1. Amall Saleh Aaisha Alahwas Lili Wu DIABETES MELLITUS TYPE I & II

2. What is Diabetes? A group of metabolic diseases in which the person has high blood glucose Insulin production is inadequate Or body cells do not respond properly to insulin

3. Symptoms INCREASED THIRSTFREQUENT URINATIONINCREASED HUNGERWEIGHT LOSSFATIGUEBLURRED VISIONSLOW-HEALING SORESFREQUENT INFECTIONS

4. Diagnosis Fasting blood glucose test Random(non-fasting) blood glucose test Oral glucose tolerance test Hemoglobin A1c test

5. Type I Diabetetes Mellitus  Autoimmune destruction of pancreatic beta cells  Little or no production of insulin  Most often diagnosed in children, adolescents and young adults  Insulin-dependent  Unknown cause; genetic http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001350/#adam_000305.disease.treatment

6. Insulin Only effective medication for Type I diabetes Administered subcutaneously via insulin pen, syringe or pump

7. Short/rapid acting insulins(15- 20 min) Intermediate acting insulins Long acting insulins Types of insulin

8. Mechanism of Action Acts via specific membrane-bound receptors on target tissue Regulates metabolism of carbohydrate, protein, and fats

9. Living with Type I Diabetes CASE STUDY

10. PATIENT PROFILE  Female;29 years old;Asian  Controlled Type I Diabetes  Diagnosed in 1998 (13 yrs old)  Symptoms lead to diagnosis : Excessive hunger/thirst Craving for sweets Sudden weight loss  The critical event that triggered diagnosis of Type I diabetes: Patient passed out at school and got sent to a hospital

11. Treatment History  Upon initial diagnosis, oral medication for one month  Soon switched to insulin injection twice/day  During puberty, attempted different types of insulin for optimal result  Age 15-20, insulin injection with syringe: Insulin aspart(NovoLog) twice/day  Age 20-28, insulin injection with pen: Insulin aspart(NovoLog FlexPen) 2-4 time/day

12. GLYCEMIC EPISODES before insulin pump… Hyperglycemia  Feeling tired and sleepy  Symptoms not obvious Hypoglycemia  Weakness  Dizziness  Sweating  Shaking of hands  Mental confusion

13. CURRENT TREATMENT  Patient is trying to become pregnant  Carries an insulin pump since Feb 2013

14. INSULIN PUMP Two functions:  Basal rate---5 time settings  Bolus rate Suggested glucometer monitoring: 7 times/day

15. Life with Type I Diabetes  Endocrinologist visit once/month  A1C test every 3 months  Podiatrist, optometrist visit once/year  In 2012, patient decided to quit her job. Job required frequent travels. Physically and emotionally draining. Her energy level could not keep up with job requirements.

16. DENTAL HYGIENE MANAGEMENT  Coral tissue with generalized moderate marginal inflammation  Type II—Probing depths 3-6mm, localized 4-6mm in posteriors  Moderate BUP

17. DENTAL HYGIENE MANAGEMENT One week after SRP of LR posteriors  Patient complained about pain and swelling that occurred 2 days after SRP  Slightly erythematous and necrotic attached gingiva and papillary tissue  Delayed tissue healing

18. Type II Diabetes Mellitus  It’s a non-insulin-dependent diabetes mellitus (NIDDM) or adult-onset diabetes  Usually occurs in older, obese adults.  Type II does not have an autoimmune cause, usually its genetics.  Insulin level can be normal, high, or low in patients with type II diabetes  It has the same symptoms as type I.

19. OVERALL M.O.A. OF DRUGS o There are many categories of type II diabetes medications that exist. o Each work differently to lower blood sugar.  Stimulate the pancreas to make and release more insulin  Stops the production and release of glucose  Blocks the action of stomach enzymes that break down carbohydrates  Improves tissue sensitivity to insulin  Stops the reabsorption of glucose in kidneys

20. Glipizide ( Glucotrol ) Pharmacologic Category- Sulfonylurea MOA- Stimulates the release of insulin, and reduces the glucose output from the liver. Adverse Effects Syncope (fainting) Hypoglycemia (low level of glucose in the blood) Weight gain Skin Rash Nausea.

