21.02.

22

Diabetes Mellitus (DM)

• DM is a chronic metabolic disease
DIABETES characterized by -hyperglycaemia due to

IN DENTISTRY
abnormalities in insulin release or insulin
effect, or both.

Assoc. Prof. Nilüfer ERSAN

Department of Dentomaxillofacial Radiology

Clinical Symptoms and Signs Diagnosis of Diabetes

• dry mouth • fungal infections
• polyphagia • vulvovaginitis
-
• polyuria • blurred vision
• polydipsia • itching
• weight loss • dry skin =
• fatigue • numbness in feet
• At least 8 hours of fasting is required for fasting plasma glucose measurement.
• urinary tract infections • Random plasma glucose can be measured at any time of the day regardless of
food intake.
• OGTT must be performed with 75 g oral glucose.
• HbA1C test cannot be used as a diagnostic test in the presence of anemia,
hemoglobinopathy or pregnancy.

Criteria for Testing Diabetes Mellitus

in Asymptomatic Individuals ge
5
• In the absence of these criteria, screening is
,
.

• BMI ≥25kg/m2 and additional risk factors:

recommended at the age of 45. If the results are
-
– Physical inactivity e
normal, tests must be repeated at least once
-
– Diabetes in a first degree relative every three years.
-
– High-risk races/ethnicities (e.g., African Americans, Latinos) • As there are no effective methods of preventing
– Women who have given birth to babies who weighed ≥4kg or delaying Type 1 DM, screening is not
-

or were diagnosed with gestational diabetes recommended.

⑤
– Hypertension (≥140/90 mmHg or on treatment for HT) • The presence of autoantibodies can be
– HDL-cholesterol <35mg/dl and/or triglyceride >250mg/dl conducted in the first-degree relatives of T1DM
patients can be tested.

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Glycaemic Targets in Diabetes

7
Monitoring in Adults
Differential
Diagnosis of
Type 1 & 2 DM
e
Targets can change depending on the duration of diabetes, age/
life expectancy, concomitant diseases and pregnancy.
If preprandial glucose values reach the target but HbA1C does
-

not, the postprandial glucose value must be checked.

Glycaemic Targets in Diabetes

Monitoring in Adults –-HbA1C
weeks.
• Fasting is not-
2
• It reflects the glucose control during the last 8-10
O
required for measurement.
Treatment of Diabetes
• This measurement is not affected by daily changes in
glucose.
• It must be checked at least 2-4 times a year.
• Incorrect measurements may be taken in situations
that shorten the life of erythrocytes, such as acute
blood loss, chronic anaemia, haemoglobinopathies
(HbS, C, and D), blood transfusion, and/or oral intake
of Vitamins C and E.

Glycaemic Targets
Basic Principles in Insulin Treatment
in the Treatment of Diabetes
• Achieving good glycaemic control early in the • Basal and bolus insulins control fasting and
course of the disease reduces microvascular
- postprandial blood glucose, respectively.
and macrovascular
- complications. • Basal or bolus insulin dosages should be
• Acute hypoglycaemia may increase the risk of adjusted, depending on whether preprandial
mortality, especially in patients with high (fasting) blood glucose or postprandial
cardiovascular risk. (postmeal) blood glucose is high.

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 21.02.22

Basic Principles in Insulin Treatment Treatment of Type 1 DM -

-
e
• Firstly, hypoglycaemias should be controlled. • Treatment of T1DM is based on the
• For each hyperglycaemic attack, presence of administration of-“basal-bolus” insulin.
prior hypoglycaemia
- should be checked. -
• Nutrition therapy and an exercise
- program
• Preferably, oral and dental treatments of the must be applied to all patients.
patient should be performed
- afterwards.

Treatment of Type 2 Diabetes Treatment of Gestational Diabetes

• Lifestyle change is an essential treatment
-
• Nutrition therapy is applied if fasting blood
component
-
for all periods. No medicine can glucose (FBG) > 95 mg/ dl and/or postmeal 1-h
replace a change in lifestyle. >140 mg/dl.
• Lifestyle changes have a positive impact not • Insulin treatment is started if target values are
only on blood glucose but on all risk factors. not achieved.

