PHYSICAL EVALUATION I (Dent 5121) Endocrine System: Diabetes Mellitus
Lecture Objectives
After todays lecture, the student will be able to: 1. Identify patients currently suffering from or having a history of diabetes mellitus through the past medical history, review of systems, and physical examination 2. Obtain information from the interview process and physical examination of the patient to determine the severity of the disease and the patients current physical status 3. Identify potential medical complications of diabetes mellitus that may require modification of the dental management of the patient 4. Identify potential oral manifestations of diabetes mellitus or its treatment
Diabetes Mellitus
Beta islet cells in the pancreas produce insulin Insulin regulates the level of glucose in the blood Insulin moves glucose from the blood into storage tissues. Glucose diffuses into most cells including neural, hepatic, and connective tissues. Adipose and muscle require insulin for entry of glucose.
Diabetes Mellitus
Insulin is secreted in response to glucose absorption by the intestine and elevated blood glucose levels. Insulin performs 3 major functions:
Lowers blood glucose concentration Enhances glucose uptake into muscle and adipose tissue by facilitating glucose transfer across cell membranes Stimulates glycogen formation in the liver.
Diabetes Mellitus
Diabetes mellitus - a chronic metabolic disorder
A lack of insulin and/or unresponsiveness of tissues to insulin Results in elevated blood glucose levels
Metabolic and vascular components
Diabetes Mellitus
Diabetes mellitus affects approximately 18 million people (7% of population) in the U.S.
14 million people diagnosed 6 million people undiagnosed
Incidence is rising
Diabetes Mellitus
Diabetes is a multifactorial disorder
Genetic predisposition Primary destruction of islets of Langerhans in the pancreas Iatrogenic factors Infectious agents
Type 1 Diabetes Mellitus
Previously called Insulin-dependent DM, IDDM, Type I
Immunologically mediated destruction of pancreatic beta cells Leads to absolute insulin deficiency Accounts for 10% of patients with diabetes Onset before age 20 (juvenile onset) 20% of patients with type 1 diabetes have a positive family history for diabetes
Type 1 Diabetes Mellitus
Thin body build Pancreas produces little or no insulin Daily injections of insulin are required More severe, greater fluctuations in blood glucose concentrations, more complications, and results in a shorter life span than diabetes mellitus type 2
Type 2 Diabetes Mellitus
Previously called Noninsulin-dependent DM, NIDDM, Type II
Altered sensitivity of peripheral tissues (especially muscle and fat cells) to insulin Relative insulin deficiency Accounts for 90% of patients with diabetes mellitus Develops gradually after age 40 Stronger genetic basis than type 1 diabetes mellitus
Type 2 Diabetes Mellitus
Usually associated with obesity Normal or elevated levels of insulin and excess glucagon release by the pancreas Usually treated with diet and/or oral hypoglycemic drugs but ~25% require insulin Less severe complications, associated with 30% decrease in life span
Risk Factors
For type 1 DM Scandinavian ethnic background For type 2 DM Over 45 yrs old Overweight (BMI > 25) Parent or sibling with DM Hypertension Hyperlipidemia Gestational diabetes Physically inactive
Other Categories of Diabetes
Impaired glucose tolerance impaired response to glucose challenge but no signs or symptoms of diabetes Gestational diabetes
Other Categories of Diabetes
Secondary diabetes mellitus other conditions that disturb insulin production or utilization such as:
Hyperpituitarism (acromegaly) Cushings syndrome Chronic pancreatitis Carcinoma of the pancreas
Clinical Findings
Type 1 diabetes
Hyperglycemia - elevation of blood glucose levels Glucosuria - glucose in urine Polyuria - increased urinary output Nocturia - urination at night Polydipsia - increased thirst Polyphagia - increased hunger Weakness Weight loss
Clinical Findings
Type 1 diabetes
Ketoacidosis
Acetone breath Kussmaul respirations (deep and rapid) Nausea and vomiting Depressed cognitive function Cardiovascular insufficiency Coma Death
Clinical Findings
Microangiopathy
Small vessels Vascular proliferation, weakening of the vessel wall, and microaneurysms Focal bleeding leads to fibrosis and scarring
Clinical Findings
Microangiopathy Retinopathy
New vessels grow on the surface of the hypoxic retina, gradually decreasing visual acuity and leading to blindness.
Renal failure
Affects capillaries of the renal glomerulus Renal hypertension Decreased excretory function Proteinuria, uremia, and death.
