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MANAGEMENT OFDIABETIC AND EPILEP
PATIENT IN DENTISTR
PRE
S
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DIABETESMELLITUS
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DEFINITION Diabetes is the most common endocrine disease .It is a group of diseas
by high levels of blood glucose resulting from defects in insulin produc
CLASSIFICATION1.TYPE 1- Insulin dependent or juvenile onset. Immune mediated
Idiopathic
2. TYPE 2-Non Insulin dependent or adult onset. Genetic defects of beta cell function
Genetic defects of insulin action Disease of exocrine pancrease Drug chemical induce Infections
3.GESTATIONAL DIBETES MELLITUS
4.IMPAIRED GLUCOSE TOLERENCE
5.IMPAIRED FASTING GLUCOSE
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TYPE 1 DM
It can occur at any age but is more common among children and young
The peak age onset is 10 to 14 yrs.
It is characterized by insulin deficiency.
In DM circulating insulin is essentially absent.
TYPE 2 DM
Non-ketotic form of diabetes that is not linked to humans lymphocyte markers on the 6th chromosomes.
High incidence of obesity.
GESTATIONAL DM
It is characterized by abnormal result on the oral glucose tolerance testduring pregnancy.
Risk of prenatal illness and death in all levels of disease severity.
IMPAIRED GLUCOSE TOLERANCE/IMPAIRED FASTING GLUCOSE TOLERA
Persons with IGT have plasma glucose level between 140 199 mg/dl aoral glucose tolerance test.
IFGT
The fasting blood sugar level is 100
125mg/dl.
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DM RISK FACTORS
Age above 45 yrs
BMI
Habitual physical activity High risk ethinicity
H/O child weight greater than 9 pounds at birth
H/O gestational diabetes
Hypertension
Triglycerides 250 mg/dl
Cholestrol 35 mg/dl
H/O vascular disease
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COMPLICATIONS
ACUTE COMPLICATIONS
Hypoglycemia
Diabetic ketoacidosis
Hyperglycemia
CHRONIC COMPLICATIONS
Microvasculature
Cardiovascular system- Artherosclerosis,Large vessel disease,Micro
Eyes
Retinopathy,Catract , Glaucoma. Kidney- Diabetic glomerulonephritis.
Nerves- Motor ,sensory , autonomic neuropathy.
Mouth- Gingivitis, Increased dental caries and Periodontal disease
Skin- Pruritis, Mycosis, Diabetic xanthoma.
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HYPERGLYCEMIAETIOLOGY
High blood sugar
Weight gain
Cessation of exercise Pregnancy
Hyperthyroidism
Corticosteroid theraphy
Fever
Acute infection
SIGNS
Hyperglycemia
Acidosis with blood PH- 7.3
Dry warm skin
Fruity, sweet breath odour
Normal to low BP
Rapid weak pulse
Altered level of consciousness
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SYMPTOMS
TYPE 1 DM
Repeated skin infection
Marked irritability Headache
Drowsiness
Malaise
Dry mouth
TYPE 2 DM
Decresed vision
Parasthesia
Loss of sensation
Postural hypotension
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CLINICAL MANIFESTATIONTYPE 1 TY
POLYURIA
+++
POLYDIPSIA ++ +
POLYPHAGIA WITH WT LOSS ++ _
RECURRENT BLURRED VISION + ++
VULVOVAGINITIS OR PRURITIS + ++
LOSS OF STRENGTH ++ +
NOCTURNAL ENURESIS ++ _
ABSENCE OS AYMPTOMS _ ++
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MANGEMENTRECOGNIZE PROBLEM
( Lack of response to sensory stimulation)
DISCONTINUE DENTAL TREATMENT
ACTIVE OFFICE EMERGENCY TEAM
POSITON PATIENT IN SUPINE POSITION WITH FEET ELEVATED
A-B-C ASSESS AND PERFORM BASIC LIFE SUPPORT AS NEEDED
D- PROVIDE DEFINITIVE MANAGEMENT AS NEEDED
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HYPOGLYCEMIAETIOLOGY
Weight loss
Increased physical exercise
Termination of pregnancy Termination of other drug therapies
Recovery from infection and fever
Inadequate food( Carbohydrate intake)
Excessive insulin dose
Sulfonyl urea theraphy
Ethanol intake
SIGNS
Weakness, Dizziness
Pale moist skin
Normal or depressed respiration
Headache
Altered level of consciousness
CLINICAL MANIFESTATION
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CLINICAL MANIFESTATIONEARLY STAGE Mild reaction
Diminished cerebral function
Changes in mood
Decreased spontaneity
Hunger
Nausea
MORE SEVERE STAGE
Sweating
Tachycardia
Increased anxiety
Belligerence
Poor judgement
Uncoporativeness
LATER SEVERE STAGE
Unconsciousness
Seizure activity
Hypotenion
Hypothermia
MANGEMENT
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MANGEMENTRECOGNIZE THE PROBLEM
( Altered consciousness)
DISCONTINUE DENTAL TREATMENT
ACTIVE OFFICE EMERGENCY TEAM
P- POSITION PATIENT COMFORTABLY
A-B-C ASSESS AND PERFORM BASIC LIFE SUPPORT AS NEDDED
D- PROVIDE DEFINITIVE MANAGEMENT
ADMINISTER ORAL CARBOHYDRATES
IF SUCCESSFUL IF UNSUCCESSFUL
Permit PT to recover Activate emergency medical services
Discharge PT Administer parentral carbohydrates
Monitor PTDischarge the PT
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DIABETIC KETOACIDOSIS:
Diabetic ketoacidosis (DKA) is a potentially life-threatening complication in patients withmellitus. It happens predominantly in those with type 1 diabetes, but it can occur in those with tyunder certain circumstances. DKA results from a shortage of insulin; in response the body switchefatty acids and producing acidic ketone bodies that cause most of the symptoms and complicatio
Signs and symptoms
Predominant symptoms are nausea and vomiting, pronounced thirst, excessive urine producabdominal pain that may be severe.
