Periodontal manageent in diabetes patient

Diabetes is a disease that has been associated with an increased risk for a number of serious, sometimes life-threatening complications. Some of those risks include, poor dental health. Studies have shown that people with diabetes are more likely to have periodontal disease than people without diabetes

A chronic metabolic disorder caused by deficiency of insulin,

the primary feature is increase in blood glucose level (hyperglycemia)

Global Prevalence

8.5% - 360millon people are diabetic in the world

types

Type 1 diabetes - β-cell destruction

Type 2 diabetes - insulin resistance

Gestational diabetes mellitus (GDM)

Other specific types of diabetes

Genetic defects in β-cell function, insulin action

Diseases of the exocrine pancreas

Drug- or chemical-induced

Others ..

Oral manifestation and complications of diabetes mellitus

Enlarged gingiva, sessile or pedunculated gingival polyp, polypoid gingival proliferations, abscess.

Cheilosis

Diminished salivary flow, mucosal drying, and cracking, burning mouth and tongue

greater predominance of candida albicans, hemolytic streptococci, and staphylococci.

lichen planus

Increased rate of dental caries

Geographic and fissured tongue

Recurrent aphthous stomatitis

Mechanisms of interaction between

diabetes and periodontal tissues

Capnocytophaga species , A. actinomycetumcomitans, C. rectus, C. species, E. corrodens, F. nucleatum, P. gingivalis, and P. intermedia.

glycemic control and alterations in microflora may increase the susceptibility of diabetics to periodontal disease.

Bacterial pathogens in diabetes mellitus

Polymorphonuclear leukocyte function in diabetes mellitus

Function of polymorphonuclear leukocytes (PMNs) impaired.

polymorphonuclear leukocyte deficiencies resulting in impaired chemotaxis, defective phagocytosis, or impaired adherence .

collagenase concentration is higher in diabetics and it is primarily derived from PMNs.

Monocytes, macrophages and cytokines in diabetes mellitus

Higher concentration IL, PG, and TNF-α have been detected in GCF.

The release of these cytokines in response to bacteria by monocytes is significantly higher.

Dysregulation of macrophages cytokine production results in,tissue destruction and alveolar bone loss. alter the function of macrophages and delay the wound healing

Altered collagen metabolism in diabetes

mellitus In the hyperglycemic state, numerous proteins and matrix molecules undergo a nonenzymatic glycosylation, resulting in accumulated advanced glycation end products (AGEs)

Collagen is cross-linked by AGE formation, making it less soluble and less likely to be normally repaired or replacedcausing precoagulatory changes, thrombus formation and thickening of basement membrane of microvasculature

Increase collagenasae activity, decreased collagen synthesis, maturation, and maintenance of collagen

Altered wound healing in diabetes mellitusThe primary reparative cell in the

periodontium is the fibroblast, which does not function properly in high-glucose environments

The collagen that is produced by these fibroblasts is susceptible to rapid degradation

Resulting in Gingival microangiopathy, Increased collagen degradation, and Glycolysation

Diebetic patient in dental office

Suspect if;

Undiagnosed…

Confirm through;Random glucose >=

200 mg/dlFasting glucose >=

126 mg/dlPost prandial blood

glucose >= 200 mg/dl 2 hrs. after Oral glucose tolerance testONLY nonsurgical oral hygiene procedures until diagnosis has been established

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

Known diabetic patients

• 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

Known diabetic patients

• When the level of control of diabetes is not known, consult patients physician and the treatment should be just limited to palliation

Known diabetic patients

• In patients with good glycemic control before starting any procedure, verify that the patient has taken medication and diet as usual

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

Known diabetic patients

• Local anesthesia is preferred, but such patients can even be safely treated in general anesthesia

Known diabetic patients

• Patients with complications require different treatment plan

• 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

Known diabetic patients

• Appointments should be of short duration

• a source of glucose such as an orange juice must be available in the dental office to avoid hypoglycemic attacks

Known diabetic patients

• 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

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

Known diabetic patients

• If the dental needs are urgent and blood sugar is poorly controlled, treatment should be provided in a hospital or other setting where more medical professionals can monitor patient

Management of Insulin Shock

• The most common diabetic emergency which a dentist encounters is hypoglycemia

• it can lead to life-threatening consequences

• it occurs when the concentration of blood glucose drops below 60 mg/dL

Management of Insulin Shock

• confusion, sweating, tremors, agitation, anxiety, dizziness, tingling or numbness, and tachycardia. Severe hypoglycemia may result in seizures or loss of consciousness

Management of Insulin Shock

• As soon as such signs or symptoms are present the dentist should check the blood glucose with a glucometer,, the “Golden Rule” is that manage the patients as if they are hypoglycemic until proven otherwise

Management of Insulin Shock

• Establish adequate airway, breathing & circulation by loosening dress near the neck, switching on the fan/air conditioners, and placing the patient in the head-low-feet-up position

Management of Insulin Shock

• If patient is conscious and able to take food by mouth, give 15g of oral carbohydrate in one of the following forms; – 4-6 ounce fruit juice or soda, – 3-4 teaspoon sugar,– a hard candy. – Small amount of honey/sweet syrup can

also be placed in the buccal fold

Management of Insulin Shock

• In unconscious patients, give 50ml of dextrose in 50% concentration or 1mg glucagon intaravenously, or give 1ml glucagon intramuscularly at almost any body site.

Management of Insulin Shock

• Following treatment, the signs and symptoms of hypoglycemia should resolve in 10 to 15 minutes

• The patient should be observed for 30 to 60 minutes after recovery. Normal blood glucose level is confirmed by a glucometer before the patient is allowed to leave

Post-operative Period

• Eating the right diet is a critical part of diabetes therapy, if the patient is expected to have difficulty in eating solid food after dental procedure; diet should be modified to soft solids or liquids

• Even the use of blender to blend food before eating is recommended

Post-operative Period

• Consult the patient’s physician for post-operative period diet plan

• It is necessary that the total caloric content and proteins/carbohydrates/fats ratio of the diet remain same

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

Instructions to be given to a diabetic

• patients should be frequently recalled for– dental examinations– prophylactic measures, such as topical

fluorides should be applied

Instructions to be given to a diabetic

• Cavities should be treated as quickly as possible. The dryness of mouth can be relieved by providing salivary substitutes or asking the patient to suck sugar-free candy or gums and frequently drink water

Instructions to be given to a diabetic

• Because their good oral health can help in maintaining good glycemic control, they should be taught that if there is a problem like a bleeding, swollen or tender gums, continuous bad taste or white patches, they should immediately contact a dentist

Instructions to be given to a diabetic

• The patients should be encouraged to quit smoking as it greatly increases the risk of periodontal disease in diabetic patients

Instructions to be given to a diabetic

• 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