Presented by:Dr. Yogender Singh

Under the guidance of:Dr. H S Grover & Faculty

CONTENTS• INTRODUCTION• DEFINITIONS• HISTORY• EPIDEMIOLOGY• CLASSIFICATION• DIAGNOSIS• INSULIN & DIABETES• CLASSICAL SIGNS, SYMPTOMS & COMPLICATIONS OF DM• DIABETES AND PERIODONTAL DISEASE• DENTAL THERAPY CONSIDERATIONS• CONCENSUS REPORT- EFP/AAP JOINT WORKSHOP• CONCLUSION• REFRENCES

INTRODUCTION

• Diabetes mellitus represents a spectrum of metabolic disorders and has emerged as a major health issue worldwide.

• It is a complex metabolic disease characterized by:

Chronic hyperglycemia,

Diminished insulin production,

Impaired insulin action, or a combination of both

• Result in the inability of glucose to be transported from the bloodstream into the tissues, which in turn, results in high blood glucose levels and excretion of sugar in the urine.

Alteration in lipid and protein metabolism.

DEFINITIONS

• International Diabetes Federation (IDF) describesDiabetes as a chronic disease that arises when thepancreas does not produce enough insulin, or whenthe body cannot effectively use the insulin it produces.

• According to Carranza, DM is defined as a complexmetabolic disorder characterized by chronichyperglycaemia, diminished insulin production,impaired insulin action or a combination of both resultin the inability of glucose to be transported from theblood stream into the tissues, which in turn results inhigh blood glucose levels and excretion of sugar in theurine.

HISTORY

• Diabetes is one of the first diseases described with an Egyptian

manuscript from 1500 BC mentioning “too great emptying of

the urine.”

• The term diabetes was probably coined by Apollonius of

Memphis around 250 BC, which literally meant “to go

through” or siphon as the disease drained more fluid than a

person could consume. Later on, the Latin word “mellitus”

was added because it made the urine sweet.

5

• Sir Frederick Grant Banting, Charles Herbert Best and

colleagues purified the hormone insulin from bovine pancreas

at the University of Toronto. Leading to the availability of an

effective treatment—insulin injections and the first patient

was treated in 1922.

• For this, Banting and laboratory director John MacLeod

received the Nobel Prize in Physiology or Medicine in 1923.

6

EPIDEMIOLOGYAccording to International Diabetes Federation (2012), there are more than 371

million people in world who have diabetes. The number of people with diabetes isincreasing in every country in which half of people with diabetes are undiagnosed. Theestimate of the actual number of diabetics in India is around 40 million.

CLASSIFICATIONS

National Diabetes Data Group(1979)- on the basis of age at onset and type of therapy:

• TYPE I- Insulin dependent DM (IDDM) or Juvenile Diabetes

• TYPE II- Non insulin dependent DM (NIDDM) or Adult onset Diabetes

American diabetic association(1997)

DM is classified on the basis of pathophysiologyof DM into 4 categories:

1. Type 1

2. Type 2

3. Other Specific types of DM

4. Gestational diabetes

CARBOHYDRATE METABOLISM, INSULIN AND DIABETES

BLOOD GLUCOSE HOMEOSTASIS

ACTIONS OF INSULIN

Characteristics of Type I and Type II Diabetes

OTHER SPECIFIC TYPES

• Those associated with diseases that involve the pancreas and

destruction of insulin producing cells.

• Endocrine diseases such as acromegaly, tumors,

pancreatectomy and drugs or chemicals are included.

GESTATIONAL DIABETES

• Under normal conditions insulin secretion is increased by 1.5 to 2.5 fold during pregnancy reflecting a state of insulin resistance

• Gestational diabetes develops in 2% to 5% of all pregnancies but disappears after delivery.

• Women who have had gestational diabetes are at increased risk of developing type 2 diabetes later in life.

• It usually has its onset in the third trimester of pregnancy and adequate treatment will reduce perinatal abnormality.

LABORATORY DIAGNOSISBLOOD TESTING

1. GLUCOSE

LABORATORY DIAGNOSIS2. Glycated Hemoglobin

URINE TESTING

1. GLUCOSE

Testing the urine for glucose with dipsticks is a common screening

procedure for detecting diabetes.

