CPR Forth Year

1. DIABETES
MELLITUS

2. Outlines
Definition
 Classifications
 Clinical manifestations
 Oral manifestations
 Diagnosis
 Complications
 Management
 Hypo/ and hyper/glycemia


3. DIABETES MELLITUS

Definition
A disorder of glucose metabolism -- hyperglycemia
due to decrease insulin secretion or decrease its
activity or both
 Normal glucose level

80 - 100 mg /100ml blood

BS < 50 mg-----------hypoglycemia in adults

BS < 40 mg-----------hypoglycemia in children


4. Fasting
glucose
level

5. Predisposing factors
Genetic factor
“if both parent ---100% offsprings”
 Disorders destroying islets of langerhans
 Other endocrine dysfunctions
 Corticosteroids
 Iatrogenic diabetes


6. Classification of diabetes
Depending on age

adult onset DM

juvenile onset DM
 Depending on insulin injections

insulin dependent DM

non insulin dependent DM
 NOW we have other classification


7. Type I DM
 Type II DM
 Impaired glucose tolerance I G T
 Impaired fasting glucose I F G
 Gestational diabetes


8. Type I, juvenile, IDDM
Genetically determined 8 %
 Usually start in young
 There is no insulin in patient’s blood
 Glucagon is high
 Pancreatic B-cells are non responsive


9. Type II, adult, NIDDM
Milder
 80 %
 Usually start in adults
 There are enough insulin
 usually don’t need exogenous insulin


10. 



May be duo to lack of insulin receptors in
peripheral tissues
It is divided into
Non obese type
Obese type

11. Non obese
obese

12. Diabetes
Signs & Symptoms

*Polydypsia
*Marked irritability

*Polyuria
*Polyphagia
*Loss of weight
*Loss of strength
*Recurrence of bed wetting
*Drowsiness
*Malaise





Type 1: the onset of symptoms is sudden
Type 2: The onset of symptoms is slow

13. Diagnosis of Diabetes Mellitus

Unequivocal elevation of plasma glucose > 140 mg/dl at
least two separate occasions after overnight fasting.

Glucose tolerance test: Considered positive if plasma
glucose conc. is 200mg/dl or higher, 2 hrs after giving
75g glucose orally. Pts should be tested in the morning
after 3 days of unrestricted CHO diet and normal
physical activity.

14. Diagnosis of Diabetes Mellitus

3. Urine sugar.

4. Test paper strips: strips available for direct estimation
of blood glucose levels. Blood obtained by finger prick is
applied directly to strip, which is washed 1 minute later.
The subsequent colour change is compared to a standard
chart to determine plasma glucose concentration.

15. complication
Acute complications
Hypoglycemic coma….more acute& danger
Hyperglycemic coma….less acute & ??
 chronic complications
Affecting large bl vessels------arteriosclerosis
Affecting small bl vessels--- microangiopathy
Affecting interstitial tissue…..incr. infections


18. Affecting large bl vessels ------ arteriosclerosis
Affecting small bl vessels --- microangiopathy
Affecting interstit tissue …. infections

22. Oral Complications &
Manifestations

Poorly controlled diabetes:

Xerostomia
Bacterial, viral & fungal infection (Candidiasis)
Poor wound healing
Increase incidence of caries, gingivitis, & periodontal
disease, periapical abscesses & burning mouth syndrome




24. Management

Any dental patient who has clear symptoms of diabetes
should be referred to a physician for diagnosis &
treatment.

Pts with findings that may suggest diabetes:
Headache, dry mouth, marked irritability, repeated skin
infection, blurred vision, paraesthesia, periodontal
abscesses, loss of sensation. In addition to the poly
syndrome

25. Management

Therapy must be a highly individual process and usually
must continue for the rest of Patients life.

Therapeutic goals for most Patients are to
1. Maintain as close to normal blood glucose levels
as possible without repeated episodes of
hypoglycemia.
2. Maintain normal body weight.
3. Control hypertension & hyperlipidemia.

26. Medical management


Type 1 Diabetes
- Diet & physical activity.
- Insulin
- Conventional
- Multiple injections
- Continuous infusion
Type 2 Diabetes
- Diet & physical activity.
- Oral hypoglycemic agents
- Insulin plus Oral hypoglycemic agents
- Insulin

27. Medical management
Oral Antidiabetic (Hypoglycemic) Drugs
Class of Drug
1.Sulfonyl ureas
- Chlorpropamide
- Acetohexamide
2. Biguanides
- Metformin
3. -glucosidase inhibitors
4. Thiazolidinediones
- Troglitizone
Daily Dose
Doses/Day
100-500mg
1500mg
1500-2500mg
1
1
1-2
75-300mg
3
400-600mg
1