Drug Interactions
• Drugs that may cause hyperglycemia:
-
corticosteroids, rifampicin, isoniazid (INH), calcium
channel blocker, diuretics, nicotinic acid derivatives
Acute Complications of Diabetes
• Drugs that may cause hypoglycemia:
Sulfamethoxazole, ciprofloxacin, miconazole,
Monoamine oxidase (MAO) inhibitors, Selective
serotonin reuptake inhibitors (SSRI)

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 21.02.22

Insulin Deficiency Hyperglycaemic Hyperosmolar State

Causes: & Causes:
-
Absolute insulin deficiency (at the onset of Type 1 DM, or with incorrect dose Usually mistakes in oral antidiabetic and insulin administration in
or use of insulin) and relative insulin deficiency (infection, trauma, emotional
stress, some medications and endocrine reasons) can cause ketoacidosis. patients with Type 2 DM (especially in older patients), chronic
Clinical Symptoms and Signs: diseases, infections and the addition of some medications (i.e.,
Blood glucose usually >250 mg/dl, polyuria, polydipsia, stomach ache, thiazides, propranolol, corticosteroid, phenytoin).
nausea/vomiting, dehydration, warm and dry skin, hyperpnea, acetone Clinical Symptoms and Signs:
breath, tachycardia and exhaustion.
Serious hyperglycaemia (blood glucose >600 mg/dl), polyuria,
Treatment:
polydipsia, tachycardia, hypotension, dehydration, confusion,
Basal insulin should be continued at the same dosage. Premixed insulins
neurological symptoms and signs.
contain bolus insulin as well; therefore, oral and dental procedures should be
performed after the patient eats a meal. Treatment:
Blood glucose must be checked prior to and after the procedure. At hospital according to clinical and laboratory test results.

Hypoglycaemia Hypoglycaemia
Causes: Treatment:
Insulin dose, method of administration; timing mistakes; incorrect choice of For mild hypoglycaemia: 15 g of carbohydrates (fruit juice, sugar or glucose
insulin; use of long-acting sulphonylurea, especially in older patients; insufficient tablet) are given; if blood glucose is <70 mg/dl and symptoms still persist
carbohydrate intake during meals; long-term exercise or alcohol consumption. after 15 minutes, 15 g of carbohydrates are given again.
Clinical Symptoms and Signs: If blood glucose is >70 mg/dl and there is less than 30min. before a main meal
In mild hypoglycaemia blood glucose is around 70 mg/dl. Patient may have cold or snack, that meal is given without waiting. If there are more than 30min.
until meal time, a carbohydrate- and protein-containing meal is given.
and moist skin, feelings of hunger, palpitations, tremors, and perspiration.
For a more severe hypoglycaemia: 30g of fast-acting carbohydrates (fruit
With a blood glucose of 50-70 mg/dl, additional symptoms, such as headache,
juice, sugar or glucose tablet) are given.
loss of attention, sleepiness, blurred vision and changing behaviors, may appear.
For severe hypoglycaemia: Glucagon 1mg SC, IM can be administered.
Blood glucose is <50 mg/dl in a severe hypoglycaemia. Loss of consciousness and
Emergency services are called. 20% of dextrose 50 ml or 5-10% of dextrose
coma develops.
100 ml IV is administered.

proket Macroangiopathy
tr!gge cus

-
• -O
Diabetes and CVS diseases pose equal amounts of risk.
• Diabetic patients suffer from accelerated atherosclerosis.
-

• Lipid metabolism is also compromised.

Chronic Complications of Diabetes • ---
CVS diseases are seen 2-5 times more often in diabetic
patients, and they appear earlier.
• The risk of cerebrovascular and peripheral artery diseases is
higher as well.
• Nearly half of diabetic patients suffer from high blood
pressure.

