You are on page 1of 4

JOURNAL OF DENTAL SCIENCES

Dr. Vimal Nayak M.D.S. Dr. Vasumati Patel M.D.S., Dr. Shalini Gupta M.D.S.

Volume 2 Issue 2

PERIODONTAL MANAGEMENT OF DIABETIC PATIENTS


Abstract At present there is strong evidence to suggest that the incidence and severity of periodontitis is influenced by the presence or absence of diabetes mellitus, as well as the degree to which the disease is controlled by patients. Other reports indicate that the existence of severe generalized periodontitis may adversely influence the control of underlying systemic disease. Further, several oral effects of undetected or poorly controlled diabetes mellitus have been identified and must be taken into consideration during treatment of diabetic patients with periodontal disease. The purpose of the article is to describe the periodontal management of diabetic patients. Key Words: Periodontitis, Diabetes Mellitus. Introduction The epidemiological data regarding diabetes mellitus coupled with the possible interrelationship between diabetes mellitus and periodontal disease suggests that all periodontist will encounter patients with diabetes mellitus and that clinicians who perform periodontal therapy must be especially aware and knowledgeable regarding this disease.1 The recently redefined diagnostic criteria of diabetes mellitus proposed by the Expert Committee of the American Diabetes Association has helped to clarify the nature and severity of the condition. Diabetes mellitus is considered to be present when sequential fasting plasma glucose levels are at between 110-126 mg/dl or 2-hour post-glucose loading plasma levels are at or above 200 mg/dl. Patients with diabetes mellitus symptoms and casual plasma glucose levels at or above 200 mg/dl should be retested on a subsequent day using fasting plasma glucose or 2-hour postglucose loading plasma levels.2 Type 1 diabetics experience b cell destruction of the islets of Langerhans of the pancreas, which may lead to an absolute insulin deficiency. Those individuals are dependent on insulin for metabolic control of their disease3 and may suffer from a more severe form of the disease, which features abrupt onset, increased frequency and severity of ketoacidosis, wider fluctuations in plasma glucose levels and possibly more severe systemic complications.4 Type 2 diabetes mellitus patients experience insulin resistance, with or without insulin deficiency. These individuals may experience a more gradual onset of signs and symptoms and may be less likely to develop ketoacidosis.5 Individuals with impaired fasting glucose demonstrate fasting plasma levels of 110126 mg/dl, while those with impaired glucose tolerance display 2-hour postglucose loading plasma levels between 140 mg/dl and 200 mg/dl. Impaired fasting glucose and impaired glucose tolerance are risk factors for future development of diabetes mellitus and cardiovascular diseases, but their relationship with periodontal disease or other oral features of diabetes mellitus has not been studied.2 Lecturer Professor Department of Periodontics, Faculty of Dental Science Dharmsinh Desai University, Nadiad - 387 001. Gujarat, India Periodontitis and systemic health Recent research has established that periodontal infection is a probable risk factor for cardiovascular disease, including atherosclerosis, myocardial infarction and stroke.20-22,24,27 For example, patients with severe periodontitis are almost twice as likely to have a fatal heart attack and three times as likely to have a stroke as patients without periodontal disease, even after adjusting for known cardiovascular risk factors such as blood lipids, cholesterol, body mass, diabetes and smoking.20,21 Furthermore, preliminary studies suggest that periodontitis may also contribute to adverse pregnancy outcomes, diabetes and other conditions.23,25,26,28 Currently, the aims of periodontal therapy are to prevent loss of the dentition, as well as restoration of periodontal form and function. No periodontal treatment protocols are available that are specifically designed to improve systemic health. One might wonder therefore whether the treatments used to prevent periodontal attachment and bone loss are also optimal for preventing systemic risk. We do not know whether the treatments to reduce the oral microbial and inflammatory burden of periodontitis and the clinical end-points that are currently used to manage periodontitis are sufficient or even appropriate to manage these systemic problems. Optimal treatments may be totally different for a high-risk individual. As an example, current periodontal maintenance programs may prevent attachment loss but may not be sufficient to prevent the inflammatory response leading to a heart attack in the susceptible individual. New information suggests that periodontal infection elicits a mild acute-phase response that changes systemic blood chemistry.28 Hemocytology data indicate that the dental profession must now embrace traditional medical diagnostic tools to manage the systemic sequela of oral infection. Periodontist of the future will need to understand routine medical diagnostic tests used to monitor patients with systemic conditions that are modified by oral infection. The impact of oral infection on systemic health thus further defines the new branch of periodontology termed periodontal medicine. Reducing the systemic risk associated Address for Correspondence : Dr. Vimal Nayak M.D.S. Department of Periodontics, Faculty of Dental Science, Dharmsinh Desai University, College Road, Nadiad - 387 001. Gujarat, India Contact no. 09727751791 E-Mail: drvim23912@yahoo.co.in 16

