DIABETES MELLITUS

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.

Classification:

Diabetes mellitus is classified into four broad

categories: type 1, type 2, gestational diabetes, and "other specific types"

Type 1 diabetes mellitus: is a chronic illness characterized by the

body’s inability to produce insulin due to the autoimmune destruction of the

beta cells in the pancreas. Onset most often occurs in childhood, but the

disease can also develop in adults in their late 30s and early 40s.

Type 2 diabetes mellitus: is characterized by insulin resistance, which

may be combined with relatively reduced insulin secretion,Type 2 diabetes

is non-insulin dependent diabetes mellitus (NIDDM), or adult onset diabetes

mellitus (AODM). In type 2 diabetes, patients can still produce insulin.

gestational diabetes:is associated with increased insulin resistance.

Most patients with gestational diabetes return to a normoglycemic state after

parturition; however, about 30 to 50% of women with a history of gestational

diabetes will develop type 2 diabetes within 10 years.

Other types

Prediabetes indicates a condition that occurs when a person's blood glucose levels are higher than normal but not high enough for a diagnosis of type 2 DM

"Secondary" diabetes refers to elevated blood sugar levels from

another medical condition. Secondary diabetes may develop when the

pancreatic tissue responsible for the production of insulin is

destroyed by disease, such as chronic pancreatitis

Other types of diabetes Genetic defects affecting beta-cell function or insulin action Pancreatic diseases or injuries (pancreatic cancer, pancreatitis, traumatic injury,cystic fibrosis, pancreatectomy) Infections (congenital rubella, Cytomegalovirus infection) Drug-induced diabetes (steroid hormones [glucocorticoids], thyroid hormone) Endocrine disorders (hyperthyroidism, Cushing’s syndrome, glucagonoma,acromegaly, pheochromocytoma)

Causes The cause of diabetes depends on the type.:

Type 1 diabetes is partly inherited and infections with some evidence

pointing at Coxsackie B4 virus.

Type 2 diabetes is due primarily to lifestyle factors and genetics and obesity

The following is a comprehensive list of other causes of diabetes:

Genetic defects of β-cell function

Maturity onset diabetes of the young

Mitochondrial DNA mutations

Genetic defects in insulin processing or insulin action

Defects in proinsulin conversion

Insulin gene mutations

Insulin receptor mutations

Exocrine pancreatic defects

Chronic pancreatitis

Pancreatectomy

Pancreatic neoplasia

Cystic fibrosis

Hemochromatosis

Fibrocalculouspancreatopathy

Endocrinopathies

Growth hormone excess (acromegaly)

Cushing syndrome

Hyperthyroidism

Pheochromocytoma

Glucagonoma

Infections

Cytomegalovirus infection

Coxsackievirus B

Drugs

Glucocorticoids

Thyroid hormone

β-adrenergic agonists

Statins[2

Risk factors for type 1 diabetes

1. Family history

2. Environmental factors. Circumstances such as exposure to a viral illness likely

play some role in type 1 diabetes.

3. Dietary factors. These include low vitamin D consumption, early exposure to

cow's milk or cow's milk formula, and exposure to cereals before 4 months of age.

None of these factors has been shown to directly cause type 1 diabetes.

4. Geography

risk factors for prediabetes and type 2 diabetes

1. Weight

2. Inactivity.

3. Family history.

4. Race.

5. Age.

6. Gestational diabetes

7. Polycystic ovary syndrome.

8. High blood pressure. .

9. Abnormal cholesterol and triglyceride levels.

Clinical Presentation: Type 1 DM is of sudden onset, whereas type 2 DM is often present for years without overt signs or symptoms. Patients with undiagnosed DM may present with one or more signs and symptoms of hyperglycemia that include polydypsia, polyphagia, polyuria, and acute manifestations of hyperglycemia (Table 2). Patients may complain of unexplained weight loss, poor wound healing, blurred vision, gingival bleeding, and high susceptibility to infections and may be easily fatigued. When complications of poor glucose control develop, patients complain of visual impairment; neurologic symptoms such as numbness, dizziness, and weakness; chest pain; gastrointestinal symptoms; genitourinary symptoms, especially urinary incontinence; and sexual dysfunction.

Diagnosis and Monitoring:

The diagnosis of DM is based on specific laboratory findings, as well as the presence of clinical signs and symptoms (Table 3). Diagnostic guidelines include fasting glucose and

casual (nonfasting) glucose levels, with restricted routine use of the oral glucose tolerance test. Both the fasting and casual plasma glucose tests provide a

determination of glucose levels at a single moment in time (at the time the blood sample is collected).

