Dental Management Ch. 14: Diabetes Mellitus

______ amplify glucose-stimulated insulin secretion by acting as a GLP-1 receptor agonist or enhancing endogenous GLP-1

"Incretins" (Secretagogues that foist cause hypoglycemia)

Management also involves medications to address the vascular, kidney, and ocular complications, including antihypertensive drugs such as _____ that reduce blood pressure, slow the decline of overall renal function, and reduce progression to diabetic neuropathy.

ACE inhibitors

Insulin secretagogues, especially the longer acting ones, have the potential to cause _________ especially in older individuals.

hypoglycemia,

A ______ reaction also may be caused by an overdose of insulin or an oral hypoglycemic agent, particularly sulfonylurea drugs.

hypoglycemic shock

The genetic component of diabetes is demonstrated by data showing concordance rates of 30% to 40% among ______ _____.

identical twins

The dentist should treat ______ aggressively by incision and drainage, extraction, pulpotomy, warm rinses, and antibiotics.

infection

Patients who have brittle diabetes (in which control is very difficult to achieve) or who require a high dosage of insulin (in type 1 diabetes) and are undergoing an invasive procedure may be at increased risk for postoperative _______

infection. (prophylaxis is still not necessary)

Glucose is rapidly taken up by the pancreatic beta cell and serves as the most important stimulus for _____ secretion

insulin

Overall, _______ disease is more severe and more frequent in patients with poorly controlled diabetes

periodontal

For Type 1 treatment the goal is to design and implement insulin regimens that mimic _____ insulin secretion.

physiologic

Gestational diabetes is abnormal glucose tolerance that first appears or is detected during _____

pregnancy

____-acting insulin aspart, lispro, or glulisine is preferred over regular insulin for prandial coverage

short

In patients with type 1 diabetes, the onset of symptoms is (slow or sudden)

sudden (days or weeks)

Repaglinide, nateglinide, and mitiglinide are not ______ but also interact with the ATP-sensitive potassium channel in beta cells, but act shorter.

sulfonylureas

The ______ are insulin secretagogues that stimulate insulin secretion by interacting with the ATP-sensitive potassium channel on the beta cell. These drugs are most effective in individuals with type 2 diabetes of relatively recent onset (<5 years) who have residual endogenous insulin production.

sulfonylureas

A number of combinations of therapeutic agents are successful in type 2 diabetes, and the dosing of agents in combination is (more, less, or the same) as when the agents are used alon

the same

Oral findings in patients with uncontrolled diabetes most likely relate to excessive loss of fluids through _______, altered response to _______; _______changes; and, possibly, increased _______ concentrations in saliva

urination (dry mouth) infection microvascular (depressed healing) glucose (increased caries

Diabetes mellitus is not a curable disease; however, strict glycemic control established through regular monitoring reduces ____ and _____ complications

vascular and ocular

Hyperglycemia leads to glucose excretion in the urine, which results in increased urinary _____.

volume (causes dehydration, possibly even coma)

________ inhibitors reduce postprandial hyperglycemia by delaying glucose absorption; they do not affect glucose utilization or insulin secretion

α-Glucosidase

___________ are not as potent as other oral agents in lowering the HbA1c but is unique because it reduces the postprandial glucose rise even in individuals with type 1 diabetes.

α-Glucosidase inhibitors

Type one Diabetes is caused by 3 things:

• Beta cell destruction, usually leading to absolute insulin deficiency • Immune mediated: presence of islet cell or insulin antibodies that identify the autoimmune process, leading to beta cell destruction • Idiopathic: no evidence of autoimmunity

______ _____ drugs can exacerbate hypoglycemia in patients taking sulfonylureas.

Beta-blocker

_________ are insulin sensitizers and have their primary site of action in the liver or peripheral tissues.

Biguanides (e.g. metformin)

Reaction or shock caused by excess insulin usually occurs in three well-defined stages, each more severe and dangerous than the one preceding it: (3)

- Mild Stage • Hunger • Weakness • Tachycardia • Pallor • Sweating • Paresthesias - Moderate Stage • Incoherence • Uncooperativeness • Belligerence • Lack of judgment • Poor orientation - Severe Stage • Unconsciousness • Tonic or clonic movements • Hypotension • Hypothermia • Rapid, thready pulse

Type 1 • Cardinal signs and symptoms are same as type 2 (common): (6) • Other signs and symptoms: (6)

- polydipsia, polyuria, polyphagia, weight loss, loss of strength - recurrence of bed wetting, repeated skin infections, marked irritability, headache, drowsiness, malaise, dry mouth

Symptoms and signs of diabetes plus casual (random) plasma glucose concentration ≥____mg/dL=diabetes. Casual is defined as obtained at any time of day without regard to time since last meal.

200

Whole-pancreas transplantation (performed concomitantly with a renal transplant) may normalize glucose tolerance and is an important therapeutic option in type ___ diabetes with ESRD

1 (

Symptoms of diabetes usually resolve when the plasma glucose is below 11.1 mmol/L (<_____ mg/dL), and thus most diabetes treatment focuses on achieving the second and third goals of long term effects.