JOURNAL OF DENTAL SCIENCES


with periodontitis requires new diagnostic tools and a set of clinical guidelines for treatment. Periodontists are trained to save teeth, but clinical guidelines to manage oral infection to protect systemic health represent a gap in knowledge. Although the current therapies used to manage periodontitis may be adequate to simultaneously manage systemic sequelae, there have been no studies to measure the systemic impact of periodontal treatments. Oral manifestations of diabetes mellitus Oral manifestations of diabetes mellitus were first described more than 100 years ago6 and may be more severe in individuals with uncontrolled type 1 diabetes mellitus compared to those with uncontrolled type 2 diabetes mellitus.7 Several studies suggest, however, that patient age at onset of diabetes mellitus, duration of diabetes mellitus and degree of metabolic control may exert a greater influence on oral and systemic complications than the type of diabetes mellitus present,8 In poorly controlled or uncontrolled diabetes mellitus whole saliva and gingival crevicular fluid may contain increased quantities of glucose,9 which may in part alter plaque microflora with a resultant influence on the development of dental caries and possibly periodontal disease.10 Increased susceptibility to oral infection, including gingivitis, periodontitis and delayed wound healing, has been described.11 Pronounced gingival enlargement may be an early sign of diabetes mellitus onset, and some case reports describe marked improvement in periodontal and/or oral health when previously undiagnosed diabetes mellitus was recognized and metabolic control established.12 The periodontist should be especially alert to the possibility that an individual has undiagnosed or poorly controlled diabetes mellitus in the presence of multiple or recurrent periodontal abscesses, unexplained edematous gingival enlargement, rapid destruction of alveolar bone or delayed healing following periodontal or oral surgical procedures.13 Management of diabetic patients Patient evaluation As previously discussed, the dental practitioner is extremely likely to encounter periodontal patients who suffer from undiagnosed or poorly controlled diabetes mellitus or others who are diagnosed and well maintained. To properly evaluate periodontal patients, the periodontist must be aware of the general and oral signs and symptoms of diabetes mellitus. Appropriate dental practice requires a thorough oral examination and an appropriate medical history. The medical history format must include questions that elicit information regarding the patients family history of diabetes mellitus and any general symptoms that may raise the practitioners level of suspicion regarding this disease. The oral examination should identify oral features suggestive of diabetes mellitus, and the presence of any such features may indicate a need for medical consultation. Traditionally, urine glucose levels have been used as a screening mechanism. For the test to be positive, however, high blood glucose levels must be present and less severe blood glucose abnormalities may go undetected. The National Diabetes Data Group and the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus have published specific recommendations

Volume 2 Issue 2

for diabetic screening, including measurement of fasting plasma glucose, glucose tolerance tests and glycated hemoglobin.14 If the test is positive, medical referral is essential to establish the diagnosis. A simple screening test for dental patient evaluation is to obtain a fasting plasma glucose level (8 or more hours of fasting) alone or in combination with a 2-hour post-glucose loading plasma test to evaluate glucose utilization. Under ideal circumstances, the 2-hour post-glucose loading plasma test should include ingestion of a measured quantity of glucose. Home monitoring devices (glucometers) are commonly used by diabetes mellitus patients for frequent or daily monitoring of their blood glucose levels. To perform the test, a one or twodrop blood sample is obtained by finger stick, placed on a reagent strip and inserted into the reflector monitor, which determines the glucose level and displays the results. In the past this technique has been used in dental offices as a screening test for suspected diabetic individuals. The test is simple, inexpensive and reasonably accurate; however, current United States federal standards regarding regulation and inspection of medical laboratories preclude its use as a screening test for suspected diabetes mellitus patients unless the dental office has been approved as a medical laboratory. It should be noted, however, that known diabetic patients can perform the reagent strip procedure in the dental office using their own glucometer as a means of monitoring their diabetes mellitus status prior to an extensive periodontal or oral surgical treatment procedure or prior to treatment likely to disrupt the patients normal dietary routine.15 Management of known diabetic patients When the periodontist is called upon to provide periodontal therapy for a previously diagnosed diabetes mellitus patient, a certain amount of detailed information should be gathered. The patient should be questioned regarding the type of diabetes, the age at onset and duration of the disease; any current medications and their method of administration. The patients degree of compliance and monitoring technique should be discussed. The practitioner should review any previous history of diabetic complications, determine the most recent laboratory results and record the name and address of the patients physician(s). By gathering this information the clinician can best relate the patients oral condition to his or her systemic status and determine whether or not medical consultation is required. Under most circumstances it would be prudent to obtain medical clearance prior to performing any extensive periodontal therapy, especially if surgery is indicated.16 In most instances the well-controlled type 1 or type 2 patient can be managed in a manner consistent with a healthy non-diabetic individual.17 Periodontal surgical procedures can be performed, although it must be assured that the patient can maintain a normal diet post-surgically. In the event that the treatment procedure modifies the patients dietary habits, dietary supplements should be recommended. Supportive periodontal therapy should be provided at relatively close intervals (2 to 3 months) since some studies indicate a slight but persistent tendency to progressive periodontal destruction despite effective metabolic diabetes mellitus control.16 17

