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Diabetes mealitus &periodontal disease



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  • Pre-Diabetes คือ ระดับน้ำตาลที่อยู่ระหว่างระดับปกติ กับ ระดับของผู้เป็นเบาหวาน
  • Pre-Diabetes คือ ระดับน้ำตาลที่อยู่ระหว่างระดับปกติ กับ ระดับของผู้เป็นเบาหวาน
  • Figure 1. Mechanisms of diabetes-mediated periodontal tissue destruction. The hyperglycemic status can directly provide favorable environment for the growth of Gram-negative periodontal pathogens, impair cellular function and host defense, and induce overproduction of proinflammatory cytokines and secretion of collagenolytic enzymes (black lines). By facilitating the formation of advanced glycation end products (AGEs), diabetes can also indirectly alter the crosslink of the extracellular matrix (gray lines) as well as the cellular activities to amplify inflammatory reactions and decrease cell viability, leading to further wound healing impairment and potential vascular change (dash black lines) in periodontal tissue (gray box).
  • There is evidence that exposing serum from periodontitis patients to LPS of periodontal pathogens leads to increased triglycerides and lower levels of high-density lipoprotein (HDL),132 and 133 which suggests that local infection, such as periodontitis, can alter systemic lipid metabolism. The mechanism is possibly due to activation of the ‘cytokine cascade’ in response to LPS. The elevation of serum lipids may also influence immune cell function by upregulatingproinflammatory cytokines and superoxide production by PMNs and altering surface marker antigens of monocytes.134 In the meanwhile, periodontitis can potentially induce insulin resistance by the overproduction of systemic proinflammatory cytokines, such as TNF-α, IL-1β, and IL-6. These cytokines will further ameliorate insulin insensitivity by destroying pancreatic β-cells, antagonizing insulin action, or altering intracellular insulin signaling through the NF-κB and c-Jun N-terminal kinase (JNK) axes.13, 40, 135 and 136
  • Metalloproteinases (MMPs) คือปฏิกิริยาของเอ็นไซม์ที่เกิดการเผชิญรังสี UV หรือการอักเสบของผิวอันเนื่องจากปฏิกิริยา ROS ส่งผลให้คอลลาเจนที่มีอยู่เกิดการเปราะหัก อีกทั้งยังขัดขวางการสร้างคอลลาเจนใหม่ ระยะยาวปฏิกิริยาของ MMPs ส่งผลให้กระบวนการสร้างเซลล์ผิวใหม่เป็นไปได้ลำบากทราบหรือไม่ว่าน้ำตาลกลูโคสชนิดเดียวกับที่ให้พลังงานแก่เซลล์ผิวของเรา สามารถทำปฏิกิริยา กับโปรตีนคอลลาเจนในชั้นผิวได้ ซึ่งปฏิกิริยานี้ล้วนส่งผลร้ายต่อความยืดหยุ่นของผิว โดยส่งให้โปรตีนคอลลาเจนขาดการเกี่ยวพันกัน เป็นสาเหตุของการเกิดริ้วรอย อีกทั้งยังเพิ่มความเสี่ยงในการเกิดการอักเสบของผิว ชะลอการเกิดเซลล์ผิวใหม่และเร่งให้เกิดริ้วรอยลึกได้เร็วขึ้น
  • การเกิด glycationของโปรตีนทำให้เกิดการสะสมของ advanced glycation end products (AGEs) ซึ่งเป็นแหล่งที่ทำให้เกิดอนุมูลอิสระ และเชื่อมโยงกับภาวะแทรกซ้อนของโรค ดังแสดงในรูปที่ 3 โดย AGEs นี้สามารถปลดปล่อยอนุมูล superoxide และ H2O2 และสามารถกระตุ้นการทำงานของ phagocytes นอกจากนี้ยังไปลดปริมาณของ glutathione ซึ่งเป็นสารต้านอนุมูลอิสระตัวหนึ่งในร่างกายภาวะที่มีอนุมูลอิสระมากเกิน แต่ปริมาณสารต้านอนุมูลอิสระไม่เพียงพอ และส่งผลให้เกิดการทำลายดีเอ็นเอ โปรตีน ไขมัน และโมเลกุลอื่น ๆจัดเป็นการทำลายแบบออกซิเดชัน (oxidative damage) โมเลกุลเป้าหมายที่เกิด oxidative damage ได้แก่ ดีเอ็นเอ โปรตีน และไขมัน ผลเสียหายต่อโมเลกุลเป้าหมายและเซลล์จะขึ้นกับลักษณะของโครงสร้างโมเลกุล ชนิดเซลล์ ชนิดอวัยวะ


  • 1. Diabetes Mealitus & PERIODONTAL DISEASE
  • 2. Diabetes mellitus metabolism hyperglycemia) Type2 Type1 oType1 Diabetes mellitus/IDDM insulin dependent diabetes oType2 Diabetes mellitus /NIDDM non-insulin-dependent diabetes , , ,
  • 3. Diabetes mellitus Type1 Diabetes Insulin dependent diabetes mellitus (IDDM) juvenile diabetes autoimmune Insulin deficiency)     , ,
  • 4. Diabetes mellitus Type2 Diabetes (NIDDM) Noninsulin dependent diabetes mellitus Insulin resistance)    abdominal obesity)  , ,
  • 5. Diabetes mellitus , ,
  • 6. Risk Factors o o o o o Pre-Diabetes
  • 7. Risk Factors o Insulin HDL Pre-Diabetes) o o Metabolic Syndrome ( kg o o
  • 8.
