Diabetes mellitus & Periodontium

relation between diabetes and periodontium

1. Presented by: Dr. Yogender Singh Under the guidance of: Dr. H S Grover & Faculty DIABETES AND PERIODONTIUM

2. CONTENTS INTRODUCTION DEFINITIONS HISTORY EPIDEMIOLOGY CLASSIFICATION DIAGNOSIS INSULIN & DIABETES CLASSICAL SIGNS, SYMPTOMS & COMPLICATIONS OF DM DIABETES AND PERIODONTAL DISEASE DENTAL THERAPY CONSIDERATIONS CONCENSUS REPORT- EFP/AAP JOINT WORKSHOP CONCLUSION REFRENCES

3. INTRODUCTION Diabetes mellitus represents a spectrum of metabolic disorders and has emerged as a major health issue worldwide. It is a complex metabolic disease characterized by: Chronic hyperglycemia , Diminished insulin production , Impaired insulin action , or a combination of both Result in the inability of glucose to be transported from the bloodstream into the tissues, which in turn, results in high blood glucose levels and excretion of sugar in the urine. Alteration in lipid and protein metabolism.

4. DEFINITIONS International Diabetes Federation (IDF) describes Diabetes as a chronic disease that arises when the pancreas does not produce enough insulin, or when the body cannot effectively use the insulin it produces.   According to Carranza, DM is defined as a complex metabolic disorder characterized by chronic hyperglycaemia, diminished insulin production, impaired insulin action or a combination of both result in the inability of glucose to be transported from the blood stream into the tissues, which in turn results in high blood glucose levels and excretion of sugar in the urine.

5. HISTORY Diabetes is one of the first diseases described with an Egyptian manuscript from 1500 BC mentioning “too great emptying of the urine.” The term diabetes was probably coined by Apollonius of Memphis around 250 BC, which literally meant “to go through” or siphon as the disease drained more fluid than a person could consume. Later on, the Latin word “mellitus” was added because it made the urine sweet. 5

6. Sir Frederick Grant Banting , Charles Herbert Best and colleagues purified the hormone insulin from bovine pancreas at the University of Toronto. Leading to the availability of an effective treatment—insulin injections and the first patient was treated in 1922. For this, Banting and laboratory director John MacLeod received the Nobel Prize in Physiology or Medicine in 1923. 6

7. EPIDEMIOLOGY According to International Diabetes Federation (2012), there are more than 371 million people in world who have diabetes. The number of people with diabetes is increasing in every country in which half of people with diabetes are undiagnosed. The estimate of the actual number of diabetics in India is around 40 million.

8. CLASSIFICATIONS National Diabetes Data Group(1979)- on the basis of age at onset and type of therapy: TYPE I- Insulin dependent DM (IDDM) or Juvenile Diabetes TYPE II- Non insulin dependent DM (NIDDM) or Adult onset Diabetes

9. American diabetic association (1997) DM is classified on the basis of pathophysiology of DM into 4 categories: Type 1 Type 2 Other Specific types of DM Gestational diabetes

10. CARBOHYDRATE METABOLISM, INSULIN AND DIABETES

11. BLOOD GLUCOSE HOMEOSTASIS

12. ACTIONS OF INSULIN

13. Characteristics of Type I and Type II Diabetes

14. OTHER SPECIFIC TYPES Those associated with diseases that involve the pancreas and destruction of insulin producing cells. Endocrine diseases such as acromegaly , tumors, pancreatectomy and drugs or chemicals are included.

15. GESTATIONAL DIABETES Under normal conditions insulin secretion is increased by 1.5 to 2.5 fold during pregnancy reflecting a state of insulin resistance Gestational diabetes develops in 2% to 5% of all pregnancies but disappears after delivery. Women who have had gestational diabetes are at increased risk of developing type 2 diabetes later in life. It usually has its onset in the third trimester of pregnancy and adequate treatment will reduce perinatal abnormality.

16. LABORATORY DIAGNOSIS BLOOD TESTING GLUCOSE

17. LABORATORY DIAGNOSIS 2. Glycated Hemoglobin

18. URINE TESTING 1. GLUCOSE Testing the urine for glucose with dipsticks is a common screening procedure for detecting diabetes. 2. KETONES Ketone bodies can be identified by the nitroprusside reaction, which measures acetoacetate , using either tab­lets or dipsticks. 3. PROTEIN Standard dipstick testing for albumin detects urinary albumin at concentrations > 300mg/L

19. CLASSICAL SIGNS & SYMPTOMS It includes polydypsia , polyphagia , polyuria, pruritis , weakness & fatigue. (More common on type 1) occur in varying degree in type 2 DM. Type 1 DM may associated with Weight loss, Ketoacidosis Restlessness, irritability & apathy may become evident.

