بسم الله الرحمن بسم الله الرحمن الرحيمالرحيم

Dental Management Dental Management of Diabetic Patientsof Diabetic Patients

ByBy

Dr. Wid Al KindiDr. Wid Al Kindi

B.D.S., H.D.O.S.B.D.S., H.D.O.S.

Al Kadhimiyah Specialized Al Kadhimiyah Specialized Dental CenterDental Center

DefinitionDefinition

DM is a group of DM is a group of metabolic diseases metabolic diseases

characterized by characterized by hyperglycemia hyperglycemia resulting from resulting from

defects in insulin defects in insulin secretion, insulin secretion, insulin

action or both.action or both.

DM can have a DM can have a significant impact significant impact on the delivery of on the delivery of

dental care. dental care.

Etiologic Classification of DMEtiologic Classification of DM(According to the American (According to the American

Diabetes Association)Diabetes Association)

Type 1 DM:Type 1 DM:

5-10% of cases.5-10% of cases. Beta-cell (insulin Beta-cell (insulin

producing cell) producing cell) destruction or defect destruction or defect in beta-cell function.in beta-cell function.

Absolute deficiency Absolute deficiency of insulin.of insulin.

Two types: Two types: 1.1. Immune mediated:Immune mediated:

Autoimmune Autoimmune destruction of destruction of insulin-producing insulin-producing beta cells of the beta cells of the pancreas. pancreas.

2.2. Idiopathic:Idiopathic: No No evidence of evidence of autoimmunity.autoimmunity.

Some forms of type 1 DM have no known Some forms of type 1 DM have no known cause and may be related to viral infections cause and may be related to viral infections or environmental factors that are poorly or environmental factors that are poorly defined.defined.

Immune mediated DM commonly occurs in Immune mediated DM commonly occurs in childhood and adolescence, but it can occur childhood and adolescence, but it can occur at any age.at any age.

Patients with type 1 DM are also prone to Patients with type 1 DM are also prone to other autoimmune disorders such as: other autoimmune disorders such as:

• Graves’ disease.Graves’ disease.• Hashimoto’s thyroiditis.Hashimoto’s thyroiditis.• Addison’s disease.Addison’s disease. Patients with type 1 DM have a high Patients with type 1 DM have a high

incidence of severe complications including incidence of severe complications including Ketoacidosis.Ketoacidosis.

Ketoacidosis: a condition in which Ketoacidosis: a condition in which acidosisacidosis in accompanied by in accompanied by ketosisketosis, , symptoms include: nausea, vomiting, symptoms include: nausea, vomiting, abdominal tenderness, confusion or abdominal tenderness, confusion or coma, extreme thirst, and weight loss. coma, extreme thirst, and weight loss. it is a life-threatening situation.it is a life-threatening situation.

Ketosis: raised levels of ketone bodies Ketosis: raised levels of ketone bodies in the body tissues. Ketone bodies are in the body tissues. Ketone bodies are normal products of fat metabolism normal products of fat metabolism and can be oxidized to produce and can be oxidized to produce energy. Elevated levels arise when energy. Elevated levels arise when there is an imbalance in fat there is an imbalance in fat metabolism, such as occurs in DM or metabolism, such as occurs in DM or starvation.starvation.

Ketosis may result in severe acidosis.Ketosis may result in severe acidosis.

Acidosis: a condition in which the acidity of Acidosis: a condition in which the acidity of body fluids and tissues is abnormally high. This body fluids and tissues is abnormally high. This arises because of a failure of the mechanisms arises because of a failure of the mechanisms responsible for maintaining a balance between responsible for maintaining a balance between acids and alkalis in the blood (acid-base acids and alkalis in the blood (acid-base balance).balance).

Acid-base balance: The balance between the Acid-base balance: The balance between the amount of carbonic acid and bicarbonate in the amount of carbonic acid and bicarbonate in the blood, which must be maintained at a constant blood, which must be maintained at a constant ratio of 1:20 in order to keep the hydrogen ion ratio of 1:20 in order to keep the hydrogen ion concentration of the plasma at a constant value concentration of the plasma at a constant value (pH 7.4). Any alteration in this ratio will disturb (pH 7.4). Any alteration in this ratio will disturb the acid-base balance of the blood and tissues the acid-base balance of the blood and tissues causing either acidosis or alkalosis. The lungs causing either acidosis or alkalosis. The lungs and kidneys play an important role in the and kidneys play an important role in the regulation of the acid-base balance.regulation of the acid-base balance.

Type 2 DM:Type 2 DM: 90-95% of cases.90-95% of cases. Results from impaired insulin function Results from impaired insulin function

(insulin resistance).(insulin resistance). Relative insulin deficiency.Relative insulin deficiency. No destruction of beta-cells.No destruction of beta-cells. Ketoacidosis is uncommon.Ketoacidosis is uncommon. The risk of developing type 2 DM increases The risk of developing type 2 DM increases

with age, obesity and lack of physical with age, obesity and lack of physical activity.activity.

