this seminar is about diabetes mellitus and brief review on prosthodontic implications

2. Serial
no
Learning objectives Domain Level Criteria
1. Classification of
diabetes
Cognitive Must know All
2. Pathophysiology of
diabetes
Cognitive Must know All
3. Diagnosis of
diabetes
Cognitive and
psychomotor
Must know All
4. Complications of
diabetes
Cognitive Must know All
5. Prosthodontic
Implications
Cognitive and
psychomotor
Must know All

3. • Introduction
• Classification
• Pathophysiology
• Clinical Features
• Diagnosis
• Complications
• Treatment
• Prosthodontic Implications
• Conclusion
• References

4. • Diabetes mellitus is a disorder of carbohydrate
metabolism characterized by hyperglycaemia and
glycosuria, reflecting a distortion in the equilibrium
between utilization of glucose by the tissues,
liberation of glucose by the liver and production-
liberation of pancreatic, anterior pituitary and
adrenocortical hormones.
Shafer’s Textbook of Oral Pathology 7th Ed.

5. • Diabetes mellitus is a metabolic disorder due to insulin
deficiency or insulin resistance.
• The incidence of diabetes is rising globally.
• It is estimated that 8.3% of the world population had diabetes
in 2011.
• This figure is expected to reach 12.5% by 2030.
• According to IDF, in India in 2017 total cases were 8.8% of
total population.
Davidson’s Principles and Practice of Medicine 22nd Ed.

6. 1. Type 1 diabetes
2. Type 2 diabetes
3. Gestational diabetes mellitus
4. Specific types of diabetes due to other causes, e.g.,
monogenic diabetes syndromes , diseases of the exocrine
pancreas, and drug- or chemical-induced diabetes or after
organ transplantation.
Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes 2019;42(Suppl. 1):S13–S28

7. • Also called as insulin dependent diabetes mellitus.
• Accounts for 5-10% of total cases
• Mainly caused by autoimmune destruction of b-cells.
• Leading to absolute insulin deficiency.
• Usually present in children.
Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes 2019;42(Suppl. 1):S13–S28

9. • Children typically present with the hallmark symptoms of
polyuria/polydipsia.
• Approximately one-third present with diabetic ketoacidosis.
• In adults the symptoms are variable.
Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes 2019;42(Suppl. 1):S13–S28

10. • Also called as non-insulin dependent diabetes mellitus.
• Accounts for 90-95 % of total cases
• Characterized by dysregulation of insulin release or peripheral
resistance of tissues.
• A progressive loss of insulin secretion occurs due to insulin
resistance.
• Usually presents in overweight or obese adults.
Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes 2019;42(Suppl. 1):S13–S28

11. • Obesity is a major cause.
• Intra-abdominal adipose tissues release large quantity of FFA
which compete with glucose as a fuel supply.
• Also cytokines are released that lead to decreased sensitivity
of tissues for insulin.
• Lack of physical activity and sedentary life are another
important determinants.
Davidson’s Principles and Practice of Medicine 22nd Ed.

13. • Frequently goes undiagnosed for many years as
hyperglycemia develops gradually.
• At earlier stages classic symptoms are not noticed by the
patient.
• It is detected in routine checkup or as accidental finding.
Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes 2019;42(Suppl. 1):S13–S28

14. • Diagnosed in the second or third trimester of pregnancy.
• Glucose tolerance due to metabolic and hormonal changes.
• 4% of total cases.
• May disappear soon after birth. But can result in macrosomia
or high birth weight.
• Lifelong screening for the development of diabetes or
prediabetes at least every 3 years.

15. • According to American Diabetic Association
Fasting Blood Sugar (FBS) > 126mg/dl.
OR
Post Prandial Blood Sugar (PPBS) >200mg/dl.
OR
HbA1c ( gycosylated ) is > 6.5 %
Classification and Diagnosis of Diabetes: Standards of Medical Care in Diabetes 2019;42(Suppl. 1):S13–S28

17. Short term complications
· Hypoglycemia
· Diabetic ketoacidosis
Long term complications
· Diabetic retinopathy
· Diabetic neuropathy
· Diabetic nephropathy
· Cardiovascular disease.
Davidson’s Principles and Practice of Medicine 22nd Ed.

