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Minor Oral Surgery > Diabetes Mellitus > Flashcards

Diabetes Mellitus Flashcards

1
Q

What is diabetes mellitus?

A

a chronic syndrome of hyperglycaemia with anomalies in carbohydrate, fat and protein metabiolism due to lack of insulin production, decreased cellular insulin sensitivity or both

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2
Q

Genetic susceptibility plays a key role in what kind of diabetes?

A

Type II diabetes
(to a lesser extent in type I diabetes) following twin studies

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3
Q

What serotypes increase an individuals susceptibility to diabetes 14 fold?

A
  • HLA-DR3
  • HLA-DR4
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4
Q

What countries have the highest incidence of diabetes?

A

Nordic countries

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5
Q

What countries have the lowest incidence of diabetes?

A

Asian countries

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6
Q

Verge postulated that early exposure to __________ could increase diabetic risk in infants

A

dairy milk

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7
Q

What viral infections have been associated with increased diabetes risk?

A
  • congenital rubella
  • 20% of new cases were positve with coxsackie antibodies
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8
Q

Insulin resistance is observed in ________ stages of pregnancy

A

later stage

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9
Q

What is the effect of physical activity type II diabetes?

A

diminishes risk by:
* increasing sensitivity to insulin
* glucose metabolism

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10
Q

The basis for the autoimmune theory of diabetes stems from …

A

inflammation within the islets of langerhans

autoimmune destruction of B cells.

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11
Q

What happens to B cells as diabetes (type I) progresses ?

A
  • decrease in number
  • decrease in their ability to regenerate
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12
Q

More than __% of type I diabetics have autoantibodies against B cells

A

90%

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13
Q

In type I diabetes there is often a normal count of other langerhans cells (a-cells, PP cells). True or false

A

True

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14
Q

Give examples of autoantibodies that can be implicated in type I diabetes

A
  • islet cell antibody
  • glutamic acid decarboxylase antibody
  • zinc transporter 8
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15
Q

What autoantigen is postulated to be implicated in the selective descruction of B cells?

A

pro-insulin

Present in b-cells and not in other langerhans cells

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16
Q

Genetic susceptibility to diabetes comes from what groups of genes?

A

Human leucocyte antigen (HLA) genes

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17
Q

What HLA genes have a strong association with diabetes ?

A

HLA-DR3
HLA- DR4

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18
Q

What type of white cell is the most abundant in islet lesions?

A

T-lymphocytes

followed by macrophages, lymphocytes and plasma cells

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19
Q

What type of immunity is involved in the pathogenesis

A
  • humoral immunity (plasma cells)
  • cellular immunity (white cells)
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20
Q

What is the role of insulin?

A

acts on insulin sensitive tissue such as adipose and muscle to encourage glucose uptake

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21
Q

What is the response of B cells to insulin resistance?

A

to increase insulin manufacture to preserve normal glucose tolerance

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22
Q

The reduction of B cells seen in diabetes is due to …

A

elevated glucose, fatty acids and amyloid deposition which causes B cell apoptosis

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23
Q

B cell loss in type II diabetes is amplified by …

A

the fact that the pancreas is incapable of regenerating B cells beyond the 3rd decade

so afer 30 years b cell regeneration is difficult /impossible

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24
Q

What is the function of GLP-1?

A

glucagon like peptide- 1 (produced in the gut)

acts on b cells to enhance insulin production

acts on a cells to suppress glucagon production

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25
Q

What is the effect of type II diabetes on GLP-1 ?

A

glucagon suppression by GLP-1 on a cells is insufficient

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26
Q

The levels of GLP-1 in diabetic patients are lower in comparison to non-diabetic patients. True or false

A

false

levels in diabetic and non-diabetic patients are similar

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27
Q

What part of the CNS regulates liver glucose?

A

hypothalamus

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28
Q

What is the role of bile acids in glucose homeostasis ?

A

they instigate fibroblast growth factor 19 (FGF-19) which induces glycogen and reduces glucose production

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29
Q

What is the consequence of hypothalamic inflammation that is caused by a fatty diet?

A

leads to reduced insulin sensitivity and dysregulation of body weight

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30
Q

What is the consequence of a high fat diet and physical inactivity?

