SAS 17: ENDOCRINE DISORDERS: DIABETES MELLITUS

diabetes mellitus

a chronic carbohydrate metabolism disorder

causing hyperglycemia and premature macrovascular disease

caused by inadequate insulin production or utilization by pancreatic beta cells

severe diabetes can be caused by history of miscarriages, stillbirths, or large births

metabolic complications of DM

abnormal fatty acid metabolism with ketoacidosis

gluten intolerance due to abnormal protein metabolism

GI symptoms, CV instability, dehydration, mental state changes, coma, death

incidence of large & small vessel disease complications of DM

diabetic retinopathy

coronary artery disease

peripheral vascular disease

diabetic nephropathy (renal disease)

neurologic complications of DM

sexual impotence

changes in GI motility

postural hypotension

autonomic neuropathy

peripheral neuropathy with prominent sensory losses

medical evaluation for DM

laboratory tests: FBS, glucose tolerance, glycosuria, HbA1c

diet control: optimal metabolic control, ketoacidosis prevention, hypoglycemia control

weight normalization, glucose monitoring, drug use

type I diabetes

requires continuous insulin therapy

severe form of diabetes with sudden onset

common in children and adolescents, can affect adults

usually caused by autoimmune reaction destroying beta cells

type 2 diabetes

aka: adult onset diabetes / non-insulin dependent diabetes mellitus (NIDDM)

the most common form of diabetes

treatment includes diet and physical activity control, oral hypoglycemic agents, and insulin

insulin helps control blood glucose levels and reduce small vessel vascular complications and neuropathies

symptoms like weight change, nausea, urination, blurred vision, loss of sensation, impotence, and postural hypotension

dental management for DM

adjunctive sedation if needed

maintain normal dietary intake

advise soft diet for patients with food difficulties

short morning appointments without meal interference

interrupt appointments with snacks for lengthy treatments

minimize infection risk with aggressive treatment and antibiotics

type 2 medications mechanism of action

stimulate pancreas to produce more insulin

inhibit liver glucose production and release

block stomach enzymes breaking down carbohydrates

improve cell sensitivity to insulin

inhibit glucose reabsorption in kidneys

slow food movement through stomach

examples of oral medications

biguanides

meglitinides

dulfonylureas

thiazolidinediones

alpha-glucosidase inhibitors

dipeptidyl-peptidase 4 (DPP-4) inhibitors

sodium glucose transporter 2 (SGLT2) inhibitors

meglitinides

stimulate the release of insulin

ex: repaglinide (prandin) / nateglinide (starlix)

sulfonylureas

stimulate the release of insulin

ex: glipizide (glucotrol) / glimepiride (amaryl) / glyburide (diabeta glynase)

dipeptidyl-peptidase 4 (DPP-4) inhibitors

stimulate the release of insulin

inhibit the release of glucose from the liver

ex: saxagliptin (onglyza) / stiagliptin (januvia) / linagliptin

(tradjenta)

biguanides

ex: metformin — fortamet / glucophage

inhibit the release of glucose from the liver and improve sensitivity to insulin

thiazolidinediones

ex: rosiglitazone (avandia) / pioglitazone (actos)

improve sensitivity to insulin

inhibit the release of glucose from the liver

these medications should not be used in people with kidney disease or heart problems

alpha-glucosidase inhibitors

ex: acarbose (precose) / miglitol (glyset)

slow the breakdown of starches and some sugars

sodium glucose transporter 2 (SGLT2) inhibitors

block glucose from being reabsorbed by the kidneys

ex: canagliflozin (invokaraa) / dapagliflozin (farxiga) / empagliflozin (jardiance)

examples of injectable medications

amylin mimetics

incretin mimetics

amylin mimetics

ex: pramlintice — symlin

used with insulin injections

stimulate the release of insulin

incretin mimetics

stimulate the release of insulin

is used with metformin and sultonyllueas

ex: exenatice (byetta} / exenatide extended release (bydureon) / liraglutide (victoza)

insulin type

rapid-acting insulin

long-acting insulin

examples of rapid-acting insulin

regular insulin

insulin isophane

insulin glulisine

insulin lispro

insulin aspart

examples of long-acting insulin

insulin glargine

insulin detemir

insulin

administered via injections or insulin pump

injections can be done with fine needles or insulin pen

long-acting insulin needed for nighttime glucose control

daily injections often combine rapid and long-acting insulins

cannot be taken orally due to stomach enzyme interference

insulin pump

about the size of a cellphone, worn on body's outside

reservoir of insulin connected to catheter under abdomen skin

programmed for automatic dispense of rapid-acting insulin, eliminating need for long-acting insulin

