PENATALAKSANAAN TINDAKAN

KEDOKTERAN GIGI PADA PASIEN

DIABETES MELLITUS

Luthfan Budi Purnomo

PERKENI Cabang Jogjakarta

Seminar “AtoZ Tindakan Pencabutan Gigi pada

Pasien Medik Compromis (2014)
Introduction
 Diabetes is associated with increased
requirement for surgical procedures and
increased post-operative morbidity and
mortality
 The stress response to surgery and resultant

hyperglycemia, osmotic diuresis, and

hypoinsulinemia can lead to peri-operative
ketoacidosis or hyperosmolar syndrome
Introduction
 Hyperglycemia impairs leukocyte function and
wound healing
 The management goal is to optimize metabolic

control through close monitoring, adequate

fluid and caloric repletion, and judicious use
of insulin
Type 2 Diabetes
DIABETESIsISNOT a MildDISEASE
NOT MILD Disease
Microvascular complication Macrovascular complication
Stroke
Diabetic 2 to 4 fold increase in
cardiovascular
Retinopathy mortality and stroke3
Leading cause
of blindness
in working age Cardiovascular
adults1
Disease
8/10 diabetic patients
die from CV events4

Diabetic
Nephropathy Diabetic
Leading cause of
Neuropathy
end-stage renal disease2 Leading cause of non-
traumatic lower
extremity amputations5

1
Fong DS, et al. Diabetes Care 2003; 26 (Suppl. 1):S99–S102. 2Molitch ME, et al. Diabetes Care 2003; 26 (Suppl.
1):S94–S98.
3
Kannel WB, et al. Am Heart J 1990; 120:672–676. 4Gray RP & Yudkin JS. In Textbook of Diabetes 1997.
5
Mayfield JA, et al. Diabetes Care 2003; 26 (Suppl. 1):S78–S79.
 Increasing DM
Prevalence in Indonesia

NATIONAL

5.7%

1.7%

1985 2007
WHO, Study Group 1985
RISKESDAS, 2007
 Prevalence of DM in Indonesia

11.1%
Maluku Utara

6.2%
Lampung
National 5.7%

1.7%
Papua

RISKESDAS, 2007
KADAR GLUKOSA DARAH
DIATUR DAN DIKENDALIKAN
DALAM RENTANG YANG SEMPIT

Puasa: 80 - <100 mg/dl

2jPP/sesaat: 80 - <140 mg/dl

Hormon Pengendali Homeostasis Bahan Bakar

 Insulin

 Counter-insulin hormone
-glucagon
-cathecolamine
-growth hormone
-glucocorticoids
INSULIN GLUCAGON
CATECHOLAMINE
GLUCOCORTICOID
GROWTH HORMONE

BLOOD GLUCOSE
BLOOD GLUCOSE
Fasting hyperglycemia

Post prandial hyperglycemia

A round the clock hyperglycemia
Breakfast Dinner
Lunch Fasting

Bed time
Day time
Fasting blood glucose

Blood glucose at bed time

+
Gluconeogenesis
 Pancreatic Islet Cells Dysfunction Leads to
Hyperglycemia in T2DM

Fewer -Cells
-Cells hypertrophy

Insufficient Excessive
insulin glucagon
+ –
+

↑ Glucose
↓ Glucose ↑ HGO
uptake

HGO=hepatic glucose output

Adapted from Ohneda A, et al. J Clin Endocrinol Metab. 1978; 46: 504–510; Gomis R, et al. Diabetes Res Clin Pract. 1989;
6: 191–198.
Kriteria diagnosis diabetes

1. A1c ≥6,5% atau

2. Glukosa plasma puasa ≥126 mg/dl atau
3. 2-jam setelah TTGO ≥200 mg/dl
4. Ada tanda khas DM, glukosa plasma sesaat
≥200 mg/dl
Klasifikasi
Tipe 1 Destruksi sel beta , umumnya menjurus
defisiensi insulin absolut
•Automun
•Idiopatik

Tipe 2 Bervariasi, dominan resistensi insulin

disertai defisiensi insulin relatif sampai
dominan defek sekresi insulin disertai
resistensi insulin

Tipe lain Defek genetik fungsi sel beta; defek

genetik kerja insulin; penyakit eksokrin
pankreas; endokrinopati; infeksi

Diabetes
mellitus
 DIABETIC COMPLICATIONS

Acute Chronic
Macrovascular
CAD
Hypoglycemia Stroke
Diabetic Ketoacidosis (DKA) PAD
Hyperglycemic Hyperosmolar State Microvascular
(HHS) Retinopathy
Nephropathy
Neuropathy
Cardiomyopathy
Diabetic foot
 Slide 17

