DIABETES & PERIODONTAL DISEASES PART 1.pptx

DIABETES & PERIODONTAL DISEASES PART 1.

1. DIABETES & PERIODONTAL DISEASES PART1 21-04-2022 1 DR SINDHURA DEPT. OF PERIODONTICS

2. CONTENTS Introduction Epidemiology Classification Classic complications of diabetes Clinical presentation and diagnosis of diabetes Oral manifestations of diabetes mellitus Mechanisms by which diabetic influence on periodontium Mechanisms by which periodontal disease influence on diabetes Management of diabetic patient Emergencies Diabetes and implant considerations Conclusion 21-04-2022 2

3. 21-04-2022 3 INTRODUCTION

4. 21-04-2022 4 Diabetes is understood by few & ignored by many - Martin Silnik With the current global epidemic of this condition, it is important that the clinician should have background knowledge of diabetes and its implications for dental care so that barriers to treatment can be avoided

5. 21-04-2022 5 WHAT IS DIABETES? Insulin is a hormone produced in beta cells of islets of Langerhans within the pancreas It is released directly into blood stream

6. 21-04-2022 6 Definition Diabetes mellitus is a clinically and genetically heterogeneous group of metabolic disorders manifested by abnormally high levels of glucose in the blood.

7. 21-04-2022 7 Epidemiology

8. 21-04-2022 8 WORLD & DIABETES

9. 21-04-2022 9 India and Diabetes

10. 21-04-2022 10 Physiology of glycemic control

11. Etiologic classification of diabetes mellitus † I. Type 1 diabetes A. Immune mediated B. Idiopathic II. Type 2 diabetes III. Other specific types A. Genetic defects of β -cell function B. Genetic defects in insulin receptor C. Diseases of the exocrine pancreas D. Endocrinopathies E. Drug- or chemical-induced F. Infections G. Uncommon forms of immune-mediated diabetes H. Other genetic syndromes sometimes associated with diabetes IV. Gestational diabetes mellitus (GDM) V . Impaired glucose tolerance , impaired fasting glucose Position statement in Diabetes Care; American Diabetic Association 2004 21-04-2022 11

12. TYPE 1 DIABETES MELLITUS 21-04-2022 12

13. Type 1 Diabetes 21-04-2022 13

14. TYPE 2 DIABETES MELLITUS 21-04-2022 14

15. Pathogenesis of type II DM 21-04-2022 15

16. Syndrome X OR Metabolic Syndrome 21-04-2022 16

17. Impaired Glucose Tolerance & Impaired Fasting Glucose 21-04-2022 17

18. Gestational Diabetes Usually in 3 rd trimester of pregnancy Overweight women >25 years age Family history of diabetes Increases perinatal morbidity and mortality After 6 weeks of parturition, reclassification is done. Most women become normoglycemic 30-50% develops Type 2 diabetes within 10 years 21-04-2022 18

19. 21-04-2022 19

20. Assessment of Glycemic Control 21-04-2022 20

21. MONITORING THE STATE OF DIABETES Blood sugar Glycosylated hemoglobin (HbA1c) Urine tests 21-04-2022 21

22. HOME BLOOD GLUCOSE MONITORING 21-04-2022 22

23. URINE TESTS Once the primary diagnostic tool Used most frequently for Type I Diabetes and Gestational diabetes Urine dip stick test Presence of glucose in the urine is detected by the generation of color changes on urine reagent strips. Ketone reagant strips detect ketone bodies in Urine 21-04-2022 23

24. GLYCEMIC CONTROL AND PERIODONTITIS Fasting and casual plasma glucose and OGTT – allow determination of glycemia at the moment in time when blood sample is drawn – not allow for evaluation over an extended time period It is a test that reveal long term glucose control. Primary test used is glycosylated hemoglobin assay (Hb A1c) This reflects blood glucose level over the preceding 6-8 weeks and may provide indication of potential response to periodontal therapy. Relatively well controlled diabetics i.e HbA1c <8% usually respond like nondiabetic patient after treatment HbA1c >10% - poor response to t/t HbA1c<10% should be established before surgical t/t is performed 21-04-2022 24

25. GLYCOSYLATED HEMOGLOBIN Binding of glucose to hemoglobin is highly stable; thus, hemoglobin remains glycated for the life span of the erythrocyte, approximately 123 ± 23 days. 21-04-2022 25

