MANAGEMENTS ORTHODONTIC TREATMENT IN PATIENTS WITH DIABETES MELLITUS
496 dm
1. ENDOCRINOPATHIES
DIABETES MELLITUS
MODERATOR
DR.ASHISH SHRESTHA
DR.VINAY MARLA
DEPARTMENT OF ORAL
PATHOLOGY AND
HISTOLOGY
PRESENTER
ROSHAN KUMAR
SHAH
BDS: 3RD YEAR(2011)
ROLL NO:496
3. DIABETES MELLITUS
A clinically and genetically heterogenous metabolic disorder
characterized by abnormally elevated blood glucose level
(hyperglycemia) and dysregulation of carbohydrate, protein,
and lipid metabolism.
Results from either a defect in insulin secretion from
pancreas or resistance of body’s cells to insulin action, or
both.
Affects almost all tissues in the bodY
Associated with significant complications of multiple organ
system, including eyes, nerves, kidneys, and blood vessels.
4. CLASSIFICATION
Etiological Classification of DM by the
American Diabetes Association (1997)
Type 1 diabetes mellitus
Type 2 diabetes mellitus
Other specific types of diabetes
Mellitus
Gestational diabetes mellitus
5. TYPE 1 DIABETES MELLITUS
Autoimmune destruction of the insulin-producing
beta cells of pancreas.
5-10% of DM cases.
Common occurs in childhood and
adolescence, or any age.
Absolute insulin deficiency.
High incidence of severe complications.
6. TYPE 2 DIABETES MELLITUS
Result from impaired insulin function. (insulin
resistance)
Constitutes 90-95% of DM
Specific causes of this form are unknown.
Risk factors : age, obesity, alcohol, diet,
family History and lack of physical activity,
etc.
8. PANCREAS – ENDOCRINE PART
Accounts for only 2% of the pancreatic mass
Nests of cells - islets of Langerhans
Four major cell types
Alpha (A) cells secrete glucagon
Beta (B) cells secrete insulin
Delta (D) cells secrete somatostatin
F cells secrete pancreatic polypeptide
10. PATHOPHYSIOLOGY CONTD…..
Normal blood glucose level to be
maintained within 60 to 150 mg/dL.
As blood sugar levels became elevated,
glucose is excreted in the urine and
causes excessive urination occurs due to
osmotic diuresis.
Increased fluid loss leads to dehydration
and excess thirst.
Since cells are starved of glucose, the
patient experiences increased hunger.
15. 0RAL MANIFESTATIONS
In people with diabetes, the first signs and
symptoms of a medical condition can
• dorealv coenldoitipon si nin ctluhdee mouth.
xerostomia,
burning sensations,
overgrowth of gum tissue,
tooth decay,
periodontal disease (6th complication)
fungal infections,
fruity (acetone) breath,A WARNING SIGN
increased thickness of saliva
16. PERIODONTITIS
Periodontal tissues frequently manifest these
changes because of chronic bacterial infections.
Recent epidemiologic evidence shows that the
prevalence of diabetes in patients with periodontitis is
significantly greater (by two times) than in people
without periodontitis.
Given that diabetes may be present for a number of
years before it is diagnosed, dentist may be the first
health professional to detect a patient’s diabetes.
17.
18. PERIODONTITIS AS A RISK FACTOR FOR DIABETES
MELLITUS
Diabetes has long been believed to be a risk factor
for periodontal disease. Results of new studies show
that the reverse might also be true.
In individuals with periodontitis :
Increase in local and systemic expression of
inflammatory cytokines, such as TNF-alpha and IL-6
Both TNF-alpha and IL-6 have been shown to impair
intracellular insulin signaling, which may lead to
insulin resistance
19. In a longitudinal study of patients with type 2
DM:
Increased risk of worsening glycemic control
seen in patients who had severe periodontitis
over a period of time which led to various
complications.
( Taylor GW,Burt BA Becker MP et al,1996)
These trials often examined the effects of
scaling and root planing on glycemic control,
either alone or in combination with adjunctive
systemic tetracycline therapy.