Updated PERKENI Type 2 Diabetes Treatment Algorithm

Diabetes STEP 1 STEP 2 STEP 3

Healthy life style Healthy life style

Note:
1. Therapy failed if
target of HbA1c < 7%
is not achieved within
2-3 months for each
step
2. In case of no HbA1c
test, the use of blood
glucose level is also
permitted. Average
blood glucose level
for a few BG test in
one day can be
converted to HbA1c
(ref: ADA 2010)
+
Mono therapy
Healthy life style
+ Healthy life style
2 OAD Combination +
Alternative option, if : Combination 2 OAD
+
• No insulin is available
• The patient is objecting insulin Basal insulin
• Blood glucose is still not optimally
controlled
Healthy life style
Insulin
+
Intensification*
3 OAD Combination

*Intensive Insulin: use of basal insulin together with insulin prandial

 OAD’s – a quick summary of the different mechanism of
actions

Incretins :GLP-1 analogue(exen-

atide)/DPP-4 inhibitors Improves Thiazolidinediones
glucose-dependent insulin secretion Increase glucose
from pancreatic β-cells, suppresses uptake in skeletal
glucagon secretion from -cells, muscle and decrease
slows gastric emptying lipolysis in adipose
tissue
Meglitinides
Biguanide (metformin)
(metformin)
Increase insulin secretion from
pancreatic -cells Decreases hepatic
glucose production
and increases uptake
Sulfonylureas
Increase insulin secretion
from pancreatic -cells
-Glucosidase inhibitors
Delay intestinal
carbohydrate absorption
GLP = glucagon-like peptide.
Adapted from Cheng and Fantus. CMAJ. 2005;172:213–226. Sli
de
18
 Oral Diabetes Drugs in Indonesia
Daily Duration
Freq/ A1C FBG vs.
Class Generic Mg/tab dose of action Time
day reduction PPG
(mg) (hr)

Glibinclamide 2.5-5 2.5-15 12-24 1-2 Before 1.5 FBG

meals
Glipizid 5-10 5-20 12-16 1

Gliklazid 30,60,80 30- 24 1-2

Sulfonylureas 320

Glikuidon 30 30- 6-8 2-3

120

Glimepiride 1,2,3,4 0.5-6 24 1

Repaglinid 1 1.5-6 3 1-1.5 Both

Glinid
Nateglinid 120 360 3 0.5-0.8 PPG

Pioglitazone 15-30 15-45 18-24 1 Indep of 0.5-1.4 FBG

TZD meals

Acarbose 50-100 100- 3 With 1st 0.5-0.8 PPG

α-glucosidase
inhibitor 300 food

PERKENI Guidelines 2012

 Oral Diabetes Drugs in Indonesia
Duration
Daily dose Freq A1C FBG vs.
Class Generic Mg/tab of action Time
(mg) /day reduction PPG
(hr)

Metformin 500-850 500-3000 6-8 1-3 With or 1.5 FBG

Biguanides after
Metformin XR 500-750 500-2000 24 1
meals

Vildagliptin 50 50-100 12-24 1-2 Indep of 0.6-0.8 Both

meals
DPP-IV Sitagliptin 25,50,10 25-100 24 1
inhibitors 0

Saxagliptin 5 5 24 1

Metformin+ 25-500/ Glib max 12-24 1-2 With or

Glibenclamide 1.25-5 20 mg/day after
meals
Glimepiride + 1-2/ 2-4/ 2
metformin 250-500 500-1000

Pioglitazone+ 15-30/ Piog max 18-24 1

Fixed dose
metformin 500-850 45 mg/day
combination
drug Sitagliptin + 50/ Sita max 1
metformin 500- 100
1000 mg/day

Vildagliptin + 50/ Vilda max 12-24 2

PERKENI Guidelines 2012
metformin 500- 100
 Insulin in Indonesia
Onset of Peak of Duration of
Type of Insulin Presentation
Action Action Action

Insulin Prandial (Meal-Related)

Insulin Short-Acting

Vial,
Regular (Actrapid®, Humulin® R) 30-60 min 120-180 min 5-8 hour
Pen/Cartridge

Insulin Analog Rapid-Acting

Insulin Lispro (Humalog®) 5-15 min 30-90 min 3-5 hour Pen/Cartridge

Insulin Glulisine (Apidra®) 5-15 min 30-90 min 3-5 hour Pen

Insulin Aspart (Novorapid®) 5-15 min 30-90 min 3-5 hour Pen, Vial

PERKENI Consensus Guidelines, 2011.