A
  • initial fill of adipose tissue under the skin
  • fat accumulates and is then stored in muscle, liver, pancreas, blood vessels and pericardial tissue.
  • adiposity in intra-abdominal cavity leads to impaired glucose uptake due to intracellular impairment of glucose signalling
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31
Q

Outline the ways in which you can test for diabetes

A
  • random venous plasma glucose
  • fasting plasma glucose
  • oral glucose tolerance test
  • glycated haemoglobin (HbA1c)
    *
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32
Q

What is the cut-off point of FPG?

A

126mg/dl

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33
Q

What is the cut-off point of OGTT?

A

200mg/dl

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34
Q

What is the purpose of HbA1c test ?

A

useful for assessing the adequacy of glycaemic control, reflecting the mean plasma glucose over the previous 2 months

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35
Q

What instances is a HbA1c test unsuitable for diagnosis of diabetes?

A
  • patients with haemoglobinopathies such as sickle cell anaemia or thalassaemia (RBCs affected)
  • children
  • acutely ill patients
  • patients on steroids
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36
Q

What is pre-diabetes?

A

patients with impaired fasting glucose (IFG) or impaired glucose tolerance

glucose levels are not elevated enough to be diabetes but greater than normally considered

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37
Q

When should pregnant women receive an OGTT? (as per endorsement by American Diabetes Association)?

A

24-28 weeks of gestation

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38
Q

Systemic manifestations of diabetes can be divided into …

A

microvascular and macrovascular

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39
Q

What types of complications are first to occur in diabetes? Give some examples

A

microvascular complications often occur first

retinopathy, neuropathy and nephropathy

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40
Q

Macrovascular complications that can arise from diabetes include…

A
  • cardiovascular disease
  • cerebrovascular accidents
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41
Q

What diabetic complication results from hyperglycaemia?

A
  • diabetic ketoacidosis
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42
Q

What diabetic complication results from hypoglycaemia?

A

diabetic coma

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43
Q

For a FPG test, what is classsified as fasting?

A

fasting is defined as no caloric intake for at least 8 hours

44
Q

What type of glucose load is used to perform the OGTT test ?

A

one containing the equivalent of 75g anhydrous glucose dissolved in watter

45
Q

When should an OGTT test for diagnosis of gestational DM not be performed?

A

they should not be performed in the morning after an overnight fast of at least 8 hours

46
Q

List indications for type II diabetes testing

A
  • > 45 years who are overweight (BMI >25kg/m2)
  • <45 years who are overweight and have additional risk factors
  • first degree relatives with DM
  • sedentary lifestyle
  • delivered baby >9lb or have been diagnosed with gestational dm
  • hypertension
  • HDL <35mg/dl or triglycerides >250mg/dl
  • previous testing with impaired glucose tolerance or impaired fasting glucose
  • history of vascular disease
47
Q

What is the effect of hyperglycaemia on kidneys?

A

causes expansion and injury of mesangial cells (contractile glomeruli cells) due to increase in mesangial cell glucose concentration

48
Q

Initial mesangium expansion is caused by ________ and subsequently ___________

A

cell proliferation

cell hypertrophy

49
Q

What is the consequence of mesangial expansion?

A

increased rebasorption; hyperfiltration

increased glomerular permeability- leads to proteinurea

absorption of proteins by proximal tubules leading to interstitial scarring and fibrosis (foreign protein presence triggers an inflammatory reaction)

50
Q

Name the preferred indicator of advanced stage diabetic nephropathy

A

tubular interstitial fibrosis

more accurate indicator of renal failure than glomerular sclerosis

51
Q

What kidney functions are affected by nephropathy?

A
  • EPO release
  • activation of vitamin D
  • salt and water homeostasis
52
Q

How does diabetic retinopathy cause blindness?

A

through long-standing microvascular damage in the retina

53
Q

What constitutes vascular damage?

A
  • increased vessel permeability and degeneration
  • micro aneurysms
  • disproportionate angiogenesis
54
Q

________ alters colour perception.

A

cellular

55
Q

What are the stages of retinopathy?

A
  • proliferative
  • non-proliferative
56
Q

Deterioration of diabetic retinopathy leads to …

A

retinal detachment

57
Q

What are the oral manifestations of diabetes?

