This document provides an overview of diabetes mellitus and its relationship to periodontal disease. It begins with definitions of diabetes and classifications of the different types. It then discusses the history, epidemiology, diagnosis, complications, and relationship between diabetes and periodontal disease. Specifically, it notes that diabetes is a risk factor for more severe periodontal disease and periodontal disease can worsen glycemic control in diabetes patients. The two-way relationship between periodontal infections and diabetes is explored.

1. Presented by:
Dr. Yogender Singh
Under the guidance of:
Dr. H S Grover & Faculty

2. 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

3. 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.

4. DEFINITIONS
• International Diabetes Federation (IDF) describes
Diabetes as a chronic disease that arises when the
pancreas does not produce enough insulin, or when
the body cannot effectively use the insulin it produces.
• According to Carranza, DM is defined as a complex
metabolic disorder characterized by chronic
hyperglycaemia, diminished insulin production,
impaired insulin action or a combination of both result
in the inability of glucose to be transported from the
blood stream into the tissues, which in turn results in
high blood glucose levels and excretion of sugar in the
urine.

5. 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

6. • 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

7. EPIDEMIOLOGY
According to International Diabetes Federation (2012), there are more than 371
million people in world who have diabetes. The number of people with diabetes is
increasing in every country in which half of people with diabetes are undiagnosed. The
estimate of the actual number of diabetics in India is around 40 million.

8. 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

9. American diabetic
association
(1997)
DM is classified on the
basis of pathophysiology
of DM into 4 categories:
1. Type 1
2. Type 2
3. Other Specific types of
DM
4. Gestational diabetes

10. CARBOHYDRATE METABOLISM, INSULIN AND DIABETES

11. BLOOD GLUCOSE HOMEOSTASIS

12. ACTIONS OF INSULIN

13. Characteristics of Type I and Type II
Diabetes

14. 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.

15. 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.

16. LABORATORY DIAGNOSIS
BLOOD TESTING
1. GLUCOSE

17. LABORATORY DIAGNOSIS
2. Glycated Hemoglobin

18. 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

19. 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.

20. 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)

21. 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

22. PERIODONTAL MANIFESTATIONS
Hirchfeld I (1934)
• Tendency towards
enlarged gingiva.
• Sessile/pedunculated
gingival polyps.
• Ploypoid gingival
proliferations
• Abscess formation
• Periodontitis
• Loosened teeth

23. 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

24. Polymorphonuclear leukocyte
function
• Impaired Chemotaxis & adherence
• Defective Phagocytosis
 Diminished primary defense against
periodontal pathogens.

25. Collagen Metabolism
Reduced synthesis of
collagen &
glycosaminoglycans
Hyperglycemic state
Reduced
collagen
maturation
Collagen
homeostasis-
Affected
GCF collagenase
activity increased

26. ADVANCED GLYCATION END PRODUCTS (AGEs)
Hyperglycemic state
Non enzymatic
Glycosylation of
proteins and
matrix molecules

27. 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 .

28. AGEs + Macrophages & Monocytes
Hyper-cellular state changes
Increased Secreation of IL-1, IGF,
TNF ἀ
AGEs
AGEs + Endothelial cells
Pre-coagulatory
•Focal thrombosis
•Vasoconstriction

29. AGEs AND PERIODONTIUM

30. 2- WAY RELATIONSHIP BETWEEN PERIODONTAL
DISEASE AND DM

31. PATHOGENESIS OF PERIODONTITIS IN DIABETES
Taylor JJ. JOP 2013

32. LINKAGE BETWEEN INFECTION,HYPERLIPIDEMIA
& INSULIN RESISTANCE

33. INFECTIONS IN PATIENTS WITH
DIABETES
Mainly due to:
• Impaired defence mechanism
1. Defects in PMN function
2. Induction of insulin resistance
3. Vascular changes
Hyperglycemic state
Glycosylation of basement
mem, proteins
• Thickning of gingival
capillaries,
• Disruption of BM
Swelling of Endothelium
Impeded
1. Oxygen diffusion
2. Metabolic waste elimination
3. PMN Migration
4. Diffusion of serum factors

34. WOUND HEALING
Wound 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

35. 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 as
Actinobacillus 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 in
addition to hyperglycemic state can lead to the growth of
particular fastidious organisms. (Zambon et al,1988)

36. 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.