Glycatedhemoglobin (Hb A1C) ≥ 6.5%.[26]

Complications of Diabetes mellitus : The major cause of the high morbidity and mortality rate associated with DM is a group of microvascular and

macrovascular (Table 4). complications affecting multiple organ system

Management Lifestyle

All type 1 diabetic patients use exogenous insulin

Types of Insulin

Rapid acting

Short acting

Intermediate acting

Long acting

Medications

See also: Anti-diabetic medication Agent and mechanism

Sulfonylurea (glyburide,glimepiride, glipizide) Stimulating insulin release by pancreatic beta cells by inhibiting the KATP channel

Metformin

Acts on liver to cause decrease in insulin

resistance

Alpha-glucosidase inhibitor(acarbose, miglitol,voglibose)

Reduces glucose absorbance by acting on small intestine to cause decrease in production of enzymes needed to digest carbohydrates

Thiazolidinediones(Pioglitazone,Rosiglitazone) Reduce insulin resistance by activating PPAR-γ in fat and muscle

Oral Manifestations of Diabetes Mellitus

1. burning mouth, 2. altered wound healing 3. increased incidence of infection. 4. Enlargement of the parotid glands and xerostomia can occur; both are

conditions that may be related to the metabolic control of the diabetic state.

5. Neuropathy of the autonomic system can also cause 6. changes in salivary secretion since salivary flow is controlled by the

sympathetic and parasympathetic pathways. 7. Periodontal disease 8. Salivary dysfunction 9. Taste dysfunction 10. non-candidal oral soft tissue lesion 11. oral mucosal disease 12. dental caries and tooth loss

General Dental Treatment Overall, diabetic patients respond to most dental treatments similarly to the way nondiabetic patients respond. Responses to therapy depend on many factors that are specific to each individual, including oral hygiene, diet, habits such as tobacco use, proper dental care and follow-up, overall oral health, and metabolic control of diabetes. key dental treatment considerations for diabetic patients include stress reduction, treatment setting, the use of antibiotics, diet modification, appointment timing, changes in medication regimens, and the management of emergencies. The use of systemic antibiotics for routine dental treatment is not necessary for most diabetic patients. Antibiotics may be considered in the presence of acute infection. Some clinicians prefer to prescribe prophylactic antibiotic coverage prior to surgical therapy if the diabetic patient’s glycemic control is poor. Medical history It is important for clinicians to take good medical history and glycemic control in first appointment.

Dite It is important for clinicians to ensure that patient has eate normally and take medication as usual.

During treatment Appointment timing for the diabetic patient is often determined by the individual’s medication regimen. For those who take insulin, the greatest risk of hypoglycemia will thus occur about 30 to 90 minutes after injecting lispro insulin, 2 to 3 hours after regular insulin, and 4 to 10 hours after NPH or Lente insulin Blood glucose monitoring depending on the patients medical history,dentists should may need to measure the blood glucose before beginning a procedure.

those who are taking oral sulfonylureas, peak insulin activity depends on the individual drug taken. Metformin and the thiazolidinediones rarely cause hypoglycemia.

If clinician suspects that patient experiencing a hypoglycemic episode He or she must terminate dental treatment and immediately administer 15 gm of fast acting oral carbohydrate such as glucose tablet ,suger,drinks or juice It is important to note patient with alpha-glucosidase inhibitors prevent the hydrolysis of sucrose and fructose to glucose,thereforehypoglycemic episode in patient with taking these drugs should be treated with direct glucose. When treating patients with a history of asthma or angina, dentists usually have the patients bring their inhaler or nitroglycerine with them to dental appointments. After treatment Clinicians should keep in mind these postoperative consideration,patient with poorly controlled DM are greater risk of developing infection and delayed wound healing Managing the Diabetic Emergency in the Dental Office: The most common emergency related to DM in the dental

office is hypoglycemia, a potentially life-threatening situation that must be recognized and treated expeditiously.49,56,57

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. Prevention starts with the practitioner being

familiar with the general medical risks for hypoglycemic events (Table 9)

-Every dental office that treats DM patients should have readily available sources

of oral carbohydrates (eg, fruit juice, nondiet soda, hard candy). As soon as a patient experiences signs or symptoms

of possible hypoglycemia, the patient or the dentist should

check the blood glucose with a glucometer, which has a

typical response time of less than 15 seconds. If a glucometer

is unavailable, the condition should be treated presumptively

as a hypoglycemic episode (Table 11)

--However, under some instances,severe hyperglycemia may present with symptoms mimicking

hypoglycemia. If a glucometer is not available, these symptoms must be treated as hypoglycemia, If it is an actual hyperglycemic

event, the small amountof extra glucose delivered will not have any deleterious effect. However, emergency measures that will elevate serum glucose should not be delayed or withheld from a DM patient

even if hyperglycemia is wrongly suspected in a patient who is actually hypoglycemic.

CONCLUSION Diabetes mellitus is a metabolic condition affecting multiple

organ systems. The oral cavity frequently undergoes changes that are related to the diabetic condition, and oral infections

may adversely affect metabolic control of the diabetic state. The intimate relationship

between oral health and systemic health in individuals with diabetes suggests a need for increased interaction between the

dental and medical professionals who are charged with the management of these patients. Oral health assessment and

treatment should become as common as the eye, foot, and kidney evaluations that are routinely performed as part of preventive

medical therapies. Dental professionals with a thorough understanding of current medical treatment regimens

and the implications of diabetes on dental care are able to help their diabetic patients achieve and maintain the best possible oral health.