2. KETONES

Ketone bodies can be identified by the nitroprusside reaction,

which measures acetoacetate, using either tablets or dipsticks.

3. PROTEIN

Standard dipstick testing for albumin detects urinary albumin at

concentrations > 300mg/L

CLASSICAL SIGNS & SYMPTOMS

It includes polydypsia,

polyphagia, polyuria, pruritis,

weakness & fatigue. (More

common on type 1) occur in

varying degree in type 2 DM.

Type 1 DM may associated with Weight loss, Ketoacidosis

Restlessness, irritability & apathy may become evident.

THE CLASSIC COMPLICATIONS OF DM

1. Diabetic Retinopathy

2. Diabetic Neuropathy

3. Diabetic Nephropathy

4. Atherosclerosis

5. Impaired wound healing

6. Periodontal disease (Loe H 1993)

DIABETES & PERIODONTIUM

ORAL MANIFESTATIONS:

• Diminished salivary flow

• Burning mouth & tongue

• Enlargement of parotid gland (Alteration in basement mem.)

• Cheilosis

• Alterations in flora of oral cavity (Predominance by Candida albicans)

• Increase rate of dental caries

PERIODONTAL MANIFESTATIONSHirchfeld I (1934)

• Tendency towards enlarged gingiva.

• Sessile/pedunculatedgingival polyps.

• Ploypoid gingival proliferations

• Abscess formation

• Periodontitis

• Loosened teeth

Factors Potentially Contributing to Development of Periodontal Disease

Polymorphonuclear

leukocyte function

Collagen Metabolism and Advanced glycation end

products

Infections in patients with

diabetes

Wound healing

Bacterial Associations

Polymorphonuclear leukocyte

function

• Impaired Chemotaxis & adherence

• Defective Phagocytosis

Diminished primary defense against periodontal pathogens.

Collagen Metabolism

Reduced synthesis of collagen & glycosaminoglycans

Reduced collagen

maturation

Collagen homeostasis-

Affected

GCF collagenaseactivity increased

Hyperglycemic state

ADVANCED GLYCATION END PRODUCTS (AGEs)

Hyperglycemic state

Non enzymatic Glycosylation of

proteins and matrix molecules

AGEs

Plays central role in diabetic complications .

Alter functions of extracelluar matrix .

Affects collagen stability and vascular integrity.

AGEs formation on collagen

Increased crosslinking between collagen molecules

Reduced solubility .

Decreased turn over rate .

AGEs + Macrophages & Monocytes

Increased Secreation of IL-1, IGF, TNF ἀ

AGEs

AGEs + Endothelial cells

•Focal thrombosis•Vasoconstriction

Pre-coagulatorychangesHyper-cellular state

AGEs AND PERIODONTIUM

2- WAY RELATIONSHIP BETWEEN PERIODONTAL DISEASE AND DM

PATHOGENESIS OF PERIODONTITIS IN DIABETES

Taylor JJ. JOP 2013

LINKAGE BETWEEN INFECTION,HYPERLIPIDEMIA & INSULIN RESISTANCE

INFECTIONS IN PATIENTS WITH DIABETES

Mainly due to:• Impaired defence mechanism 1. Defects in PMN function2. Induction of insulin resistance3. Vascular changes

Hyperglycemic state

Glycosylation of basement

mem, proteins

• Thickning of gingival capillaries,

• Disruption of BM

Swelling of Endothelium

1. Oxygen diffusion

2. Metabolic waste elimination

3. PMN Migration

4. Diffusion of serum factors

Impeded

WOUND HEALINGWound Healing is Affected as cumulative effect of:

•Altered cellular activity•Decreased collagen synthesis

•Glycosylation of existing collagen

•Increase collagenase production

Readily degrade newly synthesized, less completely cross linked collagen

•Reduced Collagen solubility•Delayed remodelling of wound site

Defective Healing

BACTERIAL ASSOCIATION• Glucose content of GCF & blood is higherin diabetics.

• Results in changed environment fo the microflora

• Presence of higher levels of specific microorganisms such asActinobacillus actinomycetemcomitans and Capnocytophaga .(Mashimo et al 1983)

• The proportion of P gingivalis was reported to be higher in non-insulin-dependent diabetes mellitus patients with periodontitis.

