Diabetes By Dr Haider Al Shamaa Medically compromised

Diabetes By Dr Haider Al Shamaa

Medically compromised patient Means patients with a disease that may complicate dental treatment, or dental treatment may complicate the disease, Here; the dentist must be alert how to avoid these complications. Diabetes Is a disease complex with metabolic and vascular components? The metabolic components including persistent elevation of blood glucose resulting from an absolute or relative lack of insulin which is secreted from the islets of langerhans of the pancreas that causes alteration in lipid -protein metabolism. The vascular components includes onset of nonspecific atherosclerosis with more specific microangiopathy that particularly affects the eyes , kidneys, upper and lower extrimities

Classification: Two types of diabetes: 1 -Diabetes mellitus. 2 -Diabetes insipidus. Diabetes insipidus: Result from genetic dysfunction of beta cell, endocrine disease, or drugs induced diabetes for example patient on cortisol.

Diabetes mellitus: 1 - Type I (Insulin Dependent Diabetes Mellitus) (IDDM): In young with insulin deficiency and result from beta cell destruction, or defect in beta cell function of pancreas leading to absolute deficiency of insulin, in this type usually there is a sudden onset of clinical symptoms which includes Polyphagia, Polyuria, And polydypsia, in addition to losses of weight, loss of strength, drowsiness, and malaise, The patient may be with sever ketoacidosis and complain from vomiting, abdominal pain, nausea, and loss of consciousness. The patient in this type us insulin to maintain life. 2 -Type II (Non-Insulin Dependent Diabetes Mellitus): Which occurs above 40 years in obese people who eat a lot and results from tissues insulin resistance with relative insulin deficiency? In this type, the patient with slow onset of clinical symptoms and the patients are not dependent on exogenous insulin to maintain life, but here diet control is of great benefit and oral antidiabetic may be needed. 3 -Type III Gestational Diabetes: This type affects females during pregnancy.

### Diabetes is of great importance to the dentist because: 1 -The dentist as a member of health teams to detect new cases of the disease. 2 -Diabetic patient may develop Hypo or hyperglycemia on the dental chair. 3 -diabetic patient may develop delayed healing after dental extraction or surgery due to low resistance. Complications: 1 -Associated with vascular system and resulting from two different pathologic changes, Atherosclerosis and microangiopathy for example retinopathy. 2 -Associated with peripheral neural system: Neuropathies may occur in lower extremities as muscle weakness, muscle cramps, deep burning pain and tingling paresthesia.

###Why diabetic patient susceptible for infection: 1 -Hyperglycemia may reduced the phagocytic function of granulocytes and facilitate the growth of micro-organisms. 2 -The ketoacidosis delays the migration of granulocytes in the area of injury and decrease the phagocytic activity. 3 -Atherosclerosis of the blood vessels will lead to vascular insufficiency and decrease the blood flow to the area of injury and facilitate the infection. her You Have Diabetes, either Doctors can determine whether a patient has a normal metabolism, prediabetes or diabetes in one of different ways:

1 -The A 1 C test - at least 6. 5% means diabetes - between 5. 7% and 5. 99% means prediabetes - less than 5. 7% means normal 2 -The FPG (fasting plasma glucose) test - at least 126 mg/dl means diabetes - between 100 mg/dl and 125. 99 mg/dl means prediabetes - less than 100 mg/dl means normal. 3 -2 hour's postprandial blood glucose: The patient given 75 -100 g of glucose, so if the glucose level after 2 hours is 200 mg/dl it is diabetes mellitus (Random blood sugar). 140 -180 mg/dl prediabetic and below 140 mg/dl normal. 4 -Oral glucose tolerance test: Reflect the rate of the absorption, uptake by the tissue and excretion in urine of glucose after 1/2, 1, and 2 hours following intake source of sugar. The normal readings are 170 mg, 120 mg, and 110 mg/dl.

Dental management: 1 -All patients with diagnosed diabetes mellitus must be referred to a edical evaluation and control. 2 -Morning appointment preferred because this is the time of high level of glucose and low level of insulin due to increase level of cortisol at morning to reduce the chance of hypoglucemia. 3 -Short duration visit and stress free to reduced the possibility of hyperglycemia because emotional stress and painful conditions may increase the secretion of cortisol and epinephrine and this cause increase level of glucose and cause hyperglycemia. therfore sedation before visit is preferable. 4 -Diabetic patient must ask about the type of medical treatment e. g. tion or tablet, diet control or combination.

5 -Patient on insulin treatment or oral antidiabetic drugs we have to prevent insulin shock from occurring during the dental treatment, the patient should be told to take the usual dosage and to eat morning breakfast before dental appointment which is best carried out on the morning. Source of sugar such as orange juice must be present in the dental office to give it to the patient if the symptoms of insulin reaction occurs in which the patient become pale with cold sensation and sweat with trimmer this is called insulin shock due to increase the rate of insulin in the blood and decrease the rate of glucose in the blood. The patient may become unconscious. Uncoscious patients give 50 ml of dextrose in 50% concentration or give 1 mg glucagon IV or give 1 ml glucagon IM at any body site The signs and symptoms should resolve in 10 -15 minutes, And the patient observed for 30 - 60 minutes with checking blood glucose before discharging the patient if normal value.

Note: It so difficult to differentiate between hyper and hypoglycemia based on symptoms alone, therefore, source of glucose given for the patient even if complain from hyperglycemia because small amount of glucose unlikely to cause significant harm with measuring blood glucose for correct diagnosis and immediate treatment. ophylactic antibiotic postoperatively to avoid infection. 7 -Patient with well-controlled diabetes can be given general anesthesia, however, in the dental office; management with local anesthesia is

Oral manifestations of patients with diabetes 1 -Dry mouth (xerostomia). 2 -Increase incidence of caries. 3 -Increase incidence of gingivitis and priodontitis. 4 -Angular chellitis. 5 -Recurrent oral ulceration. 6 -Bad odor (keton odor).