Insulin

Classification

Clinical Signs And Symptoms

Diabetes Complications

Diabetes Diagnosis In Dental Office

Treatment Plan For Minor Oral Procedures

Insulin Shock

Dentists Instruction Prior To Dental Visit

In Case Of Acute Infection

Oral Manifestations Of Diabetes

Dental Management

INSULIN

Glucose level in blood is increased after food intake. Insulin is released from beta cells in pancreas and re-leased into the blood. This hormone bind to specific receptors in body cells and help absorption of glucose into these cells, which then, glucose level in blood nor-malize.However diabetic patient have problem in secreting in-sulin, or there is cellular resistance to insulin or both. This lead to high blood glucose level that lead to many symptoms and complications.

CLASSIFICATION

Diabetic patient can be classified into:

Type 1 (less common - 10% - usually younger than 30 yrs): beta cells in pancreas are destroyed and there is no insulin secretion.

Type 2 (most common - 90% -usually obese and older): There is partial insulin deficiency and cel-lular insulin resistance.

Gestational: which occur in 5-7% of all pregnan-cies and results in loss of fetus. In case of surviving fetuses, they usually overweight. When pregnancy over, mother glycemic control return to normal but these women are at risk of developing diabetes in

the next 5-10 years. Other specific types: include more than 56 disease

that cause destruction of beta cells such as genetic, inflammation, cancer, surgery, endocrine condi-tions such as hyperpituitarism, hyperthyroidism, or could be drug-induced.

CLINICAL SIGNS AND SYMPTOMS

Patient with type 1 diabetes: the onset of symp-toms is sudden and acute. Patient usually non-obese child or young adult younger than 40 years old, but could occur at any age. Signs and symp-toms include: polydipsia, polyuria, polyphagia, weight loss, loss of strength, marked irritability, recurrence of bed wetting drowsiness, malaise, and blurred vision.

Patient also may develop ketoacidosis which charac-terized by symptoms of vimitting, abdominal pain, nausea, tachypnea, paralysis and loss of consciousness.

Patient with type 2 diabetes: usually affect obese individuals older than 40 years old. Symptoms usu-ally develop gradually and less common. Symp-toms include: polydipsia, polyuria, polyphagia, weight loss, loss of strength.

Dental Management of Diabetes mellitusOsama Asadi, B.D.S, Published for Savant Dentist Blog

Diabetes mellitus characterized by high blood glucose level and inability to produce/use insulin. More than 240 million person in the world have diabetes mellitus. Its one of the leading cause of death in United State.Dentist should recognize diabetic patient by history, clinical signs and symptoms and laboratory tests and refer it to physician when needed.

LECTURE OUTLINE

CHAPTER

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Other symptoms related to complications of diabetes type 1 and 2 includes: skin lesions, cataracts, blindness, hypertension, chest pain, and anemia

Feature Type 1 Type 2Frequency 5-10% 90-95%

age Of Onset 15 yrs 40 yrs and over

body Build Normal or thin obese

severity severe mild

insulin Requirement Almost all patients 25-30% of patients

ketoacidosis common uncommon

rate Of Clinical Onset rapid slow

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DIABETES COMPLICATIONS

Generally, Patient with poorly controlled or uncontrolled diabetes mellitus is at risk of: Infection Poor wound healing

Complications of diabetes includes:

Metabolic distrubances: (ketoacidosis) Cardiac: atherosclerosis, hypertension, conges-

tive heart failure, and myocardial infarction. Eyes: retinopathy, cataracts and blindness. Kidney: nephropathy and renal failure. Limbs: ulceration and gangrene of feet, which

lead to foot amputation. Neuropathies: dysphagia, gastric distention,

diarrhea, sexual impotence, muscle weakness and cramp, numbness, burning pain.

Diabetes mellitus (DM) is the seventh leading cause of death in US, mostly due to cardiovascular complications associated with it.

DIABETES DIAGNOSIS IN DENTAL

OFFICE

Most common type of diabetes is type 2. Dentist should be able to recognize diabetic symptoms and interpret screening tests. However, referral to physician for definitive diagnosis and treatment is important.

