INTRODUCTION

• Diabetes is a common disorder showing an exponential increase.

• It has various oral manifestations that impact the overall level of oral care.

• Physicians play an important role in optimising metabolic control in diabetic patients, thereby controlling the progression of oral complications.

• Diabetes can have a number of complications such as candidiasis, dental caries, tooth loss, gingivitis, mucosal lesions, neurosensory disorders, periodontitis, xerostomia, etc

NEED FOR ORAL HEALTH IN DIABETES

• There is robust evidence to support the relationship between oral health and diabetes.

• Despite the availability of data, oral health awareness is lacking among patients with diabetes

People with diabetes have two times higher chances of getting mouthproblems like gum disease and mouth infection

LINK BETWEEN DIABETES AND ORAL HEALTH

Diabetes can affect the mouth and teeth in the following ways:

• High blood sugar affects small blood vessels contributing to

periodontal disease and delayed healing

• Diabetics have a difficulty in warding off infections probably

due to diminished capacity of the white blood cells (WBCs) to

fight bacteria

• Xerostomia or dry mouth can occur due to autonomic

neuropathy and further accentuate caries and infections

LINK BETWEEN DIABETES AND ORAL HEALTH

• Diabetes is a major risk factor for oral diseases like periodontitis and

increases the susceptibility to periodontitis by approximately 3-fold

• Periodontitis tends to be more severe in patients with type 2

diabetes compared to those with type 1 diabetes

• Diabetes may also cause some changes in the salivary factors related

to gingivitis in children

• Children and adolescents with diabetes may have a higher risk of

periodontal disease

EPIDEMIOLOGY OF ORAL DISEASES IN DIABETES PATIENTS – INDIAN SCENARIO

Oral disease distribution in diabetics

ORAL SYMPTOMS AWARENESS IN DIABETES PATIENTS

•Periodontitis is the most common oral disease seen in diabetic patients•There is poor awareness regarding increased risk of oral diseases among

•diabetes patients

ORAL MANIFESTATIONS OF DIABETES

PERIODONTAL DISEASE• The term ‘periodontal diseases’ includes gingivitis (reversible

inflammation confined to the gingiva) and periodontitis (extension

of inflammation to the tissues beyond gingiva resulting in tissue

destruction and alveolar bone resorption)

• The tissue destruction results in the formation of a periodontal

pocket between the gingiva and the tooth

• Early periodontitis is typically asymptomatic and painless and many

patients are unaware of the condition

• Smoking is a major risk factor that significantly increases risk for

periodontitis and severity

CHARACTERS OF ADVANCED PERIODONTITIS

PREVALENCE OF PERIODONTAL DISEASE IN DIABETICS

•Periodontal status was compromised in diabetics (92.6%)•There was more need of a complex treatment in the diabetic population (58%).

PATHOGENESIS OF PERIODONTITIS IN DIABETES

• There has been growing emphasis on the ‘two-way’ relationship between diabetes and periodontitis

• Not only is diabetes a risk factor for periodontitis, but periodontitis can also have a negative effect on glycaemic control

• Periodontitis causes inflammation in the periodontal tissues stimulated by the long-term presence of the subgingival biofilm (dental plaque)

PERIODONTITIS AND DIABETES – A VICIOUS CYCLE

SIGNS AND SYMPTOMS OF PERIODONTITIS

MANAGEMENT OF PERIODONTITIS IN DIABETICS

• Oral hygiene maintenance• Mouthwashes• Referral to dentist

PREVENTION OF PERIODONTITIS IN DIABETICS

• Strict glycaemic control• Advise regular brushing 2 times a day• Advise use of dental floss and interdental

cleaning aids• Mouth washes• Regular dental check-ups

DENTAL CARIES• Dental caries is a chronic, microbial, multifactorial disease

involving an interaction between the host, the substrate and alteration of the immunological system

• It primarily affects the calcified tissues of the teeth

PATHOGENESIS OF CARIES

DIABETES AND DENTAL CARIES

• Saliva has the capacity to buffer the acid produced by

the action of bacteria on fermentable carbohydrates

• Saliva production has been reported to be reduced in

patients with diabetes with poor metabolic control,

may be as a consequence of peripheral neuropathy

in these patients

PREVENTION OF DENTAL CARIES AMONG DIABETICS

• Strict glycaemic control

• Dietary modification: Avoiding intake of refined carbohydrates

and other cariogenic foods

• Oral hygiene maintenance: Brushing twice a day

• Rinsing after meals

• Flossing and use of interdental cleaning aids

• Use of fluoride toothpastes and mouthwashes

• Regular visits to the dentist

WHO GUIDELINES ON SUGAR INTAKE IN CARIES PREVENTION FOR ADULTS

AND CHILDRENWHO recommends:

•A reduced intake of free sugars throughout the life course

•Reducing the intake of free sugars to less than 10% of total

energy intake (strong recommendation)

•Reduction of the intake of free sugars to below 5% of total

energy intake (conditional recommendation)

CANDIDIASIS• It is seen that diabetes patients with poor glycaemic control are

prone to severe and/or recurrent bacterial or fungal infections

• It has been documented that candidiasis and other

opportunistic fungal infections are early signs of diabetes

• Diabetes is a precipitating factor for increased oral mucosal

colonisation of Candida

• The glycaemic control status i.e., glycated haemoglobin

percentage (HbA1c %) of diabetes patients may directly

influence candidal colonisation and various oral manifestations

CANDIDIASIS• An Indian study showed that oral candidal carriage was observed in 76.47%

diabetes patients having good glycaemic control; 69.69% in patients with

moderate control; and 82.50% in poorly controlled diabetes patients

CLINICAL FEATURES OF CANDIDIASIS• White patches (plaques) that can be rubbed off

• Loss of taste or unpleasant taste in the mouth

• Redness

• Cracks at the corners of the mouth

• Burning sensation in the mouth

PREVENTION AND MANAGEMENT OF CANDIDIASIS

• Strict glycaemic control

• Antifungal therapy

• Using mouthwash

• Oral hygiene maintenance

XEROSTOMIA

• Xerostomia is a conventional term used to describe the subjective

complaint of dry mouth, whereas hyposalivation is an objective

reduction in salivary secretion

• Both xerostomia and hyposalivation are associated with diabetes

• Studies have shown that diabetes patients reported symptoms of dry

mouth more frequently than controls (24% vs. 18%, respectively)

