Diabetes Mellitus and Dental Management Considerations

Diabetes Mellitus: Definition, Classification, Pathogenesis, Diagnosis, Symptoms, Complications and Treatment


Definition of Diabetes Mellitus (DM):
DM is a group of metabolic disorders sharing a common underlying feature of hyperglycemia results in defects in insulin secretion, insulin action or both.

Classification:
1. Type I DM
2. Type II DM
3. Gestational DM
Others due to drugs, disease etc.

Pathogenesis:

Type I DM:
It is due to absolute lack of insulin by immunologically mediated destruction of pancreatic beta cells. The main causes are as follows:
1. Immune destructions:
   - CD4 and T-lymphocytes or CD8 and T-lymphocytes
   - IFN-Y can kill beta cells.
   - Insulitis and leukocyte infiltration disease in pancreas
   - enzymes and insulin autoantigens
2. Genetic susceptibility:
   - Class II MHC (HLA) - Chromosome 6
   - DQ alleles
3. Environmental factors:
   - Viral infections

Type II DM pathogenesis:
1. Insulin resistance by:
   - Obesity
   - Adipokines
   - Genetic defects
2. Beta cell destruction

WHO criteria for diagnosis of DM:
1. Fasting glucose > 126 mg/dl
2. Postprandial glucose > 200 mg/dl

Classical Symptoms:
1. Polyuria
2. Polydipsia
3. Polyphagia
4. Weight loss

Complications of DM:

A) Acute complications:
   1. Diabetic ketoacidosis
   2. Hyperglycemic hyperosmolar state
   3. Hypoglycemia
B) Chronic complications:
   a) Microvascular:
     - Retinopathy: Retinal damage and blindness
     - Neuropathy: Nerve damage
     - Nephropathy: Kidney damage
   b) Macrovascular:
     - MI
     - Peripheral Vascular disease
Others: Diabetic foot

Management of Diabetes Mellitus:

Investigations:
   1) Full blood count
   2) Liver function tests
   3)  Fasting or random glucose level test
   4) ECG
   5) HbA1c

Treatment:
A) Non-pharmacological:
   1. Diabetic education
     - Monitoring blood glucose, urine time to time
     - Foot care from injury: can cause foot ulcer and gangrene
     - Bp control: can cause hypertension
     - Eye examination: can cause blindness
     - Recognition of symptoms of hyperglycemia and it's home treatment
   2. Healthy Diet
   3. Keep ideal body weight
   4. Regular body exercise
   5. Avoid smoking
B) Pharmacological Treatment:
   1) Injectable Insulin (s.c)
   2) Oral antidiabetic drugs.

Dental management considerations:

Objective: To maintain blood glucose level normal

The most common complication of DM in dental clinic is hypoglycemia due to peak insulin activity which occurs when oral antidiabetic drugs or insulin level exceeds the normal physiological limit and cause severe decline in blood sugar level.

Symptoms:
   - Mood changes
   - Hunger
   - Weakness
   - Sweating
   - Tachycardia
   - Unconsciousness
   - Hypothermia
   - Seizures
   - Coma
   - And finally death may happen.

Treatment in dental clinic:
   1. The first thing we should do is terminate the dental treatment immediately.
   2. Immediate administration of 15 gram of oral carbohydrates e.g. glucose tablets, sugar, candy, soft drinks or juice.
   3.  Measure blood glucose level to confirm the diagnosis and determine if repeated carbohydrate dose is needed.
   4. If patient is unconscious and is unable to swallow then give 25 to 3o ml of a 50% dextrose solution or 1 mg of glucagon (i.v.)


Note:
1) Patients with poorly controlled diabetes mellitus are at great risk of developing infections and delayed wound healing.
2) Antibiotics should be given orally to the patients undergoing surgical procedure.
3) Aspirin is contraindicated.

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