Kansal G et al. Prosthodontic management of Diabetes mellitus patient.

Review Article
Prosthodontic Management Of Patients With Diabetes Mellitus
Gagandeep Kansal, Deepal Goyal1

Private Practioner, 1Department of Oral and Maxillofacial Pathology and Microbiology, Jan
Nayak Ch. Devi Lal Dental College, Sirsa, Haryana

Corresponding author: ABSTRACT: Diabetes mellitus is a disease

resulting from impaired insulin secretion,
Dr. Gagandeep Kansal varying degree of insulin resistance or both.
Kothi No. 369, Management of the diabetic dental patient
North Estate,Bathinda - 151001 must take into consideration the impacts of
Punjab, India diabetes on dental disease & dental treatment,
[email protected] as well as a clear appreciation for the co
morbidities that accompany long standing
Received: 10 February 2013
diabetes mellitus.
Revised: 15 March 2013
Accepted: 22 March 2013 Key words: Diabetes, Dental, Insulin,
Prosthodontics.

This article may be cited as: Kansal G, Goyal D. Prosthodontic Management Of Patients With
Diabetes Mellitus. J Adv Med Dent Scie Res 2013;1(1):38-44.

INTRODUCTION: Diabetes mellitus is a dental treatment, as well as a clear

disease of glucose, fat & protein metabolism appreciation for the co morbidities that
resulting from impaired insulin secretion, accompany long standing diabetes mellitus.1
varying degree of insulin resistance or both.
Hyperglycemia is the most clinically CLASSIFICATION
important metabolic aberration in diabetes 1. Primary
mellitus & the basis for its diagnosis. Apart
from the obvious impact of impaired glucose a. Type 1 or Insulin Dependent DM
metabolism, diabetes mellitus & chronic (IDDM)
hyperglycemia are associated with important
b. Type 2 or non-insulin Dependent
ophthalmic renal, cardiovascular,
DM (NIDDM)
Cerebrovascular & peripheral neurological
disorders. Management of the diabetic 2. Other specific types of Diabetes
dental patient must take into consideration
the impacts of diabetes on dental disease & a. Pancreatic Disease

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 Kansal G et al. Prosthodontic management of Diabetes mellitus patient.

b. Excess Endogenous production of occur. Therefore screening test is important

hormonal antagonists to insulin in type II diabetes.3

c. Medication (Corticosteroids, thiazide ADA recommends FBS screening in

diuretics, phenytoin) individuals above 45 years every 3 years, in
case of obese. Screening should also
d. Associated with genetic syndromes. considered at younger age in individuals
3. Gestational Diabetes with overweight (BMI > 25) and who have
hypertension or any vascular disease.
EPIDEMOLOGY
PATHOPHYSIOLOGY
Type I diabetes accounts for 5-10% of cases
of diabetes whereas type II diabetes TYPE I DIABETES 4
accounts for 80% of cases of diabetes in Activation of autoimmunity which leads to
USA & UK. attack on beta cells of pancreas
DIAGNOSIS TYPE II DIABETES
The diagnosis of diabetes is based on the In contrast to type I diabetes, type II
classic symptoms like polyuria, polydypsia, diabetes has no autoimmune mechanism.
polyphagia, weight loss and visual
disturbances.2 Genetic influence is much more
predominated than type I diabetes
According to American diabetic association
(ADA): Fasting blood sugar (FBS) > 126 RISK FACTORS FOR TYPE II
mg/dl or Post random blood sugar (PRBS) > DIABETES
200mg/dl
1. Obesity combined with overeating &
In the absence of these classic symptoms, under activity
glucose intolerance may exist as impaired
fasting glucose (IFG) when FBS is between 2. Ageing
100 - 125 mg/dl. Similarly plasma glucose 3. Insulin resistance, may be due to any
of 140 – 199 mg/dl called as impaired of these causes
glucose tolerance (IGT). This distinction is
important because individuals with IFG & • Abnormal insulin molecule
IGT are at increased risk of developing
• Excessive amount of circulating
atherosclerotic disease even though if they
antagonists
don't develop diabetes.
• Target tissue defects
Type I diabetes often presents with
markedly elevated plasma glucose & 4. Repeated pregnancies , particularly
associated symptoms, whereas type II is in obese women
often not diagnosed until complications

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 Kansal G et al. Prosthodontic management of Diabetes mellitus patient.

presentation. The risk of first myocardial

infarction in patients with diabetes is equal
COMPLICATIONS to that of recurrent infarction in non
Short term complications diabetics.

• Hypoglycemia Surgical site infection is more common in

uncontrolled diabetics. Neutrophil
• Diabetic ketoacidosis adherence, chemotaxis, phagocytosis, cell
mediated immunity are all compromised in
Long term complications hyper glycemic diabetics. The plasma
• Diabetic retinopathy glucose threshold for such granulocyte
dysfunction is in the range of 198 –
• Diabetic neuropathy 270mg/dl.

