Q. 2. Oral manifestations of diabetes mellitus.
• Diabetes mellitus (DM) is hyperglycaemia secondary to decreased insulin production or peripheral tissue resistance to insulin.
• Classification and aetiology is based on 1997 Report of the Expert Committee on the diagnosis and classification of diabetes mellitus.
• Comprises a group of disorders that share a common phenotype of hyperglycaemia.
i. Type 1 DM
ii. Type 2 DM
iii. Gestational diabetes
iv. Other causes—Cushing syndrome, hypothyroidism, genetic causes, viral infections of the pancreas.
• The clinical features of type 1 and type 2 DM are distinctive.
Type 1 DM
• Type 1 DM/insulin-dependent DM usually occurs in childhood or early adulthood, that is usually before the age of 40 years and results in ketoacidosis when patients are without insulin therapy.
• This account for 10% of cases of DM. Type 1 DM is caused by β islet cell failure, which is of multifactorial causes such as genetic predisposition, viral and autoimmune attacks on the β islet cells.
• The abrupt onset of symptoms, with polyuria, polydypsia, polyphagia and weight loss developing over days or weeks.
• Some cases may present as ketoacidosis during an inter current illness or following surgery.
• Occasionally, an initial episode of ketoacidosis is followed by a symptom-free interval known as ‘honeymoon period’ during, which no treatment is required.
• Characteristically, the plasma insulin is low or unmeasurable.
Glucagon levels are elevated but suppressible with insulin.
Type 2 DM
• Type 2 DM formerly known as noninsulin—dependent DM usually begins after the age of 40 years and 60% of the patients are obese. However, type 2 DM is being increasingly seen in the teenage years.
• Type 2 DM occurs with intact β islet cell function but there is peripheral tissue resistance to insulin.
• There may be some decrease in insulin production or a hyperinsulin state. These patients are not ketosis prone but may develop it under conditions of stress.
• The symptoms begin gradually, over a period of months to years. Frequently, hyperglycaemia is detected in an asymptomatic person on a routine examination.
• These patients usually do not develop ketoacidosis. In the decompensated state, they are susceptible to the syndrome of hyperosmolar hyperglycaemic state, i.e. hyperosmolar nonketotic coma.
• The plasma insulin levels are normal to high. Glucagon levels are elevated, but resistant to insulin.
• Symptoms of complications—burning feet, nocturia, diminished vision.
Gestational onset DM (GODM)
• Gestational onset DM occurs when diabetes onset is during pregnancy and resolves with delivery.
• These patients are at a higher risk for developing DM at a later date.
Other specific types of DM
They include diseases of the exocrine pancreas, various endocrinopathies (Cushing syndrome, pheochromocytoma), drug or chemical-induced DM (β-blockers, oral contraceptives), or genetic syndromes (lipodystrophies) associated with diabetes.
• Coronary artery disease
• Peripheral artery disease.
• Clinical presentations of DM may include polyuria, polydypsia, polyphagia associated with weight loss, blurred vision, recurrent candidal vaginitis, soft-tissue infections or dehydration. Many cases will be asymptomatic and picked up on routine screening.
Diagnosis of diabetes mellitus based on various test results is as follows:
a. Random plasma glucose of >200 mg/dL along with symptoms of diabetes are present.
b. Two readings of fasting plasma glucose of >126 mg/dL.
c. The 2-hour postprandial plasma glucose ≥200 mg/dL during oral glucose tolerance test, after a glucose load of 75 g.
d. Elevated HbA1c. However, the HbA1c is not an adequate screening tool for DM because it may be normal in those with impaired glucose tolerance.
e. The patient is said to have impaired glucose tolerance if the fasting plasma glucose is >110 and <126 mg/dL.
f. Impaired glucose tolerance: 2-hour plasma glucose values between 140 and 200 mg/dL.
Differentiating type 1 and type 2 DM
• Occasionally it may be difficult to differentiate between type 1 and type 2 DM based on the clinical situation. The diagnosis can be clarified by the use of the C-peptide, a product of the cleavage of pro-insulin to insulin. This will be present in those with type 2 DM and low or absent in those with type 1 DM.
• If the C-peptide is border line, checking it after a glucose load may help. In those with type 2 DM, it will increase significantly after glucose load, this response will be absent in those with type 1 DM.
• Oral antidiabetics
• Short/intermediate/long acting insulin
• Modification of life style
• Food habits
• Containing more of complex carbohydrates
Dietary regimen for a diabetic patients
The preparation of a dietary regimen for a diabetic can be considered under three steps:
• This involves the estimation of the total daily caloric requirement of the individual patient based on a number of variable factors like age, sex, weight, activity and occupation of the patient. An approximate total daily caloric requirement can be calculated as:
• Sedentary individuals 30 Kcal/kg/day.
• Moderately active individual 35 Kcal/kg/day.
• Heavily active individuals 40 Kcal/kg/day.
• This involves allocation of the calories in a proper proportion to carbohydrate, protein and fat.
• The recommended proportion of calories to be derived from each of them is given as:
However, a few more important factors need be considered at this stage are:
• The minimal protein requirement for a good nutritious diet is about 0.9 g/kg/day.
• The carbohydrates should be taken in the form of starches and other complex sugars.
• Rapidly absorbed simple sugars like glucose should generally be avoided. Use of caloric sweeteners including sucrose is acceptable in many patients.
• Fish oils containing omega 3 fatty acids have been reported to be beneficial, as antiatherogenic.
• A high-fibre diet is beneficial as it has an antiatherogenic effect mediated through lowering of blood lipids.
• This involves distribution of the calories throughout the day. This is particularly important in insulin-requiring diabetics, to avoid hypoglycaemia.
• Different distributions may be required for different lifestyles, a typical pattern of distribution of calories is:
• 20% of the total calories for breakfast
• 35% of the total calories for lunch
• 30% of the total calories for dinner
• 15% of the total calories for late-evening feed.
Q. 3. Describe general, oral and dental manifestations of various endocrine disorders.
Ans. Oral and dental manifestations of various endocrine disorders are as follows:
• Bones loss
• Compromised healing
• More accumulation of plaque.
• Face becomes enlarged and mandible is prominent with teeth widely spaced.
• Coarse facial features.
• Temporal headaches, photophobia and reduction in vision.
• Lips are thick and voice is coarse and husky.
• There is brownish pigmentation of face.
• General features like fatigue and weight gain are present.
• Cardiac effects: Coronary artery disease, hypertension and left ventricular hypertrophy are present.
• Metabolic effects: Intolerance or clinical diabetes mellitus.
• Soft tissue changes like thickening of skin, increased skin tags, acanthosis nigricans, increased sweat and sebum resulting in moist and oily skin, enlargement of lips, nose and tongue (macroglossia), increased heel pad thickness, visceral enlargement (visceromegaly), e.g. thyroid, heart (cardiomegaly) and liver, carpal tunnel syndrome, myopathy, sleep apnoea.
• Important manifestations of hyperthyroidism are weight loss with increased appetite, heat intolerance, sweating, palpitation, tremors and nervousness.
• The signs are tachycardia, atrial fibrillation, fine finger tremors, moist warm skin, lid retraction, wide palpebral fissure, lid lag and exophthalmos.
• Proptosis may cause corneal drying and damage. In severe case exophthalmos, diplopia and optic nerve compression may occur.
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