Diabetes Mellitus

Question 1

What is diabetes mellitus?

Answer 1

Metabolic condition which is characterised by abnormal glucose regulation, resulting in hyperglycaemia- can be type 1 or type 2.

Question 2

What is a potential consequence of chronic hyperglycaemia?

Answer 2

Microvascular complications- capillaries which supply nutrients to skin, nerves and other parts of the body.
Macrovascular- heart attack and stroke.

Increases risk of atherosclerosis.

Question 3

What tests are used for Diabetes Mellitus?

Answer 3

Random plasma glucose- greater than 11.1mmol/L on 2 occasions, suggests diabetes.
Glucose tolerance test- indicated if fasting sample indicates impaired fasting glucose.
HbA1C- greater than 48 mol/mol (6.5%).

Question 4

What is HbA1c and why is it a good diagnostic measure of diabetes mellitus?

Answer 4

Glycoylated haemoglobin- measures how much haemoglobin has glucose stuck to it.

This increases over time and with the glucose concentration within the blood, gives a good indication of the past few weeks.

Question 5

What is type 1 diabetes mellitus?

Answer 5

Insulin deficiency- autoimmune destruction of pancreatic beta cells, causes a lack of insulin to be produced.

Question 6

What are the consequences of insulin deficiency in T1DM?

Answer 6

Hyperglycaemia
Ketoacidosis- body cells cannot access glucose for metabolism so they start to metabolise fat which results in ketones as the end products.
Ketones are acidic- build up in the blood.

Question 7

What are the signs and symptoms of T1DM?

Answer 7

Polyuria
Polydipsia
Tiredness
Weight loss

Acute presentation- hyperglycaemia with diabetic symptoms, ketoacidosis.

Question 8

What is T2DM?

Answer 8

Defective and delayed insulin secretion and abnormal postprandial suppression of glucagon- the glucose load within the blood does not suppress glucagon- so glucagon will continue to make glycogen.
Insulin resistance.

Question 9

Describe the glucose-insulin-glucagon life cycle?

Answer 9

Glucose is taken in via the diet, insulin is released in response to this.
Glucose is then taken up by the tissues.
Glucose is used up here, therefore, glucose coenntration in the blood decreases.
Glucagon is produced, which causes the release of glycogen from the liver- until more glucose is taken in through the diet and the cycle starts again.

Question 10

What factors encompass T2DM?

Answer 10

Inadequate B cell response to an increased glucose load.
Elevated basal insulin levels.
Failure of gluconeogenesis suppression.
Insulin stimulated glucose uptake is reduced.

Question 11

What are the systemic effects fo T2DM?

Answer 11

Impaired glucose tolerance
Hyperinsulinamemia
Hypertension
Obesity with abdominal distribution
Dyslipidaemia

Question 12

Does family history play a role in diabetes?

Answer 12

In T2, yes. In T1, potentially.

Question 13

What guidance may be useful in the diagnosis and management of diabetes?

Answer 13

NICE guidelines- Diabetes in children and young people, Diabetes in adults.

Question 14

What is the typical management of T1DM?

Answer 14

Insulin from diagnosis
- either basal bolus injections- single long lasting insulin, provides background for the whole day to prevent ketoacidosis, then take some doses of short acting insulin to allow meals and exercise.
- Split-mixed- fewer injections are needed, this insulin contains rapid acting and medium insulin so that the blood sugars are maintained less well but adequately.

Question 15

How is insulin delivered?

Answer 15

Subcutaneous injection.

Question 16

What is the basis of T1DM management?

Answer 16

Nutritional advice.
Exercise
Monitoring glucose levels to determine insulin dosage.

Question 17

What methods are available for glucose monitoring?

Answer 17

Continuous glucose monitoring- attached to the skin, patient will get an alert if the blood sugar goes above the target range.

Closed loop glucose monitoring- monitor is attached to an insulin pump, which will change the levels of insulin injected subcutaneously depending on the glucose levels in the blood.

Question 18

What level of HbA1C should the patient be aiming for?

Answer 18

6-10%, not any higher than 10%.

Question 19

What is the management for T2DM?

Answer 19

Lifestyle changes- weigh loss, diet restriction.
Medication- metformin, DDP-4 inhibitors, GLP-1 mimetic, sulphonylureas.
Surgery- to help weight loss.

Question 20

Describe the method of action of diabetes medication.

Answer 20

Metformin- enhances cell insulin sensitivity.
DDP-4 inhibitors (gliptin)- block the enzyme metabolising incretin, improves insulin response to glucose.
GLP-1 mimetics- increase the level of incretin.
Sulphonylureas- increase pancreatic insulin secretion.

Question 21

Under what circumstances might someone be on insulin if they have T2DM?

Answer 21

Patient is unable to maintain glycemic control with behavioural changes, body weight reduction and oral hypoglycaemic agents.

Question 22

Describe some of the complications of DM.

Answer 22

Cardiovascular risk- caused by macrovascular and microvascular changes.
Infection risk
Reduced ability for wound healing
Neuropathy- caused by changes in the nutrient supply to the autonomic nerves by the microvascular changes.
Retinopathy
Angina, MI, atherosclerosis

Question 23

What factors do you need to consider with DM in relation to dentistry?

Answer 23

Need to work appointments around meal times- early to mid morning is best.
Stress hormones released during surgery can aggravate the diabetes control.
Poor wound healing.
Infection risk.
Be aware of diabetic emergencies.
All children with T1DM should be placed on the enhanced pathway for caries prevention.
Children with medical conditions will have increased anxiety.
Patients can become fatigued with hospital care.

Question 24

In Children with T1DM, who may be involved in the MDT for these patients?

Answer 24

Paediatric endocrinologist
Paediatric diabetes specialist nurse
Paediatric dietician
Clinical psychologist

Question 25

What are the potential dental problems in a child with T1DM?

Answer 25

Increased susceptibility to period disease
Reduced salivary flow
Increased caries rates
Candidosis
Infection

Question 26

What precautions would you take in a paediatric patient with T1DM?

Answer 26

Have the emergency kit close by and know what to do if the situation should arise.
Time appointments around meal times.
Ask them to check their blood sugars before commencing treatment that day- determine whether to proceed depending on that.

Question 27

What are the signs that someone is having a hypo?

Answer 27

unco-operative, irritable, sweating, increased heart rate, headache, fitting, unconsciousness.
Ask the parent what the child is usually like when they have a hypo.

Question 28

What is a consequence of metformin?

Answer 28

B12 deficiency- anaemia