DENTAL MANAGEMENT OF DIABETES PATIENT.

The article consists of the following topics:

1)What is Diabetes?

2)Types of Diabetes

3)Complications

4)Laboratory tests

5)Patient Management

A.What is Diabetes?

Diabetes is a chronic disorder of carbohydrates,fat,and protein metabolism wherby a defective or deficient insulin secretory response leads to impaired glucose use.Diabetes creates a physiologic predisposition for developing  generalized microvascular,macrovascular,and neuropathic complications.

B.TYPES OF DIABETES:

1) Type 1 diabetes: This form is usually associated with young people.These patients require insulin to maintain glucose homeostasis secondary to beta cell destruction in the process.

2) Type 2 diabetes: These patients cells have lost their sensitivity to insulin secondary to environmental fand genetic factors.Therefore their muscle and adipose cells cannot transport glucose.

3) Gestational diabetes: This usually develops secondary to pregnancy.Upto 40 % of women with gestational diabetes will develop type 2 diabetes within 10 years of developing geatational diabetes.

4) Secondary diabetes: This is related to a specific cause,such as removal of pancreas.

C.COMPLICATIONS OF DIABETES:

1) Complications associated with Type 1 Diabetes:

a) Diabetic ketoacidosis almost exclusively occurs in patients with type 1 diabetics.DKA is the result of severe insulin deficiency coupled with an absolute or relative increase of glucagon.

b) Patients with DKA usually have blood glucose levels >250mg/dl,ketones in the urine and serum,ph<7.2,and plasma bicarbonate <15 mEq/L.

c) Clinical manifestations include nausea and vomiting to compensate for the metabolic acidosis and kussmaul respiration to reduce carbon dioxide levels in blood.

d) The goals of treatment are to correct dehydration by starting 0.9% normal saline intravenously,using regular insulin,reversing the acidosis and treating the potassium deficiency.

2) COMPLICATIONS ASSOCIATED WITH TYPE 2:

a) Hyperosmolar nonketotic coma usually occurs in patients who are age 65 or older.The symptoms may go unrecognized for weeks.These patients have enough insulin to prevent a ketotic state,but they are severly hyperglycemic(usually>600mg/dl).

b) Left untreated,they become severely dehydrated and progress into a comatose state.

c) The treatment includes increased insulin and slow fluid replacement to prevent cerebral edema because of the sorbitol accumulation in the brain.

D.CRITERIA FOR THE DIAGNOSIS OF DIABETES MELLITUS.

a) The signs and symptoms plus a random plasma glucose concentration >=200mg/dL.

b) The fasting plasma glucose >=126 mg/dL at least two times.

c) Oral glucose tolerance test with a 2 hour postload glucose concentration >=200mg/dL and a time 0 serum glucose level >126 mg/dL.

d) The American Diabetes Association has accepted the fasting plasma glucose test as a diagnostic marker for diabetes.

e) Oral glucose tolerance test:This test measures a person’s ability to handle a glucose load over a period of time.The patient fasts overnight.In the morning,the fasting blood glucose is determined.The patient then ingests a 75-g glucose load.In children and nonpregnant adults,the blood glucose is tested every 30 mins for 2 hour.The test is considered normal if the fasting blood glucose is <110 mg/dL and the 2 hour postload blood glucose is <140mg/dL.

f) Lab findings of Type 2 Diabetes:1) High Plasma glucose 2) Glucose in the urine 3) High urine volume.

E.PATIENT MANAGEMENT OF DIABETES:

1) If plasma levels exceed and remain above 250 mg/dL as a consequence of surgical stress or infection,sliding-scale insulin therapy should be instituted.

2) Use of oral agents other than chlorpropamide should be stopped on the day of the procedure chlorpropamide,which has a longer half-life than other oral hypoglycemic,should be discontinued the day before surgery.These patients often require insulin perioperatively during major surgical procedures.Post operatively,follow the same regime adhered to for diabetes controlled by diet.

3) Most of the diabetic patients who receive insulin use a combination of intermediate-acting and regular insulin.In these patients ,total insulin dosage is usually given in the morning or divided between morning and afternoon.Usually,two thirds of the total dose is NPH and one third is regular insulin.

4) Their management includes half of the normal daily insulin is given as NPH in the morning.An intravenous line is placed and lactated Ringer’s solution started.A preoperative blood sugar is obtained.

5) During surgery,plasma glucose,serum electrolytes and arterial blood gas should be monitored.Additional regular insulin is provided as needed by titrating an insulin infusion of 5-10U/hr either subcutaneously or in the IV fluids.

6) Postoperatively,blood glucose is checked every 6-4 hr.Regular insulin should be administered to maintain plasma glucose between 150 and 200mg/dL.

7) Once the patient has resumed oral intake,NPH insulin is started.The patients plasma glucose is monitored,and the insulin dosage is adjusted with regular insulin as needed

Reference for the above article:Dental Secrets

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