artificial pancreas

an emerging treatment approach

closed-loop insulin delivery system

automatically delivers correct insulin amount

linking continuous glucose monitor to insulin pump

clinical trials encouraging, more research needed for regulatory approval

pamlintide (symlin)

additional medications prescribed for people with type 1 diabetes

injectable medication used before meals to slow food movement

high blood pressure medications: aspirin & cholesterol lowering medications may be needed

blood sugar monitoring

acute complications include hypoglycemia and hyperglycemia

oral carbohydrate should be readily available to confirm dietary habits

recommended before meals, snacks, bedtime, exercise, driving, and suspected low levels

hypoglycemia

insulin shock

common in patients taking insulin in the dental office

hyperglycemia

diabetic coma

results from insufficient insulin, usually identified before a medical emergency

chronic complications of diabetes

peripheral neuropathy

impaired healing process

increased infection susceptibility

diseases of large and small blood vessels

large blood vessel diseases: arteriosclerosis, eyes, kidneys, lower extremities

poorly controlled type 1 or type 2 diabetes patients advised for periodontal therapy

neuropathy: muscle weakness, cramps, deep burning pain, tingling sensations, numbness, sexual impotence

conditions indicating medical consultation for DM

extensive dental treatment

history of uncontrolled diabetes

patients with diabetes who are not under the care of a physician

dental treatment modifications for DM

avoid tissue trauma

adjust insulin dosage for dental procedures

minimize stress to prevent anti-insulin effects

consider treatment modifications for diabetes complications

schedule appointments after meals to prevent hypoglycemia

schedule frequent recall appointments for disease prevention

conditions indicating premedication for DM

surgical procedures may need prophylactic antibiotics in poorly controlled diabetics

potential emergency situations for DM

non-cardiac: diabetic coma (hyperglycemia)

insulin shock (hypoglycemia)

thyroid disease

affects heart, kidneys, liver, diaphragm

can lead to dwarfism or mental retardation

essential hormones for normal growth and development

caused by iodine deficiency or hyper thyroid gland activity

modulates enzyme system activities and increases metabolic rate

crucial for functioning of nervous, cardiovascular, renal, reproductive, and temperature regulating systems

hypothyroidism

minimal management concerns

due to inadequate thyroid hormone circulation

low basal metabolism due to thyroid hormone deficiency

symptoms:

• weight gain

• slow pulse

• heart dilation

• muscle weakness

• dry skin/hair, edema

• mental & physical slowness

hyperthyroidism

vasoconstrictors like epinephrine are contraindicated

uncontrolled hyperthyroidism can cause stress sensitivity

excessive thyroid hormones cause exaggerated functions

symptoms include rapid pulse, restlessness, tremors, weight loss, increased metabolism, pain, heat sensitivity

2 conditions that result in hyperthyroidism

grave’s disease

toxic nodular goiter

grave’s disease

seen mainly in young adults

results in an enlarged, highly vascular thyroid gland and protrusion of the eyeballs {exophthalmos)

toxic nodular goiter

results in nodules forming within the thyroid gland

which spontaneously secrete excessive amounts of the thyroid hormones

conditions indicating medical consultation for thyroid dx

a patient who has had thyroid dysfunction and has not received treatment to establish a normal level of circulating thyroid hormones

dental treatment modifications for thyroid dx

if a large goiter is present, position the patient upright to avoid breathing difficulties

drugs to avoid for poorly controlled hyperthyroid

epinephrine acts as a cardiovascular stimulant

atropine increases the heart rate and could precipitate a thyroid storm.

drugs to avoid for poorly controlled hyporthyroid

CNS depressants such as barbiturates & tranquilizers given in normal doses

may be overdosed because of his or her extreme sensitivity to the depressant actions of these drugs

potential emergency situations for thyroid dx

cardiac: hypothyroidism — congestive heart failure

non-cardiac: hyperthyroidism — thyroid storm or crisis

increased pulse rate

poor glycemic control in diabetic patients can NOT cause experiencing these oral findings

thyroid storm

epinephrine if used in hyperthyroidism patient may precipitate this condition:

increased sensitivity to pain and heat

patients with hypothyroidism do NOT experience this symptom:

endocrine-disrupting chemicals / EDCs

scientific knowledge on EDCs is rapidly growing

examples include DDT, Lead, Chlorpyrifos, Bisphenol A

hormones are natural chemicals produced in endocrine glands

traditional methods for assessing EDCs' health impact are inadequate

EDC exposure can disrupt various functions, posing significant health risks

defined by Endocrine Society as non-natural chemicals interfering with hormone action

increased pulse rate

poor glycemic control in diabetic patients can NOT cause experiencing these oral findings