Diabetes Mellitus

Question 1

What is diabetes mellitus?

Answer 1

Diabetes mellitus is a metabolic, chronic disease associated with abnormally high levels of the sugar glucose in the blood.

Question 2

What two mechanisms is diabetes mellitus caused by?

Answer 2

1. inadequate production of insulin (which is made by the pancreas and lowers blood glucose)
2. inadequate sensitivity of cells to the action of insulin

Question 3

What are the clinical manifestations of hypoglycaemia?

Answer 3

Racing pulse

Cold sweats

Pale face

Headache

Feeling incredibly hungry

Shivering, feeling weak in the knees

Feeling restless, nervous or anxious

Difficulty concentrating, confusion

Question 4

What are the clinical manifestations of hyperglycaemia?

Answer 4

Extreme thirst, drinking a lot and then urinating frequently as a result

Unintentionally losing a lot of weight within a few weeks

Noticeable loss of energy with muscle weakness, tiredness and generally feeling quite unwell

Nausea and stomachache

Trouble seeing

Poor concentration

Frequent infections (cystitis, thrush)

Confusion and drowsiness, or even coma

Question 5

What is the normal HbA1c?

Answer 5

4-5.6%

Question 6

What is the best laboratory test for monitoring diabetic control?

Answer 6

HbA1c

Extra:
(1) hemoglobin A1c (HbA1c) ≥ 6.5% (48mmol/mol) OR

(2) fasting plasma glucose (FPG – for at least 8 h) ≥ 126 mg/dl (7.0 mmol/L) OR
(3) two-hour plasma glucose (2-h PG) ≥ 200 mg/dl (11.1mmol/L) during an oral glucose tolerance test (OGTT) (glucose load containing 75 grams anhydrous glucose dissolved in water) OR
(4) in a patient with classic symptoms of diabetes or during a hyperglycemic crisis, a random plasma glucose ≥ 200 mg/dl (11.1 mmol/L)

Question 7

List risks of DM patients during and after surgery

Answer 7

During – hypoglycemia/hyperglycemia

After – poor wound healing and infection

Question 8

What are the characteristics of T1DM?

Question asks to compare between the two types of DM

Answer 8

Type 1:

1. Insulin dependent (absolute or marked insulin deficiency caused by T cell mediated autoimmune disease, viral infection or trauma)
2. Not related to behavioural factors or lifestyle
3. Account for 5 -10 %, mainly affect young patients
4. Treatment require continuous injection of insulin

Question 9

What are the characteristics of T2DM?

Question asks to compare between the two types of DM

Answer 9

Type 2:

1. Non-insulin dependent
2. Caused by insulin resistance + beta cell failure (both needed for disease to occur)
3. Accounts for >90% of DM, mainly in adults
4. Related to lifestyle
5. Reversible by lifestyle changes and medication like OHAs

Note:
Normally insulin sensitive cells throughout the body, most notably adipose, skeletal muscle, and liver, become less sensitive to insulin, which results in the β cells secreting larger quantities of insulin to overcome the resistance and prevent hyperglycemia. Eventually the β cells are no longer able to overcome the insulin resistance, and hyperglycemia results.

Question 10

What are the two other types of DM?

Answer 10

Gestational:
impaired glucose regulation (elevated fasting glucose or abnormal glucose tolerance) that develops or is first recognized during pregnancy
because placenta release hormones to make it harder to produce insulin

MODY (Maturity onset diabetes of the young)(5% of DM, inherited):
Trauma, pancreatitis, cystic fibrosis, and pancreatic carcinoma –> destroy beta cells

Question 11

What are the complications of DM?

Answer 11

1. Higher risk of periodontitis
2. Dental caries (root caries)
3. Xerostomia (inversely related to HbA1c levels)
4. Candida infection
5. Burning mouth syndrome
6. Poor wound healing (see below for details)
7. Neuropathy

see pdf p144 for more

Question 12

How does DM cause candida infection?

Answer 12

1. Higher levels of glucose in tissues because
2. Reduced phagocytosis and killing capacity of PMNs
3. Higher risk for denture stomatitis (mucosal surface below the acrylic portion of the denture)

Question 13

How does DM cause neuropathy?