  • 9. Signs and Symptoms Polyuria) o Polydipsia) o o Polyphagia) o Pruritus) o Weakness) o Fatigue) , , ,
  • 10. Complications • retinopathy) microvascular Diabetic Diabetic nephropathy) macrovascular • 2. • Coronary vascular disease) • Cerebrovascular disease) • Peripheral vascular disease) , ,
  • 11. Complications 3. • Diabetic neuropathy) Diabetic ulcer) • • Cataract) , ,
  • 12. Epidemiology • Severe periodontitis : Diabetic > non-diabetics. study.Taylor et al, J Perio 96) (Pima • Destructive periodontitis occurred much earlier in life in the diabetics (27% of diabetics 15-19 years old). (Pima study.Taylor et al, J Perio 96) • Higher-aged diabetic had greater periodontal attachment and bone loss than younger. (R.G. Nelson, M. Shlossman, L.M. Budding et al.Periodontal disease and NIDDM in Pima Indians. Diabetes Care 1990) •Diabetic complications increased susceptibility to periodontal disease with increased attachment loss (B.L. Mealey. Diabetes and periodontal disease: two sides of a coin.Compend
  • 13. Epidemiology •Uncontrolled Diabetes • • • acute fulminating periodontitis attachment loss bone loss acute abscess •Control of diabetes •
  • 14. Oral manifestation in Diabetic Patient oXerostomia fibrosis fat infiltration : Burning sensation, Caries Incidence oCheilosis oMild gingivitis to severe periodontitis oMultiple periodontal abscesses
  • 15. Oral manifestation in Diabetic Patient oCandidiasis Candida thrush salivary bacteria oGingival enlargement channel blocker oLichen planus calcium
  • 16. Gingivitis in a 19-year-old women with uncontrolled diabetes mellitus Robert P. Langlais, Craig Miller.THE COLOUR ATLAS OF COMMON ORAL
  • 17. Inflamed, papulonodular hyperplasia of the gingiva in a diabetic patient Robert P. Langlais, Craig Miller.THE COLOUR ATLAS OF COMMON ORAL
  • 19. Lichen planus Lynch DP. Oral examination.
  • 20. Pseudomembranous candidiasis (thrush) Impairment of the immune system, chemotherapy, Sjögren syndrome, and diabetes mellitus can also contribute to the proliferation of C albicans. Lynch DP. Oral examination.
  • 22. Relation of diabetes and periodontal disease •Host resistance •Vascular changes  membrane • basement collagen metabolism ◦ collagenase activity ◦ microorganism diabetic gingival crevice ◦ ◦ endotoxin protease collagenase production gingiva
  • 23. Relation of diabetes and periodontal disease Hyperglycemia (Ren, Fu, Deng, Qi, & Jin, 2009) • • (AGEs) • factor advanced glycation end products Periodontitis biologic mechanism diabetes gingivitisperiodontitis •
  • 24. Relation of diabetes and periodontitis clinical patterns epidemiologic sulcular oxygen crevicular fluid selective effect periodontal pocket microflora o glucose hyperglycemia ketoacidosis uncontrolled diabetes activity subgingival gram negative anaerobes host defense o o tissue microorganism collagen metabolism periodontal
  • 25. DM and Periodontitis - The 2 Way Relationship
  • 26. DM and Periodontitis - The 2 Way Relationship
  • 28. Effect of DM on  Microorganism  Host response
  • 29. Salivary flux reduction High glucose concentration in salivary and GCF Development of periodontogenic flora
  • 30. Generally in periodontal patients is noticed the presence of ◦ Porphyromonas gingivalis ◦ Tannerella forsythia ◦ Actinobacillus actinomycetemcomitans Sometime, other bacteria, such as ◦ Treponema denticola ◦ Treponema socranskii L. MARIGO, R. CERRETO, M. GIULIANI, F. SOMMA, C. LAJOLO, M. CORDARO,
  • 31. DM patients ◦ Candida albicans In type 1 DM patients ◦ Capnocytophaga spp :most frequent bacteria ◦ Porphyromonas gingivalis ◦ Prevotella intermedia L. MARIGO, R. CERRETO, M. GIULIANI, F. SOMMA, C. LAJOLO, M. CORDARO,
  • 32. In type 2 DM patients ◦ Capnocytophaga spp. : most frequent bacteria ◦ Prevotella intermedia ◦ Campylobacter rectus ◦ Porphyromonas gingivalis ◦ Actinobacillus actinomycetemcomitans. L. MARIGO, R. CERRETO, M. GIULIANI, F. SOMMA, C. LAJOLO, M. CORDARO,
  • 33. Effect of DM on  Microorganism  Host response
  • 34. (Andersen et al. 2007).