26. 21-04-2022 26

27. DIAGNOSIS Casual glucose >200mg/dl +symptoms Fasting plasma glucose >126 mg/dl 2 hour post glucose >200mg/dl 21-04-2022 27

28. SIGNS & SYMPTOMS 21-04-2022 28

29. Complication of DM 21-04-2022 29

30. 21-04-2022 30

31. Pathophysiology of Diabetes Symptoms and complications 21-04-2022 31

32. Advanced Glycosylation End products Reversible Irreversible Receptor for AGE 21-04-2022 32

33. Characterstics of advanced glycation end products 21-04-2022 33

34. AGE on collagen Increased crosslinking Formation of highly stable collagen macromolecules Resistent to normal enzyme degradation & tissue turnover Accumalation of proteins If occurs in blood vessels Modified collagen accumalates In microvasculature  thickening of vessel wall  narrowed lumen Circulating LDL immobilized in presence of AGE modified collagen Increased LDL – collagen crosslinking  atheroma formation In small vessels– AGE accumalates on BM BM thickening altered normal homeostasis – transport across membrane 21-04-2022 34

35. At cellular level- Receptors for AGE Expressed on certain cells sustained hyperglycemia increased RAGE- AGE interactions On endothelial cells Increased vascular permeability In smooth muscle cells  increased proliferation In monocytes macrophages  chemotaxis increased Cell oxidant stress 21-04-2022 35

36. Signs and Symptoms Polyphagia Polydypsia Polyurea Blurry vision Dry mouth , dry skin Fatigue Unexplained loss of weight Tingling or pain in feet or legs Wounds that do not heal quickly Sexual dysfunction 21-04-2022 36

37. Oral Diseases and Diabetes 21-04-2022 37

38. Oral manifestations and complications 21-04-2022 38

39. Oral Manifestations 21-04-2022 39

40. Oral Manifestation Cracking of Oral Mucosa Increased tooth sensitivity Enlarged gingiva Sessile or pedunculated gingival polyps ,periodontitis and loosened teeth 21-04-2022 40

41. ORAL MANIFESTATIONS OF DIABETES Accumulation of dental plaque & food debris Burning mouth / tongue Altered taste sensation Neutrophil & Macrophage function altered Immunological deficiency Microangiopathy and ultilisation of protein for energy  retard repair of tissues. prevalence of dry socket. Drug side-effects : lichenoid reaction may be associated with sulphonylurea . ( chlopropamide ) 21-04-2022 41

42. Oral manifestations and complications No specific oral lesions associated with diabetes. However, there are a number of issues of concern Oral neuropathies Burning tongue Depapillation and fissuring of the tongue. (Martin Gillis et al 2003) 21-04-2022 42

43. Oral manifestations and complications 21-04-2022 43 Increased risk of infection

44. Oral manifestations and complications Delayed healing of wounds Due to microangiopathy and utilization 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 21-04-2022 44

45. 21-04-2022 45 Part II

46. CONTENTS Introduction Epidemiology Classification Classic complications of diabetes Clinical presentation and diagnosis of diabetes Oral manifestations of diabetes mellitus Mechanisms by which diabetic influence on periodontium Mechanisms by which periodontal disease influence on diabetes Management of diabetic patient Emergencies Diabetes and implant considerations Conclusion 21-04-2022 2

47. Diabetes and Periodontal Diseases 21-04-2022 47

48. Periodontal disease in diabetic patients follows no consistent / distinct pattern 21-04-2022 48

49. Cianciola et al 1982 Periodontitis in type I --appears to start after 12 yrs Localized to 1 st molars , incisors Periodontal disease in diabetics follows no consistent pattern of destruction severe inflammation , deep periodontal pockets , frequent periodontal abscesses- in poor controlled diabetics Caarraro et al 1978- similar destuction in non-diabetics and diabetics upto 30 yrs 21-04-2022 49

50. MECHANISMS BY WHICH DIABETES MAY INFLUENCE PERIODONTIUM 21-04-2022 50

51. 1. GCF GLUCOSE LEVEL Twice amount of glucose in GCF of diabetic patients ( Ficara et al JPR 1975 ) 21-04-2022 51