Type 2 DM is more prevalent in people with Type 2 DM is more prevalent in people with hypertension. hypertension.

There often is a strong genetic There often is a strong genetic predisposition.predisposition.

Other specific types:Other specific types: These are These are relatively uncommon, possible causes relatively uncommon, possible causes are:are:

Genetic defects of beta-cells function Genetic defects of beta-cells function or insulin action.or insulin action.

Pancreatic diseases.Pancreatic diseases. Endocrinopathies.Endocrinopathies. Malnutrition.Malnutrition. Drug- or chemical-induced DM. (Drugs Drug- or chemical-induced DM. (Drugs

like: Dilantin, interferon, thiazides, like: Dilantin, interferon, thiazides, glucocorticoids can impair insulin glucocorticoids can impair insulin secretion).secretion).

Certain viruses (Cytomegalovirus, Certain viruses (Cytomegalovirus, mumps, coxsackievirus). mumps, coxsackievirus).

Gestational DM (GDM):Gestational DM (GDM): This is defined as any This is defined as any

degree of glucose degree of glucose intolerance with onset or intolerance with onset or first recognition during first recognition during pregnancy.pregnancy.

GDM complicates GDM complicates approximately 4% of approximately 4% of pregnancies in the USA.pregnancies in the USA.

In the majority of cases, In the majority of cases, glucose regulation will glucose regulation will return to normal after return to normal after delivery. However, women delivery. However, women who have GDM are at who have GDM are at increased risk of increased risk of developing type 2 DM developing type 2 DM later in life.later in life.

PathophysiologyPathophysiology

Insulin serves a critical Insulin serves a critical role in the regulation of role in the regulation of blood glucose.blood glucose.

It is synthesized in the It is synthesized in the beta-cells of the pancreas beta-cells of the pancreas and is secreted rapidly into and is secreted rapidly into the blood in response to the blood in response to elevations in blood sugar, elevations in blood sugar, such as after a meal.such as after a meal.

Insulin maintains glucose Insulin maintains glucose homeostasis by promoting homeostasis by promoting uptake of glucose from the uptake of glucose from the blood into cells and by its blood into cells and by its storage in the liver as storage in the liver as glycogen.glycogen.

Insulin also promotes the uptake of fatty Insulin also promotes the uptake of fatty acids and amino acids, as well as their acids and amino acids, as well as their subsequent conversion into triglyceride and subsequent conversion into triglyceride and protein stores.protein stores.

A lack of insulin or insulin resistance, as A lack of insulin or insulin resistance, as seen in DM, results in an inability of insulin-seen in DM, results in an inability of insulin-dependent cells to use blood glucose as an dependent cells to use blood glucose as an energy source.energy source.

Stored triglycerides are broken down into Stored triglycerides are broken down into fatty acids, which serve as an alternative fatty acids, which serve as an alternative source of fuel, and an elevation in blood source of fuel, and an elevation in blood ketones leads to diabetic ketoacidosis.ketones leads to diabetic ketoacidosis.

As blood glucose levels become elevated As blood glucose levels become elevated (hyperglycemia), glucose is excreted in the (hyperglycemia), glucose is excreted in the urine and excessive urination (polyuria) urine and excessive urination (polyuria) occurs because of osmotic diuresis.occurs because of osmotic diuresis.

Increased fluid loss leads to dehydration and Increased fluid loss leads to dehydration and excessive thirst (polydispia). excessive thirst (polydispia).

Since cells are starved of glucose, the Since cells are starved of glucose, the patient experiences increased hunger patient experiences increased hunger (polyphagia).(polyphagia).

The diabetic patient often loses weight, The diabetic patient often loses weight, since the cells are unable to take up glucose.since the cells are unable to take up glucose.

Symptoms of DMSymptoms of DM

Type 1:Type 1:

Cardinal symptoms (common): Polydipsia, Cardinal symptoms (common): Polydipsia, polyuria, polyphagia, weight loss, loss of polyuria, polyphagia, weight loss, loss of strength.strength.

Other symptoms: Recurrence of bed Other symptoms: Recurrence of bed wetting, repeated skin infections, marked wetting, repeated skin infections, marked irritability, headache, drowsiness, malaise, irritability, headache, drowsiness, malaise, dry mouth.dry mouth.

Type 2:Type 2:

Cardinal Symptoms (much less common): Cardinal Symptoms (much less common): Polydipsia, polyuria, polyphagia, weight Polydipsia, polyuria, polyphagia, weight loss, loss of strength.loss, loss of strength.

Usual symptoms: Slight weight loss or gain, Usual symptoms: Slight weight loss or gain, gastrointestinal upset, nausea, urination at gastrointestinal upset, nausea, urination at night, vulvar pruritus, blurred vision, night, vulvar pruritus, blurred vision, decreased vision, paresthesias, dry flushed decreased vision, paresthesias, dry flushed skin, loss of sensation, impotence, postural skin, loss of sensation, impotence, postural hypotension. hypotension.