Clinical Findings
Macroangiopathy
Large blood vessels Thickened vascular endothelium Platelet aggregation and release of growth factors Stimulation of smooth muscle proliferation Thickening of the internal layer of the endothelium Vascular narrowing Atherosclerotic plaques form at damaged endothelial sites Altered coagulation promotes thrombosis
Clinical Findings
Macroangiopathy Atherosclerosis
Ischemic heart disease
Myocardial infarction
Cerebrovascular accidents Peripheral vascular disease
Clinical Findings
Peripheral neuropathy
Numbness, paresthesia, anesthesia, pruritis, and burning pain Decubitus ulcers and amputations Muscle weakness and cramps
Clinical Findings
Autonomic insufficiency
Orthostatic hypotension Impotence Urinary incontinence Alternating bouts of diarrhea and constipation
Clinical Findings
Susceptibility to infection
Gangrene of the soft tissues and osteomyelitis of bone Abnormal collagen production, altered chemotaxis, and poor response to infections
Clinical Findings
Type 2 diabetes
Symptoms and signs are often innocuous and longstanding before the diagnosis is made Symptoms (less common than in DM 1)
Polyuria Polyphagia Polydipsia Weight loss
Clinical Findings
Type 2 diabetes
Retinopathy and neuropathy may be present but usually not until later in the course of the disease Ketoacidosis and renal disease occur less frequently in type 2 diabetes mellitus than in type 1
Diagnosis
Clinical signs and symptoms Hyperglycemia
Fasting blood glucose level greater than 126 mg/dl on more than one occasion defines diabetes mellitus. 2 hour postprandal glucose level greater than 200 mg/dl after administration of 75 to100 grams of glucose
Medical Treatment
Type 1 diabetes
Diet and physical activity Insulin therapy
Short-acting (regular or semilente) Intermediate-acting (NPH or lente) Long-acting (ultralente)
Quantity and type of insulin is a gauge of the degree of hyperglycemia Pancreatic transplant
Medical Treatment
Type 2 diabetes
Caloric restriction, weight reduction, and mild to moderate exercise Oral hypoglycemic agents require functioning beta islet cells in pancreas Insulin in 25-30% of patients
Medical Treatment
Monitoring the effectiveness of therapy
Fasting and preprandial glucose levels between 70-120 mg/dl Glycosylated hemoglobin (hemoglobin A1C) less than 7% of total hemoglobin
Medical Treatment
Level of Control of Diabetes Fasting and Hemoglobin preprandial A1C levels glucose levels Well-controlled Moderately wellcontrolled Poorly controlled <120 mg/dl 121-160 mg/dl >160 mg/dl <7% 7-10% >10%
Medical Treatment
Self-monitoring blood glucose levels
Handheld glucometers
Review of Systems
Do you have diabetes or high blood sugar? Does any one in your family have diabetes or high blood sugar? Do you urinate frequently, drink a lot, and feel hungry a lot?
Review of Systems
When were you first diagnosed as diabetic? What has your physician told you about your high blood sugar? What was your last blood glucose level? What does it normally run? What was your last hemoglobin A1C level? What medications are you taking for your high blood sugar?
Review of Systems
Do you have high blood pressure or problems with your kidneys? Have you had any chest pain, heart attacks, or strokes? Do you have any areas of numbness, tingling, or pain, especially in your legs and feet? Do you have any bedsores or areas that are not healing very quickly? Have you ever had any body parts amputated because of your diabetes?
Review of Systems
How often do you have infections? Have you had any changes in your vision? Have you ever had to go to the emergency room because of your diabetes? How often do have dizziness, weakness, sweating anxiety and confusion or other symptoms of low blood sugar?
Assessment
ASA Physical Status Level of Control Complications
Renal failure Retinopathy Atherosclerosis/ischemic heart disease/CVA Peripheral neuropathy Autonomic insufficiency Susceptibility to infection/gangrene/amputations
Assessment
ASA Physical Status
ASA PS II
Well-controlled with dietary modifications, oral hypoglycemic agents or insulin and without complications
Assessment
ASA Physical Status ASA PS III
Well-controlled or moderately well-controlled with insulin with mild to moderate complications Poorly controlled without complications
ASA PS IV
Moderate or poorly controlled with severe complications Moderate or poorly controlled with renal failure
Oral manifestations and dental considerations
Xerostomia Burning tongue
Oral manifestations and dental considerations
Gingivitis and periodontitis
Caries
Oral manifestations and dental considerations
Candidiasis
Oral manifestations and dental considerations
Delayed wound healing Acetone breath Parotid gland swelling Lichenoid drug reactions (oral hypoglycemics)
Lecture Objectives
After todays lecture, the student will be able to: 1. Identify patients currently suffering from or having a history of diabetes mellitus through the past medical history, review of systems, and physical examination 2. Obtain information from the interview process and physical examination of the patient to determine the severity of the disease and the patients current physical status 3. Identify potential medical complications of diabetes mellitus that may require modification of the dental management of the patient 4. Identify potential oral manifestations of diabetes mellitus or its treatment
Preparation for Class Exercise on 4/17/08
Anderson to Lund Cerebrovascular Accidents (strokes) Diabetes mellitus
Maier to Yeboah
Clinical Seminar Session
Group 7/8 Tomorrow 1:30 3:30 pm
7th Floor North Clinic Bring your name tag, safety glases and a pen! Dress appropriately for patients!
Review Session
Tuesday, April 22nd 8 am 1-451 Moos
Clinical Seminar Examination
Friday, April 25th Time change:
New time: 9:40-12 pm
Room change:
New room: Moos 2-620