A
  • burning mouth syndrome (or glossodynia)
  • candidiasis
  • dental caries
  • gingivitis
  • neurosensory dysethesias
  • periodontitis
  • salivary dysfunction
  • taste dysfunction
  • xerostomia
58
Q

Diabetic neuropathy affects both the _____ and ___ systems

A

autonomic and somatic nervous systems

59
Q

What are the pathological changes that occur in neuropathy?

A
  • endothelial thickening
  • subsequent hypoxia

(blood supply to neurons is compromised which causes them to suffer from hypoxia)

60
Q

What is the consequence of disease progression on neuropathy?

A
  • loss of sensation to thermal/physical stimuli

patients can experience allodynia (pain in response to traditionally non-painful stimuli) or hyperesthesia (heightened pain response)

61
Q

Autonomic and sensory fibres are more affected in neuropathy when compared to motor neurones. True or false

A

True

62
Q

Longer fibres are affected first in neuropathy (exhibit signs of degeneration). How is this clinically manifested?

A

parasthesia, anaesthesia and loss of reflexes in the feet

similar symptoms can follow in the hands

63
Q

Neuropathy that affects both the hands and feet is termed as …

A

Glove and stocking distribution

64
Q

What is the consequence of neuropathy induced anaesthesia in diabetics ?

A

they do not respond to lower limb injuries thus increasing the risk of ulcers and of greater consequence amputation.

65
Q

State some ways in which neuropathy in the autonomic nervous manifests itself

A
  • orthostatic hypotension
  • diarrhoea
  • urinary incontinence
66
Q

The atherosclerotic process is ________ diabetics, particularly if poorly controlled

A

accelerated

67
Q

What is diabetic cardiomyopathy?

A

It described injury to the cardiac muscle cells and their performance, non atrributable to hypertension of CAD disease in diabetics

68
Q

What are the primary signs of cardiomyopathy?

A
  • changes in myocardial structure
  • changes to calcium signalling and calcium uptake
69
Q

Cellular behaviour within vessels are affected by ________ and ________ which favour thrombosis in diabetics

A

oxidative stress and longstanding inflammation

70
Q

Glycaemic control is proportional to the severity of periodontal disease; this relationship is also bidirectional. Briefly elucidate the meaning of this

A

this means that poor periodontal health worsens diabetes

poorly controlled diabetes will also worsen the periodontal condition

71
Q

Outline probable theories for the negative bidirectional relationship observed with periodontitis and diabetes

A
  • change in bacterial composition of subgingival plaque
  • weakened immune defence which impair leucocyte action
  • release of tumour necrosis factor

these increase collagen breakdown and decrease collagen synthesis; resulting in destruction of the periodontum

72
Q

What is the cause of increased caries susceptibility in diabetes?

A
  • reduced salivary production - reduced acid buffering capacity providing a good environment for S. mutans
  • periodontal destruction
73
Q

Salivary dysfunction in diabetics is especially seen in what kinds of patients?

A

those with neuropathy

74
Q

What is the cause of xerostomia from diabetes?

A
  • soft tissue irritation
  • chronic inflammation
  • discomfort
75
Q

What are the potential causes of xerostomia in diabetic patients?

A
  • reduced parotid salivary flow rate
  • diabetic medications
76
Q

Xerostomia resulting from diabetic medications often presents first as…

A

polydipsia

77
Q

What is a potential cause for salivary hypofunction in diabetes ?

A

alteration of the basement membrane of the salivary glands

78
Q

What is a contributing factor for altered taste sensation observed in diabetics?

A

reduced saliva

79
Q

Immunosuppression of diabetics predisposes them to opportunistic infections like candidiasis. List risk factors for diabetics to develop fungal infections

A

poorly controlled diabetics that
* smoke
* wear dentures
* are long term steroid user

80
Q

Diabetics with dental and facial abscesses should be treated with urgency to avoid…

A

spread to deep fascial spaces

81
Q

Oral lichen planus is seen to be associated more often with what type of diabetes?

A

Type I diabetes

Oral lichen planus is also thought to have autoimmune aetiology (remember autoimmune diseases do not often occur independently)

82
Q

What is the MOA of sulfonylureas?

