Dental considerations in daibetes patient

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DENTAL CONSIDERATION IN PATIENT WITH DAIBETES

By :Payoj Chaudhary

2INTRODUCTION

• Diabetes mellitus is a clinical syndrome characterised by hyperglycemia caused by absolute or relative deficiency of insulin.

• characterized by abnormally elevated blood glucose level and dysregulation of carbohydrate , protein & lipid metabolism.

3Etiologic classification of Diabetes Mellitus

Type 1 diabetes mellitus

• Beta cell destruction usually leading to absolute insulin deficiency

• Immune mediated• Idiopathic

Type 2 diabetes mellitus

• Insulin resistance and relative deficiency

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5Other specific types

• Genetic defects of beta-cell functions

• Decrease of exocrine pancreas

• Endocrinopathies

• Drug or chemical usage

• Infections

6Gestational diabetes mellitus (GDM)

• Defined as any degree of glucose intolerance with onset or first recognition during pregnancy.

• 4% of pregnancy.

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Classical symptoms of DM

Delayed wound healingWeight loss

weakness

polyuria polydipsia polyphagia

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Complications

• People with DM have an increased incidence of both microvascular and macrovascular complications.

Major organs/systems showing changes Long term complications

Cardiovascular system: heart, brain, blood vessels

Myocardial infarction; atherosclerosis; hypertension; microangiopathy; cerebral vascular infarcts; cerebral hemorrhage

Pancreas Islet cell loss; insulitis (Type 1); amyloid (Type 2)

Kidneys Nephrosclerosis; glomerulosclerosis; arteriosclerosis; pyelonephritis

Eyes Retinopathy; cataracts; glaucoma

Nervous system Autonomic neuropathy; peripheral neuropathy

Peripherals Peripheral vascular atherosclerosis; infections; gangrene

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Oral manifestations

• Much attention given to heart diseases, kidney diseases, nerve diseases and eye diseases associated with diabetes.

• Oral complications are often overlooked.

• There is a strong relationship between a person's oral health and their general health.

• In people with diabetes, the first signs and symptoms of a medical condition can develop in the mouth.

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Oral manifestations

Oral conditions include• xerostomia, • burning sensations, • overgrowth of gum tissue, • tooth decay, • periodontal disease (6th complication)• fungal infections, • fruity (acetone) breath, • increased thickness of saliva and altered taste sensation

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XEROSTOMIA

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OVERGROWTH OF GUM TISSUE

14TEETH DECAY

15ORAL CANDIDIASIS

16Periodontitis (the 6`th complication of DM)

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Diagnosis

• Random plasma glucose level of 200 mg/dL or greater.

• Fasting plasma glucose level of 126 or greater. (Normal 70-110 mg/dL)

• Oral glucose tolerance test (OGTT) value in blood of 200 mg or greater.

• ADA recommend >45 y/o screened every 3 years.

Diabetes Care, 2000National Institutes of Health, Aug 2001

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Glucometer

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Monitoring

Laboratory Evaluation of Diabetes Control:

Glycosylated Hemoglobin Assay (Hb A1c)

4 – 6% Normal

<7% Good Diabetes Control

7 – 8% Moderate Diabetes Control

>8% Action suggested to improve diabetes control

American Diabetes Association Guidelines

20General Management Considerations

21Medical management

• Objective :

Maintain blood glucose levels as close to normal as possible

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Medical management

Activity and Exercise 30 minutes of moderate activity on most days of the week

Healthy diet:

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Insulin

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Types of Insulin

Short acting

Intermediate acting

Long acting

Analogs

: Regular insulin

: Lente insulin

NPH insulin

: Ultralente

Short acting : Lispro, Aspart Long acting : Glargine

26Dental cosiderations

27Dental management considerations

To minimize the risk of an intraoperative emergency, clinicians need to consider some issues before initiating dental treatment.

• Medical history: Take history and assess glycemic control at initial appointment.• Glucose levels• Frequency of hypoglycemic episodes• Medication, dosage and times.• Consultation


Scheduling of visits• Morning appointment • Do not coincide with peak activity.

Diet• Ensure that the patient has eaten normally and taken medications

as usual.

Prophylactic antibiotics • Established infection • Pre-operation contamination wound • Major surgery


Blood glucose monitoring• Measured before beginning. (˃70 mg/dL)

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.

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Known diabetic patients

• Inquire about the medication, the type, severity and control of diabetes, the physician treating the patient and the date of last visit

• The dentist should be aware of the patient’s recent glycated hemoglobin values.