Complications of DMComplications of DM Ketoacidosis.Ketoacidosis. Hyperosmolar nonketotic Hyperosmolar nonketotic

coma.coma. Diabetic Diabetic

retinopathy/blindness.retinopathy/blindness. Cataracts.Cataracts. Diabetic nephropathy/renal Diabetic nephropathy/renal

failure.failure. Accelerated atherosclerosis Accelerated atherosclerosis

(coronary heart disease).(coronary heart disease). Ulceration and gangrene of Ulceration and gangrene of

feet.feet. Diabetic neuropathy Diabetic neuropathy

(dysphagia, gastric distention, (dysphagia, gastric distention, diarrhea, impotence, muscle diarrhea, impotence, muscle weakness/cramps, numbness, weakness/cramps, numbness, tingling, deep burning pain)tingling, deep burning pain)

Early death.Early death.

Diabetic ulcer in the feet

Moderate nonproliferative diabetic retinopathy in a right eye. Larger haemorrhages and whitish lesions with fluffy borders representing cotton-wool spots have developed.

Minimal nonproliferative diabetic retinopathy in a right eye. A few red dots representing haemorrhages and/or microaneurysms are seen temporally in the macular are which is the dark area surrounding the dark spot in the centre of the image (arrows).

Diagnosis of DMDiagnosis of DM Criteria for the diagnosis of DM (approved Criteria for the diagnosis of DM (approved

by The American Diabetes Association’s by The American Diabetes Association’s Expert Committee)Expert Committee)

1.1. Cardinal symptoms of DM + casual Cardinal symptoms of DM + casual (random) plasma glucose level (taken at (random) plasma glucose level (taken at any time of the day without regard to time any time of the day without regard to time since last meal) of ≥ 200 mg/dL. (Normal since last meal) of ≥ 200 mg/dL. (Normal fasting plasma glucose is < 110 mg/dL.) fasting plasma glucose is < 110 mg/dL.) OROR

2.2. Fasting plasma glucose level of ≥ 126 Fasting plasma glucose level of ≥ 126 mg/dL. mg/dL. OROR

3.3. 2-hour plasma glucose level of ≥ 200 2-hour plasma glucose level of ≥ 200 mg/dL during an oral glucose tolerance mg/dL during an oral glucose tolerance test.test.

Oral Glucose Tolerance TestOral Glucose Tolerance Test

This test reflects the rate of absorption, uptake This test reflects the rate of absorption, uptake by tissues, and excretion in the urine of glucose.by tissues, and excretion in the urine of glucose.

The test should be performed using a glucose The test should be performed using a glucose load containing the equivalent of 75-100 g of load containing the equivalent of 75-100 g of anhydrous glucose dissolved in water, after a anhydrous glucose dissolved in water, after a night of fasting. Venous blood samples are night of fasting. Venous blood samples are drawn from the arm just before and 1,2 and 3 drawn from the arm just before and 1,2 and 3 hours after ingestion of glucose. Urine samples hours after ingestion of glucose. Urine samples also are collected at each interval.also are collected at each interval.

The most characteristic alterations seen in The most characteristic alterations seen in diabetes are an increased fasting blood glucose diabetes are an increased fasting blood glucose (126 mg/dL or higher), an increased peak value (126 mg/dL or higher), an increased peak value (200 mg/dL or higher), and a delayed return to (200 mg/dL or higher), and a delayed return to normal in the 2- and 3- hour samples.normal in the 2- and 3- hour samples.

The terms “impaired fasting glucose” The terms “impaired fasting glucose” or IFG and “impaired glucose or IFG and “impaired glucose tolerance” or IGT refer to a metabolic tolerance” or IGT refer to a metabolic stage between the stages of normal stage between the stages of normal glucose homeostasis and DM. This glucose homeostasis and DM. This stage includes people with fasting stage includes people with fasting plasma glucose levels of 110 mg/dL or plasma glucose levels of 110 mg/dL or greater but less than 126 mg/dL. greater but less than 126 mg/dL.

Medical Management of DMMedical Management of DM

DM is not a curable disease. DM is not a curable disease. Therapeutic goals for most of the patients Therapeutic goals for most of the patients

include:include: To maintain blood glucose levels as close to To maintain blood glucose levels as close to

normal as possible without repeated normal as possible without repeated episodes of hyperglycemia.episodes of hyperglycemia.

To strive to maintain normal body weight.To strive to maintain normal body weight. To control hypertension and hyperlipidemia.To control hypertension and hyperlipidemia. To develop a flexible treatment plan that To develop a flexible treatment plan that

does not dominate the patient’s life any does not dominate the patient’s life any more than is necessary. more than is necessary.

Treatment of patients with DMTreatment of patients with DM

Type 1 DM:Type 1 DM: Diet and physical activity.Diet and physical activity. Insulin:Insulin: Conventional.Conventional. Multiple injections.Multiple injections. Continuous infusion.Continuous infusion. Pancreatic Pancreatic

transplantation.transplantation. Type 2 DM:Type 2 DM: Diet and physical activity.Diet and physical activity. Oral hypoglycemic Oral hypoglycemic

agents.agents. Insulin + Oral Insulin + Oral

hypoglycemic agents.hypoglycemic agents. Insulin.Insulin.

