Fourth year dentistry students

General medicine
Diabetes mellitus
1st and 2nd lectures
By
Asst. professor
Ahmed Almerzoug
September 2023
Objectives
At the end of these 2 lectures student should
1- understand definition, clinical picture, diagnosis, complications and
general management of DM
2- Oral manifestations of DM
3- oral complications in DM patients
4- Considerations in dental management of dm patients
Risk Factors for T2DM
Genetics Environment Lifestyle Social Determinants

Family history Weight gain/obesity Acculturation

Race or ethnicity Physical inactivity
Poor sleep
Smoking
 How do you define Obesity?
•Abnormal or excessive fat accumulation
that presents a risk to health.
•Body mass index (BMI)*

= *BMI is a screening

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tool, but it does not
diagnose body fatness
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or health.

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 *In Asians,
Overweight:
≥23 kg/m2
Diabetes Care
2015;38:150

2017-2018 <2% 25% 31% 42%

Symptoms of DM
• Symptoms of Type 1 Diabetes
• Polydipsia (increased thirst)
• Polyuria (increased urination)
• Polyphagia (increased hunger)
• Weight loss
• Loss of strength
• Other symptoms
• Skin infections
• Irritability
• Headache
• Drowsiness
• Malaise
• Dry mouth
Symptoms of Type 2 Diabetes
• symptoms are uncommon
• Weight gain (or loss)
• Night time urination
• Genital fungal infections
• Blurred vision
• Decreased vision
• Paresthesias
• Impotence
• Postural hypotension
DIAGNOSIS
• Random blood glucose (by itself is not reliable for diagnosis but can provide
information on real time blood glucose for monitoring purposes)
• Diagnostic criteria for DM
• Fasting blood glucose ? 126 mg/dl. OR Symptoms of DM (polyuria, polydipsia,
wt. loss)
plus casual blood glucose that is ? 200 mg/dl, OR, Two hour post-prandial
blood glucose ? 200 mg/dl
• Glycosylated hemoglobin (HbA1c gt7 measures blood glucose past 2-3 months
• Urinalysis - not reliable
Complications
• Acute Complications of DiabetesThere are three major acute
complications of
diabetes related to short-term imbalances in
blood glucose levels
• Hypoglycemia.
• Diabetes Ketoacidosis (DKA).
• HHNS, which is also called hyperglycemic
hyperosmolar nonketotic coma or hyperglycemic
hyperosmolar syndrome.
Hyperglycemia (Ketoacidosis
• Disorientation
• Rapid, deep breathing
• Hot, dry skin
• Acetone breath
• Hypotension
• Coma (blood glucose 300 to 600 mg/dl)
HYPERGLYCEMIC
HYPEROSMOLARNONKETOTIC SYNDROME
• Hyperglycemia predominate, with alterations of
the sensorium (sense of awareness). At the same
time, ketosis is minimal or absent.
• The basic biochemical defect is lack of effective
insulin (ie, insulin resistance). The patients
persistent hyperglycemia causes osmotic diuresis,
resulting in losses of water and electrolytes.
• To maintain osmotic equilibrium, water shifts
from the intracellular fluid space to the
extracellular fluid space.
• With glucosuria and dehydration, hypernatremia
and increased osmolarity occur.
Hypoglycemia
• Hypoglycemia symptoms will unlikely occur if blood glucose levels
are gt than 45 mg/dl
• CNS/Adrenergic Effects Headache, mental confusion, somnolence,
sweating, tachycardia, tremors, nervousness (40 mg/dl or less)
• Disorientation (30 mg/dl or less)
• Seizures/Coma (25 mg/dl or less)
HYPOGLYCEMIA
• HYPOGLYCEMIA (INSULIN REACTIONS)The blood glucose
falls to less than 50 to 60
mg/dL (2.7 to 3.3 mmol/L).
• It can be caused by too much insulin or oral
