Diabetes Mellitus and the Dental Professional...Aug 08, 2014 · CONFIDENTIAL AND PROPRIETARY Types of Diabetes Mellitus •Type 2 –Inability of the pancreas to produce enough insulin

CONFIDENTIAL AND PROPRIETARY

Diabetes Mellitus and the

Dental Professional

Contents

Diabetes – The Disease

• What is Diabetes Mellitus?

• Epidemiology

• Signs and symptoms

• Risk factors

Diabetes- Management

• Management of Diabetes

• Diagnosis

• Systemic Complications

Implications for Oral Health

• Oral Complications

• Management Considerations for the Dental Patient with Diabetes

What is Diabetes Mellitus?

“Diabetes is a group of diseases marked

by high levels of blood glucose resulting

from defects in insulin production,

insulin action, or both.”

CDC Website (http://www.cdc.gov/diabetes/pubs/general11.htm

Types of Diabetes

• Pre-Diabetes

• Diabetes Mellitus

• Type 1

• Type 2

• Gestational Diabetes

Types of Diabetes

• Pre-diabetes

–A condition that occurs when a person’s blood glucose

levels are higher than normal but not high enough for a

diagnosis of type 2 diabetes

–79 million people in the U.S. have pre-diabetes

–Almost always occurs before people develop type 2

diabetes

–More likely to develop type 2 diabetes within 10 years

–More likely to have a heart attack or stroke

National Diabetes Fact Sheet 2011. (http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011)

Types of Diabetes Mellitus

• Type1

–Autoimmune disease – body destroys insulin-

producing cells in the pancreas

–Require daily insulin for survival

–Also known as Insulin Dependent Diabetes Mellitus

(IDDM) or Juvenile Onset Diabetes

–Begins in adolescence

–Accounts for 5-10% of

diabetic population

Types of Diabetes Mellitus

• Type 2

– Inability of the pancreas to produce enough insulin (insulin deficiency) and/or inability for the body to use insulin properly (insulin resistance)

– Also known as Non-Insulin Dependent Diabetes Mellitus (NIDDM)

– Multiple risk factors

– 40+ years

– Most common form of diabetes

– Accounts for 82-92% of diabetics

Types of Diabetes

• Gestational

–Occurs during pregnancy of 2-10% of females not previously diagnosed with diabetes

–Screening at 24-28 weeks of pregnancy

–Temporary but higher risk of developing Type 2 in future

Diabetes – Epidemiology

•346 million

–346 million people worldwide have diabetes

•80%

–More than 80% of people with diabetes live in low- and

middle-income countries

•2030

–WHO projects that diabetes deaths will double between

2005 and 2030

World Health Organization (http://www.who.int/mediacentre/factsheets/fs312/en/index.html )

Prevalence estimates of Diabetes 2025

International Diabetes Federation. IDF Diabetes Atlas, 6th edn. Brussels, Belgium: International Diabetes Federation, 2013.

http://www.idf.org/diabetesatlas

Diabetes Facts

• Affects 29.1 million people (9.3%) of

the U.S. population all ages

– 21 million diagnosed

– 8.1 million undiagnosed

• Up to 27.8% of patients are unaware

they have the disease

• Leading cause of kidney failure,

amputation and blindness among

adults in the U.S.

• Major cause of heart disease and

stroke

• 7th leading cause of death

Centers for Disease Control and Prevention. National Diabetes Statistics Report: Estimates of Diabetes and Its

Burden in the United States, 2014. Atlanta, GA: U.S. Department of Health and Human Services; 2014.)