52. 2. SUBGINGIVAL MICROBIOTA Type I DM Capnocytophaga P.intermedia P.gingivalis Type II DM A.A P.intermedia C.rectus P.gingivalis Gusberti et al 1982 21-04-2022 52

53. 21-04-2022 53 Edward et al 2010 The glucose content of GCF modifity proportion of certain species within the biofilm

54. Adherence Chemotaxis Phagocytosis Inflammatory mediators Neutrophil – 1 st line defence 3. EFFECT ON HOST RESPONSE 21-04-2022 54

55. ADVANCED GLYCATION END PRODUCTS Highly stable collagen macromolecules 21-04-2022 55

56. 21-04-2022 56 NISHIMURA et al 2007

57.     Hyperglycemia   Glycosylation of basement membrane proteins   Thickening of basement membrane   Altered structural and physical properties of BM   Disruption of collagen fibers in BM, swelling of endothelium   Impedes oxygen diffusion, metabolic waste elimination   Susceptibility to infection 4.EFFECT ON THE MICROVASCULAR SYSTEM 21-04-2022 57 Brownlee et al 1994

58. 5. COLLAGEN METABOLISM Chronic microbial wounding of periodontium 21-04-2022 58

59. MECHANISM BY WHICH PERIODONTAL DISEASE MAY INFLUENCE ON DIABETES Increase in insulin resistance & poor glycemic control Treatment that reduces periodontal inflammation may restore insulin sensitivity & improved glycemic control Increased CRP, IL-6, TNF- α + Endotoxins Increased CRP, IL-6 , TNF- α  worsen insulin resistance Treatment that reduces inflammatory markers may restore insulin sensitivity & improved glycemic control 21-04-2022 59

60. TREATMENT FOR DIABETICS American diabetes association has given standards of care to guide treatment  achieve HbA1c levels <7% 21-04-2022 60

61. MEDICATIONS NEWLY APPROVED AGENTS Amylin analogues ( Pramilintide ) Secreted by beta cells Modulates gastric emptying Prevent post prandial rise Exenedin -4 ( Incretin Hormone) Mimics incretin hormones of mammals Enhances insulin secretion Slows gastric emptying Reduces body weight 21-04-2022 61

62. INSULIN Indications : Type 1 diabetics In type II patients with insulinopenia in whom diet and oral agents are inadequate to attain target glycemic control. Women with gestational diabetes mellitus who are not controlled with diet alone 21-04-2022 62

63. PERIODONTAL MANAGEMENT CONSIDERATIONS To minimize the risk of an intraoperative emergency, periodontist need to consider the following before initiating dental treatment 21-04-2022 63

64. Morning appointments Determine the exact type being used, onset and peak activity. Prescribed insulin and medications have been taken, followed by a meal If pt took usual dosage of insulin in morning – but then failed to eat or ate lighter breakfast than usual – high risk of hypoglycemia MANAGEMENT OF KNOWN DIABETIC PATIENT 21-04-2022 64

65. Well controlled diabetics can be treated similar to nondiabetics , most dental procedures should be short, atraumatic 21-04-2022 65

66. POST OPERATIVE MANAGEMENT Normal diet post-surgically. Dietary supplements. Supportive periodontal therapy should be provided at relatively close intervals (2 to 3 months) 21-04-2022 66

67. In many instances, the type 2 patient is not well controlled by rigid standards, yet the patient’s physician will provide medical clearance to perform periodontal therapy because the patient is likely to tolerate the procedure without undue difficulty. In this circumstance, the periodontist should proceed with caution since the treatment outcome may be compromised. It should be remembered that inadequate diabetes mellitus control can adversely affect The severity of the periodontal disease response, The patient’s wound healing capacity The ability of the patient to withstand both emotional and physical stress. 21-04-2022 67

68. MANAGEMENT OF UNCONTROLLED DIABETIC PATIENTS 21-04-2022 68

69. EMERGENCIES Much more likely to be encountered in the dental office than other complications severe hypoglycemia is a life-threatening Hypoglycemia is the result of absolute or relative therapeutic insulin excess and compromised glucose counter-regulation . Blood glucose falls- insulin decreases Increase in glucagon and epinephrine In diabetics-Physiological response to decreasing blood glucose decreases over time Hypoglycemia unawareness Normal release of above hormones do not occur So severe hypoglycemia without warning Hypoglycemia 21-04-2022 69

