Diabetes Mellitus and Periodontitis

Diabetes Mellitus and Periodontitis A two way relationship
Downloaded at Perio Craze http://drprem.blogspot.com
Introduction
Disease of metabolic dysregulation Hyperglycemia Defects in Insulin secretion or action or both Chronic elevation Why important for a periodontist?
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Type 1 Diabetes
Occurs at young age; can also occur in later life Most frequent chronic disease in children Cell mediated auto immune disorder Destruction of cells of pancreas Destruction rate is variable Multiple genetic predisposition Linked to the presence of Human Leukocyte Antigens (HLA) Environmental factors (Viral infections)also play a role
Oral Diseases and Diabetes
Oral manifestations and complications

No specific oral lesions associated with diabetes. However, there are a number of issues of concern
Oral neuropathies Burning mouth syndrome Burning tongue Temporomandibular joint dysfunction (TMD) Depapillation and fissuring of the tongue. (Martin Gillis et al 2003)

Salivary glands
Xerostomia is common, but reason is unclear. Tenderness, pain and burning sensation of tongue. May secondary enlargement of parotid glands with sialosis.
Dental caries
Increase caries prevalence in adult with diabetes. (xerostomia, increase saliva glucose) Hyperglycemia state shown a positive association with dental caries.
Oral Manifestations
Cheilosis
Alteration of flora of oral cavity Predominance of candida albicans
Oral Manifestation
Cracking of Oral Mucosa
Increased tooth sensitivity
Increased incidence of Enamel Hypoplasia http://drprem.blogspot.com

Increased risk of infection
Reasons unknown, but macrophage metabolism altered with inhibition of phagocytosis. Thickening of vascular endothelium altering tissue hemostasis Peripheral neuropathy and poor peripheral circulation Immunological deficiency High sugar medium Decrease production of Ab Candidial infection are more common and adding effects with xerostomia

Delayed healing of wounds
Due to microangiopathy and ultilisation of protein for energy, may retard the repair of tissues. Increase prevalence of dry socket.
Miscellaneous conditions
Pulpitis : degeneration of vessels Neuropathies : may affect cranial nerves. (facial) Drug side-effects : lichenoid reaction may be associated with sulphonylurea. (chlopropamide) Ulcers
Walter et al 1985
Diabetes and Periodontal Diseases
Gingivitis
Higher risk of developing gingivitis ( Jenkins et al 2001 Perio 2000) The prevalence of gingivitis in children and adolescents is nearly twice when compared with non diabetics (DePommereau et al 1998 JCP) Diabetes mellitus- associated Gingivitis Specific entity in the recent classification of gingival diseases ( Holmstrup et al 1999 Ann Periodontol, Issue 4) Several studies show a positive association Normalizing the glycemic levels may significantly reduce the severity and extent of gingivitis in diabetics (Karjalainen et al 1996 J Dent Res )
Periodontitis
GCF shows an increased glucose level Diabetic status increases the host susceptibility to periodontal infection due to impaired immune response. (Dranchman et al 1966, Crook et al 1998) Increased calculus formation in patients with diabetes, may be due to an increased concentration of serum calcium in both parotid and submandibular saliva (Marder et al.1975 JOP)
Factors of Diabetic influence on Periodontium
Sub gingival microbiota GCF Glucose levels Periodontal vasculature Host response Collagen metabolism
Subgingival microbiota
Early studies showed possible differences in subgingival colonization Recent studies, however show very little differences. Periodontally diseased sites in diabetic patients harbor similar species as comparable in non diabetic individuals. ( Christagu et al JCP 1998, Zambon et al JOP 1988, Sastrowijoto et al JCP 1989) Lack of significant differences in the primary bacterial etiological agent in non diabetic and diabetic patients
GCF Glucose level
Twice amount of glucose in GCF of diabetic patients (Ficara et al JPR 1975) Decreased chemotaxis of periodontal fibroblasts to PDGF in a hyperglycemic environment ( Nishimura et al. 1998 Ann Perio) Thus, affects periodontal wound healing and also host response to microbial challenge. Should also promote a unique hyperglycemic environment, resulting in shifts of the microbial flora.
Periodontal Vasculature
Periodontal vasculature is also affected like other vessels Basement membrane of the endothelial cells of gingival capillaries are thickened (Frantzis et al. 1971 JOP, Listgarten et al.1974 JOP, Seppala et al.1997 JOP) Leads to impaired oxygen and nutrient supply Two fold increase in AGE in diabetic gingiva ( Schmidt et al 1996) Increased oxidant stress in capillaries Leading to wide spread vascular injury
AGE and Periodontal Vasculature
Act by Stimulation of arterial smooth muscle proliferation AGE modified collagen inhibits normal degradation leading to thickness of basement membrane AGE modified collagen can bind circulating LDL resulting in atheroma and further narrowing. Thus results in increased severity and progression of periodontitis
AGE and its effects on PDL A Hypothesis