18. • The most common diabetic emergency in the dental office is
hypoglycemia.
• Initial signs : mood changes, decreased spontaneity, hunger
and weakness.
• Followed by sweating, incoherence, tachycardia.
• Results in unconsciousness, hypotension, hypothermia,
seizures, coma, even death.

19. • Terminate all dental procedures and alert the patient.
• Blood glucose with a glucometer should be checked.
• 15 gm carbohydrate ( 6 oz orange juice, 3-4 teaspoons sugar)
• Glucagon 1 mg s.c, i.m. followed by oral glucose supplement
or Dextrose-50 20- 50 ml i.v.

20. • DKA is a medical emergency.
• In children and adolscents , mortality is due to cerebral
oedema.
• In adults, hypokalemia, acute respiratory distress syndrome
and comorbid conditions like MI.
• Cardinal features are; hyperketonemia, hyperglycemia and
metabolic acidosis.
• A fixed rate iv insulin infusion of 0.1U/kg weight/hr is
recommended to treat DKA.
• Also fluid replacement and potassium supplements are
considered.
Davidson’s Principles and Practice of Medicine 22nd Ed.

21. • Diabetic retinopathy is most common cause of blindness in diabetics
in the age of 30 – 65 years.
• Diabetic neuropathy is symptom less in majority of diabetics.
If occurs, glove and stocking impairment is most common.
• Diabetic nephropathy is the earliest complication & affects 30% of
type I & 4% of type II diabetes.
• Cardiovascular disease occurs in type II diabetics. Coronary heart
disease develops at an earlier age in diabetics.
Kansal G, Goyal D. Prosthodontic Management Of Patients With Diabetes Mellitus. J Adv Med Dent Scie Res 2013;1(1):38-44.

22. A. DIET AND LIFESTYLE
i. Healthy eating
ii. Weight management
iii. Exercise
iv. Alcohol
B. Oral hypoglycemic agents
Metformin is first line therapy for type II DM.
C. Insulin therapy

23. MEDICAL HISTORY
• Take thorough past medical history.
• Frequency of hypoglycaemic episodes.
• Medication, dosage and times.
• Assess glycemic control at initial appointment.
Chanchal K ,Sangeetha M.Diabetes Mellitus and Prosthodontic Care. Int J Multi Res Mod Edu 2017;3(1) 294-96.

24. STRESS REDUCTION
• It is generally best to plan dental treatment to occur either before or
after periods of peak insulin activity.
• Greatest risk of hypoglycaemia will occur after insulin injections.
• Conscious sedation and profound anaesthesia should be considered
• Frequent oral prophylaxis.
• Use of antibiotics prophylactically as well as post operative.

25. • Diabetes is a risk factor for the prevalence and severity of
gingivitis and periodontitis.
• Periodontitis is considered as 6th complication of diabetes.
• It promote periodontitis through an exaggerated
inflammatory response to the periodontal microflora.
Archives of Medicine and Health Sciences / Jan-Jun 2015 / Vol 3 | Issue 1

26. • Mucosal conditions include burning mouth, and an increased
incidence of opportunistic infection.
• Most common is candidiasis. Can be in the form of median
rhomboid glossitis, denture stomatitis and angular cheilitis.
• Lichen planus and recurrent aphthous stomatitis, have been
reported
Archives of Medicine and Health Sciences / Jan-Jun 2015 / Vol 3 | Issue 1

27. • Dry mouth, or xerostomia, has also been reported in of
diabetic patients.
• A lack of saliva in the mouth allows bacteria to accumulate.
This increases the risk of developing halitosis (bad breath),
tooth decay, and gum diseases.
Archives of Medicine and Health Sciences / Jan-Jun 2015 / Vol 3 | Issue 1

28. • Asymptomatic bilateral enlargement of the parotid glands has
been reported in uncontrolled DM cases.
• Mucormycosis is a rare but serious systemic fungal infection
that may occur in patients with uncontrolled DM which
appears as palatal ulceration or necrosis.