20. THE CLASSIC COMPLICATIONS OF DM Diabetic Retinopathy Diabetic Neuropathy Diabetic Nephropathy Atherosclerosis Impaired wound healing Periodontal disease ( Loe H 1993)

21. DIABETES & PERIODONTIUM ORAL MANIFESTATIONS: Diminished salivary flow Burning mouth & tongue Enlargement of parotid gland (Alteration in basement mem .) Cheilosis Alterations in flora of oral cavity (Predominance by Candida albicans ) Increase rate of dental caries

22. PERIODONTAL MANIFESTATIONS Hirchfeld I (1934) Tendency towards enlarged gingiva. Sessile/ pedunculated gingival polyps. Ploypoid gingival proliferations Abscess formation Periodontitis Loosened teeth

23. Factors Potentially Contributing to Development of Periodontal Disease

24. Polymorphonuclear leukocyte function Impaired Chemotaxis & adherence Defective Phagocytosis Diminished primary defense against periodontal pathogens.

25. Collagen Metabolism Reduced synthesis of collagen & glycosaminoglycans Reduced collagen maturation Collagen homeostasis- Affected GCF collagenase activity increased Hyperglycemic state

26. ADVANCED GLYCATION END PRODUCTS (AGEs) Hyperglycemic state Non enzymatic Glycosylation of proteins and matrix molecules

27. AGEs Plays central role in diabetic complications . Alter functions of extracelluar matrix . Affects collagen stability and vascular integrity. AGEs formation on collagen Increased crosslinking between collagen molecules Reduced solubility . Decreased turn over rate .

28. AGEs + Macrophages & Monocytes Increased Secreation of IL-1, IGF, TNF ἀ AGEs AGEs + Endothelial cells Focal thrombosis Vasoconstriction Pre- coagulatory changes Hyper-cellular state

29. AGEs AND PERIODONTIUM

30. 2- WAY RELATIONSHIP BETWEEN PERIODONTAL DISEASE AND DM

31. PATHOGENESIS OF PERIODONTITIS IN DIABETES Taylor JJ. JOP 2013

32. LINKAGE BETWEEN INFECTION,HYPERLIPIDEMIA & INSULIN RESISTANCE

33. INFECTIONS IN PATIENTS WITH DIABETES Mainly due to: Impaired defence mechanism Defects in PMN function Induction of insulin resistance Vascular changes Hyperglycemic state Glycosylation of basement mem , proteins Thickning of gingival capillaries, Disruption of BM Swelling of Endothelium Oxygen diffusion Metabolic waste elimination PMN Migration Diffusion of serum factors Impeded

34. WOUND HEALING Wound Healing is Affected as cumulative effect of: Altered cellular activity Decreased collagen synthesis Glycosylation of existing collagen Increase collagenase production Readily degrade newly synthesized, less completely cross linked collagen Reduced Collagen solubility Delayed remodelling of wound site Defective Healing

35. BACTERIAL ASSOCIATION Glucose content of GCF & blood is higherin diabetics. Results in changed environment fo the microflora Presence of higher levels of specific microorganisms such as Actinobacillus actinomycetemcomitans and Capnocytophaga . ( Mashimo et al 1983) The proportion of P gingivalis was reported to be higher in non-insulin-dependent diabetes mellitus patients with periodontitis. This may be due to the abnormal host defense mechanisms in addition to hyperglycemic state can lead to the growth of particular fastidious organisms. ( Zambon et al,1988)

36. EFFECT OF DIABETES ON PERIODONTITIS Data of multiple studies reveal strong evidence Diabetes is a risk factor for gingivitis & periodontitis . The level of glycemic control appears to be an important determinant in this relationship. Cianciola et al 1982 In children with type 1 diabetes, the prevalence of gingivitis was greater than in non-diabetic children with similar plaque levels. Sastrowijoto S et al 1990 Improvement in glycemic control may be associated with decreased gingival inflammation . Papapanou PN 1996 Majority of the studies demonstrate a more severe periodontal condition in diabetic adults than in adults without diabetes. Tsai C et al 2002 In a large epidemiologic study in the United States, adults with poorly controlled diabetes had a 2.9-fold increased risk of having periodontitis compared to non-diabetic adult subjects ; conversely,well -controlled diabetic subjects had no significant increase in the risk of periodontitis . Salvi GE et al 2005 Rapid and pronounced development of gingival inflammation in relatively well-controlled adult type 1 diabetic subjects than in non-diabetic controls, despite similar levels of plaque accumulation and similar bacterial composition of plaque, suggesting a hyperinflammatory gingival response in diabetes.