Number (in Millions) of Persons with Diagnosed Diabetes in the U.S., 1980-2009

CDC 2011

www.cdc.gov/diabetes

Diagnosed Diabetes Prevalence 2004

0 - 6.5

6.6 - 8.0

8.1 - 9.4

9.5 - 11.1

> 11.2

Percentage of Adults with Diagnosed Diabetes Aged ≥ 20 Years www.cdc.gov/diabetes

28/08/2014 15:28 © Author / Presentation Reference Slide 14

0 - 6.5

6.6 - 8.0

8.1 - 9.4

9.5 - 11.1

> 11.2

Percentage of Adults with Diagnosed Diabetes Aged ≥ 20 Years www.cdc.gov/diabetes

CONFIDENTIAL AND PROPRIETARY 28/08/2014 15:28 © Author / Presentation Reference Slide 15

0 - 6.5

6.6 - 8.0

8.1 - 9.4

9.5 - 11.1

> 11.2

Age-adjusted

percent

0 - 19.4

19.5 - 23.8

23.9 - 27.0

27.1 - 30.7

> 30.8

County-level Estimates of Obesity among Adults aged ≥ 20 years:

United States 2009

Diagnosed Diabetes/Obesity Prevalence

0 - 6.5

6.6 - 8.0

8.1 - 9.4

9.5 - 11.1

> 11.2

Percentage of Adults with Diagnosed obesity Aged ≥ 20 Years

0 - 19.4

19.5 - 23.8

23.9 - 27.0

27.1 - 30.7

> 30.8

Signs and Symptoms of Uncontrolled Diabetes Mellitus

Polydipsia Polyuria Polyphagia

3Ps of the uncontrolled diabetic state

http://www.cdc.gov/diabetes/consumer/learn.htm#2

Signs and Symptoms of Uncontrolled Diabetes Mellitus

Signs and symptoms of uncontrolled Diabetes Mellitus

Risk Factors of Diabetes

http://www.cdc.gov/diabetes/consumer/learn.htm

Obesity

• >120 % ideal body weight or a BMI, Body Mass Index, over 27 kg/m2

– WHO define obesity as BMI ≥ 30, but those with a BMI >27 are at high risk of heart disease and other problems

• Fat cells more insulin resistant (IR) than muscle cells—more insulin produced to keep blood glucose levels normal

• Risk Type 2 increases with degree of obesity and duration—increased insulin production can not be maintained indefinitely so hyperglycemia occurs

• Central obesity linked with IR; hypertension also linked with central obesity

www.who.int/gho/ncd/risk_factors/obesity_text/en/

Age Over 45 Years

• The basal metabolic rate (BMR) declines with increasing age

• Could lead to weight gain

• More fat cells insulin resistance over time

• Insulin resistance prolonged time pre diabetes diabetes

ADA 2003, Diabetes Care 2003; 26(3): 917-932

Contents

• Epidemiology

• Risk factors

• Diagnosis

• Controlled rather than

• Type 1

–Daily insulin therapy

– Injection

–New modalities

• Controlled rather than cured

• Type 2

–Weight reduction

–Exercise

– Improved diet

–Oral medications

– Insulin therapy long-term

www.diabetes.org National Diabetes Fact Sheet 2011. (http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011)

Laboratory Diagnostic Tests

• Fasting Plasma Glucose (FPG)

• Oral Glucose Tolerance Test (OGTT)

• Postprandial blood glucose

• Glycosylated Hemoglobin (HbA1c)

– A measure of blood glucose control over a 4-

month period

– High Performance Liquid Chromatography

www.diabetes.org

American Diabetes Association Recommendations for HbA1c Levels

< 6 Normal value

INTERPRETATION HbA1c (%)

< 7 Treatment goal for patient with diabetes;

diet, exercise and/or medications should

control glucose levels well enough to

maintain HbA1c values <7%

> 8 Physician intervention in diabetes

management regimen is recommended

to improve glycemic control

Borgnakke et al. Effect of periodontal disease on diabetes: Review.J Clin Period, 2013.

ADA Diabetes Management

ww.diabetes.org

Systemic Complications of Diabetes

1. Retinopathy

Visual impairment up to and including blindness from retinopathy, glaucoma, cataract and corneal disease

2. Nephropathy

Renal failure

3. Neuropathy

Sensory loss and damage to limbs

4. Macrovascular Disease

–Heart Disease and stroke

–Leading cause of death

5. Poor Wound Healing

Foot ulceration, gangrene and lower limb amputation

6. Periodontal Disease (Loe 1993)

6th complication of diabetes

Ryan et al, 2003. www.diabetes.org National Diabetes Fact Sheet 2011. (http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011)

Contents

• Epidemiology

• Risk factors

• Diagnosis

Mechanisms Linking Periodontitis & Diabetes

Workshop funded by an unrestricted

educational grant from Colgate to the

European Federation of

Periodontology and the American

Academy of Periodontology

Diabetes and Periodontitis

• Poorly controlled diabetes increases the risk of

periodontitis

• Periodontal disease can make glycemic control

more difficult.