  • 35. neutrophil Hyperglycemia Macrophage/Monocyte Fibroblast (Andersen et al. 2007).
  • 36. Cell Function ◦ Neutrophils : adherence chemotaxis : ◦ Monocyte and Macrophage : bacteria antigen proinflammatory cytonkine : GCF AGE-RAGE monocyte Proinflammatory American Academy of Periodontology,2006 : NF-kB
  • 37. Cell Function Fibroblast ◦ Collagen ◦ Collagen GAGs Enzyme ◦ Collagenase American Academy of Periodontology,2006
  • 38. Vascular alteration Hyperglycemia AGE Vascular alteration
  • 39. Vascular alteration AGE-Collagen : enzyme degradation ◦ Thickening of blood vessel decreased Lumen ◦ Basement membrane Endothelium ◦ LDL ◦ VEGF atherosclerosis American Academy of Periodontology,2006
  • 40. Vascular alteration AGE-RAGE Endothelium ◦ Permeability ◦ thrombosis American Academy of Periodontology,2006
  • 41. Cytokines Hyperglycemia Cell AGE
  • 42. Attachment and Bone Loss AGE-Bone : Bone metabolism Bone turnover : cellular , structural , functional characteristic American Academy of Periodontology,2006
  • 43. Attachment and Bone Loss Attachment and Bone loss ◦ tissue metabolism ◦ Bone healing Bone Turnover rate ◦ proliferation of Osteoblast ◦ collagen ◦ apoptosis fibroblast Osteoblast attachment and bone loss American Academy of Periodontology,2006
  • 44. Impaired Wound Healing Fibroblast Hyperglycemia Impaired Wound Healing Glucose in GCF
  • 45. :
  • 46. Impaired Wound Healing Plasma Glucose ◦ Glucose GCF Gingival sulcus Periodontal Pocket ◦ Pocket Bacteria wound healing ◦ Glucose Healing ◦ attachment fibroblast ◦ fibroblast American Academy of Periodontology,2006
  • 47. Glycation Oxidative stress
  • 48. Glycation Hyperglycemia Non-enzymatic glucose metabolism Advance glycation end products (AGEs) :
  • 49. Glycation AGEs WBC RAGE Phagocyt e IL-6 , TNF alpha MMPs Osteocla st :
  • 50. Oxidative stress DNA,Protein,Lipid,etc. Advance Lipoxition End Products RBC RBC disfunction :
  • 51. Treatment
  • 52. Diabetes Mealitus 1. 2. Agents Enhancing the Effectiveness of Insulin • Metformin • Troglitazone Agents Augmentating the supply of Insulin • Sulfonylurea 3. Insulin :
  • 53. Insulin o o o o o o o o :
  • 54. Periodontitis DM Non insulin dependent patient Insulincontrolled patient Uncontrolled :
  • 55. Periodontitis (mechanical debridement)   Tetracycline Doxycycline ◦ Poorly uncontrolled :
  • 56. Dental management
  • 57. Uncontrolled patient and Poorly control patient Only emergency care antibiotic therapy oral infection Terry D. Rees. Periodontal management of the patient with diabetes mellitus.
  • 58. Well-controlled patient complete periodontal therapy surgical procedures the presence of medical complications associated with diabetes mellitus should be carefully evaluated and considered in any periodontal therapeutic decision Terry D. Rees. Periodontal management of the patient with diabetes mellitus.
  • 59. Periodontal therapy o o o o conscious sedation) atraumatic) o o epinephrine insulin epinephrine insulin preoperative :
  • 60. Management of diabetic emergencies o Hyperglycemic o Hypoglycemic
  • 61. Hyperglycemic •breathing may become rapid and deep (Kussmaul’s respiration) •hot and dry skin •‘‘acetone’’ breath may be evident. •Severe hypotension •coma may follow. Coma is usually associated with plasma glucose levels of between 300 and 600 mg/dl. Terry D. Rees. Periodontal management of the patient with diabetes mellitus.
  • 62. conscious hyperglycemic hospital emergency room basic life support procedures unconscious open airway administration of 100% oxygen non-glucose-containing intravenous fluids should be administered to prevent vascular collapse. Terry D. Rees. Periodontal management of the patient with diabetes mellitus.
  • 63. Hypoglycemic shock plasma glucose levels drop below 40 mg/dl. ◦ exercise ◦ diabetes mellitus drug overdose, ◦ stress or failure by the patient to properly control his or her dietary Intake. Terry D. Rees. Periodontal management of the patient with diabetes mellitus.
  • 64. Hypoglycemic shock oTachycardia oHypotension oHypothermia oloss of consciousness oseizures and even death Terry D. Rees. Periodontal management of the patient with diabetes mellitus.
  • 65. orange juice administration of oral carbohydrates candy Early treatment soft drinks Treatment patient remains unresponsive hospital emergency room Terry D. Rees. Periodontal management of the patient with diabetes mellitus.
  • 66. 5410810004 5410810014 5410810024 5410810034 5410810044 5410810054