JOURNAL OF DENTAL SCIENCES


It should be remembered that inadequate diabetes mellitus control can adversely affect the severity of the periodontal disease response, the patients wound healing capacity and the ability of the patient to withstand both emotional and physical stress. The clinician should insist that the patient achieve and sustain a highly effective level of oral physiotherapy, and in most instances a nonsurgical approach to periodontal therapy is preferred, with or without the use of appropriate antibiotic therapy. In the event that antibiotic therapy is anticipated, microbiological testing to identify putative periodontal pathogens is suggested.17 Management of uncontrolled or poorly controlled diabetic patients The uncontrolled or poorly controlled diabetic patient or the diabetes mellitus patient who does not know his or her control status should not receive elective dental treatment until the condition is stabilized or medical clearance obtained.17 Prophylactic antibiotic therapy should be used for performing emergency oral or periodontal surgical procedures to minimize the potential for postoperative infections and delayed wound healing.18 Periodontal therapy other than emergency treatment may be contraindicated in the poorly controlled diabetes mellitus patient until appropriate metabolic controlled is achieved. In many instances this may require short- or long-term prescription of insulin or oral medications by the physician. The physician should be made aware of recent controlled studies that indicate that periodontal therapy may facilitate metabolic control of diabetes mellitus and, when possible, a coordinated medicaldental plan of action should be implemented to achieve optimum patient health.19 Periodontal therapy The well-controlled diabetes mellitus patient with periodontal disease is often an acceptable candidate for complete periodontal therapy, including surgical procedures when indicated.17 As discussed previously, however, the presence of medical complications associated with diabetes mellitus should be carefully evaluated and considered in any periodontal therapeutic decision.18 In most instances periodontal surgical therapy should be carefully planned and coordinated with the patients physician to insure minimal disruption of metabolic diabetes mellitus control. Most authorities recommend that periodontal surgery be scheduled in the morning after breakfast and medication administration.18 Treatment procedures should be short (2 hours or less), as atraumatic as possible and should not significantly interfere with the patients normal dietary intake.19 Patient anxiety should be managed to minimize endogenous epinephrine release, because epinephrine may increase insulin utilization and deplete insulin levels more quickly.16 In most instances preoperative oral sedation is suitable for this purpose.19 In the event that general anesthesia or intravenous conscious sedation techniques are necessary or if extensive surgical procedures are likely to alter the patients dietary intake, then changes in the type 1 patients insulin intake may be necessary under the guidance of the patients physician. Decisions regarding the prophylactic use of antibiotics in conjunction with periodontal surgery are best made on a case by- case basis since there is

Volume 2 Issue 2

no evidence-based information to indicate that antibiotic premedication is necessary.16 The poorly controlled type 1 patient is not a good candidate for periodontal therapy other than necessary emergency services. Medical coordination is probably indicated for any type of periodontal therapy and hospitalization may be required for emergency care. If time permits, microbiological testing is desirable to identify putative periodontal pathogens prior to antibiotic therapy. If stable metabolic control is achieved, routine periodontal therapy may be considered with close medical monitoring.1 In general, all diabetes mellitus patients should be encouraged to maintain meticulous oral hygiene and to receive supportive periodontal therapy at intervals necessary to sustain a high level of periodontal health.15 Conclusion Diabetes mellitus is a common medical disorder that will be encountered by every periodontist. Knowledge by the periodontist of the general and oral signs and symptoms of undiagnosed or poorly controlled diabetes mellitus are essential, and patients displaying these signs or symptoms should receive medical referral. Patients suspected, or known to suffer from undiagnosed or uncontrolled diabetes mellitus should receive only emergency care until their health status has been properly evaluated. In the event the degree of control of a known diabetic is unknown or the patient is poorly controlled, antibiotic therapy should be administered in conjunction with any necessary surgical procedure or in the presence of oral infection. The periodontist must be prepared to manage diabetic emergencies should they occur in the dental office, and hypoglycemic incidents are most likely. Under most circumstances, the well-controlled diabetes mellitus patient can receive safe and effective periodontal therapy with some modification of office protocol, and there is little reason to anticipate that the controlled diabetes mellitus patient cannot look forward to a lifetime of periodontal health if proper and timely periodontal therapy is rendered and the patient maintains effective oral hygiene measures accompanied by appropriate supportive periodontal recall therapy. References: 1. Mealey BL. Impact of advances in diabetes care on dental treatment of the diabetic patient. Compendium Contin Educ Dent 1998: 19: 4158. 2. American Diabetes Association. Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Committee report. Diabetes Care 1997: 20: 11831197. 3. American Diabetes Association. Position statement. Implications of the diabetes control and complications trial. Diabetes Care 1997: 20(suppl 20): S62S64. 4. Murrah VA. Diabetes mellitus and associated oral manifestations: a review. J Oral Pathol 1985: 4: 272281. 5. Atkinson MA, Maclaren MK. What causes diabetes? Sci Am 1990: 263: 6271. 6. Albrecht M, Banoczy J, Tamas G Jr. Dental and oral symptoms of diabetes mellitus. Community Dent Oral Epidermiol 1988: 16: 378380. 18

