Diabetes is a metabolic disorder characterized by insulin deficiency and high blood glucose levels. There are two main types: type 1 caused by autoimmunity and type 2 associated with obesity and insulin resistance. Oral complications of diabetes include increased risk of periodontal disease, dental caries, infections, and delayed wound healing. Dental treatment requires consideration of a patient's glycemic control and scheduling around medication intake to prevent hypoglycemic emergencies. Hypoglycemia is treated with oral glucose while severe hyperglycemia may require insulin administration and medical intervention.

1. Diabetes Mellitus
patients
in dental management
shabeel pn

2. 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.

3. 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, adult-onset diabetes
(NIDDM)
 Other specific types
JADA, Oct 2001

4. Comparison 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

5. Gestational diabetes mellitus (GDM)
 Defined as any degree of glucose
intolerance with onset or first recognition
during pregnancy.
 4% of pregnancy in US.

6. Pathophysiology
 Healthy people blood glucose level maintained
within 110mg to 140mg/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.

7. Pathophysiology
 Lack of insulin or insulin resistance, result
in inability of insulin-dependent cells to use
glucose.
 Triglycerides broken down to fatty acids
blood ketones↑  diabelic ketoacidosis.

8. Diagnosis
 A casual plasma glucose level of 200 mg/dL or
greater with symptoms presented.
 Fasting plasma glucose level of 126 or
greater.(Normal <110 mg/dL,IGT,IFG)
 Oral glucose tolerance test (OGTT) value in
blood of 200 mg or greater.
ADA recommend >45 y/o screened every 3 years.
Diabetes Care, 2000
National Institutes of Health, Aug 2001

9. 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.

10. Medical management
 Glycated hemoglobin assay (HbA1c )
reflects mean glycemia levels over the
proceding 2~3 months. (normal < 7%)
 HbA1c also a predictor for development of
chronic complications.

11. Medical management
 Exercise and diet control
 Insulin : rapid, short, intermediate, long acting.
 Oral antidiabetic agents

12. Oral manifestations and
complications
No specific oral lesions associated with diabetes. However,
there are a number of problems by present 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.

13. Oral manifestations and
complications
 Salivary glands
 Xerostomia is common, but reason is unclear.
 Tenderness, pain and burning sensation of tongue.
 May secondary enlargement of parotid glands with sialosis.
 Dental caries
 Increase caries prevalence in adult with diabetes. (xerostomia,
increase saliva glucose)
 Hyperglycemia state shown a positive association with dental
caries.

14. 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 Ab
 Candical infection are more common and adding effects with
xerostomia

15. 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
sulphonylurea. (chlopropamide)
 Ulcers
New Zealand Journal, Jan 1985

16. Dental management
considerations
To minimize the risk of an intraoperative emergency,
clinicians need to consider some issues before initiating
dental tx.
 Medical history : take hx and assess glycemic control at
initial appt.
 Glucose levels
 Frequency of hypoglycemic episodes
 Medication, dosage and times.
 Consultation

17. Dental management
considerations
 Scheduling of visits
 Morning appt. (endogeneous cortisol)
 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

18. 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.

19. Emergency management
 Hypoglycemia
Initial signs : mood changes, decreased
spontaneity, hunger and weakness.
Followed by sweating, incoherence,
tachycardia.
Consequenced in unconsiousness,
hypotention, hypothermia, seidures, coma,
even death.

20. Emergency management
 15 grams of fast-acting oral carbonhydrate.
 Measured blood suguar.
 Loss of conscious, 25-30ml 50% dextrose
solution iv. over 3 min period.
 Glucagon 1mg.
 911, 119

21. Emergency management
 Severe hyperglycemia
A prolonged onset
Ketoacidosis may develop with nausea,
vomiting, abdominal pain and acetone odor.
Difficult to different hypo- or hyper-.

22. Emergency management
 Hyperglycemia need medication intervention
and insulin administration.
 While emergency, give glucose first !
 Small amount is unlikely to cause significant
harm.
JADA, Oct 2001

23. Conclusion