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?


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 β 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 Hypoplasiahttp://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

(D’Aituo 2004 JDR, Loos et al 2000 JOP)

• Periodontal infection may elevate the systemic inflammatory

state and exacerbate insulin resistance.


Periodontitis and Glycemic Control

Adapted fromJanket et al 2008OOOO Endo


Adapted fromJanket et al 2008OOOO 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. Darré 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)http://drprem.blogspot.com

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 patient’s 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 stressedhttp://drprem.blogspot.com

Emergency Management


Emergencies

• Hypoglycemia

• Diabetic keto acidosis

• Hyperosmolar Non-Ketotic Hyperglycaemia

• Lactic Acidosis


Hypoglycemia

Early stage More severe stage Later severe stage

Diminished cerebral functionChanges in mood

HungerNausea

SweatingTachycardia

Increased anxietyBizarre behavioral patterns

UnconsciousnessSeizure activity

HypotensionHypothermia

ComaDeath


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 olanzapinehttp://drprem.blogspot.com

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


“ 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


Documents

Diabetes Mellitus and Periodontitis