Dental ManagementDental Management

Detection of the patient with DMDetection of the patient with DM

Known diabetic personKnown diabetic person

1.1. Detection by history:Detection by history:

• Are you diabetic?Are you diabetic?• What medications are you taking?What medications are you taking?• Are you being treated by a physician?Are you being treated by a physician?

2.2. Establishment of severity of disease and Establishment of severity of disease and degree of control:degree of control:

• When were you first diagnosed as diabetic?When were you first diagnosed as diabetic?• What was the level of the last measurement What was the level of the last measurement

of your blood glucose?of your blood glucose?• What is the usual level of your blood glucose?What is the usual level of your blood glucose?• How are you being treated for your diabetes?How are you being treated for your diabetes?• How often do you have insulin reactions?How often do you have insulin reactions?• How much insulin do you take with each How much insulin do you take with each

injection, and how often do you receive injection, and how often do you receive injections?injections?

• Do you test your urine for glucose?Do you test your urine for glucose?• When did you last visit your physician?When did you last visit your physician?• Do you have any symptoms of diabetes at the Do you have any symptoms of diabetes at the

present time? present time?

Undiagnosed Undiagnosed diabetic persondiabetic person

1.1. History of signs and History of signs and symptoms of diabetes symptoms of diabetes or its complications.or its complications.

2.2. High risk for developing High risk for developing diabetesdiabetes

• Parents who are Parents who are diabetic.diabetic.

• Gave birth to one or Gave birth to one or more large babies.more large babies.

• History of spontaneous History of spontaneous abortions or stillbirths.abortions or stillbirths.

• Obese.Obese.• Over 40 years of age.Over 40 years of age.

3.3. Referral or screening Referral or screening test for diabetes.test for diabetes.

DM and The MouthDM and The Mouth

A number of oral conditions have been A number of oral conditions have been associated with DM, particularly in patient associated with DM, particularly in patient with poor control of the disease. However, with poor control of the disease. However, most patients are unaware of the oral most patients are unaware of the oral health complications of their disease.health complications of their disease.

Therefore, it is important for dentists to Therefore, it is important for dentists to educate patients about oral complications educate patients about oral complications of DM and the need for proper preventive of DM and the need for proper preventive care.care.

Periodontal disease Periodontal disease DM, especially when poorly controlled, DM, especially when poorly controlled,

increases the risk of periodontitis (according increases the risk of periodontitis (according to the American Academy of Periodontology).to the American Academy of Periodontology).

Several contributing factors have been Several contributing factors have been proposed, including:proposed, including:

Reduced PMN leukocyte function.Reduced PMN leukocyte function.

Abnormalities in collagen metabolism:Abnormalities in collagen metabolism:• Changes in collagen metabolism in diabetic Changes in collagen metabolism in diabetic

individuals contribute to wound-healing individuals contribute to wound-healing alterations and periodontal destruction.alterations and periodontal destruction.

• The production of collagenase is increased in The production of collagenase is increased in many diabetic patients. Increased many diabetic patients. Increased collagenase production readily degrades collagenase production readily degrades newly formed collagen.newly formed collagen.

Diabetes is believed to promote Diabetes is believed to promote periodontitis through an exaggerated periodontitis through an exaggerated inflammatory response to the periodontal inflammatory response to the periodontal microflora. microflora.

Hyperglycemia results in increased gingival Hyperglycemia results in increased gingival crevicular fluid glucose levels, which may crevicular fluid glucose levels, which may significantly alter periodontal wound-significantly alter periodontal wound-healing events by changing the interaction healing events by changing the interaction between cells and their extracellular matrix between cells and their extracellular matrix within the periodontium.within the periodontium.

The formation of advanced glycation end The formation of advanced glycation end products (AGE) which adversely affect products (AGE) which adversely affect collagen stability and vascular integrity.collagen stability and vascular integrity.

Glycation: The chemical linkage of glucose Glycation: The chemical linkage of glucose to a protein, to form a glycoprotein.to a protein, to form a glycoprotein.

Glycation of body proteins has been Glycation of body proteins has been postulated as a cause of complications of postulated as a cause of complications of DM.DM.

AGE are damaged proteins that result from AGE are damaged proteins that result from the glycation of a large number of body the glycation of a large number of body proteins, which can accumulate and cause proteins, which can accumulate and cause permanent damage to tissues. This damage permanent damage to tissues. This damage is more prevalent in DM due to the chronic is more prevalent in DM due to the chronic exposure to blood with high concentrations exposure to blood with high concentrations of glucose. It is believed to be partly of glucose. It is believed to be partly responsible for the damage to the kidney, responsible for the damage to the kidney, eyes, and blood vessels that characterizes eyes, and blood vessels that characterizes long-standing DM.long-standing DM.