• Diabetic nephropathy Optimal control of plasma glucose is

important both in prevention & management
• Cardiovascular disease. of infection. 6
Diabetic retinopathy is most common cause ORAL MANIFESTATIONS OF
of blindness in diabetics in the age of 30 - 65 DIABETES
years.
• Oral conditions include burning mouth,
Diabetic neuropathy is symptom less in altered wound healing, and an increased
majority of diabetics, although it can be seen incidence of infection.
as symmetrical altered sensation in the toes
& feet. Involvement of autonomic nervous • Enlargement of the parotid glands
system can affect gastric motility, erectile and xerostomia
function, bladder function, cardiac function • Neuropathy
& vascular tone. 5 • Diabetes is a risk factor for the
prevalence and severity of gingivitis
Diabetic nephropathy is the earliest
and periodontitis.
complication & affects 30% of type I & 4%
• Risk of attachment loss and alveolar
of type II diabetes. This complication
bone loss approximately 3 fold when
decreases over a period of time as age
compared to non diabetic control
increases.
subjects.
Cardiovascular disease occurs in majority of • Enlarged gingival tissues, multiple
type II diabetics. Approximately 75% of periodontal abscesses.
type II diabetic patients die of • Changes in the function of host
cardiovascular disease. Coronary heart defense cells.
disease develops at an earlier age in • Changes in the collagen metabolism,
diabetics & atypical angina symptoms & wound healing alternations and
congestive heart failure are a more common periodontal destruction.

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 Kansal G et al. Prosthodontic management of Diabetes mellitus patient.

• Periodontal infection increased the 5) Treatment: The use of antibiotics in

risk of poor glycemic control by six case of infection and Diet
fold. Modification.
• Oral Candida infection also occurs in
Appointment Timings8
increased frequency in diabetics. 7
• Diabetic patients can receive dental
PROSTHODONTIC MANAGEMENT
treatment in the morning.
OF DIABETIC DENTAL PATIENT

Key dental treatment considerations for • But, it is generally best to plan dental
diabetic patients include: treatment to occur either before or
after periods of peak insulin activity.
1) Medical history :
• Take history and assess glycemic • Greatest risk of hypoglycemia will
control at initial appt. occur about
• Glucose levels a. 30-90 min after injecting
• Frequency of hypoglycemic episodes Lispro Insulin.
• Medication, dosage and times.
2) Establishing the levels of glycemic b. 2 – 3 Hours after injecting
control early in the treatment regular insulin
process: c. 4-10 hours after injecting
• Patients recent glycated Hb values Lente Insulin

3) Stress Reduction : Diabetic Emergencies Management

• Endogenous production of • The most common diabetic

epinephrine and cortisol increase emergency in the dental office is
during stressful situations. hypoglycemia.

• Profound anesthesia reduces pain • Signs and symptoms of

and minimizes endogenous hypoglycemia include;- Confusion ,
epinephrine release. sweating, tremors, agitation, anxiety,
dizziness, tingling or numbness, and
• Conscious sedation should be tachycardia. Severe hypoglycemia
considered for extremely anxious may result in seizures or loss of
patient. consciousness.

4) Oral hygiene instructions, frequent • Blood glucose with a glucometer

prophylaxis & monitoring of should be checked.
periodontal health, as there is
increased risk of periodontal disease. • If glucometer is not available,
condition is treated as hypoglycemic
episode and the patient should be

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 Kansal G et al. Prosthodontic management of Diabetes mellitus patient.

given approx. 15g of oral • The well controlled diabetic is

carbohydrate. probably at no greater risk of
postoperative infection than in non
• If patient is unable to take food by diabetic. Therefore in routine oral
mouth i.v line is in place, 25-50 ml surgical procedures do not require
of 50% dextrose solution (D50) or prophylactic antibiotics.
1mg of glucagon can be given
intravenously. • In poorly controlled diabetic patient,
prophylactic antibiotics should be
• Signs and symptoms of considered. 12
hypoglycemia should reduce in 10-
15 min. Diabetes and prosthodontics 13

Marked Hyperglycemia: If glucometer is not • Abutment Failure.

available, these symptoms must be treated as
hypoglycemia. 9 • Tissue abrasions are more likely in
denture wearers.
Signs & symptoms of hypoglycemia 10
• Erythematous candidosis is
Mild associated to the use of upper total
denture or prosthesis (denture
• Anxiety
stomatitis).
• Tachycardia
• Sweating • Oral carrier rate and density of C.
albicans in denture wearers of
Severe
diabetic group were higher.
• Confusion
• Increased residual ridge resorption.
• Seizures
• Coma • Mucostatic impressions should be
made.
Management of hypoglycemia 11
Diabetes and implant surgery 14
• Terminate all dental procedures
• Implant dentistry is not
• Alert the patient contraindicated in most diabetics
• 15 gm carbohydrate( 6 oz orange • Diabetics patients with blood glucose
juice, 4 oz cola, 3-4 teaspoons sugar) levels of around 100 Mg/dl
• In case of uncooperative patient, • Sedative procedures and antibiotics.
Glucagon 1 mg s.c, i.m. followed by
oral glucose supplement or Dextrose- • Need for a stress reduction protocol,
50 20- 50 ml i.v. diet evaluation before after surgery

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 Kansal G et al. Prosthodontic management of Diabetes mellitus patient.

and control of the risk of infection CONCLUSION

are all addressed.
Diabetes is a common metabolic disorder
• Corticosteroids, often used to associated with glucose intolerance &
decrease edema, swelling and pain longterm complications. Especially in type
may not be used in the diabetic’s II diabetes, a clustering of co morbidities
patient. (obesity, hypertension, and dyslipidaemia)
not only predisposes to diabetes but
•
Detrimental effects of diabetes on importantly, cardiovascular disease as well.
osseointegration can be modified
using aminoguanidine systemically. Management of diabetic dental patient
15 should focus on periodontal health & the
delivery of comprehensive dental care with
minimal disruption of metabolic
homeostasis & recognition of diabetic co
morbidities.

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Source of Support: Nil

Conflict of Interest: None declared

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