Grossi SG, Genco RJ. Periodontal disease and diabetes mellitus: a two-way

relationship. Ann Periodontol. 1998 Jul;3(1):51-61.

Type 1 Diabetes - Periodontal Disease

• Increased risk of gingivitis

More gingival inflammation and bleeding in children with diabetes

than children without diabetes, after accounting for plaque1

• Periodontitis 6 times greater in young people with

Type 1 diabetes compared with those without

diabetes2

1. DPERU, University of Adelaide Special Topic No. 3, Diabetes and Oral Health 2. Ryan et al, 2003.

Type 2 Diabetes

People with diabetes are 2-3

times more likely to suffer from

periodontitis

Mealey BL, Oates TW; American Academy of Periodontology. Diabetes mellitus

and periodontal diseases. J Periodontol. 2006 Aug;77(8):1289-303.

Adapted from Lalla et al., 2008 ADEA Curriculum Resource Center,

and Dental Learning Systems, LLC.

Type 2 Diabetes – Extensive Literature Review

• Meta-analysis of 23 studies concluded that the prevalence and severity of periodontal disease is greater in diabetics than non-diabetics (Khader et al, 2006)

• Poor glycemic control leads to an increased risk for alveolar bone loss and more severe progression of periodontal disease (DPERU, University of Adelaide Special Topic No. 3, Diabetes and Oral Health)

• Periodontal disease can be more severe if the diabetic patient is a smoker (US Department of Health and Human Services, 2000)

• Glycemic control influences relationship between diabetes and periodontal disease (Mealey et al, 2007)

CONFIDENTIAL AND PROPRIETARY © Author / Presentation Reference Slide 36

Periodontal Disease and mortality in

Diabetic patients (type 2 diabetes)

0 No or mild Moderate Severe

Periodontal Disease

cardiorenal deaths; all other natural deaths

Diabetes Care 28:27–32, 2005

Effect of periodontal treatment in HbA1c levels : Controlled Clinical Trial

Calabrese N, et al. Diabetes Metab. 2011 Nov;37(5):456-459. 8 m

Baseli

Periodontal Treatment Control n=44 n=49

P<0,001 P<0,033

Management Considerations for the Dental Patient with Diabetes

• A Call to Action for Integrated Management of the Diabetic Patient

• Collaborate with medical colleagues

IDJ Vol 58:4 2008.

Identification of Unrecognized Diabetes and Pre-Diabetes in a Dental Setting

Algorithm of 2 dental parameters:

1.# Missing teeth

2.% deep periodontal pockets

601 patients

>30 year old

Not told they had

pre- diabetes or diabetes

Self reported risk factor:

Family history of diabetes

Hypertension

High cholesterol

Overweight

2nd appointment following overnight fast for FPG

Pre Diabetes 100-125mg/dL

Diabetes ≥126mg/dL

28/08/2014 15:28 © Author / Presentation Reference Slide 39

Lalla et al.,J Dent. Res. 2013.

Lalla et al.,J Dent. Res. 2011.

Diabetes – Potential Oral Complications

• Periodontal disease

• Dental caries

• Salivary dysfunction / xerostomia

– Increased urination or alterations in salivary glands

– Drug-induced

Pihlstrom BL. Periodontal risk assessment, diagnosis and treatment planning.

Periodontol 2000. 2001;25:37-58.

• Periodontal disease (Periodontitis & Gingivitis)

• Dental caries

• Salivary dysfunction

• Oral infections (eg. Candidiasis)

– Antifungal agents

– Dentures

Periodontol 2000. 2001;25:37-58.

