Diabetes Mellitus

PRESENTED BY :-DR. ABHISHEK SHARMA

Introduction Diabetes mellitus is a metabolic disease characterized by dysregulation

of carbohydrate, protein and lipid metabolism.

The primary feature of this disorder is elevation in blood glucose levels (hyperglycemia),resulting from either a defect in insulin secretion from the pancreas, a change in insulin action, or both.

Normal Blood Sugar Levels :- Normal fasting (No food for 8 hours) 70-110 mg/dl Post-prandial (2 hours after eating) <140mg/dl Random blood sugar level <200mg/dl

Diabetes is diagnosed by any one of the following :-

Two consecutive fasting blood glucose tests that are equal to or greater than 126 mg/dL

Any random blood glucose that is greater than 200 mg/dL

An A1c test that is equal to or greater than 6.5 percent. A1c is an easy blood test that gives a three month average of blood sugars

A two-hour oral glucose tolerance test with any value over 200 mg/dL

CLASSIFICATION :-

Diabetes mellitus is broadly classified into :-Type 1 - Insulin dependent diabetes mellitus (IDDM)Type 2 - Non-insulin dependent diabetes mellitus (NIDDM)Gestational Diabetes – Occurs during pregnancySecondary Diabetes – May be caused due to :-

Genetic defects of cell function of pancreasGenetic defects of insulin actionAny disease of pancreas such as

pancreatitis, neoplasm of pancreasEndocrinal disorder like Cushing’s Syndrome,

PheochromocytomaDrug induced such as by glucocorticoids

(cortisone), thyroid hormone

Elevated blood glucose level and the by-products of glucose metabolism lead to cardiovascular disease, cerebrovascular disease, nephropathy, neuropathy and retinopathy.

Elevated or decreased blood glucose levels may also lead to altered mental status and metabolic encephalopathy.

Surgical procedures and stress causes increase in blood glucose level.

Diabetes on the other hand also affect surgical procedures.

SIGNS & SYMPTOMS OF DIABETES MELLITUS

Polydipsia (excessive thirst) Polyuria (excessive urination) Polyphagia (excessive hunger) Unexplained weight loss Changes in vision like blurring Weakness, malaise Irritability Nausea Dry mouth Ketoacidosis Acanthosis nigricans Peripheral skin pigmentation/ulcers Non-ketotic hyperosmolar coma Poor wound healing

Oral manifestations :-

Dry mouth Burning sensation on the tongueAtrophy of tongue coatingPeriodontal disease Increase rate of dental caries Odontalgia Candida infectionLichenoid reaction

Gingivitis in uncontrolled diabetic patient

Pseudomembranous Candidiasis

Lichen Planus

INVESTIGATIONS & DIAGNOSIS :- The diagnosis of DM can be established by using a

number of methods :-

A random blood glucose above 200 mg/dL is suggestive of DM.

A fasting blood glucose between 100 and 125 mg/dL is considered to represent a pre-diabetic state. A fasting blood glucose above 126mg/dL is diagnostic of DM.

Oral glucose tolerance test can be used. In this :- Fasting blood sample is taken 75gm sugar given orally Blood samples are taken at half hour intervals for

2-3 hours Normal blood glucose level should be <180mg/dL

after 1 hour and return to normal level after 2 hours.

Another assay that can be used to determine long-term glucose control is the fructosamine test. The normal range for fructosamine is 2.0 to 2.8 mmol/L.

Glycosylated Hemoglobin :-

(Reflects blood sugar level in the last three months)

A) 4 -6% it is normal ; patient is not diabetic.B) < 7% patient is controlled.C) > 7% patient is uncontrolled.

COMPLICATIONS OF DIABETES MELLITUS :-Short term complications :- Hyperglycemia Hypoglycemia Diabetic ketoacidosis Non-ketotic diabetic acidosis Diabetic comaLong term complications :- Retinopathy

Vision changes Blindness

Nephropathy (renal failure) Neuropathy

Sensory Loss of sensation in hands and feet (other areas may be affected as

well) Autonomic

Changes in cardiac rate, rhythm, conduction

Macrovascular disease (accelerated atherosclerosis)Peripheral vascular diseaseCardiovascular (coronary artery disease)

Cerebrovascular (stroke) Alterations in wound healing. Recurrent infections.