70. Signs and symptoms of hypoglycemia Confusion Shakiness, tremors Agitation Anxiety Diaphoresis Dizziness Tachycardia Feeling of impending doom Seizures Loss of consciousness 21-04-2022 70

71. DIABETIC KETOACIDOSIS Most common life threatening hyperglycemic emergency Insulin requirement - type 1 diabetic patients during periods of physiological stress Metabolic abnormality - hyperglycemia and metabolic acidosis. 21-04-2022 71

72. Management includes Continuous intravenous infusion of regular ( shortacting ) insulin Fluid replacement. Electrolyte replacement for potassium and phosphate is also required. Identification and treatment of the underlying precipitating condition that triggered the diabetic ketoacidotic event. 21-04-2022 72

73. 21-04-2022 73 Wound healing after periodontal therapy in diabetics

74. 21-04-2022 74 well-controlled diabetes mellitus - respond to non-surgical periodontal therapy The clinical findings were supported by an intact PMN function and similar microbiological changes. Cliristgiiu M et al 1998

75. 21-04-2022 75 Arya et al 2017 Diabetes mellitus may have a negative impact on the outcome of endodontic treatment in terms of periapical healing. Nonsurgical endodontic treatment did not improve HbA1c levels in patients with type 2 diabetes.

76. 21-04-2022 76 Retamal et al 2020 Diabetic wound healing decreased epithelial and connective tissue healing, increased levels of inflammation biofilm formation. Myofibroblast differentiation was delayed in diabetic periodontal wounds at early time points. However, myofibroblasts persisted at later time points of healing. The present study suggests that diabetes alters the involvement of myofibroblasts during periodontal wound healing

77. 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 21-04-2022 77

78. DIABETIC DISTURBANCES IN IMPLANT WOUND HEALING 21-04-2022 78

79. “ DENTAL IMPLANTS AND DIABETES ! ” 21-04-2022 79

80. CONCLUSION With the current rise in number of people with diabetes, it is important for the clinician to have a background understanding of this condition Dentist plays a major role in oral hygiene education . The knowledgeable diabetic patient can be a great source of information as to how treatment can be best managed. 21-04-2022 80

81. Patients should be made aware of the periodontitis -diabetes inter relationship The relationship between these two maladies appears bi-directional/ two way in so far that the presence of one condition tends to promote the other, and that the meticulous management of either may assist treatment of the other. When diabetes is combined with other conditions eg cardiovascular, nervous disorders, then multidisciplinary approach with the diabetes care team or GP would help to ensure the optimum treatment for this group of people. 21-04-2022 81

82. REFERENCES Carranza, Newman-Clinical Periodontology. 11th edition. Mealey L & Ocampo G. Diabetes mellitus and periodontal disease. Periodontology 2000 2007;44:127–153. W. Aubrey Soskolne , Avigdor Klinger. The relationship between periodontal diseases and diabetes : an overview. Ann Periodontol 2001;6:91-98. Anthony M. Iacopina . Periodontitis and diabetes interrelationships: Role of inflammation. Ann Periodontol 2001;6:125-137. 21-04-2022 82

83. Brian L Mealey and Thomas W Oates. Diabetes and periodontal diseases. J Periodontol 2006 ;77 :1289-1303 Taylor G. Bidirectional relationship between diabetes and periodontal diseases: an epidemiologic perspective. Ann Periodontal 2001;6:99-112. Fiorellini J and Nevins M. Dental Implant considerations in the diabetic patient. Perio 2000 2000;23:73-77 Flemming F etal ; Implants In Medically Compromised Patients ; crit review oral biol med 2003;14;4: 305 -316 21-04-2022 83

84. Arya S, Duhan J, Tewari S, Sangwan P, Ghalaut V, Aggarwal S. Healing of Apical Periodontitis after Nonsurgical Treatment in Patients with Type 2 Diabetes. J Endod . 2017 Oct;43(10): 1623-1627 . Balci Yuce H, Karatas Ö, Tulu F, Altan A, Gevrek F. Effect of diabetes on collagen metabolism and hypoxia in human gingival tissue: a stereological, histopathological, and immunohistochemical study. Biotech Histochem . 2019 ;94(1): 65-73 . 21-04-2022 84