( Tetracyclines decrease the production
of matrix metalloproteinase such as
collagenase )
20. In a more recent evaluation of scaling and
root planing combined with systemic
doxycycline therapy for 2 wks ,diabetic pts
showing improvement in periodontal health
also had significant improvement in glycemic
control and vice versa.
When researchers performed scaling and
root planing but did not administer adjunctive
antibiotic therapy, some studies showed
significant improvement in glycemic control
after treatment, while others showed no
significant improvement in glycemic control
despite improvements in patients’ periodontal
health.
23. SALIVARY GLAND DYSFUNCTION
Dry mouth (xerostomia) and salivary
hypofunction is common in patients with
diabetes.
When the normal environment of the oral
cavity is altered because of a decrease in
salivary flow or alteration in salivary
composition, a healthy mouth becomes
susceptible to dental caries and tooth
deterioration.
24. DIABETES AND CANDIDIASIS
Contributing factors for oral candidiasis in patients with diabetes
salivary dysfunction
compromised immune function
salivary hyperglycemia that provides a potential substrate for fungal
growth
Oral lesions associated with candidiasis include
median rhomboid glossitis
atrophic glossitis
denture stomatitis
angular cheilitis
Amphotericin B, nystatin, clotrimazole, miconazole, ketoconazole,
fluconazole, itraconazole
25. ACUTE ORAL INFECTIONS
Recurrent bouts of herpes simplex virus,
periodontal abscesses or palatal ulcers are
common in patients with diabetes.
Published reports of life-threatening deep
neck infection from a periodontal abscess
and fatal palatal ulcers are available.
29. KNOWN DIABETIC PATIENTS
inquire about the medication, the type, severity and
control of diabetes, the physician treating the patient
and the date of last visit
The dentist should be aware of the patient’s recent
glycated hemoglobin values.
HbA1c values of less than 8% indicate relatively good
glycemic control; greater than 10% indicate poor
control
When the level of control of diabetes is not known,
consult patients physician .
30. KNOWN DIABETIC PATIENTS
Patients, receiving good medical management without
serious complications such as renal disease,
hypertension, or coronary atherosclerotic heart
disease, can receive any indicated dental treatment
Local anesthesia is preferred, but such patients can
even be safely treated in general anesthesia
Morning appointments should be preferred because
this is the time of high glucose and low insulin activity
This reduces the risk of hypoglycemic episodes during
the dental procedures
31. KNOWN DIABETIC PATIENTS
a source of glucose such as an orange juice
must be available in the dental office to avoid
hypoglycemic attacks
Prophylactic antibiotics for patients taking
high doses of insulin to prevent post-operative
infection are recommended
It's best to do surgery when blood sugar
levels are within normal range
32. KNOWN DIABETIC PATIENTS
To avoid hyperglycemia use anxiety reduction
protocol
Emotional stresses and painful conditions
increase the amount of cortisol and epinephrine
secretion which induce hyperglycemia so
pre-treatment anxiety should be reduced by
sedation
pain during procedures can be avoided by a
potent anesthesia
33. INSTRUCTIONS TO BE GIVEN TO A
DIABETIC
diabetic patients should be strongly motivated
to maintain a good oral hygiene by
brushing after every meal
using floss daily
keeping their dentures clean
patients should be frequently recalled for
dental examinations
prophylactic measures, such as topical fluorides
should be applied
34. The patients should be encouraged to quit
smoking as it greatly increases the risk of
periodontal disease in diabetic patients
Diabetics should be informed that they
are more likely to catch dental diseases
than the normal ones because awareness
and knowledge increases the tendency to
seek preventive dental care, and improves
chances of maintaining healthy mouth
35. REFERENCES
Davidson’s principles and practice of
Medicine 21st Edition
Burket’s oral medicine 11th Edition
Medical emergencies in dental office, Stanley
F Malamed 4th Edition
Medical problems in dentistry C. Scully & R.
A. Cawson 4th Edition
Carranza’s clinical periodontology 11th edition
