of problems by presence of hyperglycemia. Periodontal disease
Microangiopathy altering antigenic challenge.
Altered cell-mediated immune response and impaired of neutrophil chemotaxis.
Increased Ca+ and glucose lead to plaque formation.
Increased collagen breakdown.
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PDL changes in NIDDM Patient from 8 years
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Oral manifestations and complications
Salivary glands Xerostomia is common, but reason is unclear. Tenderness, pain and burning sensation of tongue. May cause secondary enlargement of parotid glands with
sialosis.
Dental caries Increase caries prevalence in adult with diabetes. (xerostomia,
increase saliva glucose) Hyperglycemia state shows a positive association with dental
caries.
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Sialosis Carious lesion on teeth with Xerostomia
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Oral manifestations and complications Increased risk of infection
Reasons unknown, but macrophage metabolism altered with inhibition of phagocytosis.
Peripheral neuropathy and poor peripheral circulation Immunological deficiency High sugar medium Decrease production of Antibodies
Candidal infection are more common and adding effects with xerostomia
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Oral manifestations and complications
Delayed healing of wounds Due to microangiopathy and ultilisation of protein for energy,
may retard the repair of tissues.
Increase prevalence of dry socket.
Miscellaneous conditions Pulpitis : degeneration of vascular. Neuropathies : may affect cranial nerves. (facial) Drug side-effects : lichenoid reaction may be associated with
sulphonylureas (chlopropamide) Ulcers
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Subacute Lichenoid Reaction Diabetic Ulcer
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Dental management considerations
To minimize the risk of an intraoperative emergency, clinicians need to consider some issues before initiating dental treatment.
Medical history: Take history and assess glycemic control at initial appointment. Glucose levels Frequency of hypoglycemic episodes Medication, dosage and times. Consultation
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Dental management considerations Scheduling of visits
Morning appointment Do not coincide with peak activity.
Diet Ensure that the patient has eaten normally and taken medications as usual.
Blood glucose monitoring Measured before beginning. (<70 mg/dL)
Prophylactic antibiotics Established infection Pre-operation contamination wound Major surgery
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Dental management considerations
During treatment The most complication of DM occur is hypoglycemia episode. Hyperglycemia
After treatment Infection control Dietary intake Medications : salicylates increase insulin secretion and
sensitivity avoid aspirin.
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Emergency management
Hypoglycemia
Initial signs : mood changes, decreased spontaneity, hunger and weakness.
Followed by sweating, incoherence, tachycardia.
Results in unconsciousness, hypotension, hypothermia, seizures, coma, even death.
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Emergency management
15 grams of fast-acting oral carbohydrate.
Measured blood sugar.
Loss of consciousness: 25-30ml 50% dextrose solution iv. over 3 min period.
Glucagon 1mg.
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Emergency management
Severe hyperglycemia A prolonged onset
Ketoacidosis may develop with nausea, vomiting, abdominal pain and acetone odor.
Difficult to different hypoglycemia or hyperglycemia.
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Emergency management
Hyperglycemia needs medical intervention and insulin administration.
While emergency, give glucose first !
Small amount is unlikely to cause significant harm.
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Conclusion
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