• HbA1c values of less than 8% indicate relatively good glycemic control; greater than 10% indicate poor control

• When the level of control of diabetes is not known, consult patients physician and the treatment should be just limited to palliation

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• In patients with good glycemic control before starting any procedure, verify that the patient has taken medication and diet as usual

• Patients, receiving good medical management without serious complications such as renal disease, hypertension, or coronary atherosclerotic heart disease, can receive any indicated dental treatment

• Local anesthesia is preferred, but such patients can even be safely treated in general anesthesia

• Morning appointments should be preferred because this is the time of high glucose and low insulin activity

• This reduces the risk of hypoglycemic episodes during the dental procedures


• Appointments should be of short duration

• a source of glucose such as an orange juice must be available in the dental office to avoid hypoglycemic attacks

• Prophylactic antibiotics for patients taking high doses of insulin to prevent post-operative infection are recommended

• It's best to do surgery when blood sugar levels are within normal range

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To avoid hyperglycemia use anxiety reduction protocol

Emotional stresses and painful conditions increase the amount of cortisol and epinephrine secretion which induce hyperglycemia so • pre-treatment anxiety should be reduced by sedation • pain during procedures can be avoided by a potent

anesthesia

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Management of Diabetic emergency

• If the dental needs are urgent and blood sugar is poorly controlled, treatment should be provided in a hospital or other setting where more medical professionals can monitor patient

• The most common diabetic emergency which a dentist encounters is hypoglycemia

• it can lead to life-threatening consequences

• it occurs when the concentration of blood glucose drops below 60 mg/dL

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Management of Insulin Shock

Insulin shock is a hypoglycemic reaction to over dosage of insulin, a skipped meal, a strenous exercise by an insulin dependent diabetic( type I).

Features • confusion, sweating, tremors, agitation,• anxiety, dizziness, tingling or numbness, tachycardia.

• Severe hypoglycemia may result in seizures or loss of consciousness , convulsions and coma.

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• As soon as such signs or symptoms are present the dentist should check the blood glucose with a glucometer.

• Establish adequate airway, breathing & circulation by loosening dress near the neck, switching on the fan/air conditioners

• place the patient in the head-low-feet-up position

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If patient is conscious and able to take food by mouth, give 15g of oral carbohydrate in one of the following forms; • 4-6 ounce fruit juice or soda, • 3-4 teaspoon sugar,• a hard candy. • Small amount of honey/sweet syrup can also be placed in

the buccal fold

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• In unconscious patients, give 50ml of dextrose in 50% concentration or 1mg glucagon intravenously, or give 1ml glucagon intramuscularly at almost any body site.

• Following treatment, the signs and symptoms of hypoglycemia should resolve in 10 to 15 minutes

• The patient should be observed for 30 to 60 minutes after recovery.

• Normal blood glucose level is confirmed by a glucometer before the patient is allowed to leave

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As soon as such signs or symptoms are present the dentist should check the blood glucose with a glucometer,, the “Golden Rule” is that manage the patients as if they are hypoglycemic until proven otherwise

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Hyperglycemia

Clinical symptoms • thirst, increased urine output and dehydration.• progressive reduction in conscious level and

hypotension, with coma and cessation of urine output in severe cases.

Management• Primary assessment and resuscitation securing the

airway, breathing and circulation.• Transport to a hospital facility.

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Post-operative Period

Eating the right diet is a critical part of diabetes therapy,

If the patient is expected to have difficulty in eating solid food after dental procedure;

Diet should be modified to soft solids or liquids

Even the use of blender to blend food before eating is recommended

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Post-operative Period

Consult the patient’s physician for post-operative period diet plan

It is necessary that the total caloric content and proteins/carbohydrates/fats ratio of the diet remain same

44Instructions to be given to a diabetic

diabetic patients should be strongly motivated to maintain a good oral hygiene by

• brushing after every meal• using floss daily• keeping their dentures clean


patients should be frequently recalled for

• dental examinations• prophylactic measures, such as topical fluorides should

be applied


Cavities should be treated as quickly as possible.

The dryness of mouth can be relieved by providing salivary substitutes or

Asking the patient to suck sugar-free candy or gums and

frequently drink water


Because their good oral health can help in maintaining good glycemic control,

They should be taught that if there is a problem like a bleeding, swollen or tender gums, continuous bad taste or white patches,

They should immediately contact a dentist


The patients should be encouraged to quit

smoking as it greatly increases the risk of periodontal disease in diabetic patients


Diabetics should be informed that they are more likely to catch dental diseases than the normal ones.

Awareness and knowledge increases the tendency to seek preventive dental care, and

Improves chances of maintaining healthy mouth.

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Conclusion

MCQ

• 1)TYPE 1 DM is associated with

a)insulin resistance

b)defect in mitochondrial DNA

c)islet cell auto Antibodies

d)beta cell dysfunction

• 2)glycosylated haemoglobin assay(hbA1c)level of 4%_6% indicates

a)normal value

b)good diabetes control

c)moderate diabetes control

d)poor diabetes control

• 3)Enzyme deficient in diabetes mellitus is

a)glucokinase

b)hexokinase

c)phosphorylase

d)pyrophosphate dehydrogenase

• 4)oral hypoglycemic, which should be stopped prior to surgery under GA

a)pioglitazone

b)gliclazide

c)metformin

d)glibenclamide

• 5)An individual has a fasting blood glucose concentration of 115 mg/dl on three occasion,what is your conclusion?

a)he is normal

b)he is diabetic

c)he has impaired glucose tolerance

d)he needs further evaluation by other boichemical tests.

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Dental considerations in daibetes patient