37. EFFECT OF PERIODONTAL DISEASE ON DIABETES Periodontal diseases can have a significant impact on the metabolic state in diabetes. The presence of periodontitis increases the risk of worsening of glycemic control over time. Williams RC Jr., Mahan CJ. 1960 Type 1 diabetic patients with periodontitis had a reduction in required insulin doses following scaling and root planing , localized gingivectomy , and selected tooth extraction combined with systemic procaine penicillin G and streptomycin Taylor GW et al 1996 In a 2-year longitudinal trial, diabetic subjects with severe periodontitis at baseline had a six-fold increased risk of worsening of glycemic control over time compared to diabetic subjects without periodontitis Rodrigues DC et al 2003 Better improvement in glycemic control in a diabetic group treated with scaling and root planing alone compared to diabetic subjects treated with scaling and root planing plus systemic amoxicillin/clavulanic acid. Promsudthi A et al 2005 In older, poorly controlled type 2 diabetic subjects who received scaling and root planing plus adjunctive doxycycline showed a significant improvement in periodontal health but only a non significant reduction in HbA1c values.

38. MECHANISM BY WHICH PERIODONTAL DISEASE MAY INFLUENCE DIABETES

39. EFFECTS OF DIABETES ON THE RESPONSE OF PERIODONTAL THERAPY Many diabetic patients show improvement in clinical parameters of disease immediately after therapy, patients with poorer glycemic control may have a more rapid recurrence of deep pockets and a less favorable long-term response. Further longitudinal studies of various periodontal treatment modalities are needed to determine the healing response in individuals with diabetes compared to individuals without diabetes.

40. CURRENT MEDICAL MANAGEMENT OF DIABETES MELLITUS DIET : The goals of this intervention include weight reduction, improved glycemic control, with blood glucose levels in the normal range, and lipid control. Exercise : Regular physical exercise to weight reduction, increased cardiovascular fitness, and physical working capacity.

41. 3.Pharmacological therapy :

42. Anti-AGE Therapies It include Aminoguanidine , ALT-946, ALT 711, Statins ( Cervistatin ) Pyridoxamine , the natural form of vitamin B6, is effective at inhibiting AGEs at 3 different levels. prevents the degradation of protein- Amadori intermediates to protein-AGE products. In diabetic rats, pyridoxamine reduces hyperlipidemia and prevents AGE formation. scavenges the carbonyl byproducts of glucose and lipid degradation Benfotiamine , a lipid-soluble thiamine derivative, inhibits the AGE formation pathway.

43. DENTAL THERAPY CONSIDERATIONS Patients with well-controlled diabetes can often be treated in a similar way to non-diabetic patients. Communicate with patient’s physician to obtain control of blood glucose levels Control acute infections. As aggravated glycemic control increases the risk of micro & macrovascular diabetic complications like- Stroke, MI, Heart Failure.

44. Timing of treatment Patients with well controlled DM can be treated similarly to non-diabetic patients for most routine dental needs. Keep appointments short, atraumatic, and stress-free morning appointments Use appropriate vasoconstrictor agents F or stressful procedures the usual drug regime may be altered

45. ANTIBIOTICS USE Antibiotics are not necessory for routine procedures in patients with well-controlled diabetes. But considered in the presence of overt oral infection. The combination of mechanical debridement+ systemic tetracycline provide greater positive effect on glycemic control in some DM patients.

46. DENTAL IMPLANT CONSIDERATIONS IN THE DIABETIC PATIENT Diabetes-induced changes in bone formation: Inhibition of collagen matrix formation Alterations in protein synthesis Increased time for mineralization of osteoid Reduced bone turnover Decreased number of osteoblasts and osteoclasts Altered bone metabolism Reduction in osteocalcin production Possible Diabetic Disturbances in Implant Wound Healing Process In Implants

47. DIABETIC EMERGENCIES Hypoglycemic crisis Hyperglycemic crisis

48. MANAGEMENT OF HYPOGLYCEMIA FACTORS THAT INCREASE THE RISK OF HYPOGLYCEMIA Skipping or delaying food intake Injection of too much insulin Injection of insulin into tissue with high blood flow ( eg , injection into thigh after exercise such as running) Increasing exercise level without adjusting insulin or sulfonylurea dose. Inability to recognize symptoms of hypoglycemia Denial of warning signs or symptoms Past history of hypoglycemia Hypoglycemia unawareness Low Blood Glucose Sign & symptoms occurs as fall in blood glucose level below 60 mg/dl . Severe hypoglycemia refers to fall in blood glucose concentration below 40 mg% (2.2-mmol/1) requiring help from outside for recovery.

49. SIGN & SYMPTOMS Low Blood Glucose Severe hypoglycaemia may result in seizures or loss of consciousness. The most common emergency related to DM in the dental office and a potentially life-threatening situation that must be recognized and treated expeditiously. MENTAL CONFUSION, SUDDEN MOOD CHANGE LETHARGY,…. TACHYCARDIA , NAUSEA, COLD CLAMMY SKIN , HUNGER, INCREASED GASTRIC MOTILITY , HYPOTENTION , HYPOTHERMIA.