Answer 13

1. Neural cells death due to decreased vasculature

uncontrolled high blood sugar damages nerves and interferes with their ability to send signals, leading to diabetic neuropathy.

2. Neuropeptides like nerve growth factors and substance P are relevant to wound healing, which promote cell chemotaxis, induce growth factor production, stimulate cell proliferation
3. Decreased neuropeptides is associated with neuropathy
4. Moreover, sensation can modulate immune response, with denervated skin exhibit reduced leukocyte infiltration
5. Deposition of sorbitol and fructose in axon/ myelin sheath reduce oxidative resistance of neurons

Question 14

What is the oral condition if the patient continues the diabetic medication without intake of food? (1mark)

Answer 14

Hypoglycemia –> excessive salivation

Question 15

2 signs that the patient may complain about the condition (2marks)

Answer 15

Drooling, thick saliva, difficulty in speaking

Question 16

What is the most probable diagnosis? (1mark)

Answer 16

Diabetic hypoglycemia

Question 17

One device to monitor the oxygen saturation (1mark)

Answer 17

Pulse oximeter

Question 18

Two ways to resolve airway obstruction (2makrs)

Answer 18

1. Chin lift and jaw thrust (lying down)
2. Bag-valve-mask ventilation with high flow oxygen
3. Take out foreign object causing obstruction

Question 19

Investigation to delineate the extent of swelling (1mark)

Answer 19

MRI

Question 20

Two definite treatments (2marks) (pain on left molar + DM)

Answer 20

Incision and drainage

Extraction of molar

Question 21

Precautions for IDDM patients (2marks)

Answer 21

IDDM = insulin-dependent diabetes mellitus
1. Take good medical history + assess glycemic control

2. Schedule visits in the morning (more cortisol –> higher blood sugar level)
3. Don’t schedule visits at peak insulin activity
4. Tell patient to eat breakfast + take insulin
5. Be aware of hypoglycemic episodes

Question 22

What questions will you ask to assess the diabetic control?

Answer 22

What medications did you take today?

Did you take the same amount as you would normally take?

How often do you check your glucose level?

What was the most recent reading?

Question 23

How do you manage the condition if the patient is hypoglycaemic?

Answer 23

Depends if patient is conscious?

Question 24

How do you manage a hypoglycaemic patient that is conscious?

Answer 24

1. Treat with 15g simple carbohydrates (one-half can of soda / 3 to 4 glucose tablets)
2. Repeat finger-stick glucose test in 15 mins
3. If blood glucose level > 3.3 mmol/L –> ask patient to eat meal / mixed snack that include carbohydrate, lipids, fats to maintain blood glucose level (pure carbohydrate diet will cause patient to revert back to hypoglycemia quickly, while sustained glucose release is preferred)
4. If blood glucose level < 3.3 mmol/L –> repeat intake of 15g simple carbohydrates and re-measure after 15 mins until > 60 mg/dL

Question 25

How do you manage a hypoglycaemic patient that is unconscious?

Answer 25

1. Administer 5 –25 g of 50% dextrose solution intravenously
   Or 1 mg glucagon injection intramuscularly
2. Refer to A&E

Question 26

Look over page 4-6 (Old written)

For treatment algorithms

Answer 26

NOW

Question 27

What is diabetic coma

Answer 27

A life-threatening, reversible form of unconsciousness, caused by severe hypoglycemia, advanced diabetic ketoacidosis or nonketotic hyperosmolar coma

Question 28

Medication for DM (List 2)

Answer 28

1. Metformin/ biguanide
   - Decrease hepatic glucose production
   - First line therapy, no risk of hypoglycemia
   - Can cause diarrhea, abdominal discomffort, nausea, vomiting
2. Sulfonylurea
   - Close K ATP channel on pancreatic B cells, stimulate insulin secretions
   - Generics available
   - Can cause hypoglycemia, weight gain

Question 29

How does hyperglycemia activate pathways of inflammation, oxidative stress and apoptosis?

Answer 29

Page 4 old written doc