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  1. 1. Diabetes Claire Nowlan Nov 28, 2003
  2. 2. Comparison of type 1 and 2 diabetes <ul><li>Type 1 </li></ul><ul><li>10% of diabetics </li></ul><ul><li>Age of onset – young </li></ul><ul><li>Severe </li></ul><ul><li>Requires insulin </li></ul><ul><li>Normal build </li></ul><ul><li>Little genetic component </li></ul><ul><li>Type 2 </li></ul><ul><li>90% of diabetics </li></ul><ul><li>Age of onset – 40+ </li></ul><ul><li>Mild </li></ul><ul><li>May require insulin, usually hypoglycemics </li></ul><ul><li>Obese </li></ul><ul><li>Strong genetic component </li></ul>
  3. 3. Pathophysiology <ul><li>Type 1 diabetes – beta cells are destroyed, eventually no insulin is produced </li></ul><ul><li>Type 2 diabetes – insulin secretion is reduced, target cells become relatively insulin resistant </li></ul>
  4. 4. The Pancreas <ul><li>Main role is to excrete digestive enzymes </li></ul><ul><li>Islets of Langerhans contain alpha cells which excrete glucagon, and beta cells which excrete insulin </li></ul><ul><li>Glucose stimulates insulin secretion from beta-cells </li></ul><ul><li>Insulin binds with cells surface receptors to allow glucose transport into the cell </li></ul><ul><li>Glucagon mobilizes glucose to be released from the liver </li></ul>
  5. 5. Symptoms of diabetes <ul><li>Polydipsia (increased drinking) </li></ul><ul><li>Polyuria (increased urination) </li></ul><ul><li>Weight loss </li></ul><ul><li>Weakness </li></ul><ul><li>Increased infections </li></ul><ul><li>Blurred vision </li></ul>
  6. 6. Complications <ul><li>Macrovascular </li></ul><ul><ul><ul><li>Stroke </li></ul></ul></ul><ul><ul><ul><li>MI </li></ul></ul></ul><ul><ul><ul><li>Ulcers </li></ul></ul></ul><ul><ul><ul><li>Amputation </li></ul></ul></ul><ul><li>Microvascular </li></ul><ul><ul><ul><li>Retinopathy - blindness </li></ul></ul></ul><ul><ul><ul><li>Nephropathy – renal failure </li></ul></ul></ul><ul><li>Neuropathy – numbness, tingling, pain , sensory deficits, and autonomic involvement </li></ul><ul><li>Infections </li></ul>
  7. 7. Lab tests - diagnosis <ul><li>Random glucose </li></ul><ul><ul><li>>11.0 mmol/L + symptoms </li></ul></ul><ul><li>Fasting glucose </li></ul><ul><ul><li>>6.9 mmol/L </li></ul></ul><ul><li>Hb A1c </li></ul><ul><ul><li>A long term measure of diabetic control </li></ul></ul><ul><ul><li>> 8% </li></ul></ul>
  8. 8. Emergencies <ul><li>Ketoacidosis </li></ul><ul><ul><li>In type 1 patients only </li></ul></ul><ul><ul><li>Marked hyperglycemia (high serum glucose) causes osmotic diuresis </li></ul></ul><ul><ul><li>Patient loses excess water, Na, K, and ketones released from the liver cause an acidosis </li></ul></ul><ul><ul><li>Precipitated by an infection, insulin error or omission, or occurs in a previously undiagnosed patient </li></ul></ul><ul><ul><li>Treated with insulin, fluid replacement, K replacement </li></ul></ul><ul><ul><li>Type 2 diabetics can have a much less serious variant of this called Hyperglycemic hyperosmolar nonketotic state </li></ul></ul>
  9. 9. Emergencies <ul><li>Hypoglycemia </li></ul><ul><ul><li>May occur with an overdose of insulin/oral medication or a missed meal </li></ul></ul><ul><ul><li>Only some medications cause hypoglycemia – Glyburide, Glicazide, Chlorpropamide </li></ul></ul><ul><ul><li>Patient gets diaphoretic, weak, shaky, palpitations, difficulty thinking, vision changes and may lose consciousness </li></ul></ul><ul><ul><li>Patient needs glucose – a glass of juice, a candy, or if comatose, IV 50% glucose solution, IM glucagon, glucose gel </li></ul></ul><ul><ul><li>Some patients are totally unaware of their hypoglycemia until they lose consciousness </li></ul></ul>
  10. 10. Medical management <ul><li>The tighter the control, the fewer complications– BUT – the more risk of getting hypoglycemic </li></ul><ul><li>IDEAL management </li></ul><ul><ul><li>Fasting glucose 4.0 – 7.0 mmol/L </li></ul></ul><ul><ul><li>1-2 hour postmeal 5.0 – 11.0 mmol/L </li></ul></ul><ul><li>Type 1 diabetes – insulin tx– usual starting dose about 20 units/day (testing 2-5 x/day) </li></ul><ul><li>Type 2 diabetes – oral hypoglycemics +/- insulin (testing 1-2x/day) - diet only (testing 2x/month) </li></ul><ul><li>Infection, stress, pregnancy, surgery will all disturb control </li></ul>
  11. 11. Dental management <ul><li>Assess control/severity </li></ul><ul><ul><li>What medications are you taking (or diet only) </li></ul></ul><ul><ul><li>Type 1 vs Type 2 </li></ul></ul><ul><ul><li>When were they first diagnosed </li></ul></ul><ul><ul><li>How often do they measure their glucose </li></ul></ul><ul><ul><li>What are their usual measurements </li></ul></ul><ul><ul><li>Frequency of hypoglycemic reactions (can they feel them coming on?) </li></ul></ul><ul><ul><li>How much insulin do they use </li></ul></ul><ul><ul><li>When did they last see their doctor </li></ul></ul>
  12. 12. Your biggest worries: <ul><li>Hypoglycemia during a procedure </li></ul><ul><li>Oral surgeries that will prevent the patients from getting their usual caloric requirements </li></ul><ul><li>Brittle diabetics (extreme fluctuations of hypo/hyperglycemia) – usually occurs after years of high dose insulin therapy </li></ul><ul><li>Acute oral infections that precipitate hyperglycemia </li></ul><ul><li>Be more aggressive with antibiotics in patients with high sugars </li></ul>
  13. 13. Oral complications <ul><li>Xerostomia </li></ul><ul><li>Infections – especially candidiasis </li></ul><ul><li>Increases caries </li></ul><ul><li>“ Burning mouth syndrome” </li></ul><ul><li>So – test for diabetes in suspicious patients </li></ul>