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The Disease: Diabetes Mellitus is a group of diseases associated with metabolic and vascular elements. Defects in insulin production, action, or both results in high levels of blood glucose, which can ultimately lead to adverse complications, or even death. According to the CDC, data from the most recent year for which it is available (2007) states that 23.6 million people in the United States - 7.8% of the population - have diabetes (3). As the seventh leading cause of death in the U.S. in 2006, diabetes accounts for 72, 507 deaths, and "its incidence will continue to grow, as indicated by high rates of impaired fasting glucose levels, increased rates of obesity, and the trend toward more sedentary lifestyles" (8). Type 1 diabetes, also known as "juvenile diabetes," is responsible for 10% of diabetes cases, the majority of which occur in children (9).
Etiology: A genetic component, more so in type 2 than type 1, has been found to be involved in the origin of diabetes (1). In addition, type 1 diabetes is classified as the result of an immune attack, due to some environmental factor, against the insulin-producing beta cells in the pancreas leading to a deficiency of insulin. This autoimmune attack differs from type 2 diabetes, which is characterized by insulin resistance accompanying insulin deficiency. The hormone insulin is responsible for converting glucose into energy; thus, a lack of insulin results in high levels of glucose in the blood which have potential for serious damage to the body's organ systems (2).
Pathogenesis: As blood glucose persists at high levels due to destruction of the insulin-producing beta cells, it can lead to eventual damage of the body's organs systems. Elevated blood glucose levels result in "excessive urination due to osmotic diuresis, excessive thirst as a result of increased fluid loss, and increased hunger since cells are starved of glucose" (4). Aside from the cardinal symptoms of polydipsia, polyuria, and polyphagia, potential complications may arise ranging from cardiovascular disease to diabetic retinopathy. Cardiovascular diseases, including stroke and heart attack, "is the major cause of death in people with diabetes" (5). According to JDRF, high blood glucose contributes to high cholesterol and hypertension, both of which may damage the cells lining artery walls. In addition, extremely low blood sugar leading to unconsciousness or even death, progressive deterioration of the kidneys, injury to the autonomic nerves, as well as destruction of small blood vessels in the retina are potential complications developed by patients with type 1 diabetes (5). It is evident that without treatment or control of the disease, diabetes can be fatal.
Systemic signs and symptoms: The cardinal symptoms of type 1 diabetes mellitus include polydipsia, polyuria, polyphagia, weight loss, and loss of strength (6). Other symptoms may present as repeated skin infections, increased irritability, headache, and drowsiness. The onset of symptoms in patients with type 1 diabetes is very sudden and acute, and may include diabetic ketoacidosis, in which the body will produce excess acidic ketone bodies (9).
Medical diagnostic tests to support the diagnosis: Diagnosing diabetes relies on the presence of a complex of symptoms including the aforementioned cardinal symptoms, microangiopathy of the retina, presence of glucose and acetone in the urine verified with urinalysis to prove abnormal glucose metabolism, fasting blood glucose level at or above 126 mg/100mL, 2-hour postprandial blood glucose level at or above 200 mg/100mL, and a lowered oral glucose tolerance level (6). The current standard laboratory test is fasting glucose level. In addition, glycosylated hemoglobin levels (HbA1c) are used to assess the control of hyperglycemia in diabetic patients (6).
Oral signs and symptoms: In diabetic patients, oral manifestations include accelerated periodontal disease, gingival proliferations, periodontal abscesses, and oral ulcerations. Xerostomia, candidiasis, mucormycosis, and numbness, burning, or pain in oral tissues are among the other oral signs and symptoms associated with diabetes. These indications are most likely associated with excessive fluid loss, altered response to infection, and possible increased salivary glucose concentrations (6).
Oral diagnostic tests: An oral glucose tolerance test may be performed, in which the blood glucose levels are measured five times over a period of three hours (7). A normal response is characterized as a 2-hour glucose level of less than or equal to 110mg/dL. A noticeably abnormal oral glucose tolerance test is diagnostic of diabetes (7).
Dental treatment plan modifications: According to Dental Management of the Medically Compromised Patient, all dental procedures can be performed without special precautions if diabetes is well-controlled. For insulin-controlled patients, it is recommended to schedule morning appointments, and advise the patient to take usual insulin dosage and normal meals on the day of the appointment. A glucose source, such as juice or soda, should be available, provided the patient experiences symptoms of insulin reaction. If a diabetic patient presents with serious medical complications, treatment modifications may be necessary, as the patient is more susceptible to further difficulties. Careful and continuous monitoring of the patient's status is compulsory (6).
Oral diagnosis: 20 year old female patient presents with localized severe periodontitis, and fractured lower anterior teeth.
Dental treatment plan recommendations: Management of periodontal issues, followed by necessary restorative treatment. Local anesthesia with vasoconstrictor may be utilized.
Appropriate questions posed to the medical consultant supported by data collection: Patient reports diagnosis of diabetes 5 years ago and rarely checks blood/urine glucose levels. Patient claims disease is "poorly-controlled." Please comment on patient's diabetes status. Medical lab tests required: fasting blood glucose levels, HbA1c. Thank you.