29.  Impressions should be taken in mucostatic technique.
 Concept of neutral zone technique should be employed to
reduce the bone resorption.
 Denture border and tissue surfaces of the dentures should be
smooth without any sharp nodules or over extensions to
prevent tissue damage.
Chanchal K ,Sangeetha M.Diabetes Mellitus and Prosthodontic Care. Int J Multi Res Mod Edu 2017;3(1) 294-96.

30.  Proper oral hygiene instructions can be given to patients to avoid
fungal infections.
 As there is decrease denture retention due to less salivation, frequent
sipping of water and use of sugarless gums may help them to
maintain salivary flow.
 Also salivary reservoirs can be incorporated in dentures.
 Use of soft liners ( tissue conditioners )
 Relining of dentures.
Chanchal K ,Sangeetha M.Diabetes Mellitus and Prosthodontic Care. Int J Multi Res Mod Edu 2017;3(1) 294-96.

31.  It is better to keep the finish line supragingival to avoid
damaging soft tissue.
 The chamfer margin is a better option as it applies less force or
stress on weakened tooth.
 Ante's law should be obeyed.
 Hygienic pontic should be preferred as much as possible for
ease of cleansing action.
 Proper flossing should be done to maintain the oral hygiene.
Chanchal K ,Sangeetha M.Diabetes Mellitus and Prosthodontic Care. Int J Multi Res Mod Edu 2017;3(1) 294-96.

32.  All components of RPD must be designed appropriately such that
prosthesis is tissue friendly.
 Especially in distal extension cases, stress equalization should be
considered.
 Proper oral hygiene and denture hygiene or maintenance instructions
should be given to the patients.
Chanchal K ,Sangeetha M.Diabetes Mellitus and Prosthodontic Care. Int J Multi Res Mod Edu 2017;3(1) 294-96.

33.  Implant is not absolutely contraindicated in most diabetics.
 Need for a stress reduction protocol, diet evaluation before
and after surgery and control of the risk of infection are all
addressed.
 Corticosteroids should not be used.
 Detrimental effects of diabetes on osseointegration can be
modified using aminoguanidine systemically.
Kansal G, Goyal D. Prosthodontic Management Of Patients With Diabetes Mellitus. J Adv Med Dent Scie Res 2013;1(1):38-44.

34. • A thorough medical history is required for any patient in need
of dental treatment.
• All the systemic conditions should be under medical control
before commencing any dental treatment.
• Good oral hygiene maintenance is a pre requisite for ensuring
the long term successful prosthodontics treatment.

35. • Shafer’s Textbook of Oral Pathology 7th Ed.
• Ganong’s Review of Medical Physiology 23rd Edition
• Davidson’s Principles and Practice of Medicine 22nd Ed.
• Carranza’s Clinical Periodontology 11th Ed,
• Classification and Diagnosis of Diabetes: Standards of Medical Care
in Diabetes 2019;42(Suppl. 1):S13–S28
• Kansal G, Goyal D. Prosthodontic Management Of Patients With
Diabetes Mellitus. J Adv Med Dent Scie Res 2013;1(1):38-44.
• Chanchal K ,Sangeetha M.Diabetes Mellitus and Prosthodontic Care.
Int J Multi Res Mod Edu 2017;3(1) 294-96.
• Oral health management considerations in patients with diabetes
mellitus Archives of Medicine and Health Sciences / Jan-Jun 2015 /
Vol 3 | Issue 1
• Rahman B. Prosthodontic concerns in a diabetic patient. Int J Health
Sci Res. 2013;3(10):117-120.