AGE enriched Gingival tissue
Activation of 1.Endothelial RAGE - Permebility Adhesion molecules 2. Macrophage RAGE Cytokines MMPS 3. Fibroblast RAGE MMPS Collagenase Exaggerated response to periodontal pathogens Accelerated destruction of non mineralized C.T and bone in diabetes
Host Response
Collagen Metabolism

Increased Collagenase activity ( Ramamurthy et al. 1983 JPR) Collagenases primarily degrade newly formed collagen AGE-modified collagen predominates Net effect is destruction of newer collagen and dominance of older, cross-linked collagen. Leading to impaired wound healing
Insulin Therapy and Periodontitis
Periodontal Abscess
Periodontium in Brittle Diabetes
More susceptible to gingivitis, gingival hyperplasia and periodontitis Increased cytokines in gingival tissues Decreased growth factors interference with the healing of tissues. Increased levels of serum triglycerides may be related to greater probing depths and attachment loss
Periomedicine
Double Edged Sword
Periodontitis influence on Diabetes

Systemic inflammation plays a major role in insulin sensitivity and glucose dynamics. Periodontal diseases can induce or perpetuate an elevated systemic chronic inflammatory state Increased serum C-reactive protein, Increased interleukin-6, Increased fibrinogen levels (DAituo 2004 JDR, Loos et al 2000 JOP) Periodontal infection may elevate the systemic inflammatory state and exacerbate insulin resistance.
Periodontitis and Glycemic Control
Adapted from Janket et al 2008 OOOO Endo
Adapted from Janket et al 2008 OOOO Endo

Studies on Glycemic Control

Conflicting results The Cochrane review by Simpson et al (2004-till date) has not yet been completed due to less availability of controlled trials L. Darr et al.2008(Diabetes Metab) has reviewed 25 studies on glycemic control and has done meta analyses of them and states that treatment of periodontal disease could improve glycemic control. Aldridge et al. 1995, Calbacho et al.2005 shows no improvement Al Mubarak et al. 2002, Faria-Almeida et al. 2006, Grossi et al.1997, Stewart et al. 2001 and many studies has showed drastic improvement in glycemic control. More controlled trials warranted
Assessment of Glycemic Control
Home Blood Glucose Monitoring
Urine Tests
Glycosylated Hemoglobin
Treatment
Pharmacological Treatment
Oral Hypoglycemics
Insulin
Dewitt et al 2003 J Am Med Assn
Different ways of Insulin Delivery
Insulin Syringe
Insulin Pen
Insulin Pump
Newer Insulin Inhaler
Future trends in Management

Oral Insulins Amylin analogues ( Pramilintide) Secreted by beta cells Modulates gastric emptying Prevent post prandial rise of glucagon Preoduces satiety causing weight loss Exenedin -4 (Incretin Hormone) Mimics incretin hormones of mammals Enhances insulin secretion Slows gastric emptying Reduces body weight (Mealey et al. 2007 Perio 2000)
Dental Management of Diabetic Patient
Dental management considerations

To minimize the risk of an intraoperative emergency, clinician need to consider the following before initiating dental treatment. Medical history :
Glucose levels Frequency of hypoglycemic episodes Medication and dosage. Consultation

Scheduling of visits
Morning appt. Do not coincide with patients peak activity.
Diet
Ensure that the patient has eaten normally and taken medications as usual.
Blood glucose monitoring

Measured before beginning. (<70 mg/dL)
Prophylactic antibiotics
Established infection Pre-operation contamination wound Major surgery

During treatment
The most common complication of DM is hypoglycemic episode. Hyperglycemia
After treatment
Infection control Dietary intake Medications : Salicylates increase insulin secretion and sensitivity avoid aspirin.
Periodontal Treatment and Diabetes

Clinician should make sure that prescribed insulin has been taken, followed by a meal Morning appointments are appropriate because of optimal insulin levels Monitor vitals, including blood glucose prior to treatment Procedures performed may alter the patients ability to maintain caloric intake, therefore post-op insulin doses should be altered accordingly Tissues should be handled as atraumatically and minimally as possible (less than 2 hrs) Epinephrine should not be used in concentration greater than 1:100,000 due to epinephrine effects on insulin Diet recommendations should be made to maintain proper glucose balance Frequent recall and fastidious home oral care should be stressed
Emergency Management
Emergencies
Hypoglycemia Diabetic keto acidosis Hyperosmolar Non-Ketotic Hyperglycaemia Lactic Acidosis
Hypoglycemia
Early stage More severe stage Later severe stage
Diminished cerebral function Changes in mood Hunger Nausea
Sweating Tachycardia Increased anxiety Bizarre behavioral patterns
Unconsciousness Seizure activity Hypotension Hypothermia Coma Death
Emergency management
15 grams of fast-acting oral carbohydrate. Measure blood sugar. Loss of consciousness, 25-30ml 50% dextrose solution iv. over 3 min period. Glucagon 1mg i.m or s.c
Severe hyperglycemia A prolonged onset Ketoacidosis may develop with nausea, vomiting, abdominal pain and acetone odor. Difficult to different hypo- or hyper-.
Hyperglycemia need medication intervention and insulin administration. While emergency, give glucose first ! Small amount is unlikely to cause significant harm.
Jenner et al,JADA, 2001
Drugs causing hyperglycemia