XEROSTOMIA• It is seen that the salivary flow rates are impaired in subjects with

type 1 diabetes, especially in those with neuropathy

• In type 2 diabetes patients, unstimulated and stimulated salivary

flow rates are also significantly reduced

CLINICAL FEATURES OF XEROSTOMIA• Oral mucosal dryness and redness

• Difficulty in chewing, swallowing and speaking

• Pain in the mouth

• Oropharyngeal burning

• Increased fungal infections

• Increased caries

• Dysgeusia

• Halitosis

• Difficulty in wearing dentures

MANAGEMENT OF XEROSTOMIA• Local salivary stimulation, e.g., use of a sugarless chewing gum

• Systemic salivary stimulation using bromhexine,

anetholetrithione, pilocarpine and cevimeline, etc.

• Sprays or gels with lubricating properties to provide

symptomatic relief

• Use of artificial saliva and saliva substitutes

• Oral hygiene maintenance

BURNING MOUTH SYNDROME• The higher prevalence of burning mouth syndrome (BMS) found among the

patients with diabetic peripheral neuropathy supports the fact that a

neuropathic process may be the underlying cause of BMS

• It may be prudent to screen patients with a recent onset of BMS for presence

of diabetes. There exist similarities between BMS and peripheral diabetic

neuropathy

• These include the description of clinical symptoms that characterise both the

conditions, specifically burning, tingling, numbness, pain, scalding and itching

• Both BMS and diabetic neuropathy respond to similar classes of drugs that

interrupt or modulate these symptoms

ORAL MUCOSAL LESIONS• Oral mucosal lesions (OMLs) show high prevalence in diabetes patients.

• The presence of OMLs such as lichen planus and recurrent aphthous

ulceration have frequently been diagnosed in diabetes patients

• A study showed that the most common lesions in the oral mucosa were

ulcerative lesions (traumatic and aphthous ulcers)

• Higher occurrence of OMLs was significantly associated with poor

metabolic control

ORAL HEALTH AND HEART DISEASE

• There is evidence that oral infection is associated with coronary

atherosclerosis and that bacterial DNA has been identified in

atherosclerotic plaques

• Clinical evidence has shown that there is a relation between dental

infection and incidence of coronary events

• Data available from the Insulin Resistance Atherosclerosis Study showed

that chronic hyperglycaemia was positively associated with increased

intimal–medial wall thickness (IMT)

ORAL HEALTH AND HEART DISEASE

RECOMMENDATIONS ON DENTAL CARE FOR PEOPLE WITH DIABETES

• Enquire annually if a diabetes patient follows local recommendations on

day-to-day dental care and attends a dental professional regularly for

oral health check-ups

• Enquire at least annually for symptoms of gum disease (including

bleeding when brushing teeth and gums which are swollen or red)

• In patients not performing adequate day-to-day dental care, remind

them that this is a normal part of diabetes self-management and

provide general advice as needed

RECOMMENDATIONS ON DENTAL CARE FOR PEOPLE WITH DIABETES

• In patients with possible symptoms of gum disease, advise them

to seek early attention from a dental health professional

• Education of diabetes patients should include explanation of the

implications of diabetes, particularly poorly controlled diabetes,

for oral health, especially gum disease

ORAL HYGIENE PRACTICES IN INDIA

• Various oral hygiene practices are used in India

• There is scarce awareness with regard to the use of correct brushing

methods and agents used in oral hygiene maintenance

• Majority of the people are unaware about the relationship between oral

hygiene and systemic diseases or disorders

• Most diseases show their first appearance through oral signs and

symptoms and they remain undiagnosed or untreated because of this

missing awareness

ORAL HYGIENE PRACTICES IN INDIA

• Diabetic individuals should be educated to refrain from hazardous

practices that can do harm to oral structures

• Improper brushing techniques and cleaning agents can have detrimental

effects on teeth and surrounding structures causing trauma, infections

and wasting diseases

MANAGEMENT CONSIDERATIONS FOR A DIABETES PATIENT BEFORE DENTAL

PROCEDURES

• It is essential to obtain a thorough history of the patient along with the

details of any complications, hypoglycaemic episodes, etc

• Generally morning appointments should be advised

• For patients on insulin, the appointment should not clash with the peak

insulin activity thereby precipitating hypoglycaemia

• Advise the patient to eat normally and take all the medications as per advise

• Postponing non-emergency dental care procedures if the blood sugar is too

high

MANAGEMENT CONSIDERATIONS FOR A DIABETES PATIENT BEFORE DENTAL

PROCEDURES• People with diabetes wearing orthodontic appliances like braces should contact

their orthodontist immediately if a wire or bracket results in a cut inside their

tongue or mouth

• The dentist may record the blood glucose prior to the procedure using blood

glucose monitors

• Well controlled diabetics can be treated like non-diabetic patients

• Keeping the dentist up-to-date on the patient's diabetic condition and treatment

and also the physician about his/her oral condition and treatment, so that they

can work together as a team to help one control diabetes and periodontal disease