AGE binding to macrophage and monocyte AGE binding to macrophage and monocyte receptors also may result in increased receptors also may result in increased secretion of interleukin-1 and tumor secretion of interleukin-1 and tumor necrosis factor-necrosis factor-αα, resulting in increased , resulting in increased susceptibility to tissue destruction.susceptibility to tissue destruction.

The formation of AGEs results in collagen The formation of AGEs results in collagen accumulation in the periodontal capillary accumulation in the periodontal capillary basement membranes, causing membrane basement membranes, causing membrane thickening. AGE-stimulated smooth-muscle thickening. AGE-stimulated smooth-muscle proliferation increases the thickness of proliferation increases the thickness of vessel walls. These changes decrease tissue vessel walls. These changes decrease tissue perfusion and oxygenation.perfusion and oxygenation.

AGE-modified collagen in gingival blood AGE-modified collagen in gingival blood vessel walls binds circulating Low-density vessel walls binds circulating Low-density lipoprotein (LDL) -that enable lipids like lipoprotein (LDL) -that enable lipids like cholesterol and triglycerides to be cholesterol and triglycerides to be transported within the water-based transported within the water-based bloodstream- which is frequently elevated in bloodstream- which is frequently elevated in diabetes, resulting in atheroma formation and diabetes, resulting in atheroma formation and further narrowing of the vessel lumen.further narrowing of the vessel lumen.

These changes in the periodontium may These changes in the periodontium may dramatically alter the tissue response to dramatically alter the tissue response to periodontal pathogens, resulting in increased periodontal pathogens, resulting in increased tissue destruction and diminished repair tissue destruction and diminished repair potential.potential.

The presence of severe The presence of severe periodontal infection may periodontal infection may increase the risk of increase the risk of microvascular and microvascular and macrovascular diabetic macrovascular diabetic complications.complications.

Patients with poorly controlled DM have an increased rate of surgical wound infections and poor wound healing, and, therefore, some researchers have recommended that management of periodontal disease be conservative and nonsurgical as much as possible.

Since prevention plays a primary role in periodontal disease control in diabetic patients, they may need more frequent plaque control and scaling than nondiabetic patients.

39 years old patient with an 8-year history of poorly controlled type 1 diabetes. There is a rapid progressionof bone loss, the severity of which exceeds that expected from plaque and calculus levels.

Studies have indicated that smoking increases the risk of periodontal disease several fold in diabetic patients. Therefore, tobacco use cessation counseling should be a part of the management of patients with DM.

Periodontal disease in a patient with poorly controlled diabetes mellitus. This palatal view displays granulomatous tissue at the gingival margin.

Gingivitis in a 19-year-old women with uncontrolled diabetes mellitus.

Salivary gland dysfunctionSalivary gland dysfunction Studies have reported Studies have reported

xerostomia in 40 – 80% of xerostomia in 40 – 80% of diabetic patients.diabetic patients.

Diabetic patients with Diabetic patients with poorly controlled disease poorly controlled disease have been found to have have been found to have lower stimulated parotid lower stimulated parotid flow rates than people with flow rates than people with well-controlled DM and well-controlled DM and nondiabetic control nondiabetic control subjects.subjects.

Frequent sipping of water Frequent sipping of water or use of sugarless gum or use of sugarless gum may lessen the dryness.may lessen the dryness.

Asymptomatic, bilateral Asymptomatic, bilateral enlargement of the parotid enlargement of the parotid glands has been reported glands has been reported in 24 – 48% of patients in 24 – 48% of patients with DM, and patients with with DM, and patients with uncontrolled DM have uncontrolled DM have exhibited a greater exhibited a greater tendency for enlargement.tendency for enlargement.

The etiology of diabetic salivary gland The etiology of diabetic salivary gland dysfunction may be related to:dysfunction may be related to:

Polyuria, poor hydration.Polyuria, poor hydration. Autonomic nervous system dysfunction Autonomic nervous system dysfunction

cause changes in salivary secretion since cause changes in salivary secretion since salivary flow is controlled by the salivary flow is controlled by the sympathetic and parasympathetic pathwayssympathetic and parasympathetic pathways

Antidiabetic medications.Antidiabetic medications. Alteration in the basement membranes of Alteration in the basement membranes of

the salivary glands. the salivary glands.

Fungal infectionsFungal infections Diabetic people have an increased predisposition Diabetic people have an increased predisposition

to manifestations of oral candidiasis, including to manifestations of oral candidiasis, including median rhomboid glossitis, denture stomatitis median rhomboid glossitis, denture stomatitis

and angular cheilitis.and angular cheilitis. This predisposition may be due to xerostomia, This predisposition may be due to xerostomia,

increased salivary glucose levels or immune increased salivary glucose levels or immune dysregulation.dysregulation.