Coffee ground vomiting (vomiting of altered blood) occurs in a minority of patients; this tenfrom erosion of the esophagus.[3] In severe DKA, there may be confusion, lethargy, stupor or evemarked decrease in the level of consciousness).
MANAGEMENT:
1 Fluid replacement
2 Insulin
3 Potassium
4 Bicarbonate
5 Cerebral edema
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MANAGEMENT BY DRUGS
Metfromin
Rosiglitazone
Glipizide
Acarbose
Repaglinide
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EPILEPSY
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DEFINITIONRECURRENT PAROXYSMAL DISORDER OF CEREBRAL FUNCTION MARKEDSUDDEN , BRIEF ATTACKS OF ALTERED CONSCIOUSNESS MOTOR ACTIVITSENSORY PHENOMENA.
CAUSES
Congenital abnormalities
Perinatal injuries
Metabolic and toxic disorders
Head trauma
Tumors and other space occupying lesions
Vascular disease
Infectious disease
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ABSENCE SEIZURE & PARTIALSEIZUREDIAGNOSTIC CLUES FOR THE PRESENCE OF SEIZURE:
Sudden onset of immobility & blank stare
Simple automatic behaviour
Slow blinking eyelids
Short duration
Rapid recovery
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MANAGEMENT
RECOGNIZE PROBLEM
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RECOGNIZE PROBLEM
( Lack of response to sensory stimulation)
DISCONTINUE THE DENTAL TREATMENT
ACTIVE OFFICE EMERGENCY TEAM AS NEDDED
POSITION THE PT IN SUPINE POSITION WITH FEET ELEVATED
Seizure Ceases reassure Pt Seizure continues( 75
active emergency me
Allow Pt to recover before discharge A-B-C Perform basic l
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TONIC CLONIC SEIZURE( GRANMAL)
DIAGNOSTIC CLUES: Presence of aura prior to loss of consciousness
Tonic- clonic muscle contraction
Clenched teeth, tongue biting
PREMODAL PHASE
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RECOGNIZE AURA
DISCONTINUE DENTAL TREATMENT
ICTAL PHASE
ACTIVATE OFFICE EMERGENCY TEAM
P-POSITION PATIENT IN SUPINE POSTION WITH FEET ELEVATED
CONSIDER ACTIVATION OF EMERGENCY MEDICAL SERVICES
A-B-C ASSESS & PERFORM BASIC LIFE SUPPORT AS NEEDED
DEFINITE CARE ADMINISTER O2 MONITOR VITAL SIGNS
REASSURE PT AND PERMIT RECOVERY DISCHARGE PT
TO HOPITAL TO HOME TO PHYSICIAN
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TONIC-CLONIC STATUS MANAGEM
PREMODAL PHASE
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RECOGNIZE AURA
DISCONTINUE DENTAL TREATMENT
ICTAL PHASE
ACTIVATE OFFICE EMERGENCY TEAM
P-POSITION PATIENT IN SUPINE POSTION WITH FEET ELEVATED
CONSIDER ACTIVATION OF EMERGENCY MEDICAL SERVICES
A-B-C ASSESS & PERFORM BASIC LIFE SUPPORT AS NEEDED
DEFINITE CARE
PROTECT PT FROM INJURY
IF SEIZURE PERSISTS FOR MORE THAN 15 MINS
A-B-C PERFORM VENIPUNCTURE &ANTICONVULSANT
DEFINITIVE CARE PROTECT PT ADMINISTER 50% IV DEXTRO
FROM INJURY UNTIL EMERGENCY
ASSISTANCE ARRIVES
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MANAGEMENT OF EPILEPSY BY
DRUGS Carbamazepine 15-25 mg/kg
Phenytoin 3-8 mg/kg
Phenobarbitol 2-4 mg/kg
Primidone 10-20 mg/kg
Ethosuximide 10-30 mg/kg
Clonazepam 0.03-0.3 mg/kg
Valporate 15-60 mg/kg
NEW DRUGS Oxcarbazepine
Felbamate
Tiagabine
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