• Periodontal disease

• Dental caries

• Salivary dysfunction

• Oral infections (eg. Candidiasis)

• Oral mucosal disorders

– Lichen planus

• Pain management

• Steroids (topical/systemic)

– Burning mouth syndrome

– Glossodynia

Periodontol 2000. 2001;25:37-58.

Periodontal Disease is Common and Influenced by Many Factors

• Main cause – Dental Plaque

• Risk factors

–Age

–Smoking/Tobacco

–Genetics

–Stress

–Medications

–Clenching or grinding

–Other systemic diseases

–Poor nutrition and obesity www.perio.org.

Stages of Periodontal Disease I

Reprinted by permission of the ADEA Curriculum Resource Center, www.adea.org/crc.

PMN polymorphonuclear neutrophils

Stages of Periodontal Disease II

PMN polymorphonuclear neutrophils

Stages of Periodontal Disease III

PMN polymorphonuclear neutrophils, PGE2 Prostaglandin E2, MMP matrix metalloproteinase

Stages of Periodontal Disease IV

Diabetic Emergency Symptoms

Hypoglycemia

• Nervous (shaky)

• Dizzy/ Confused

• Headache

• Hunger

• Cold clammy skin

• Fast heartbeat

• Irritability

• Syncope

Hyperglycemia

• Weak

• Tired

• Frequent urination

• Thirst

• Decreased appetite

• Blurry vision

• Itchy dry skin

• Fruity breath

Blood Glucose Levels

http://www.ama-assn.org/resources/doc/csaph/a04csa11-fulltext.pdf

Hypoglycemia - Management

• For early, mild symptoms

– Offer liquid glucose or fruit juices (not diet) are

preferred

– Give sugar snacks when liquid is not available

(soft consistency preferred)

• For more severe symptoms such as

drowsiness, convulsions or coma

– Seek immediate medical assistance (call 911)

www.diabetes.org http://www.ama-assn.org/resources/doc/csaph/a04csa11-fulltext.pdf

Hyperglycemia

• Accurate medical history

– Age, family history, hypertension, hypercholesterolemia

• Aggravated by infections

• Common symptoms may indicate diabetes or poorly controlled disease

– Weakness

– Tiredness

– Frequent urination

– Increased thirst

– Blurred vision

– Itchy skin

• Refer to a medical practitioner

www.diabetes.org http://www.ama-assn.org/resources/doc/csaph/a04csa11-fulltext.pdf

• Close collaboration with medical practitioner /

Adjustment of insulin or oral hypoglycemic medications

• Regular full periodontal assessments

• Consider antibiotics with surgical procedures

• Monitor blood glucose prior to and during treatment

• Have glucose sources available in case of a

hypoglycemic event

• Educate patients on potential oral complications

www.diabetes.org

• Examinations

– Collaboration with medical practitioner

• Refer newly diagnosed patients with diabetes for oral assessment

• Medical history

– Full periodontal assessment

• Treatment considerations

– Respond well with good glycemic control

– Poor glycemic control results in

• Slow wound healing

• Possible need for systemic antibiotics

– Smoking cessation

•Follow-up / Recall

– More frequent visits

•Homecare

–Plaque control is key

Brushing at least 2 x daily

Interdental cleaning

• Dentists have an opportunity and

responsibility to:

– Identify patients who are at risk for Diabetes

Mellitus (DM)

– Assist those with DM in achieving optimum

oral and total health

Dentist’s Role

• Opportunity and responsibility to:

– Educate patients about the oral complications

of Diabetes Mellitus

– Promote proper oral health behaviors that

limit the risks of tooth loss, periodontal

disease, and oral soft tissue pathologies

Dentist’s Role

Taylor GW. Bi-directional interrelationships between diabetes and periodontal diseases: an epidemiologic perspective. Ann

Periodontol. 2001;6:99-112.