Mucormycosis is a rare but serious systemic Mucormycosis is a rare but serious systemic fungal infection that may occur in patients with fungal infection that may occur in patients with

uncontrolled DM.uncontrolled DM. Oral involvement usually appears as palatal Oral involvement usually appears as palatal

ulceration or necrosis. Patients often have ulceration or necrosis. Patients often have facial cellulitis and anesthesia, nasal facial cellulitis and anesthesia, nasal discharge, fever, headache and lethargy discharge, fever, headache and lethargy (mental and physical sluggishness).(mental and physical sluggishness).

Treatment usually includes systemic Treatment usually includes systemic antifungal therapy.antifungal therapy.

Oral candidiasis in a patient with poorly controlled DM. The dorsum of the tongue is erythematous, and numerous hyphae were present microscopically.

Oral burning and taste Oral burning and taste disturbancesdisturbances

Clinicians should consider DM in the Clinicians should consider DM in the diagnosis of patients experiencing burning diagnosis of patients experiencing burning mouth or tongue.mouth or tongue.

The burning may be due to peripheral The burning may be due to peripheral neuropathy, xerostomia (Dry mucosal neuropathy, xerostomia (Dry mucosal surfaces are easily irritated) or candidiasis.surfaces are easily irritated) or candidiasis.

Good glycemic control may lessen the Good glycemic control may lessen the burning sensation.burning sensation.

Clonazepam (trade name: Rivotril) may be Clonazepam (trade name: Rivotril) may be beneficial in some patients with complaints beneficial in some patients with complaints of oral burning sensation + Restriction of of oral burning sensation + Restriction of caffeine and alcohol intake.caffeine and alcohol intake.

Some diabetic patients have a mild Some diabetic patients have a mild impairment of the sweet taste sensation. impairment of the sweet taste sensation. This may be related to xerostomia or This may be related to xerostomia or disordered glucose receptors. Taste disordered glucose receptors. Taste alterations may be more common in people alterations may be more common in people with uncontrolled DM.with uncontrolled DM.

Lichen planus and lichenoid Lichen planus and lichenoid reactionsreactions

A study reports that the A study reports that the prevalence of oral lichen prevalence of oral lichen planus is significantly higher planus is significantly higher in patients with type 1 DM in patients with type 1 DM and slightly higher in and slightly higher in patients with type 2 DM than patients with type 2 DM than in control subjects. However, in control subjects. However, this may be a side effect of this may be a side effect of oral hypoglycemic agents oral hypoglycemic agents (sulfonylurea compounds) or (sulfonylurea compounds) or antihypertensive antihypertensive medications (β-blockers). medications (β-blockers). Furthermore, a recent large Furthermore, a recent large study found no evidence of study found no evidence of increased prevalence of increased prevalence of lichen planus in patients lichen planus in patients with type 1 DM compared with type 1 DM compared with nondiabetic control with nondiabetic control subjects.subjects.

Dental cariesDental caries Some studies have Some studies have

demonstrated that demonstrated that diabetic patients have diabetic patients have more active dental caries more active dental caries than control subjects. than control subjects.

Other studies have Other studies have shown no increase in shown no increase in prevalence of caries in prevalence of caries in diabetic patients.diabetic patients.

Elevated salivary glucose Elevated salivary glucose levels and xerostomia levels and xerostomia may predispose this may predispose this population to caries. population to caries. However, low-However, low-carbohydrate diabetic carbohydrate diabetic diets should theoretically diets should theoretically reduce caries prevalence.reduce caries prevalence.

Traumatic ulcers and irritation Traumatic ulcers and irritation fibromasfibromas

A recent study has A recent study has reported that people reported that people with type 1 DM have a with type 1 DM have a higher prevalence of oral higher prevalence of oral traumatic ulcers and traumatic ulcers and irritation fibromas than irritation fibromas than do nondiabetic control do nondiabetic control subjects. subjects.

These findings may be These findings may be related to altered wound related to altered wound healing patterns in these healing patterns in these patients.patients.

Traumatic ulcer of the tongue.

Potential problems related to the Potential problems related to the dental procedures for diabetic dental procedures for diabetic

patientspatients

Hypoglycemia (insulin shock).Hypoglycemia (insulin shock). Increased susceptibility for Increased susceptibility for

infections.infections. Delayed wound healing.Delayed wound healing. Increased bleeding tendency.Increased bleeding tendency.

Insulin shockInsulin shock

Patients who are treated with insulin must Patients who are treated with insulin must closely adhere to their diet. If they fail to eat in closely adhere to their diet. If they fail to eat in a normal manner but continue to take their a normal manner but continue to take their regular insulin doses, they may experience a regular insulin doses, they may experience a hypoglycemic reaction caused by an excess of hypoglycemic reaction caused by an excess of insulin.insulin.

A hypoglycemic reaction also may be due to an A hypoglycemic reaction also may be due to an overdose of insulin or oral hypoglycemic agent.overdose of insulin or oral hypoglycemic agent.

Insulin shock usually occurs in 3 well-defined Insulin shock usually occurs in 3 well-defined stages, each more severe and dangerous that stages, each more severe and dangerous that the one preceding it.the one preceding it.

