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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