• This may be due to the abnormal host defense mechanisms inaddition to hyperglycemic state can lead to the growth ofparticular fastidious organisms. (Zambon et al,1988)

EFFECT OF DIABETES ON PERIODONTITIS

Data of multiple studies reveal strong evidence

•Diabetes is a risk factor for gingivitis &

periodontitis.

•The level of glycemic control appears to be an

important determinant in this relationship.

Cianciola et

al

1982 In children with type 1 diabetes, the prevalence of gingivitis was greater than in

non-diabetic children with similar plaque levels.

Sastrowijot

o S et al

1990 Improvement in glycemic control may be associated with decreased gingival

inflammation.

Papapanou

PN

1996 Majority of the studies demonstrate a more severe periodontal condition in

diabetic adults than in adults without diabetes.

Tsai C et al 2002 In a large epidemiologic study in the United States, adults with poorly controlled

diabetes had a 2.9-fold increased risk of having periodontitis compared to non-

diabetic adult subjects; conversely,well-controlled diabetic subjects had no

significant increase in the risk of periodontitis.

Salvi GE et

al

2005 Rapid and pronounced development of gingival inflammation in relatively well-

controlled adult type 1 diabetic subjects than in non-diabetic controls, despite

similar levels of plaque accumulation and similar bacterial composition of plaque,

suggesting a hyperinflammatory gingival response in diabetes.

EFFECT OF PERIODONTAL DISEASE ON DIABETES

• Periodontal diseases can have a significant impact on the

metabolic state in diabetes. The presence of periodontitis

increases the risk of worsening of glycemic control over time.

Williams RC Jr.,

Mahan CJ.

1960 Type 1 diabetic patients with periodontitis had a reduction in required insulin

doses following scaling and root planing, localized gingivectomy, and selected

tooth extraction combined with systemic procaine penicillin G and streptomycin

Taylor GW et al 1996 In a 2-year longitudinal trial, diabetic subjects with severe periodontitis at

baseline had a six-fold increased risk of worsening of glycemic control over time

compared to diabetic subjects without periodontitis

Rodrigues DC

et al

2003 Better improvement in glycemic control in a diabetic group treated with scaling

and root planing alone compared to diabetic subjects treated with scaling and

root planing plus systemic amoxicillin/clavulanic acid.

Promsudthi A

et al

2005 In older, poorly controlled type 2 diabetic subjects who received scaling and root

planing plus adjunctive doxycycline showed a significant improvement in

periodontal health but only a non significant reduction in HbA1c values.

MECHANISM BY WHICH PERIODONTAL DISEASE MAY INFLUENCE DIABETES

Acute bacterial and viral infections

Chronic gram-negative periodontal infections have significantly higher serum markers of inflammation such as c-reactive protein (CRP), IL-6, and fibrinogen than subjects without periodontitis.

Periodontal treatment may reduce inflammation locally and also decrease serum levels of the inflammatory mediators that cause insulin resistance, thereby positively affecting glycemic control

EFFECTS OF DIABETES ON THE RESPONSE OF PERIODONTAL THERAPY

• Many diabetic patients show improvement in clinical

parameters of disease immediately after therapy, patients with

poorer glycemic control may have a more rapid recurrence of

deep pockets and a less favorable long-term response.

• Further longitudinal studies of various periodontal treatment

modalities are needed to determine the healing response in

individuals with diabetes compared to individuals without

diabetes.

CURRENT MEDICAL MANAGEMENT OF DIABETES MELLITUS

1. DIET : The goals of this intervention includeweight reduction, improved glycemic control,with blood glucose levels in the normalrange, and lipid control.

2. Exercise : Regular physical exercise to weightreduction, increased cardiovascular fitness,and physical working capacity.

3.Pharmacological therapy :

Anti-AGE Therapies

• It include Aminoguanidine, ALT-946, ALT 711, Statins (Cervistatin)

• Pyridoxamine, the natural form of vitamin B6, is effective at inhibiting AGEs at 3 different levels.– prevents the degradation of protein-Amadori

intermediates to protein-AGE products.

– In diabetic rats, pyridoxamine reduces hyperlipidemiaand prevents AGE formation.

– scavenges the carbonyl byproducts of glucose and lipid degradation

– Benfotiamine, a lipid-soluble thiamine derivative, inhibits the AGE formation pathway.