Mild stage:Mild stage: The most common , The most common , characterized by:characterized by:

Hunger Hunger WeaknessWeakness TachycardiaTachycardia PallorPallor SweatingSweating Paresthesias Paresthesias Trembling Trembling

It occurs before meals, during exercise, and It occurs before meals, during exercise, and when food has been omitted or delayed. when food has been omitted or delayed.

Moderate stage:Moderate stage: in this stage, because in this stage, because blood glucose is substantially drops, the blood glucose is substantially drops, the patient becomes characterized by:patient becomes characterized by:

IncoherenceIncoherence UncooperativenessUncooperativeness BelligerenceBelligerence Lack of judgmentLack of judgment Poor orientationPoor orientation

The chief danger during this stage is that The chief danger during this stage is that patients may injure themselves or someone patients may injure themselves or someone else (e.g., if the patient is driving).else (e.g., if the patient is driving).

Severe stage:Severe stage: characterized by: characterized by:

Unconsciousness Unconsciousness Tonic or clonic muscular movementsTonic or clonic muscular movements HypotensionHypotension HypothermiaHypothermia Rapid thready pulse Rapid thready pulse

Most of these reactions take place:Most of these reactions take place: During sleep, after the 1During sleep, after the 1stst two stages have two stages have

gone unrecognized.gone unrecognized. After exercise. After exercise. After the ingestion of Alcohol.After the ingestion of Alcohol.

The reaction to excessive insulin can be The reaction to excessive insulin can be corrected by:corrected by:

Giving the patient sweetened fruit juice or Giving the patient sweetened fruit juice or anything with sugar in it.anything with sugar in it.

Patients in the severe stage (unconscious) Patients in the severe stage (unconscious) are best treated with an IV glucose solution, are best treated with an IV glucose solution, glucagon or epinephrine may be used for glucagon or epinephrine may be used for transient relief.transient relief.

Steps of dental management of Steps of dental management of diabetic patientsdiabetic patients

If patient is uncontrolled/poorly controlled:If patient is uncontrolled/poorly controlled:

Provide appropriate emergency care only.Provide appropriate emergency care only. Request referral for medical evaluation, Request referral for medical evaluation,

management, and risk factor modification:management, and risk factor modification:

• If symptomatic, seek IMMEDIATE referral.If symptomatic, seek IMMEDIATE referral.• If asymptomatic, request routine referral.If asymptomatic, request routine referral.

If patient is well-controlled:If patient is well-controlled:1.1. Non-insulin dependant patient: all dental Non-insulin dependant patient: all dental

procedures can be performed without procedures can be performed without special considerations.special considerations.

2.2. Insulin controlled patient:Insulin controlled patient:• All dental procedures can be performed All dental procedures can be performed

without special considerations.without special considerations.• Morning appointments are usually best.Morning appointments are usually best.• Patient advised to take usual insulin dosage Patient advised to take usual insulin dosage

and normal meals on day of dental and normal meals on day of dental appointment; information confirmed when appointment; information confirmed when patient comes for appointment.patient comes for appointment.

• Advise patient to inform dentist or staff if Advise patient to inform dentist or staff if symptoms of insulin reaction occur during symptoms of insulin reaction occur during dental visit.dental visit.

• Glucose source Glucose source (orange juice, soda, (orange juice, soda, glucola) should be glucola) should be available and given available and given to the patient if to the patient if symptoms of insulin symptoms of insulin reaction occur.reaction occur.

3.3. If extensive surgery is needed:If extensive surgery is needed:

• Early Morning appointments.Early Morning appointments.• Use anxiety control protocol, but avoid Use anxiety control protocol, but avoid

deep sedation techniques in deep sedation techniques in outpatients. outpatients.

• Monitor pulse, respiration, and blood Monitor pulse, respiration, and blood pressure before, during, and after pressure before, during, and after surgery.surgery.

• Maintain verbal contact with the Maintain verbal contact with the patient during surgery.patient during surgery.

• Antibiotic prophylaxis can be Antibiotic prophylaxis can be considered for patients with brittle considered for patients with brittle diabetes and those taking high dose of diabetes and those taking high dose of insulin who also have chronic states of insulin who also have chronic states of oral infection.oral infection.

• Infections are treated aggressively.Infections are treated aggressively.

• If the patient is allowed to eat before the surgery, If the patient is allowed to eat before the surgery, then have the patient eat a normal breakfast then have the patient eat a normal breakfast before surgery and take the usual dose of regular before surgery and take the usual dose of regular insulin (short-acting) but only 1/3 – 1/2 the dose of insulin (short-acting) but only 1/3 – 1/2 the dose of NPH insulin (intermediate-acting) and the normal NPH insulin (intermediate-acting) and the normal dose of oral hypoglycemic agent in the non-insulin dose of oral hypoglycemic agent in the non-insulin controlled patients.controlled patients.