JOURNAL OF DENTAL SCIENCES


7. Ureles SD. Case report: a patient with severe periodontitis in conjunction with adult-onset diabetes. Compendium Contin Educ Dent 1983: 4: 522528. Glavind L, Lund B, Loe H. The relationship between periodontal state, diabetes duration, insulin dosage and retinal changes. J Periodontol 1968: 39: 341347. Ficara AJ, Levin MP, Grower MF, Kramer GD. A comparison of the glucose and protein content of gingival fluid from diabetics and non-diabetics. J Periodontal Res 1975: 10: 171175. Hallmon WW, Mealey BL. Implications of diabetes mellitus and periodontal disease. Diabetes Educ 1992: 18: 310315. Akintewe TA, Kulasekara B, Adetuyibi A. Periodontitis diabetica: a case report from Nigeria. Trop Geogr Med 1984: 36: 8586. Archer CB, Rosenberg WMC, Scott GW, MacDonald DM. Progressive bacterial synergistic gangrene in a patient with diabetes mellitus. J R Soc Med 1984: 77(suppl 4): 13. Rees TD. The diabetic dental patient. Dent Clin North Am 1994: 38: 447463. National Diabetes Data Group. Diabetes in America. NIH Publication No. 95-1468. Washington, DC: NIH, 1995: 11 13, 37. Montgomery MT, Rees TD, Moncrief JW. The diagnosis and management of the diabetic patient: implications for dentistry. Austin, TX: Department of Health, 1992. Rees TD, Otomo-Corgel J. The diabetic patient. In: Wilson TG, Kornman KS, Newman MG, ed. Advances in periodontics. Chicago: Quintessence Publishing, 1992: 278 295. Mealey BL. Periodontal implications: medically compromised patients. Ann Periodontol 1996: 1: 256326. American Dental Association. Council of Access, Prevention and Interpersonal Relations. Patients with diabetes. Chicago: American Dental Association, 1994: 117.

Volume 2 Issue 2

8.

9.

10.

11.

12.

13. 14.

15.

16.

17.

19. Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993: 329: 977986. 20. Beck JD, Garcia RG, Heiss G, Volconos P, Offenbacher S. Periodontal disease and cardiovascular disease. J Periodontol 1996: 67(suppl): 11231137. 21. Beck JD, Offenbacher S, Williams RC, Gibbs P, Garcia R. Periodontitis: a risk factor for coronary heart disease? Ann Periodontol 1998: 3: 127141. 22. DeStefano F, Anda LF, Kahn HS, Williamson DF, Rasell CM. Dental disease and risk of coronary heart disease and mortality. BMJ 1993: 306: 688691. 23. Grossi SG, Genco RJ. Periodontal disease and diabetes mellitus: a two-way relationship. Ann Periodontol 1998: 3: 5161. 24. Mattila KJ, Niemeier MS, Valtonen VV, Rasi VP, Kesaniemi YA, Syrjala SL, Jungell PS, Isoluoma M, Hietaniemi K, Jokinen MJ. Association between dental health and acute myocardial infarction. BMJ 1989: 298: 779782. 25. Offenbacher S, Beck JD, Lieff S, Slade G. Role of periodontitis in systemic health: Spontaneous preterm birth. J Dent Ed 1998: 62: 852858. 26. Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, McKaig R, Beck J. Periodontal disease as a possible risk factor for preterm low birth weight. J Periodontol 1996: 67(suppl): 11031113. 27. Scannapieco FA. Position paper. Periodontal disease as a potential risk factor for systemic diseases. J Periodontol 1998: 69: 841850. 28. Soskolne WA. Epidemiological and clinical aspects of periodontal diseases in diabetics. Ann Periodontol 1998: 3: 3 12.

18.

19

You might also like