28. Medical management
Types of Insulin
Action
Duration of Action
(hours)
Lispro (Humilin)
Short acting
1-1.5
Regular
Rapid
4-6
NPH
Intermediate
6-12
Lente
Intermediate
6-12
Protamine Zinc
Long
14-24

29. Management




Insulin Shock
Patients being treated with insulin must follow their
diet closely. If they fail to eat in a normal pattern but
continue to take their regular insulin injection, they may
experience a hypoglycemic reaction caused by an excess
of insulin (insulin shock).
Corrected by giving the patients sweetened fruit
juice or anything with sugar in it.
Patients in the severe stage (unconsciousness)
treated with glucose solution IV; glucagon / epinephrine
for transient relief.

30. Dental Management
1.
Non-Insulin-dependent Patients
All dental procedures can be performed with out
special precautions, unless complication of diabetes is
present.
2.
Insulin – controlled Patients
a. Usually all dental procedures can be performed.
b. Morning appointments best.
c. Patients advised to take usual insulin dosage and
normal meals on day of dental appointment;
information confirmed when patients come for
appointment.

31. Dental Management






d. Patients advised to inform dentist if symptoms of
insulin reaction occur during dental visit.
e. Source of glucose (orange juice, soda) available &
given to Patients if symptoms of insulin reaction occur.
3. If extensive surgery needed:
- Consult with physician concerning dietary need
during post operative period.
- Antibiotic prophylaxis for patients with brittle
diabetes and with high doses of
insulin with chronic states of oral infection.

32. Dental Management









Dental therapy of Patients with Diabetes and acute oral
infection
Non-insulin controlled Patients may require insulin;
consultation with physician.
Insulin-controlled Patients - require insulin (increased
dose).
Patients with brittle diabetes/ Patients with receiving
high insulin dosage should have culture (s) taken from
infected area for a sensitivity testing.
Infections should be treated using standard methods
- warm intra oral rinses
- I&D
- Pulpotomy, pulpectomy, extraction etc.
- Antibiotics.

33. Dental Management

Basic aim of treatment is to simultaneously cure the
oral infection and respond to the need to regain
control of the diabetic condition.
Decision making for dental therapy of Patients with diabetes
depending on the blood glucose( Glucometer) reading
Fasting blood glucose ( Glucometer reading)
<70mg/dl defer elective therapy >200mg/dl defer elective therapy;
(or) give CHO.
give hypoglycemics (or insulin)
(or) refer to physician.

34. Hyperglycemia
 In hyperglycemia
there is syndrome of
poly/:
poly/urea, poly/dipsia, poly/phagia,
blurred vision, pruritus….
 Start by nocturnal enuresis with loss of
weight  coma

35. Pruritus
Hyperglycemia

36. Hypoglycemia
 In Early –CNS
: hunger, nausea,
hyperactive
 In Moderate--- adrenaline is
released...> sweating, bizarre
behavioral patterns
 In severe: unconscious, seizures,
hypotension & hypothermia
 Acute complications are common

37. Hypoglycemia

38. D/D hypoglycemia & hyperglycemia
In hypoglycemia
onset : rapid [ min]
Skin
: cold & wet
Breath : no odor
 In hyperglycemia
onset : slow [ hours & days ]
Skin
: hot & dry
Breath : acetone



If still in doubt, give glucose till medical assist
DM patient with impaired conscious should be
managed as having hypoglycemia until proved
otherwise

39. Manag of hypogly a-consc
1- Recognition of hypoglycemia
2- Terminate dental procedures
3- Supine position with feet elevated
4- A, B,C: Asses and perform basic life support as needed
5-Definitive care
oral CHO
orange juice
6- Recovery
observe for at least 1h

40. Manag of hypogly b-unconsc
1- No time for recognition of hypoglycemia
2- Terminate dent procedures
3- Supine position with feet elevated
4- A, B,C: Asses and perform basic life support as needed
5- Definitive care
summoning of medical assistance
IV
CHO
50% dextrose
IV or IM
1mg glucagon
SC 0.5mg of 1:1000epinephrine
6- Recovery
oral CHO after recovery
Glucagon injection

42. Manag of hypergly a-consc
1-recognition of hyperglycemia
2-avoid any dental pro & terminate any one

43. Manag of hypergly b-unconsc
1- Identify the case
2- Terminate dent procedures
3- Supine position with feet elevated
4- A, B,C: Asses and perform basic life support as
needed
5- Definitive care
Summoning of medical assistance
IV CHO
5% dextrose
?? insulin in emergency [with
monitoring blood glucose
give O2
6- Transport to hospital

44. Medical Alert bracelet and
necklace

45. Check list

46. ‫أحد حارات دمشق القديمة‬
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