50. Low Blood Glucose If patient is UNCONSCIOUS

51. Repeated hypoglycaemic episodes are hazardous for CNS; hence, one should find out the cause and treat it or correct it by adjusting the patient's therapy. Low Blood Glucose If patient becomes CONSCIOUS PREVENTION ADMINISTRATION OF 15g OF ORAL CARBOHYDRATE (JUICE,CANDY)

52. MANAGEMENT OF HYPERGLYCEMIA High Blood Glucose A medical emergency from hyperglycemia is less likely to occur in the dental office since it develops more slowly than hypoglycaemia. It occurs when blood glucose levels over 200mg/dl for extended period of time. In Type 1 DM- ketoacidosis may occur- Characterized by- Disorientation, rapid & deep breathing, hot drying skin & acetone breath. Type 2 DM- hyperosmolar non- ketotic diabetic acidosis. Severe hypotention & Loss of consciousness occurs if left untreated.

53. High Blood Glucose Under some instances, severe hyperglycemia may present with symptoms mimicking hvpoglycemia. If a glucometer is not available, these symptoms must be treated as hypoglycemia. Care is initiated by activating the emergency medical system , opening the airway, and administering oxygen. Circulation and vital signs should be maintained and monitored, and the patient should be transported to a hospital .

54. DIABETES & PERIODONTAL DISEASE: CENSUS REPORT OF THE JOINT EFP/AAP WORKSHOP ON PERIODONTITIS & SYSTEMIC DISEASES (CHAPPLE LC,GENCO R. J PERIODONTOL 2013)

55. GUIDELINE- A [Suggested Guidelines for physicians and other medical health professions for Use in Diabetes Practice] Patients with diabetes should be told that periodontal disease risk is increased by diabetes. If they suffer from periodontal disease, their glycaemic control may be more difficult , and they are at higher risk for diabetic complications such as cardiovascular and kidney disease. Patients with type 1, type 2 and gestational diabetes should receive a thorough oral examination , which includes comprehensive periodontal examination. For all newly diagnosed type 1 and type 2 diabetes patients, subsequent periodontal examinations should occur & annual periodontal review is recommended. For children and adolescents diagnosed with diabetes, annual oral screening is recommended from the age of 6–7 years by referral to a dental professional.

56. GUIDELINE- B [Suggested guidelines for use in dental practice] If periodontitis is diagnosed, manage it properly. If not, patients with diabetes should be placed on a preventive care regime and monitored regularly for periodontal changes. Patients with diabetes presenting with any acute oral/periodontal infections require prompt oral/ periodontal care. Patients with diabetes who have extensive tooth loss should be encouraged to pursue dental rehabilitation to restore adequate mastication for proper nutrition. Provide oral health education. Patients who present without a diabetes diagnosis, but at risk for type 2 diabetes and signs of periodontitis should be informed about their risk for having diabetes, assessed using a chair-side HbA1C test, and/or referred to a physician for appropriate diagnostic testing and follow-up care.

57. GUIDELINE- C [Recommendations for patients with diabetes at the physician’s practice/ office] If your physician has told you that you have diabetes, you should make an appointment with a dentist to have your mouth and gums checked. This is because people with diabetes have a higher chance of getting gum disease. Gum disease can lead to tooth loss and may make your diabetes harder to control.

58. GUIDELINE- D [Recommendations for patients at the dental surgery/office who have diabetes or are found to be at risk for diabetes] People with diabetes have a higher chance of getting gum disease. If you have been told by your dentist that you have gum disease, you should follow up with necessary treatment as advised. If you do not have diabetes, but your dentist identified some risk factors for diabetes including signs of gum disease, it is important to get a medical check-up as advised.

59. CONCLUSION Diabetes mellitus has significant impact on tissues throughout the body, including the oral cavity. As research indicates that poorly controlled diabetes increases the risk periodontitis. Alteration in host defence and tissue homeostasis appear to play a major role. Advances in medical management of DM require a heightened awareness by the periodontist in the various treatment regimens used by diabetic patients. Familiarity with various medications, monitoring equipments, and devices used by diabetic patient allows provision of appropriate periodontal therapy while minimizing the risk of complications.

60. REFERENCES Taylor JJ, Preshaw PM, Lalla E. A review of the evidence for pathogenic mechanisms that may link periodontitis and diabetes. J Periodontol 2013;84:S113-S34. The position paper on diabetes & periodontal disease. J Periodontol 2000;71:664-78. Grossi SG, Genco RJ. Periodontal Disease and Diabetes Mellitus: A Two-Way Relationship. Ann Periodontol 1998;3:51-61. Periodontal Medicine Rose, Cohen Carranza’s Clinical Periodontology 11 th edition Davidson’s Principles and Practice of Medicine 21 st edition

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