DENTAL THERAPY CONSIDERATIONS• Patients with well-controlled diabetes can often be treated in

a similar way to non-diabetic patients.

• Communicate with patient’s physician to obtain control of blood glucose levels

• Control acute infections.

• As aggravated glycemic control increases the risk of micro & macrovascular diabetic complications like- Stroke, MI, Heart Failure.

Timing of treatment

Patients with well controlled DM can be treated similarly to non-diabetic patients for most routine dental needs.

• Keep appointments short, atraumatic, and stress-free

• morning appointments

• Use appropriate vasoconstrictor agents

• For stressful procedures the usual drug regime may be altered

ANTIBIOTICS USE

• Antibiotics are not necessory for routine procedures in patients with well-controlled diabetes.

• But considered in the presence of overt oral infection.

• The combination of mechanical debridement+ systemic tetracycline provide greater positive effect on glycemic control in some DM patients.

DENTAL IMPLANT CONSIDERATIONS IN THE DIABETIC PATIENT

• Diabetes-induced changes in bone formation:

• Inhibition of collagen matrix formation

• Alterations in protein synthesis

• Increased time for mineralization of osteoid

• Reduced bone turnover

• Decreased number of osteoblasts and osteoclasts

• Altered bone metabolism

• Reduction in osteocalcinproduction

Possible Diabetic Disturbances in Implant Wound Healing Process In Implants

DIABETIC EMERGENCIES

• Hypoglycemic crisis

• Hyperglycemic crisis

MANAGEMENT OF HYPOGLYCEMIA

FACTORS THAT INCREASE THE RISK OF HYPOGLYCEMIA

Skipping or delaying food intake

Injection of too much insulin

Injection of insulin into tissue with high blood flow (eg, injection into thigh after

exercise such as running)

Increasing exercise level without adjusting insulin or sulfonylurea dose.

Inability to recognize symptoms of hypoglycemia

Denial of warning signs or symptoms

Past history of hypoglycemia

Hypoglycemia unawareness

Low

Bloo

d G

luco

se• Sign & symptoms occurs as fall in blood glucose

level below 60 mg/dl.

• Severe hypoglycemia refers to fall in blood glucose

concentration below 40 mg% (2.2-mmol/1)

requiring help from outside for recovery.

SIGN & SYMPTOMSLo

w Bl

ood

Glu

cose

Severe hypoglycaemia may result in seizures or loss

of consciousness.

The most common emergency related to DM in the

dental office and a potentially life-threatening situation

that must be recognized and treated expeditiously.

MENTAL CONFUSION, SUDDEN MOOD CHANGE

LETHARGY,….TACHYCARDIA , NAUSEA,

COLD CLAMMY SKIN, HUNGER, INCREASED

GASTRIC MOTILITY, HYPOTENTION ,

HYPOTHERMIA.

Low

Bloo

d G

luco

seIf patient is

UNCONSCIOUS

Give 50 ml of 50% intravenous glucose- through a large vein to avoid thrombophlebitis.

As soon as patient recovers consciousness, start oral carbohydrate intake, otherwise 5-10% glucose infusion has

to be continued till patient recovers consciousness.

Intramuscular injection of 1.0 ml of glucagon may be given if hypoglycaemia is insulin induced. It promotes

glycogenolysis, gluconeogenesis.

If patient does not regain consciousness inspite of normal blood glucose levels, then cerebral oedema is likely possibility which should be treated with intravenous

dexamethasone or mannitol.

Repeated hypoglycaemic episodes are hazardous for

CNS; hence, one should find out the cause and treat it

or correct it by adjusting the patient's therapy.

Low

Bloo

d G

luco

seIf patient becomes

CONSCIOUS

PREVENTION

ADMINISTRATION OF 15g OF ORAL

CARBOHYDRATE (JUICE,CANDY)

MANAGEMENT OF HYPERGLYCEMIAH

igh

Bloo

d G

luco

se

• A medical emergency from hyperglycemia is less

likely to occur in the dental office since it develops

more slowly than hypoglycaemia.

It occurs when blood glucose levels over 200mg/dl for

extended period of time.

In Type 1 DM- ketoacidosis may occur- Characterized by-

Disorientation, rapid & deep breathing, hot drying skin &

acetone breath.

