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2. DIABETES MELLITUS
Diabetes mellitus is a metabolic disease characterized by dysregulation
of carbohydrate, protein, and lipid metabolism.The
primary feature of this disorderis elevation in blood glucose
levels (hyperglycemia), resulting from either a defectin insulin
secretionfrom the pancreas, a change in insulin action, or
both.
Classification:
Diabetes mellitus is classified into four broad
categories: type 1, type 2, gestational diabetes,and "other specific types"
Type 1 diabetes mellitus:is a chronic illness characterized by the
body’s inability to produce insulin due to the autoimmune destruction of the
beta cells in the pancreas. Onset most often occurs in childhood, but the
disease can also develop in adults in their late 30s and early 40s.
Type 2 diabetes mellitus:is characterized by insulin resistance, which
may be combined with relatively reduced insulin secretion,Type2 diabetes
is non-insulin dependentdiabetes mellitus (NIDDM), or adult onset diabetes
mellitus (AODM). In type 2 diabetes,patients can still produce insulin.
gestational diabetes:is associated with increased insulin resistance.
Most patients with gestational diabetes return to a normoglycemic state after
parturition; however, about 30 to 50% of women with a history of gestational
diabetes will develop type 2 diabetes within 10 years.

3. Other types
Prediabetes indicates a condition that occurs when a person's blood glucose
levels are higher than normal but not high enough for a diagnosis of type 2
DM
"Secondary" diabetesrefersto elevated blood sugarlevels from
another medicalcondition.Secondarydiabetesmay develop when the
pancreatic tissue responsible for the production of insulin is
destroyedby disease,such as chronic pancreatitis
Other types of diabetes
Genetic defects affecting beta-cell function or insulin action
Pancreatic diseases or injuries (pancreatic cancer, pancreatitis, traumatic
injury,cystic fibrosis,pancreatectomy)
Infections (congenital rubella, Cytomegalovirusinfection)
Drug-induced diabetes (steroid hormones [glucocorticoids],thyroid
hormone)
Endocrine disorders (hyperthyroidism, Cushing’s syndrome,
glucagonoma,acromegaly,pheochromocytoma)
Causes
The cause of diabetes depends on the type.:
Type 1 diabetes is partly inherited and infections with some evidence
pointing at Coxsackie B4 virus.
Type 2 diabetes is due primarily to lifestyle factors and genetics and obesity
The following is a comprehensive list of other causes of diabetes:
 Genetic defects of β-cell function

4.  Maturity onsetdiabetes of the young
 Mitochondrial DNA mutations
 Genetic defects in insulin processing or insulin action
 Defects inproinsulin conversion
 Insulin gene mutations
 Insulin receptormutations
 Exocrine pancreatic defects
 Chronic pancreatitis
 Pancreatectomy
 Pancreatic neoplasia
 Cystic fibrosis
 Hemochromatosis
 Fibrocalculouspancreatopathy
 Endocrinopathies
 Growth hormone excess (acromegaly)
 Cushing syndrome
 Hyperthyroidism
 Pheochromocytoma
 Glucagonoma
 Infections
 Cytomegalovirus infection
 Coxsackievirus B
 Drugs
 Glucocorticoids
 Thyroid hormone
 β-adrenergic agonists
 Statins[2
Risk factors for type 1 diabetes
1. Family history
2. Environmental factors. Circumstances such as exposure to a viral illness likely
play some role in type 1 diabetes.
3. Dietary factors. These include low vitamin D consumption, early exposure to
cow's milk or cow's milk formula, and exposure to cereals before 4 months of age.
None of these factors has been shown to directly cause type 1 diabetes.
4. Geography

5. risk factors for prediabetes and type 2 diabetes
1. Weight
2. Inactivity.
3. Family history.
4. Race.
5. Age.
6. Gestational diabetes
7. Polycystic ovary syndrome.
8. High blood pressure. .
9. Abnormal cholesterol and triglyceride levels.
Clinical Presentation:
Type1 DM is of sudden onset, whereas type2 DM is often presentfor years
without overt signs or symptoms. Patients
with undiagnosed DM may presentwithone or moresigns
and symptomsof hyperglycemiathat includepolydypsia,
polyphagia, polyuria, and acutemanifestations of hyperglycemia
(Table 2). Patients may complain of unexplained
weight loss, poor wound healing, blurred vision, gingival
bleeding, and high susceptibility to infections and may be
easily fatigued. When complications of poor glucose control
develop, patientscomplain of visualimpairment; neurologic
symptomssuchas numbness, dizziness, and weakness; chest
pain; gastrointestinal symptoms; genitourinary symptoms,
especially urinary incontinence; and sexualdysfunction.

7. Diagnosis and Monitoring:
The diagnosis of DM is based on specific laboratory findings,
as well as the presence of clinical signs and symptoms
(Table 3). Diagnostic guidelines include fasting glucose and
casual (nonfasting) glucose levels, with restricted routine use of the oral glucose
tolerance test. Both the fasting and casual plasma glucose tests provide a
determination of glucose levels at a single moment in time (at
the time the blood sample is collected).
 Glycatedhemoglobin(Hb A1C)≥ 6.5%.[26]
Complications of Diabetes mellitus : The major cause of the high morbidity
and mortality rate associated with DM is a group of microvascular and
macrovascular (Table 4).
complications affecting multiple organ system