hypoglycemic agents, too little food, or
excessive physical activity.
• It often occurs before meals, especially if
meals are delayed or snacks are omitted.
Complications of Diabetes Mellitus
• Complications of Diabetes Mellitus(more common and severe with type I)
. Macrovascular (large vessel) disease
(accelerated atherosclerosis)
Heart CHD, congestive heart failure
Cerebrovascular stroke
Peripheral gangrene
Microvascular (small vessel) disease
(thickened capillary basement membrane)
Nephropathy kidney failure
Retinopathy blindness
Complications …CONT
Neuropathy (gt50 of all diabetics)
Impotence
Bladder dysfunction
Paresthesias
Neuropathic pains (diabetic neuropathy,
including burning mouth)
Neuromuscular dysfunction
Muscle weakness
Muscle cramps
Decreased resistance to infection
Management of DM
1. life style modifications :- control body weight
2. Regular sport
3. Dietary modifications : decrease refined sugar and avoid fatty meals
increase vegetable consumption and whole grain diet which must be
rich in fibers
Insulin
• Insulin One of the two principle hormones produced and secreted by
the pancreas (the other is glucagon)
• Insulin is produced by the beta cells and glucagon is produced by the
alpha cells in the islets of Langerhans
• Insulin promotes the entry of glucose into most cells of the body and
thus controls the rate of carbohydrate metabolism glucose can then
be used immediately for energy or it will be stored in the form of
glycogen or fat
Insulin
• Types of Insulin Rapid acting 5-15min Lispro Aspart
• Short acting 30-60min Regular
• Intermediate 2-4h NPH Lente
• Long acting 6-10h Ultralente
Glargine
• Premixed 30-60min 70NPH/30 regular
Diabetic Macrovascular Complications
• Diabetic macrovascular complications result from changes in the
medium to large blood vessels.
• Blood vessel walls thicken, sclerose, and become occluded by
plaque that adheres to the vessel walls. Eventually, blood flow is
blocked.
• Coronary artery disease, cerebrovascular disease, and
peripheral vascular disease are the three main types of
macrovascular complications that occur more frequently in the
diabetic population.
Myocardial infarction
• Myocardial infarction is twice as common in diabetic men and
three times as common in diabetic women. Coronary artery
disease may account for 50- 60 of all deaths in patients with
diabetes.
• Patients may not experience the early warning signs of
decreased coronary blood flow and may have silent myocardial
infarctions.
• These silent myocardial infarctions may be discovered only as
changes on the electrocardiogram. This lack of ischemic
symptoms may be secondary to autonomic neuropathy
Cerebrovasculer complications
• Cerebral blood vessels are similarly affected by accelerated
atherosclerosis.Occlusive changes or the formation of an embolus elsewhere
in the vasculature that lodges in a cerebral blood vessel can lead to transient
ischemic attacks and strokes.
• People with diabetes have twice the risk of developing cerebrovascular
disease, and studies suggest there may be a greater likelihood of death from
cerebrovascular disease in patients with diabetes.
Diabetic Macrovascular ComplicationsSigns and symptoms of peripheral
vascular disease include diminished peripheral pulses and intermittent
claudication (pain in the buttock thigh, or calf during walking).
• The severe form of arterial occlusive disease in the lower extremities is largely
responsible for the increased incidence of gangrene and subsequent
amputation in diabetic patients
RETINOPATHY