Glucagon Corticosteroids Diazoxide Intravenous dextrose Diuretics Epinephrine Estrogens Isoniazid Lithium Phenothiazines Phenytoin Salicylates (acute toxicity) Triamterene Tricyclic antidepressants Atypical antipsychotics, especially olanzapine
Drugs causing Hypoglycemia

Acetaminophen Alcohol Anabolic steroids Clofibrate Disopyramide Gemfibrozil Monoamine oxidase inhibitors (MAOIs) Pentamidine Sulfonylurea medications
Diabetes and Dental Implants
Diabetes and Implant considerations

Diabetes induced bone changes Inhibition of collagen matrix formation Alterations in protein synthesis Increased time for mineralization of osteoid Reduced bone turn over Decreased number of osteoblasts and osteoclasts Altered bone metabolism Reduction in osteocalcin production
Diabetic Disturbances in Implant Wound Healing

Blood Clot Formation
Changes in wound healing Proteins
Bone Resorption phase
Decreased number of Osteoclasts

Inhibition of Collagen Formation Decreased Osteoblasts Reduced bone turn over and altered bone homeostasis
Matrix Formation phase
Bone Deposition phase
Maintanence of Osseointegration
Dental Implants and Diabetes !

The National Institute of Health Consensus Development Conference Statement on Dental Implants(USA) 1998 A well-controlled diabetic has
no contraindications provided that proper preoperative assessment is carefully done.

No longer an absolute contraindication (Nevins et al.Int J Oral Maxillofac Implants. 1998) Implants can be placed in controlled diabetic patients Hassan et al. Implant Dent 2002 showed 95.7% success rate (only 5 implants failed in 113 implants) Kapur et al 1998 concluded that implants can be successfully used in diabetic patients with low to moderate levels of metabolic control Shernoff et al 1994 showed 92.7% success
Conclusion
Commonly encountered in dental office Complete medical history to be known by the dentist Dentist should be aware of hypoglycemia and should be in a position to manage it Dentist plays a major role in oral hygiene education Patients should be made aware of the periodontitis-diabetes inter relationship

Diabetes Mellitus and Periodontitis

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Diabetes Mellitus and Periodontitis A two way relationship

Downloaded at Perio Craze http://drprem.blogspot.com

Oral Diseases and Diabetes

Oral manifestations and complications

Oral manifestations and complications

Alteration of flora of oral cavity Predominance of candida albicans

Cracking of Oral Mucosa

Increased tooth sensitivity

Increased incidence of Enamel Hypoplasia http://drprem.blogspot.com

Oral manifestations and complications

Oral manifestations and complications

Diabetes and Periodontal Diseases

Factors of Diabetic influence on Periodontium

GCF Glucose level

AGE and Periodontal Vasculature

AGE and its effects on PDL A Hypothesis

Insulin Therapy and Periodontitis

Periodontium in Brittle Diabetes

Double Edged Sword

Periodontitis influence on Diabetes

Periodontitis and Glycemic Control

Adapted from Janket et al 2008 OOOO Endo

Adapted from Janket et al 2008 OOOO Endo

Studies on Glycemic Control

Assessment of Glycemic Control

Home Blood Glucose Monitoring

Dewitt et al 2003 J Am Med Assn

Different ways of Insulin Delivery

Newer Insulin Inhaler

Future trends in Management

Dental Management of Diabetic Patient

Dental management considerations

Dental management considerations

Blood glucose monitoring

Dental management considerations

Periodontal Treatment and Diabetes

Hypoglycemia Diabetic keto acidosis Hyperosmolar Non-Ketotic Hyperglycaemia Lactic Acidosis

Diminished cerebral function Changes in mood Hunger Nausea

Sweating Tachycardia Increased anxiety Bizarre behavioral patterns

Unconsciousness Seizure activity Hypotension Hypothermia Coma Death

Drugs causing hyperglycemia

Drugs causing Hypoglycemia

Diabetes and Dental Implants

Diabetes and Implant considerations

Diabetic Disturbances in Implant Wound Healing

Changes in wound healing Proteins

Bone Resorption phase

Decreased number of Osteoclasts

Matrix Formation phase

Bone Deposition phase

Dental Implants and Diabetes !

no contraindications provided that proper preoperative assessment is carefully done.

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