Glucometer in the Dental office

Blood glucose results are vital signs –

you may save a patient’s life!

www.diabetes.org

Summary

• The number of people living with diabetes will increase

significantly in the future

• The complications associated with diabetes can be

directly linked to the level of glycemic control achieved

• Dental professionals have an important role to play in the

recognition, identification and management of the diabetic

patient

• Medical and dental professionals must work together to

achieve the best results for people with diabetes and the

community

Considerations for all your patients

• One effective option for preventing early gum disease

(gingivitis) is a triclosan/copolymer toothpaste, which

Colgate markets as Colgate Total®

• Colgate Total® is indicated to prevent and treat gingivitis and

plaque, and to help prevent caries.

• Colgate Total® is not indicated to prevent or treat serious gum

disease (periodontitis) or other diseases including Diabetes

Mellitus.

Periodontal Disease at a Glance

Gingivitis Periodontitis

Cause Bacterial plaque / biofilm Bacterial plaque / biofilm

Signs Inflammation of the

gingiva: redness,

swelling, bleeding

Inflammation of the

periodontium: pocket

formation, attachment

loss, bone loss

Other • May/may not progress

into periodontitis

• Reversible

• Always preceded by

gingivitis

• Irreversible

The Role of Plaque Control in Gum Health

Vast majority of research has

focused on this part of the

cascade

We need to focus our

efforts here….

The Cochrane Collaboration

• International non-

profit organisation that

prepares, maintains, and

disseminates systematic

up-to-date reviews of

health care interventions

The Cochrane Collaboration. (http://www.cochrane.org/cochrane-reviews/about-cochrane-library)

•Consists of over 28,000 dedicated people from over 100 countries.

•They work together to help healthcare providers, policy-makers, patients, and their advocates make well-informed decisions about health care

•The members of The Cochrane Collaboration are organized into groups, known as 'entities'

Background and Aims of The Cochrane Collaboration

Cochrane Reviews are

now the

“gold standard” for

systematic reviews.

Background and Aims of The Cochrane Collaboration

CONFIDENTIAL AND PROPRIETARY 64

Evaluating Scientific Evidence

•The main work of The Cochrane

Collaboration is done by more than

fifty Cochrane Review Groups

•Methods Groups have been

established to develop and update

methodology

•The work of Cochrane Groups is

facilitated in various ways by the

work of Cochrane Centres around

the world.

•The consumer network help to

establish priorities and identify

outcomes relevant to patient

Organization of The Cochrane Collaboration

Plaque PlaqueSeverity

Gingivitis BleedingGums

Calculus Caries

Reducti

s Regula

Clinical Effects of Triclosan/Copolymer

Toothpaste

Riley P, Lamont T. Triclosan/copolymer containing toothpastes for oral health. Cochrane Database Syst Rev. 2013 Dec 5;12:CD010514. doi: 10.1002/14651858.CD010514.pub2.

Results •Plaque and Gingivitis:

– 22% reduction in plaque compared with control (1.70

vs 2.17; 20 studies, 2675 participants).

– 41% reduction in plaque severity compared with

control (0.22 vs 0.37; 13 studies, 1850 participants).

– 22% reduction in gingivitis compared with control

(0.95 vs 1.22; 20 studies, 2743 participants).

– 48% reduction in gingival bleeding compared with

control (0.14 vs 0.27; 15 studies, 1998 participants).

Conclusions • This systematic review has shown that significant oral health

benefits can result from using a triclosan/copolymer fluoride

toothpaste when compared to the benefits of using a toothpaste

with fluoride alone (without triclosan/copolymer). There was a

22% reduction in plaque, a 22% reduction in gingivitis, a 48%

reduction in bleeding gums.

• There was insufficient evidence to show a difference between

either toothpaste in preventing periodontitis.

• There was no evidence of any harmful effects associated with the

use of triclosan/copolymer toothpastes in studies up to three

years in length.

Summary

•The Cochrane Review of triclosan/copolymer

affirms the ingredient’s clinical benefit in

managing plaque, gingivitis, calculus, and caries.

•No side effects were noted in any of the studies

reviewed.

•Finally, this review reaffirms results reported in

previously authored systematic reviews1-3..