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 21.02.22

Microangiopathy Diabetic Neuropathy

• Diabetic neuropathy is a mainly axonal degeneration in
• Microangiopathy mainly causes neuropathy,
which motor, sensory or autonomic nerve fibers become
retinopathy and nephropathy in diabetic stiff and which is associated with damage to small vessels
that nourish neurons.
patients.
• Stiffness of autonomic fibers causes patients to complain
of burning and freezing sensations, numbness, tingling
and prickling of the feet.
• Weakness, exhaustion and gait disorder are the main
complaints associated with motor fiber stiffness.

Diabetic Neuropathy Diabetic Nephropathy

• When the autonomic nervous system is affected, • The worsening of the renal function that develops
– orthostatic hypotension,
– resting tachycardia, mostly due to damaged intraglomerular arteriols.
– painless myocardial infarction,
• It is the most common cause of end-stage renal
– urine retention,
– urinary incontinence, disease.
– perspiration disorders,
• In Type 1 DM patients, it usually develops 5-15 years
– impotence,
– hypoglycaemia unawareness, after diagnosis.
– night vision problems,
• It can be detected even at the time of diagnosis in
– decreased saliva and
– gastroparesis may be experienced. Type 2 DM.

Diabetic Foot
– Poor metabolic state (poor glycaemic control, high blood pressure,
dyslipidaemia),
– musculoskeletal system and neurological problems,
– alcoholism,
ORAL HEALTH IN PATIENTS
– smoking, WITH DIABETES
– inadequate daily care and hygiene,
– athlete’s foot infections,
– calluses and
– walking barefoot
can cause diabetic foot.
• Lower limb amputations are related to diabetes
40-60% of the time.

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 21.02.22

The Relationship between The Relationship between

Diabetes and Oral Health Diabetes and Oral Health
• Educating patients is crucial to protect and maintain oral and • Oral and dental complications are experienced
dental health. frequently in diabetic patients.
• Dentists can help with early diagnosis by assessing oral • Not much of a difference exists between the oral
symptoms of diabetes and resulting complications. health options for diabetic patients with good
• Preventive measures and dental treatments make it easier to metabolic control and systemically healthy people.
maintain oral and dental health and to keep diabetes in
However, the management and monitoring of the
metabolic control.
process need to be case sensitive.

The Relationship between

Periodontal status
Diabetes and Oral Health
• Surgical interventions that are performed under • The level of periodontal destruction is affected
directly or indirectly by glycaemic control and by the
general anaesthesia or procedures lasting longer individual’s immune system capacity in diabetes.
than two hours are considered major surgical • There are a couple of mechanisms explaining the
operations. changes diabetes causes in the organs and tissues
(including periodontium).
• Prior to the procedure, the patient’s renal and
• Diabetic patients who have their disease under
hepatic functions must be assessed, and any metabolic control respond to periodontal treatment
existing electrolyte imbalances must be replaced. considerably different from those who do not.

polyar!c
salvayglads
Dry Mouth in Diabetes Dry Mouth in Diabetes

-
Top
• Xerostomia can develop in diabetic patients due to • In diabetes, burning mouth syndrome, which
various reasons: polyuria, glandular disorder in develops due to peripheral neuropathy,
salivary glands or the use of antihypertensive drugs. causes xerostomia, candidiasis and taste
• Oral mucosa may be traumatized during eating or
speaking, or there may be an increase in stomatitis
- in the mouth.
disturbance
and candida infections. • These adversely affect the patient’s food
• Patients using removable dentures should be intake and create a negative effect on
informed about oral care as well as maintenance of metabolic control of diabetes.
the dental prostheses and the need to renew them.