• If the patient must not eat or drink before oral If the patient must not eat or drink before oral surgery, and will have difficulty eating after surgery, and will have difficulty eating after surgery, instruct patient to not take the usual surgery, instruct patient to not take the usual dose of regular insulin (short-acting) or NPH dose of regular insulin (short-acting) or NPH insulin (intermediate-acting) in insulin controlled insulin (intermediate-acting) in insulin controlled patients and oral hypoglycemic agent in non patients and oral hypoglycemic agent in non insulin controlled patients. Start IV of D5W insulin controlled patients. Start IV of D5W (Dextrose 5% in water) in surgeries under GA. And (Dextrose 5% in water) in surgeries under GA. And sliding scale insulin when needed (involves sliding scale insulin when needed (involves intravenous administration of a standard insulin intravenous administration of a standard insulin to tightly regulate blood glucose levels).to tightly regulate blood glucose levels).

• Advise patients not to resume normal Advise patients not to resume normal insulin / oral hypoglycemic agent doses until insulin / oral hypoglycemic agent doses until they are able to return to usual level of they are able to return to usual level of caloric intake and activity level.caloric intake and activity level.

• Watch for signs of hypoglycemia.Watch for signs of hypoglycemia.

• Consult patient’s physician if any questions Consult patient’s physician if any questions concerning modification of the insulin concerning modification of the insulin regimen dose.regimen dose.

References References Belfiore F, Mogensen CE, New Concepts in Diabetes and Its Belfiore F, Mogensen CE, New Concepts in Diabetes and Its

Treatment. Basel, Karger, 2000, P.138-139.Treatment. Basel, Karger, 2000, P.138-139. Bruce R. Donoff, Massachusetts General Hospital manual of Oral and Bruce R. Donoff, Massachusetts General Hospital manual of Oral and

Maxillofacial Surgery, 3Maxillofacial Surgery, 3rdrd edition, Don Ladig, Mosby-Year Book, Inc, edition, Don Ladig, Mosby-Year Book, Inc, 1997, Known diabetic patient undergoing elective surgery, P.3.1997, Known diabetic patient undergoing elective surgery, P.3.

Ira B. Lamster, Evanthia Lalla, Wenche S. Borgnakke and George W. Ira B. Lamster, Evanthia Lalla, Wenche S. Borgnakke and George W. Taylor, The Relationship Between Oral Health and Diabetes Mellitus, Taylor, The Relationship Between Oral Health and Diabetes Mellitus, J Am Dent Assoc 2008;139;19S-24S. J Am Dent Assoc 2008;139;19S-24S.

James W. Little, Donald A. Falace, Craig S. Miller, Nelson L. Rhodus, James W. Little, Donald A. Falace, Craig S. Miller, Nelson L. Rhodus, Dental Management of the Medically Compromised Patient, 7Dental Management of the Medically Compromised Patient, 7thth edition, Linda Duncan, Mosby-Elsevier, 2008, Part 6: Endocrine and edition, Linda Duncan, Mosby-Elsevier, 2008, Part 6: Endocrine and Metabolic Disease, Chapter 15: Diabetes Mellitus, P.211-235.Metabolic Disease, Chapter 15: Diabetes Mellitus, P.211-235.

Larry J. Peterson, Edward Ellis, James R. Hupp, Myron R. Tucker, Larry J. Peterson, Edward Ellis, James R. Hupp, Myron R. Tucker, Contemporary Oral and Maxillofacial Surgery, 4Contemporary Oral and Maxillofacial Surgery, 4thth edition, Linda edition, Linda Duncan, Mosby-Elsevier, 2003, Part 1: Principles of Surgery, P.15-Duncan, Mosby-Elsevier, 2003, Part 1: Principles of Surgery, P.15-17.17.

Laskaris G., Pocket atlas of oral diseases, 2nd revised and enlarged Laskaris G., Pocket atlas of oral diseases, 2nd revised and enlarged edition, 2006, Georg Thieme Verlag, P.139.edition, 2006, Georg Thieme Verlag, P.139.

Martin S. Greenberg, Michael Glick, Burket’s Oral Medicine Diagnosis Martin S. Greenberg, Michael Glick, Burket’s Oral Medicine Diagnosis & Treatment, 10& Treatment, 10thth edition, 2003, BC Decker Inc, Part II: Diagnosis and edition, 2003, BC Decker Inc, Part II: Diagnosis and management of oral and salivary gland diseases, Chapter 9: Salivary management of oral and salivary gland diseases, Chapter 9: Salivary gland diseases, P.254-255., Part IV: principles of medicine, Chapter gland diseases, P.254-255., Part IV: principles of medicine, Chapter 21: Diabetes Mellitus, P.563-577.21: Diabetes Mellitus, P.563-577.

Rajesh V. Lalla, Joseph A. D’Ambrosio, Dental management Rajesh V. Lalla, Joseph A. D’Ambrosio, Dental management considerations for the patient with diabetes mellitus, J Am Dent considerations for the patient with diabetes mellitus, J Am Dent Assoc 2001;132;1425-1432.Assoc 2001;132;1425-1432.

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