Patient is diagnosed with diabetes when one of these tests is confirmed: Fasting blood glucose level 126 mg/dL Random blood glucose + (symptoms) 200

mg/dL Oral glucose tolerance test 200 mg/dL HbA1C 6.5%

TREATMENT PLAN FOR MINOR ORAL

PROCEDURES

Patient with uncontrolled or poorly controlled dia-betes should be send to physician for treatment.

Patient with controlled type 1 diabetes: in case of non-invasive dental procedure, patients can be treated just like non-diabetic patients, however, be aware of patients susceptibility to infection and poor wound healing.

In invasive dental procedure: after consultation with patient physician, blood glucose level is taken. If it is between 70-200 mg/dL then dental procedure can be done. If it is 200 mg/dL, then elective dental proce-dure should be deferred until glucose level normalize.

Patient with controlled type 2 diabetes: No treat-ment modification required. Be cautious of pa-tients susceptibility to infection and impaired wound healing.

For diabetes type 1 and 2, major surgical procedure with general anesthesia require special management other than what described above.

These guidelines are for diabetic patient who suffers only from diabetes mellitus without any other compli-cations. Medically compromised diabetic patient who suffer from diabetic complications (such as hyperten-sion, renal impairment, etc..) require special attention and treatment plan modification.

INSULIN SHOCK

When patient take their insulin and do not eat, this re-sults in hypoglycemia that called insulin shock. It also occur when they eat but take insulin overdose, or oral hypoglycemic medication overdose. The initial signs and symptoms include: hunger, weak-ness, trembling, tachycardia, pallor, and sweating. If left undetected it can lead to sever symptoms (hypoten-sion, hypothermia, tonic clonic movements) and loss of consciousness. Dentist should instruct the patient to take their usual meal and insulin injection before coming to the clinic. Morning appointment is preferred.

DENTISTS INSTRUCTION PRIOR TO

DENTAL VISIT

Patient should eat normal meals before appoint-ment and take their medication.

Take a morning appointment Have their medication and glucose (juice, non-diet

cola, etc..) available at dental visit. Inform the dentist about any insulin reaction when

they first occur.

After dental appointment, patient should keep his eat-ing routine and medications. They should keep good oral hygiene and restrict to dentists instruction to pre-vent infection and impaired wound healing, dry socket, and osteomylitis from happening.

IN CASE OF ACUTE INFECTION

Antibiotic prophylaxis for patient after dental proce-dure is not required unless patient suffer from infection and/or systemic symptoms of infection (lymphadenop-athy, fever).In case of patient with infection, patients insulin dos-age should be altered with consultation, and infection is treated locally.

Insulin dosage guidelines Oral hypoglycemic-controlled patients: may re-

quire insulin, consult with physician. Insulin-controlled patient: may need increased in-

sulin dosage, consult with physician. Patient with brittle diabetes (fluctuating, too high

and too low) and patient receiving high dose of in-sulin: culture is taken from infected area for antibi-otic sensitivity test. Culture is sent to testing, and antibiotic therapy is initiated with penicillin or its alternatives in case of allergies. If patient condi-tion did not response to medication, antibiotic is

selected from test result and therapy is initiated.

In all cases, infection should be treated locally with: Warm intraoral rinses Incision and drainage Pulpotomy, endodontics, or extraction And antibiotic

ORAL MANIFESTATIONS OF DIABETES

Patient with uncontrolled diabetes mellitus may suffer from: Xerostomia Poor wound healing infection Oral ulceration and lesions candidiasis Burning pain in the mouth Periapical abscess caries

These are due to excessive loss of tissue fluid, altered response to infection, microvascular changes, and in-creased glucose level in saliva.

Patient with diabetes has increased inflammatory re-sponse, reduced wound healing, and microvasculature changes which contribute to: Periodontal diseases Gingival diseases and proliferation Periodontal abscess

DENTAL MANAGEMENT

Follow what have been discussed earlier regarding management and treatment planning for such patient. Analgesia: avoid aspirin and NSAIDs in patient

taking sulfonylureas, because it can worsen the hy-poglycemia

Antibiotics: antibiotic prophylaxis is not required unless there is an infection or brittle diabetes.

Anesthesia: usual dose. However, in patient with cardiac symptoms, limit dose to 2 cartridge con-taining 1:100,000 epinephrine.

Blood pressure: monitor blood pressure, because diabetes is associated with hypertension.

REFERENCE

Little and Falaces Management of Medically Compromised Patients, 8th Edition.

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