The eye pathology referred to as diabetic retinopathy is caused by

changes in the small blood vessels in the retina, the area of the
eye that receives images and sends information about the images
to the brain.
• It is richly supplied with blood vessels of all kinds small arteries
and veins, arterioles, venules, and capillaries.

• Nearly all patients with type 1 diabetes and more than 60 of

patients with type 2 diabetes have some degree of retinopathy
after 20 years
•
Diabetic foot
• Diabetic FootFoot ulcers are one of the main complications of
DM, with a 15 lifetime risk for foot ulcers in all diabetic patients.
• With damage to the nervous system, a person with diabetes
may not be able to feel his or her feet properly.
• Normal sweat secretion and oil production that lubricates the
skin of the foot is impaired.
Diabetic foot…cont.
• These factors together can lead to abnormal pressure on the
skin, bones, and joints of the foot during walking and can lead to
breakdown of the skin of the foot.
• Sores may develop.
• Damage to blood vessels and impairment of the immune system
from diabetes make it difficult to heal these wounds.
• Bacterial infection of the skin, connective tissues, muscles, and
bones can then occur.
• These infections can develop into gangrene.
Salivary gland dysfunction and xerostomia
•Dry mouth complaints (xerostomia) and salivary hypofunction noticed in patients with diabetes, which may be
due to polyuria, or an underlying metabolic or endocrine problem. When the normal environment of the oral
cavity is altered because of a decrease in salivary flow or alteration in salivary composition, a healthy mouth can
become susceptible to dental caries and tooth deterioration. Dry, atrophic and cracking oral mucosa is the
eventual complication from insufficient salivary production. Accompanying mucositis, ulcers and desquamation,
as well as an inflamed, depapillated tongue, are also common problems
Diabetes Mellitus and Periodontal Disease
• While the exact relationship between DM and
periodontal disease remains unclear, the bulk of
evidence suggests that periodontal disease is
more prevalent and severe among diabetics than
among non-diabetics
Candidiasis

•Oral candidiasis is an opportunistic fungal infection commonly associated with hyperglycemia and is thus a
frequent complication of marginally controlled or uncontrolled diabetes.
• Oral lesions associated with candidiasis include median rhomboid glossitis (central papillary atrophy),
atrophic glossitis, denture stomatitis, pseudomembraneous candidiasis (thrush) and angular cheilitis
• Candida albicans is a constituent of the normal oral microflora that rarely colonizes and infects the oral
mucosa without predisposing factors. These include immunologically compromised conditions (for example,
AIDS, cancer or diabetes), the wearing of dentures in conjunction with poor oral hygiene and the long-term use
of broad-spectrum antibiotics
Oral Manifestations of DM
• xerostomia
• enlargement of parotid glands
• burning mouth/tongue
• altered taste
• candidiasis
• mucormycosis
• periodontal disease
• increased caries risk
ORAL COMPLICATIONS OF DIABETES

•Gingivitis and periodontal disease

• The susceptibility to periodontal disease is the most common oral complication of diabetes. The patient with
poorly controlled diabetes is at greater risk of developing periodontal disease. It starts with gingivitis and then,
with poor glycemic control, progresses to advanced periodontal disease. Children with diabetes and adults with
less-than-optimal metabolic control show a tendency toward higher gingivitis scores
• patients with type 1 diabetes and chronic, marginal metabolic control of the disease have more extensive and
severe periodontal disease than do patients who maintain rigorous control of their diabetes. Patients with type 1
diabetes and retinopathy tend to exhibit more loss of periodontal attachment by the fourth and fifth decades of
life.
Dental management
• Dental Management Considerations Screening/identification
• Prevention of hypoglycemia
• Planning dental treatment and surgery
• Infection management
• Antibiotic prophylaxis
• Oral manifestations
Dental management …. Cont.2
• Prevention of Hypoglycemia(Insulin Reaction)Make sure pt has normal meals
along with insulin
• AM appointments best - avoids peak insulin action
• Watch for hypoglycemic symptoms Mood change,
hunger, anxiety, tremor, headache,
lightheadedness, sweating, nausea, tachycardia
• Tell patient to advise you at first onset of
symptoms
• Check with glucometer if patient becomes
symptomatic
• Treatment oral CHO (sugar, OJ, cola, candy,
cake icing) do not give oral CHO if unconscious!
Dental management …cont.3
• Dental Treatment Guidelines A well controlled, stable diabetic,
whether diet controlled, on oral hypoglycemics, or taking
insulin, requires little or no modification for routine dental care,
including surgery
• Make sure patient has normal meals and continues
normal insulin administration
• For poorly controlled, uncontrolled or symptomatic diabetics, defer
elective treatment and consult with physician to determine stability
and control of their disease
Dental management …cont.4
• Following Oral SurgeryIf the patient is unable to eat a normal diet as
a result of the surgery, encourage alternate dietary intake such as a
liquid dietary supplement (e.g. Ensure)
• Insulin may need to be decreased if food intake is decreased
• Presence of infection may temporarily increase the insulin
requirement
• Postoperative antibiotics are not necessary if diabetes is well
controlled may be indicated for poorly controlled diabetic, especially if
oral/dental infection present