21. Drug Interaction  Levels of Glipizide may be increased by:  Beta Blockers  Cimetidine  Cyclic Anti-depressants  MAO Inhibitors  Selective Serotonin Re-uptake Inhibitors.  Levels of Glipizide may be decreased by  Corticosteroids (orally inhaled) and (systemic)  Loop Diuretics  Thiazide Diuretics. Dietary Consideration- If tablet is taken with food a delayed release of insulin occurs. Therefore, take the tablets 30 minutes before meals.

22. Metformin (Fortamet) Pharmacologic Category- Biguandes MOA- Inhibits the release of glucose from the liver. Decreases intestinal absorption of glucose and improves insulin sensitivity. Adverse Effects- Nausea Diarrheas Rash Hypoglycemia

23. Drug Interaction  Levels of Metformin may be increased by:  Carbonic Anhydrase Inhibitors  Cephalexin  Cimetidine  Dalfampridine  Ranolazine.  Levels of Metformin may be decreased by :  Corticosteroids (orally inhaled) and (systemic)  Somatropin  Thiazide Diuretcs Dietary Consideration- Metformin may cause GI upset, so to decrease GI upset administer with a meal.

24. Rosiglitazone (Avandia) Pharmacologic Category- Thiazolidinedione MOA- Lowers blood glucose by improving target cells response to insulin, and it is dependent on insulin for activity. Adverse Effects- Weight gain Anemia Edema Hypoglycemia

25. Drug Interaction Levels of Rosiglitazone can be increased by: MAO Inhibitors Selective Serotonin Reuptake Inhibitors Vasodilators Levels of Rosiglitazone can decreased by :  Corticosteroids (orally inhaled) and (systemic)  Thiazide Diuretcs  Loop Diuretics

26. Saxagliptin (Onglyza) Pharmacologic Category- dipeptidyl peptidase inhibitor-4 (DPP-4) MOA- Reduces blood glucose. Regulates the incretion hormones such as glucagon-like peptide-1 (GLP-1) and glucose-dependent insulin tropic polypeptide (GIP). Adverse Effects- Upper respiratory tract infection Peripheral edema Hypoglycemia

27. Drug Interaction Levels of Saxagliptin can be increased by : MAO inhibitors ACE inhibtors Selective Serotonin Reuptake Inhibitors Levels of Saxagliptin can be decreased by:  Corticosteroids (orally inhaled) and (systemic)  Thiazide Diuretcs  Loop Diuretics

28. Acarbose (precose) Pharmacologic Category: Alpha-glucosidose inhibitors MOA- Inhibits the metabolism of sucrose to glucose and fructose. Adverse Effects- Flatulence (Gas) Diarrhea Abdominal pain No major drug interaction These medications are used as an adjunct to exercise and diet to improve glycemic control in adults with type 2 diabetes.

29. Role of the Dental Hygiene Team Providing definitive screening of patients. Be familiar with ADA standards of medical care. Use The Diabetes Risk Test questions to educate and motivate. Refer patients for medical follow-up when indicated.

30. QUESTIONS FOR THE CLASS Q1. Name one drug that interacts with Metformin.

31. Answer  Carbonic Anhydrase Inhibitors  Cephalexin  Cimetidine  Dalfampridine  Ranolazine.  Corticosteroids (orally inhaled) and (systemic)  Somatropin  Thiazide Diuretcs

32. Q2 List symptoms of diabetes mellitus.

33. Answer Increased thirstFrequent urinationIncreased hungerWeight lossFatigueBlurred VisionSlow-healing soresFrequent infections

34. Q3 Which type of diabetes is insulin- dependent? Which type is non-insulin dependent?

35. Answer Type I-insulin dependent Type II- non-insulin dependent

36. Q4 Which drug is used to treat Type I- DM?

37. Answer Insulin

38. REFERENCES American Diabetes Association. Standards of medical care in diabetes 2014. Diabetes Care.2014;vol. 37:no. Supplement 1:S14-S80. Wilkins, Esther M. Clinical Practice of Dental Hygienist. Philadelphia. Lippincott William & Wilkin, 2013. Print. Wynn, R. L., Meiller, T. F., Crossley, H. L. (2014). Drug information handbook for dentistry. (20th ed.) St. Louis, MO: Wolters Kluwer Health Inc. http://www.diabetes.org/living-with-diabetes/treatment-and care/medication/insulin/insulin-basics.html http://www.medicalnewstoday.com/info/diabetes/ http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0001350/#adam_000305.disease.treatme nt