The worldwide prevalence of diabetes is relatively high and has increased at an alarming rate due to high-calorie diets, decreased physical activity, and growing trends towards obesity. In the United States, it is estimated that 5% of the population have diagnosed diabetes, while another 2% to 3% of adults have the disease without being aware of it. Diabetes imposes a heavy economic burden on society, and can greatly reduce patient’s quality of life when poorly managed. In 1997, it was estimated that the annual medical costs associated with diabetes in the US population amounted to $44 billion, while another $40 billion was attributed to lost workdays, restricted activities and permanent disability.
Diabetes mellitus is a chronic disorder affecting carbohydrate, fat and protein metabolism. There are three types of diabetes:
Type 1 : An autoimmune disease causing an absolute insulin deficiency.
Type 2 : Is triggered by insulin resistance and an insulin secretory defect. This type accounts for 90 – 95% of cases in the US
Gestational : This is caused by an abnormal glucose tolerance during pregnancy.
There is no definitive cure for diabetes, but controlling and closely monitoring blood glucose levels can prevent both acute and chronic complications, suppress systemic and general symptoms. The lack of glycemic control in diabetic patients can affect not only systemic health, but also their oral health.
DIAGNOSIS AND TREATMENT
The absolute diagnostic criterion of the American Diabetes Association is based on a fasting plasma glucose threshold of 126mg/dL. However, a non-fasting plasma glucose level of 200mg/dL or greater, in the presence of other classical symptoms, is also indicative of diabetes. Classical symptoms of diabetes include polydipsia (increased thirst), polyuria (increased urination), and polyphagia (increase in appetite), weakness and fatigue, prurtus (itching), peripheral neuropathy and blurred vision.
Diabetes can affect anyone at any age, but the most important risk factor include obesity, ethnic background (African-American, Hispanic, American Indian, Asian, Pacific Islander), hypertension, abnormal fat metabolism, previously identified impaired glucose tolerance, a history of vascular polycystic ovarian disease, and family history of diabetes. Prevalence also increases significantly with age (over 45 years old), and women are more frequently affected than men.
Modifiable risk factors include maintaining a healthy diet, avoiding extra weight, performing regular exercise, and smoking cessation. Additionally, scheduling regular visits to the physician and dentist can significantly decrease the risk of developing type II diabetes.
The fundamental objective of diabetes therapy is to normalize blood glucose levels to concentrations as close as possible to those of non-diabetic patients.
Oral health complications can be amplified by the systemic consequences of diabetes. Persistently poor glycemic control has been associated with the incidence and progression of gingivitis, Periodontitis, and alveolar bone loss, and duration of diabetes is closely associated with the severity of periodontal disease. Multiple mechanisms of action have been proposed to explain the impact of diabetes; degenerative vascular changes which alter nutrient and leukocyte migration to gingival tissue decrease oxygen diffusion and elimination of metabolic waste, thereby enhancing the severity of Periodontitis. Collectively, the degradation of newly synthesized collagen in connective tissues, and the depression of the immune system, can both contribute to a predisposition to periodontal disease and impaired wound healing. The degree of metabolic control and the presence of other complications ( e.g., retinopathy and nephropathy) can also exacerbate the symptoms and effects of periodontal infections. Concurrent risk factors (plaque, smoking, stress, medications, pregnancy, and hormonal variations) are cumulative and should be considered in the assessment of the periodontal status of a patient.
Conversely, periodontal infection can influence glycemic levels. Recent findings suggest the proinflammatory proteins (e.g., Tumor Necrosis Factor TNF-a, and Interleukin IL-lb) can induce insulin resistance by interfering with lipid metabolism. Moreover, the responses of interleukins to inflammation have been reported to antagonize insulin action. It is hypothesized that the highly vascular inflamed periodontium may act as a portal to systemic circulation for bacterial and locally produced inflammatory mediators. While still an equivocal issue, it appears that prevention and treatment of periodontal infections can have beneficial effect on glycemic control in diabetic patients.
ORAL COMPLICATIONS RELATED TO DIABETES
- Acute oral infections (recurrent herpes simplex virus, periodontal abscess or palatal ulcer)
- Periodontitis and gingivitis
- Burning mouth syndrome and glossodynia
- Dental Caries
- Lichen planus
- Neurosensory dysesthesias
- Salivary dysfunction
- Taste dysfunction
In general, patients with well controlled diabetes can undergo dental treatment with only minimum restrictions.
Overall, dental management strategies should be adapted to patients’ needs, and include more frequent visits, comprehensive drug histories, dietary evaluations and counseling, smoking cessation recommendations, assessment of salivary functions, and instructions for proper oral hygiene.
Smile Beautifully, Smile Confidently, Smile Frequently