EMERGENCIES IN DIABETES :- Hypoglycemia (Also c/a Insulin Shock)

The most common diabetic emergency in the dental office, a potentially life-threatening complication that must be managed accordingly.

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.

The dental practitioner should give the patient approximately 15 gms of oral carbohydrate in a form that will be absorbed rapidly such as glucose solution or orange juice.

If the patient is unable to take food by mouth and an intravenous line is in place, 25 to 50 mL of a 50% sterile dextrose solution (D50) or 1 mg of glucagon can be given intravenously.

If an intravenous line is not in place, 1 mg of glucagon can be injected subcutaneously or intramuscularly at almost any body site.

In some instances, marked hyperglycemia may present with symptoms mimicking hypoglycemia.

Diabetic ketoacidosis and hyperosmolar non-ketotic acidosis require immediate medical evaluation and treatment. In the dental office, care is limited to activating the emergency medical system, opening the airway and administering oxygen, evaluating and supporting circulation, and monitoring vital signs. The patient should be transported to a hospital as soon as possible.

Hyperglycemia ComaDiabetic Ketoacidosis - It is a state of uncontrolled lipid

catabolism associated with insulin deficiency.

- It occur in the cases of :- 1. Undiagnosed diabetes 2. Interruption of insulin 3. Infection Signs & Symptoms :- Acidosis leading to vomiting, hyperventilation and acetone breath. Osmotic diuresis and polyuria leading to dehydration, hypotension, tachycardia and xerostomia.

Management :- After ensuring that the coma is due to hyperglycemia, give IV fluid for rehydration and to correct electrolytic and insulin balance.

MANAGEMENT OF PATIENT WITH DIABETES MELLITUS :- SURGERY IN DIABETIC PATIENTS NOT TREATED WITH INSULIN :- For all surgery :-

Defer surgery until the diabetes is well controlled. Schedule an early morning appointment ; avoid lengthy appointments. Use an anxiety-reduction protocol. Monitor pulse, respiration, and blood pressure before, during, and after surgery. Maintain verbal contact with the patient during surgery. If the patient must not eat or drink before oral surgery and will have difficulty eating

after surgery, instruct him or her to skip any oral hypoglycemic medications that day. If the patient can eat before and after surgery, instruct him or her to eat a normal

breakfast and to take the usual dose of hypoglycemic agent. Treat infections aggressively. Check blood glucose every 4 to 6 hours while NPO and supplement with short-

acting insulin using the sliding scale. For patients with “fair” metabolic control (fasting blood glucose < 180 mg/dL),

cover with regular or rapid-acting insulin such as lispro, aspart, glulisine as needed using the sliding scale.

For patients with “poor” metabolic control (fasting blood glucose > 180 mg/dL), start continuous insulin infusion (CII) because the use of sliding-scale insulin (SSI) is unlikely to obtain adequate blood glucose control.

SURGERY IN DIABETIC PATIENTS TREATED WITH INSULIN :- For minor surgery :-

Hold any oral agents (if treated with combination therapy) on the day of surgery. For patients with “fair” metabolic control, hold the short-acting insulin and give half the

dose of intermediate-acting insulin (neutral protamine Hagedorn [NPH]) the morning of surgery.

While NPO, infuse 5% dextrose in normal saline (D5NS) plus KCl (10–20 mEq/L) at 100 mL/hr.

Check blood glucose every 4 to 6 hours while NPO and supplement with short-acting insulin using the sliding scale .

Patients treated with basal (glargine) insulin should receive their usual basal insulin dose. Similarly, patients treated with CII (continuous insulin infusion) therapy (insulin pump) should receive their usual basal infusion rate.

Restart preadmission insulin therapy once food intake is tolerated. For patients with “poor” metabolic control (fasting blood glucose > 180 mg/dL), start

CII because the use of SSI (sliding scale insulin) therapy is unlikely to obtain adequate blood glucose control.

For major surgery :- Hold any oral agents on the day of surgery. Start insulin infusion before surgery and continue during the perioperative period

because the use of SSI is unlikely to obtain adequate blood glucose control.

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