A

bind to sulfonylurea receptors on beta cells and trigger release of insulin

83
Q

Give examples of sulfonylureas

A
  • glipizide, glimepiride (3rd gen)
84
Q

What is the MOA of meglitinides ? Give some examples

A

bind to sulfonylurea receptors as well

nateglinide

85
Q

What is the MOA of biguanides? Give an example

A
  • decrease gluconeogenesis and increases peripheral glucose uptake

Metformin

86
Q

What is the MOA of thiazolidinediones ? Give examples

A

activate peroxisome proliferator-activated receptor gamma (PPAR-y) to affect glucose and lipid metabolism

pioglitazone

87
Q

What is the MOA of acarbose miglitol ?

A

inhibits alpha-glucosidase in the gut and this prevents break down of some complex carbohydrates into simple sugars that then cannot be absorbed

88
Q

Give examples of diabetic agents that are insulin secretagogues

A
  • sulfonylurea
  • meglitinides
89
Q

Give examples of drugs that are insulin sensitizers ?

A
  • biguanides
  • thiazolidinediones
90
Q

What are the adverse effects of sulfonylureas?

A
  • hypoglycaemia
  • weight gain
91
Q

What are the adverse effects of meglitinides?

A

generally none but hypoglycaemia is possible

92
Q

What are the adverse effects of biguanides?

A
  • diarrhoea
  • abdominal pains
  • risk of lactic acidosis
93
Q

What diabetic agent is contraindicated in renal insufficiency and heart failure?

A

biguanides

94
Q

What diabetic agent promotes weight loss and has a low risk of developing hypoglycaemia when used alone?

A

biguanides

95
Q

What are the adverse effects of thiazolidinediones?

A
  • weight gain
  • water retention
  • may precipitate congestive heart failure
  • possible risk of experiencing bone loss
96
Q

What are the adverse effects of acarbose miglitol ?

A
  • bloating
  • diarrhoea
  • flatulence (action of colonic bacteria on undigested carbohydrates)
97
Q

Why are neurosensory disorders such as burning mouth syndrome (glossodynia) seen in diabetes?

A

reduced density of epithelial nerve fibres with axonal degeneration

results in persistent painful condition

98
Q

What diet and lifestyle changes should be recommended to diabetic patients?

A
  • aim to intake approx. 1000 kilocalories under energy needs to improve insulin sensitivity
  • limit carbohydrate intake- beneficial for patients that are on insulin medication
  • high fibre diet for cardiovascular health and glycaemic control
  • exercise - reduce abdominal fat, improve BP, improve circulation, improve insulin sensitivity
99
Q

What type of insulin should be used during fasting?

A

long acting insulin

100
Q

Rapid acting insulin is used to cover ___________.

A

meal times

101
Q

Briefly outline how the circulation and vascularisation in diabetics impact wound healing

A
  • decreased vascularity in diabetics potentially encourages hypoxia
  • hypoxia increased inflammation and free radical release
  • hyperglycaemia increases free radical production and AGE (advanced glycation end products)
  • AGE inhibits vascular proliferation
  • hyperglycaemia prevents gap junction (proteins) formation and encourages TNF-a production which synergistically inhibit angiogenesis
102
Q

Innate immunity is suppressed in diabetics. What is the reason for this ?

A
  • AGE products decrease neutrophil and monocyte count in circulation
  • neutrophils and monocytes may also be inactivated
  • decrease in antimicrobial proteins produced by oral epithelial cells (caused by high blood glucose)
  • TNF-alpha presence which inhibits the inflammatory cascade- the first stage of healing. TNF-a is seen in obese and type II diabetics
103
Q

Give examples of antimicrobial proteins produced by oral epithelial cells

A
  • beta defensins
  • cathelicidin
  • psoraisin
104
Q

Give examples of growth factors that are involved in wound healing

A
  • EGF- epidermal
  • IGF- insulin like
  • NGF- nerve
105
Q

There are lower levels of growth factors involed in healing seen in diabetics. True or false

A

True

106
Q

NGF encourages proliferation of what kinds of cells?

A
  • keratinocytes
  • endothelial cells
107
Q

What is the consequence of suppression of the HPA axis through stress?

A

predisposition of patients to infection and delayed healing

Minor Oral Surgery (36 decks)

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