8. Management
Lifestyle
All type 1 diabetic patients use exogenous insulin
Types of Insulin
Rapid acting
Short acting
Intermediate acting
Long acting
Medications
See also:Anti-diabetic medication Agentand mechanism
Sulfonylurea (glyburide,glimepiride,glipizide)
Stimulating insulin release
by pancreatic beta cells by
inhibiting the KATP channel
Metformin Acts on liver to cause
decrease in insulin

9. resistance
Alpha-glucosidase
inhibitor(acarbose, miglitol,voglibose)
Reduces glucose
absorbance by acting
on small intestine to cause
decrease in productionof
enzymes needed to digest
carbohydrates
Thiazolidinediones(Pioglitazone,Rosiglitazone)
Reduce insulin resistance
by activating PPAR-γ in
fat and muscle
Oral Manifestationsof Diabetes Mellitus
1. burning mouth,
2. altered wound healing
3. increased incidence of infection.
4. Enlargement of the parotid glands and xerostomiacan occur; both are
conditions that may be related to the metabolic control of the diabetic
state.
5. Neuropathy of the autonomic system can also cause
6. changes in salivary secretionsince salivary flow is controlled by the
sympathetic and parasympathetic pathways.
7. Periodontal disease
8. Salivary dysfunction
9. Taste dysfunction
10. non-candidal oral soft tissue lesion
11. oral mucosal disease
12. dental caries and tooth loss

10. GeneralDentalTreatment
Overall, diabetic patients respond to most dental treatments
similarly to the way nondiabetic patients respond.Responses
to therapy depend on many factors that are specific to each
individual, including oral hygiene, diet, habits such as
tobacco use, properdental care and follow-up, overall oral
health, and metabolic control of diabetes.
key dental treatment considerations
for diabetic patients include stress reduction, treatment setting,
the use of antibiotics, diet modification,appointment
timing, changes in medicationregimens,and the management
of emergencies.
The use of systemic antibiotics for routine dental treatment
is not necessaryfor most diabetic patients. Antibiotics
may be considered in the presence of acute infection.Some
clinicians preferto prescribe prophylactic antibiotic coverage
prior to surgical therapy if the diabetic patient’s glycemic control
is poor.
Medical history
It is important for clinicians to take good medical history and glycemic
control in first appointment.
Dite
It is important for clinicians to ensure that patient has eate normally and take
medication as usual.
During treatment
Appointmenttiming for the diabetic patient is oftendetermined
by the individual’s medicationregimen.
For those who take insulin, the greatest risk of hypoglycemia
will thus occurabout 30 to 90 minutes after injecting
lispro insulin, 2 to 3 hours after regular insulin, and 4 to
10 hours after NPH or Lente insulin
Blood glucose monitoring depending on the patients medical history,dentists
should may need to measure the blood glucose before beginning a
procedure.

11. those who are taking oral sulfonylureas, peak insulin activity
depends on the individual drug taken. Metformin and the
thiazolidinediones rarely cause hypoglycemia.
If clinician suspects that patient experiencing a hypoglycemic episode
He or she must terminate dental treatment and immediately administer 15
gm of fast acting oral carbohydrate such as glucose tablet ,suger,drinks or
juice
It is important to note patient with alpha-glucosidase inhibitors prevent the
hydrolysis of sucrose and fructose to glucose,thereforehypoglycemic
episode inpatient with taking these drugs should be treated with direct
glucose.
When treating patients with a history of asthma or
angina, dentists usually have the patients bring their inhaler
or nitroglycerine with them to dental appointments.
After treatment
Clinicians should keep in mind these postoperative consideration,patient
with poorly controlled DM are greater risk of developing infection and
delayed wound healing
Managing the Diabetic Emergencyin the Dental Office:
The most common emergency related to DM in the dental
office is hypoglycemia, a potentially life-threatening situation
that must be recognized and treated expeditiously.49,56,57
Signs and symptoms include confusion, sweating, tremors,
agitation, anxiety, dizziness, tingling or numbness, and tachycardia.
Severe hypoglycemia may result in seizures or loss of
consciousness.Prevention starts with the practitioner being
familiar with the general medical risks for hypoglycemic
events (Table 9)

12. -Every dental office that treats DM patients should have readily available sources
of oral carbohydrates (eg, fruit juice, nondiet soda, hard
candy). As soon as a patient experiences signs or symptoms
of possible hypoglycemia, the patient or the dentist should
check the blood glucose with a glucometer, which has a
typical response time of less than 15 seconds. If a glucometer
is unavailable, the condition should be treated presumptively
as a hypoglycemic episode (Table 11)
--However, under some instances,severe hyperglycemia may present with symptoms mimicking
hypoglycemia. If a glucometer is not available, these
symptoms must be treated as hypoglycemia, If it is an actual hyperglycemic
event, the small amountof extra glucose delivered will not have any deleterious effect.
However, emergency measures that will elevate serum glucose
should not be delayed or withheld from a DM patient
even if hyperglycemia is wrongly suspected in a patient who is
actually hypoglycemic.

13. CONCLUSION
Diabetes mellitus is a metabolic condition affecting multiple
organ systems. The oral cavity frequently undergoes changes
that are related to the diabetic condition, and oral infections
may adversely affect metabolic controlof the diabetic state.
The intimate relationship
between oral health and systemic health in individuals with
diabetes suggests a need for increased interaction between the
dental and medical professionals who are charged with the
management of these patients. Oral health assessment and
treatment should becomeas common as the eye, foot, and
kidney evaluations that are routinely performed as part of preventive
medical therapies. Dental professionals with a thorough
understanding of current medical treatment regimens
and the implications of diabetes on dental care are able to help
their diabetic patients achieve and maintain the best possible
oral health.