 Insulin in Indonesia (Cont’d)
Onset of Peak of Duration of
Type of Insulin Presentation
Action Action Action

Insulin Intermediate-Acting

Vial,
NPH (Insulatard®, Humulin® N) 2-4 hour 4-10 hour 10-16 hour Pen/Cartridge

Insulin Long-Acting

Insulin Glargine (Lantus®) 2-4 hour No Peak 20-24 hour Pen

Insulin Detemir (Levemir®) 2-4 hour No Peak 16-24 hour Pen

Insulin Campuran

70% NPH 30% Regular

30-60 min Dual 10-16 hour Pen/Cartridge
(Mixtard®, Humulin® 30/70)

70% Insulin Aspart Protamin

10-20 min Dual 15-18 hour Pen
30% Insulin Aspart (Novomix® 30)

75% Insulin Lispro Protamin

5-15 min Dual 16-18 hour Pen/Cartridge
25% Insulin Lispro (HumalogMix® 25)

PERKENI Consensus Guidelines, 2011.

Stress Response and Glucose Regulation
 The responses include
 Release of catabolic hormones
 Inhibition of insulin secretion and action
 Anti-insulin effects of surgical stress

 Insulin resistance induced by circulating

stress hormones
 Effect of surgical stress on pancreatic
β cell function
The Peri-operative Milieu Hypercatabolism
(Dagogo-Jack & Alberti, 2002;;Marks, 2003; Dhatariya et al., 2011)
Diabetes Related Patients factors Associated
with Worse Outcome
 Poor peri-operative glycaemic control
 Complications of diabetes:

► Cardiovascular disease
► Microvascular disease

Dhatariya et al., 2011

Cardiovascular autonomic function tests

Blood pressure test

 Blood pressure response to standing up (fall in

systolic blood pressure): 10 mmHg (normal), 11-29

mmHg (borderline), ≥30 mmHg (abnormal)
 Blood pressure response to sustained handgrip

(increase in diastolic blood pressure): ≥16 mmHg

(normal), 11-15 mmHg (borderline), 10 mmHg
(abnormal)
 Comprehensive Care Pathway

Preoperative Theatre and

Primary care assessment recovery Discharge
referral

Hospital
Surgical admission Post-operative
outpatient care

(Dhatariya et al., 2011)

 Comprehensive Care Pathway

Primary care Preoperative

assessment
Theatre and
recovery
referral
Discharge

Surgical Hospital Post-operative

outpatient admission care

Ensure that potential effects of diabetes and associated

co-morbidities on the outcome of surgery are
considered
Ensure that diabetes and co-morbidities are optimally
managed

(Dhatariya et al., 2011)

Peri-operative glycaemic control

 A1c <8.5%
 Blood glucose levels 108-180 mg/dl

(Dhatariya et al., 2011)

 Comprehensive Care Pathway
Primary care Preoperative Theatre and
referral assessment recovery Discharge

Hospital Post-operative
Surgical admission care

outpatient

Arrange pre-operative assessment

Avoid overnight pre-operative admission to
hospital whenever possible

(Dhatariya et al., 2011)

 Comprehensive Care Pathway
Preoperative
Primary care Theatre and
referral recovery Discharge
assessment

Surgical Hospital Post-operative

outpatient admission care

Ensure that glycaemic control optimized prior to

surgery
Ensure that co-morbidities are recognized and
optimized prior to admission

(Dhatariya et al., 2011)

 Comprehensive Care Pathway
Primary care Preoperative
assessment Theatre and
referral recovery Discharge

Surgical
outpatient
Hospital Post-operative
care

admission
Minimize the metabolic consequences of
starvation and surgical stress
Maintain optimal blood glucose control throughout
the admission
Prevent hospital acquired foot pathology

(Dhatariya et al., 2011)

 Comprehensive Care Pathway
Primary care Preoperative Theatre and
referral assessment
recovery Discharge

Surgical Hospital Post-operative

outpatient admission care

Avoid unnecessary use of VRIII (insulin infusion)

Check the blood glucose prior to induction of
anesthesia
Monitor the blood glucose regularly
Maintain the blood glucose in the range 108-180
mg/dl

(Dhatariya et al., 2011)

 Comprehensive Care Pathway
Primary care Preoperative Theatre and
referral assessment recovery Discharge

Surgical
outpatient
Hospital
admission Post-operative
care
Ensure glycaemic control, fluid and electrolyte balance
are maintained
Optimize pain control
Encourage an early return to normal eating and drinking,
facilitating return to the usual diabetes regimen

(Dhatariya et al., 2011)

 Comprehensive Care Pathway
Primary care Preoperative Theatre and
referral assessment recovery
Discharge

Surgical Hospital Post-operative

outpatient admission care

Ensure early discharge

Ensure that factors likely to delay discharge are
identified at the pre-operative assessment

(Dhatariya et al., 2011)

THANK YOU