Type 2 DM- hyperosmolar non-ketotic diabetic acidosis.

Severe hypotention & Loss of consciousness occurs if left

untreated.

Hig

h Bl

ood

Glu

cose

• Under some instances, severe hyperglycemia may

present with symptoms mimicking hvpoglycemia.

• If a glucometer is not available, these symptoms

must be treated as hypoglycemia.

Care is initiated by activating the emergency

medical system, opening the airway, and

administering oxygen. Circulation and vital signs

should be maintained and monitored, and the

patient should be transported to a hospital .

DIABETES & PERIODONTAL DISEASE: CENSUS REPORT OF THE JOINT EFP/AAP WORKSHOP ON PERIODONTITIS & SYSTEMIC DISEASES

(CHAPPLE LC,GENCO R. J PERIODONTOL 2013)

GUIDELINE- A[Suggested Guidelines for physicians and other medical health professions for Use in Diabetes

Practice]

• Patients with diabetes should be told that periodontal diseaserisk is increased by diabetes.

• If they suffer from periodontal disease, their glycaemic controlmay be more difficult, and they are at higher risk for diabeticcomplications such as cardiovascular and kidney disease.

• Patients with type 1, type 2 and gestational diabetes should

receive a thorough oral examination, which includes comprehensive periodontal examination.

• For all newly diagnosed type 1 and type 2 diabetes patients, subsequent periodontal examinations should occur & annual periodontal review is recommended.

• For children and adolescents diagnosed with diabetes, annual oral screening is recommended from the age of 6–7 years by referral to a dental professional.

GUIDELINE- B[Suggested guidelines for use in dental practice]

• If periodontitis is diagnosed, manage it properly. If not, patientswith diabetes should be placed on a preventive care regime andmonitored regularly for periodontal changes.

• Patients with diabetes presenting with any acute oral/periodontalinfections require prompt oral/ periodontal care.

• Patients with diabetes who have extensive tooth loss should beencouraged to pursue dental rehabilitation to restore adequatemastication for proper nutrition.

• Provide oral health education.

• Patients who present without a diabetes diagnosis, but at risk for type 2 diabetes and signs of periodontitis should be informed about their risk for having diabetes, assessed using a chair-side HbA1C test, and/or referred to a physician for appropriate diagnostic testing and follow-up care.

GUIDELINE- C[Recommendations for patients with diabetes at the physician’s practice/ office]

• If your physician has told you that you have diabetes,you should make an appointment with a dentist tohave your mouth and gums checked. This is becausepeople with diabetes have a higher chance of gettinggum disease. Gum disease can lead to tooth loss andmay make your diabetes harder to control.

GUIDELINE- D[Recommendations for patients at the dental surgery/office who have diabetes or are

found to be at risk for diabetes]

• People with diabetes have a higher chance ofgetting gum disease. If you have been told byyour dentist that you have gum disease, youshould follow up with necessary treatment asadvised.

• If you do not have diabetes, but your dentistidentified some risk factors for diabetesincluding signs of gum disease, it is importantto get a medical check-up as advised.

CONCLUSION• Diabetes mellitus has significant impact on tissues throughout the

body, including the oral cavity. As research indicates that poorlycontrolled diabetes increases the risk periodontitis.

• Alteration in host defence and tissue homeostasis appear to play amajor role.

• Advances in medical management of DM require a heightenedawareness by the periodontist in the various treatment regimensused by diabetic patients.

• Familiarity with various medications, monitoring equipments, anddevices used by diabetic patient allows provision of appropriateperiodontal therapy while minimizing the risk of complications.

REFERENCES

• Taylor JJ, Preshaw PM, Lalla E. A review of the evidence for pathogenic mechanisms that may link periodontitis and diabetes. J Periodontol 2013;84:S113-S34.

• The position paper on diabetes & periodontal disease. J Periodontol 2000;71:664-78.

• Grossi SG, Genco RJ. Periodontal Disease and Diabetes Mellitus: A Two-Way Relationship. Ann Periodontol 1998;3:51-61.

• Periodontal Medicine Rose, Cohen

• Carranza’s Clinical Periodontology 11th edition

• Davidson’s Principles and Practice of Medicine 21st edition

THANK YOU