Beruflich Dokumente
Kultur Dokumente
of Medically
compromised pa3ents: Endocrine
System
Endocrine System
• The endocrine system is an informa3on signal
system like the nervous system, yet its effects
and mechanism are classifiably different.
• The endocrine system's effects are slow to
ini3ate, and prolonged in their response,
las3ng from a few hours up to weeks.
• The nervous system sends informa3on very
quickly, and responses are generally short
lived.
Endocrine System
• Special features of endocrine glands are, in
general,
– their ductless nature,
– their vascularity, and
– commonly the presence of intracellular vacuoles
or granules that store their hormones.
• This is opposite to exocrine glands (salivary,
sweats, GIT glands)
Endocrine System
• Specialized endocrine organs –
– thalamus, pineal, pituitary, thyroid, pancrease,
adrenal, testes/ovary
• Secondary endocrine Organs –
– bone, kidney (renin, erythropoie3n), liver, heart,
gonads
Endocrine System
• Major endocrine systems:
– TRH-TSH-T3/T4
– GnRH-LH/FSH-Sex hormones
– CRH-ACTH-Cor3sol
– Renin-angiotensin-aldosterone
– Lep3n-Insulin
Diabetes Mellitus
Diabetes Mellitus
• Defini3on
– Syndrome of chronic hyperglycaemia due to
rela3ve insulin deficiency, resistance or both.
• Causes
– Increase insulin resistance (Problem in the
peripheral 3ssue in responding to insulin)
– Insulin deficiency (Problems in the pancreas to
secrete insulin)
Diabetes Mellitus
• Pathophysiology
– Beta-cells of the pancrea3c islets secretes insulin
which then go the target organs with the prime
target organ being liver. It has glucose receptor
thus responds based on glucose levels.
– Alpha-cells meanwhile secretes glucagon which
ac3on opposites of the insulin. It has no glucose
receptor thus responds based on the insulin level
Diabetes Mellitus
– Liver being the principle target organ for glucose
homeostasis absorbs and stores glucose (as glycogen).
It also does gluconeogenesis from fat and protein.
90% of glucose is from liver glycogen and hepa3c
gluconeogenesis. Remaining 10% from kidney
gluconeogenesis.
– Brain is the major consumer of glucose and are not
dependent on insulin (obligatory uptake). Other
organs such as fat and muscle needs insulin to
consume glucose (faculta3ve uptake). When glucose
in not available (starva3on), brain consumes ketones
body as a subs3tute.
Diabetes Mellitus
• Thus Low/resistance in insulin causes
– Increase hepa3c glucose output
– Reduce u3lisa3on by various organs
– Reduce storage of excess energy (glucose via
glycogen, fat and protein)
– Increase renal reabsorp3on of glucose
– Reduce incre3n hormones
Diabetes Mellitus
Diabetes Mellitus
• Screening has 2 pathways
– Symptoma3c pa3ents
• Tiredness, lethargy, polyuria, polydipsia, polyphagia, weight
loss, pruritus vulvae, balani3s
– Asymptoma3c pa3ents (annually)
• BMI 23 kg/m2 or have a waist circumference 80 cm for
women and 90 cm for men AND
• First-degree rela3ve with diabetes, History of cardiovascular
disease (CVD), Hypertension, Impaired glucose tolerance
(IGT) or impaired fas3ng glucose (IFG), High density
lipoprotein (HDL) cholesterol <0.9 mmol/L or triglycerides
(TG) >2.8 mmol/L, Women who delivered a baby weighing 4
kg or were diagnosed with gesta3onal diabetes mellitus,
Women with polycys3c ovarian syndrome (PCOS)
Diabetes Mellitus
Diabetes Mellitus
• History
– When diagnosed
– How diagnosed
– Why check for DM
– Medica3on used
– Any recent change in medica3on
– Any complica3ons
• Acute
• Chronic
– Ask control level (Home monitoring / HbA1c)
Diabetes Mellitus
• Common medica3on
• Biguanides– weight neutral and no risk of hypoglycemia but
risk for lac3c acidosis in CKD cases, long term Vit B12
deficiency
– Meformin (Glucophage)
• Sulphonylurea – risk for hypoglycaemia (should be taken 30
minutes before meal) and weight gain
– Glibenclamide – worst risk for hypoglycemia
– Glicazide (Diamicrone)
• Insulin
– Actrapid (Meal / short ac3ng),
– Insulitard (Basal / intermidiete ac3ng),
– Mixtard (Premixed / biphasic ac3ng)
Diabetes Mellitus
• Monitoring
– HbA1c - Perform A1c approximately every 3–6
months (intervals depend on whether A1c targets
are achieved): 3 monthly, if A1c is above target
and to allow assessment of effect of therapeu3c
adjustment. 6 monthly, if A1c target is achieved
and stable. Target < 6.5% in young newly
diagnosed, not so 3ght in elderly
Dental Management
• History
– Detailed history on DM and other associated
diseases
– Medica3on type, dosage and changes
– Follow-up, compliance and control(HbA1c value)
– Medica3on and food intake on day of treatment
• Examina3on
– Any signs sugges3ng poor control – periodon33s,
dry mouth, candidiosis, amputated leg, poor
eyesight
Dental Management
• Inves3ga3on
– Random blood sugar pretreatment
• Treatment
– Early morning appointment of possible
– Postponed if poor control – and refer to medical
doctor to op3mize
– Ensure con3nua3on of normal food / medica3on
intake post treatment
– An3bio3cs?
– Avoid DM emergencies –
• Hypoglycemia
• Diabe3c Ketoacidosis and hyperosmolar hyperglycemic state
Dental Management
• Hypoglycemia
• Low plasma glucose level (<4.0 mmol/L) OR
Development of autonomic or neuroglycopenic
symptoms
Dental Management
• Diabe3c Ketoacidosis
– Capillary blood glucose >11 mmol/L (200mg/dL) AND
– Capillary ketones >3 mmol/L (31mg/dL) or urine ketones ≥2+ AND
– Venous pH <7.3 and/or bicarbonate <15 mmol/L