37. 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.

38. 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

39. 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.

40. CURRENT MEDICAL MANAGEMENT OF
DIABETES MELLITUS
1. DIET : The goals of this intervention include
weight reduction, improved glycemic control,
with blood glucose levels in the normal
range, and lipid control.
2. Exercise : Regular physical exercise to weight
reduction, increased cardiovascular fitness,
and physical working capacity.

41. 3.Pharmacological therapy :

42. 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 hyperlipidemia
and prevents AGE formation.
– scavenges the carbonyl byproducts of glucose and
lipid degradation
– Benfotiamine, a lipid-soluble thiamine derivative,
inhibits the AGE formation pathway.

43. 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.

44. 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

45. 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.

46. 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 osteocalcin
production
Possible Diabetic Disturbances in Implant
Wound Healing Process In Implants

47. DIABETIC EMERGENCIES
• Hypoglycemic crisis
• Hyperglycemic crisis

48. 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 Blood Glucose
• 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.

49. SIGN & SYMPTOMS
Low Blood Glucose
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.
Severe hypoglycaemia may result in seizures or loss
of consciousness.

50. If patient is
UNCONSCIOUS
Low Blood Glucose
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.

51. ADMINISTRATION OF 15g OF ORAL
CARBOHYDRATE (JUICE,CANDY)
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 Blood Glucose
If patient becomes
CONSCIOUS
PREVENTION

52. MANAGEMENT OF HYPERGLYCEMIA
High Blood Glucose
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.
• A medical emergency from hyperglycemia is less
likely to occur in the dental office since it develops
more slowly than hypoglycaemia.

53. High Blood Glucose
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 .
• Under some instances, severe hyperglycemia may
present with symptoms mimicking hvpoglycemia.
• If a glucometer is not available, these symptoms
must be treated as hypoglycemia.

54. DIABETES & PERIODONTAL DISEASE: CENSUS REPORT OF THE JOINT
EFP/AAP WORKSHOP ON PERIODONTITIS & SYSTEMIC DISEASES
(CHAPPLE LC,GENCO R. J PERIODONTOL 2013)

55. GUIDELINE- A
[Suggested Guidelines for physicians and other medical health professions for Use in Diabetes
Practice]
• Patients with diabetes should be told that periodontal disease
risk is increased by diabetes.
• If they suffer from periodontal disease, their glycaemic control
may be more difficult, and they are at higher risk for diabetic
complications 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.

56. GUIDELINE- B
[Suggested guidelines for use in dental practice]
• If periodontitis is diagnosed, manage it properly. If not, patients
with diabetes should be placed on a preventive care regime and
monitored regularly for periodontal changes.
• Patients with diabetes presenting with any acute oral/periodontal
infections require prompt oral/ periodontal care.
• Patients with diabetes who have extensive tooth loss should be
encouraged to pursue dental rehabilitation to restore adequate
mastication 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.

57. 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 to
have your mouth and gums checked. This is because
people with diabetes have a higher chance of getting
gum disease. Gum disease can lead to tooth loss and
may make your diabetes harder to control.

58. 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 of
getting gum disease. If you have been told by
your dentist that you have gum disease, you
should follow up with necessary treatment as
advised.
• If you do not have diabetes, but your dentist
identified some risk factors for diabetes
including signs of gum disease, it is important
to get a medical check-up as advised.

59. CONCLUSION
• Diabetes mellitus has significant impact on tissues throughout the
body, including the oral cavity. As research indicates that poorly
controlled diabetes increases the risk periodontitis.
• Alteration in host defence and tissue homeostasis appear to play a
major role.
• Advances in medical management of DM require a heightened
awareness by the periodontist in the various treatment regimens
used by diabetic patients.
• Familiarity with various medications, monitoring equipments, and
devices used by diabetic patient allows provision of appropriate
periodontal therapy while minimizing the risk of complications.

60. 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

61. THANK YOU