200

Those with a 2-hour postprandial blood glucose level of _____ mg/100 mL or higher also should be referred.

200

Patients with an estimated fasting blood glucose level of _____ mg/100 mL or higher should be referred to a physician for medical evaluation and treatment, if indicated.

126

Fasting plasma Glucose ≥____mg/dL on two occasions = diabetes. Fasting is defined as no caloric intake for at least 8 hours.

126 (This fasting glucose value is consistently associated with the risk for retinopathy.)

For persons older than age 45 years, screening should occur routinely at ___-year intervals.

3

Type ____ disease is the most prevalent type of diabetes mellitus.

2

The incidence of type ___ diabetes increases with age and is primarily an adult disease. In contrast, type ____ diabetes occurs in 0.3% of Americans but is more than four times more prevalent than type 2 diabetes in persons younger than 20 years of age.

2 1

Glucose load is usually given as Glucola, which contains ____ g of glucose in a 7-fl oz bottle. Venous blood samples are drawn from the arm just before and most often at ___ hours after ingestion of the glucose.

75 2

The A1C reflects glucose levels in the blood over the preceding ____ months, which is the approximate life span of a red blood cell.

3 (It is standard practice to measure HbA1c levels at least twice a year and up to 4 times)

Overall poor functional capacity (i.e., <___metabolic equivalent levels [METs]) increases the risk of complications during and after dental treatment.

4

The ADA recommends screening tests for diabetes mellitus for all persons who are _____ years of age and older and for persons with risk factors such as obesity, family history, belonging to an ethnic or minority group at risk for diabetes, the combination of low HDL cholesterol and high triglycerides, high blood pressure, or gestational diabetes and for women who have delivered large babies 236(weighing >9 lb at birth) or who have had spontaneous abortions or stillbirths or have signs and symptoms of diabetes or its complications

45

According to some sources, diabetes may be undiagnosed in as many as ___% of all patients who have the condition presenting for dental treatment

50

Patients who have not seen their physician recently (within the previous _____ months), who have had frequent episodes of insulin ______, or who report signs and symptoms of diabetes may have disease that is unstable

6 shock

Glycosylated hemoglobin (by A1C assay) ≥____=diabetes

6.5%

In most individuals, the target HbA1c should be less than ____% with a more stringent target for some patients.

7

____ and ______ can potentially enhance the efficacy of some oral sulfonylureas and enhance hypoglycemia; thus, they should be used judiciously.

Aspirin and NSAIDs

_______ insulin helps keep blood sugars at a consistent level when you are not eating - but it is not enough to cover glucose spikes after meals. ______ insulins, on the other hand, are taken at mealtime and act rapidly in the body, serving to manage the elevation of glucose levels following meals.

Basal Prandial

________ inhibitors are new and lower the blood glucose by selectively inhibiting this co-transporter, which is expressed almost exclusively in the proximal, convoluted tubule in the kidney. This inhibits glucose reabsorption, lowers the renal threshold for glucose, and leads to increased urinary glucose excretion.

Sodium-glucose co-transporter-2 (SGLT2)

______ is a very effective insulin regimen for patients with type 1 diabetes. These "pumps" consist of a real-time sensor and can provide continuous subcutaneous infusion of rapid-acting through abdominal skin

Continuous subcutaneous insulin infusion (CSII)

Complications of Diabetes Mellitus • Metabolic disturbances: ketoacidosis and hyperosmolar nonketotic coma (type 2 diabetes) • Cardiovascular: accelerated atherosclerosis (coronary heart disease1); two thirds have high blood pressure; risk for stroke and heart disease death is two to four times higher among people with diabetes • Eyes: retinopathy, cataracts; diabetes is leading cause of new cases of blindness among adults • Kidney: diabetic nephropathy; diabetes is leading cause of renal failure • Extremities: ulceration and gangrene of feet; diabetes is leading cause of non-accident-related leg and foot amputations • Diabetic neuropathy: dysphagia, gastric distention, diarrhea, impotence, muscle weakness or cramps, numbness, tingling, deep burning pain • Early death: diabetes is the seventh leading cause of death in the United States, most commonly caused by cardiovascular disease

For your info

_____ receptor agonists increase glucose-stimulated insulin secretion, suppress glucagon, and slow gastric emptying. These agents do not promote weight gain.

GLP-1

_______ (repaglinide [Prandin] and nateglinide [Starlix]) increase the secretion of insulin in the presence of glucose in a manner similar to that of the sulfonylureas; however, 244they are more rapid in action and have a shorter duration.

Glinides

Use office ________ to ensure good glucose control.