1.Gunsolley,,JC. J Am Dent Assoc. 2006. 2 Parakevas, S. Int J Dent Hyg. 2005. 3. Davies R et al. J Clin Periodontol.2004

Triclosan Copolymer

copolymer forms a network trapping triclosan onto oral surfaces

Maintains anti-bacterial activity for up to 12 hours

Colgate Total® Mode of Action

1. Xu 2004

Triclosan/copolymer dentifrice: plaque viability suppressed for 12 hours

after brushing as indicated by red color

Control (identical formulation except no triclosan/copolymer):

plaque rapidly gained viability as indicated by green color

0 hr 3 hrs 6 hrs 12 hrs

Plaque Viability Study - Visual Results

Before

Treatment

12 hours after

Colgate Total

Before

treatment

12 hours after

Colgate Total

Cross-

sections

Cross-

sections

projecti

Whole Mouth Antimicrobial Effects: Fine, et al. (2012)*

• A randomized, double-blind, crossover clinical study design was used to

assess the antibacterial effects of three commercially available

dentifrice formulations.

• Thirty five subjects met the inclusion/exclusion criteria and were

placed on a 4-week wash-out phase consisting in twice daily brushing

with the provided soft-bristle toothbrush and commercially-available

fluoride toothpaste.

• After the 4 weeks washout phase, subjects arrived at dental clinic 12

hours after brushing to provide baseline samples from 4 oral

microenvironments: teeth, saliva and scrapping from the cheeks and

tongue.

*Fine D. Whole mouth antimicrobial effects after oral hygiene: comparison of three dentifrice formulations. J Clin Perio 2012; 39: 1056-1064.

• After baseline sample collection, subjects were (1) assigned their test

dentifrice according to a computer-generated randomization schedule,

(2) provided an overwrapped tube of their first-assigned toothpaste

and identical, new toothbrush, and (3) instructed to brush twice daily

with their assigned product for the next 13 days. On the morning of the

day 14, subjects reported to the dental clinic 12 hours after their

morning brushing for sample collection from the same oral

microenvironments harvested at baseline. Subjects left the clinic on

day 14 with instructions to start another 4 weeks washout phase, to be

followed by baseline sample collection, 13-day use of their second-

assigned toothpaste, and 12-hour, post brushing sample collection

pattern was followed for use of the third-assigned product by each of

the 35 subjects.

Triclosan/copolymer/fluoride

commercial toothpaste

Sodium Fluoride

Silica Toothpaste

Stannous fluoride/

hexamethasphosphate

commercial toothpaste

Plaque

Saliva, Cheeks, Teeth, Tongue

Conclusions

• Soft tissues can act as a reservoir for bacteria to recolonize teeth

• Dentifrice containing triclosan/copolymer demonstrated significant reductions in plaque at all 4 soft tissue sites and with all 6 micro-organisms compared with stannous fluoride or the sodium fluoride dentifrices.

‡ Statistically significant reduction in cultivable anaerobic bacteria for Colgate Total ® compared with ordinary fluoride

toothpaste and stannous fluoride toothpaste

Inhibits Bacterial Re-Growth* Results shown vs a non antibacterial toothpaste

*Fine D. Whole mouth antimicrobial effects after oral hygiene: comparison of three dentifrice formulations. J Clin Perio 2012; 39: 1056-1064

Clinical Case

Colgate Total® Toothpaste containing triclosan/copolymer* is the most clinically researched toothpaste.

*Colgate Total toothpaste is approved through the New Drug Application process to help prevent gingivitis. Not

approved for the prevention or treatment of serious gum disease or other diseases. "

* Colgate Total®, Colgate-Palmolive, New York, NY ** Colgate Total® is approved through the New Drug Application process to

help prevent cavities, gingivitis, and plaque

Colgate Resources

• Colgateprofessional.com • Colgateoralhealthnetwork.com

Diabetes Educational Resources

American Diabetes Association: www.diabetes.org

American Dental Association: www.ada.org

Small Steps Big Rewards: www.ndep.nih.gov

Colgate Professional Website:

www.colgateprofessional.com

Thank you!

Diabetes Mellitus and the Dental Professional...Aug 08, 2014 · CONFIDENTIAL AND PROPRIETARY Types of Diabetes Mellitus •Type 2 –Inability of the pancreas to produce enough insulin

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