Glucometer

_____-_______ agents other than insulin (with the exception of amylin analogue and α-glucosidase inhibitors) are ineffective in type 1 diabetes

Glucose-lowering (first line in initial type 2)

_______ diabetes management has the goal of achieving near-normal glycemia.

Intensive

______ is associated with a metallic taste

Metformin

______ reduces FPG and insulin levels, improves the lipid profile, and promotes modest weight loss.

Metformin

________ (Glucophage), representative of Biguanides of agents, reduces hepatic glucose production and improves peripheral glucose utilization slightly

Metformin (Glucophage), representative of this class of agents, reduces hepatic glucose production and improves peripheral glucose utilization slightly

_____ and lack of______ are the primary environmental factors involved in the pathogenesis of type 2 diabete

Obesity physical activity

_____ _____ is the leading cause of death in patients with type 1 diabetes.

Renal failure

_______ occurs in all forms of diabetes. It consists of nonproliferative changes (microaneurysms, retinal hemorrhages, retinal edema, and retinal exudates) and proliferative changes (neovascularization, glial proliferation, and vitreoretinal traction) and is the leading cause of blindness in the United States

Retinopathy

Insulin ______ are Agents That Affect the ATP-Sensitive K+ Channel in beta cells and enhance GLP-1 Receptor Signaling.

Secretagogues

_____-acting insulin analogues should be injected just before (<10 min) or just after a meal; ______ insulin is given 30 to 45 min before a meal.

Short regular

________ promote a redistribution of fat from central to peripheral locations. Circulating insulin levels decrease with use, indicating a reduction in insulin resistance

Thiazolidinediones

________ reduce insulin resistance by binding to the PPAR-γ nuclear receptor (which forms a heterodimer with the retinoid X receptor)

Thiazolidinediones

States, most insulin is formulated as ______.

U-100 (100 units/mL) - this goes up if patient is more resistant

_____ and ______ are the major adverse effects of insulin therapy.

Weight gain and hypoglycemia

Severe ______ leads to coma and death if it is not identified and treated.

acidosis

The person with type 1 diabetes develops metabolic _______

acidosis.

The relative risk that patients with diabetes will require ______ of an extremity because of diabetic complications is more than 40 times that of normal persons.

amputation

The decision to use ______ prophylaxis or coverage typically involves consultation with the patient's physician and is related to poor glycemic control.

antibiotic

Macrovascular disease (________) occurs earlier and is more widespread and more severe in persons with diabetes

atherosclerosis

Type 1 diabetes is primarily the result of pancreatic _____ cell destruction and is characterized by insulin deficiency. Type 2 diabetes is characterized by insulin _____ and relative insulin _____.

beta resistance/deficiency

Diabetes affects oral health, and oral health affects diabetes meaning its ______

bidirectional

The risk that a person with diabetes will become ______ is 20 times greater than that for the general population

blind

patients with uncontrolled _______ are more susceptible to infection and infection spread, and healing of traumatic and surgical wounds is delayed

diabetes

Insulin regimens (do or do not) reproduce the precise insulin secretory pattern of the pancreatic islet.

do not

Individuals with diabetes are 25 times more likely to acquire ______ than persons without diabetes

end-stage renal disease (ESRD)

For diabetic patients with concurrent hypertension or history of recent MI or with a cardiac arrhythmia, the dose of _____ should be limited to no more than two cartridges containing 1 : 100,000 epinephrine.

epinephrine

An _______regimen to increase insulin sensitivity and promote weight loss should also be instituted.

exercise (for type 2)

Patients in the severe stage (unconsciousness) are best treated with an intravenous _______ solution; glucagon or epinephrine may be used for transient relief.

glucose

Diabetes mellitus is a group of metabolic diseases characterized by high blood _______ levels and the inability to produce and/or use _____.

glucose insulin

Basal insulin requirements are provided by _______-acting (NPH insulin, insulin glargine, or insulin detemir)

long

The extent of glycosylation of hemoglobin A that results in formation of HbA1c (i.e., glycated hemoglobin) in red blood cells is used to detect and assess the _____ level and _____ of hyperglycemia in patients with diabetes

long-term and control

The vascular complications of diabetes include premature _______ disease and serious _______ disease.

macrovascular microvascular

Lack of insulin or deficient action of insulin leads to abnormalities in carbohydrate, fat, and protein ______

metabolism (i.e., increased production of glucose from glycogen, fat, and protein).

Diabetic nephropathy, caused by _________ of the capillaries of the glomerulus, leads to ESRD in 30% to 40% of patients with type 1 diabetes

microangiopathy

In the extremities, diabetic ______ may lead to muscle weakness, muscle cramps, a deep burning pain, 235tingling sensations, and numbness

neuropathy (ome cases of oral paresthesia and burning tongue are caused by this complication.)

Whereas glycemic control tends to dominate the management of type 1 diabetes, the care of individuals with type 2 diabetes must also include attention to the treatment of conditions associated with type 2 diabetes such as ______ ______.

obesity, hypertension, dyslipidemia, cardiovascular disease (especially heart)

2-Hour postload glucose ____=diabetes during an OGTT. The test should be performed as described by the WHO using a glucose load containing the equivalent of 75 g of anhydrous glucose dissolved in water.*

≥200 mg/dL