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 21.02.22

Planning Prior to Dental Treatment

Oral Disease Symptoms, Signs and Complications in Patients Oral Complications in Diabetes
Prone to Diabetes
• The patient needs to be assessed in case of the following symptoms and
signs are found during the clinical examination.
• The following oral complications may develop
-
• Increased risk of infection -
• Dry mouth in diabetes as a result of susceptibility
- to
>
-
--
• Enlargement of salivary glands • Increase in dental caries
-infections, peripheral neuropathy and vascular
zenstem
• Taste disturbances • Increase in periodontal
-
• Orofacial pain -F diseases and immunological deficiency.
• Hyperkeratosis, erythroplakia,
leukoplakia - • Gingival hyperplasia
• Dentists can play a crucial role in the early
• Oral lichen planus -
• Recurrent periodontal abscess
~
• Ulceration • Increase in saliva glucose level diagnosis of diabetes through the checking of
• Attachment and bone loss
• Fibromatous developments,
herpetic lesions • Burning mouth syndrome oral symptoms during clinical examinations
• Lesions that affect the tongue • Oral candidiasis
(median rhomboid glossitis,
geographic tongue, fibroma, • Impaired wound healing
leucoplakia, pseudomembranous • Acetone-like breath odor
glossitis)

Pretreatment Approaches in Patients

with Diabetes
• -
Bacterial plaque -
• Dry mouth
• Increased risk of dental caries
• The patient should be consulted to a physician.
-
• Prior to dental treatment, the type and treatment of diabetes must
accumulation related =
• Increase in periodontal
-
be considered.
to increased Ca2+ and -
diseases
• Information must be gathered regarding action times and
mechanisms of the - drugs used, as well as their interaction with
glucose level in saliva -
• Gingival hyperplasia other drugs.
• Lichenoid lesions
• Ulcer
-
• Recurrent periodontal abscess
• Increase in saliva glucose level
• -
Morning appointments should be preferred.
• Prior to restorative treatments and minor surgical procedures,

-
diabetic patients are requested to take their morning medications
• Attachment and bone loss and have their routine meal.
• Pulpitis
-
&

• Burning mouth syndrome • Necessary measures must be taken with regard to hypoglycemia
• Oral candidiasis risk.
• Alveolitis -
• Antibiotic treatment must be administered in case of - an infection.
-
• Impaired wound healing
• Risk of acute exacerbation must be taken into consideration in
chronic infections.

Pretreatment Approaches in Patients Pretreatment Approaches in Patients

with Diabetes with Diabetes
• Slowing down of the GIS tract can increase vomit • Patients must not be kept waiting for a long
reflexes and aspiration. A diabetic patient’s
physician must be consulted about drugs such as -
period of time, and attention must be paid to
- H2 blockers and prokinetic agents in order to pain
-
control.
reduce the risk of aspiration caused by slowing • Pregnant patients must be assessed with regard
down of the GIS. to their pregnancy and diabetes prior to
• Regarding general anaesthesia and major surgical treatment.
treatment procedures, oral antidiabetic agents
must be stopped 48 hours prior to treatment in • Patients with gestational diabetes must be
consultation with the patient’s physician. warned of the possibility of postnatal diabetes
• Risk of hypoglycaemia must be checked in the and the continuation of yearly endocrinological
event of delay in food intake. checkups must be recommended.

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 21.02.22

Risk Groups in Dental Practices with Regard to Risk Groups in Dental Practices with Regard to
the Metabolic Control State of Diabetes the Metabolic Control State of Diabetes
Patients with diabetes at Low-Risk Group Patients with diabetes at Medium-Risk Group
– Fasting blood glucose level < 180-240 mg/dl
-
– Fasting blood glucose level< 180 mg/dl
-
– HbA1C level < 8-10%
-
– HbA1C value < 8%

Treatment Plan
Treatment Plan
1. Medical consultation is required.
1. Medical consultation may be required.
-

-
2. All restorative treatments can be performed.
2. Any kind of dental treatment can be performed -
3. Simple surgical procedures can be performed.
under optimum
-
conditions 4. Detailed medical consultation is required for complicated
surgical procedures.

Risk Groups in Dental Practices with Regard to

the Metabolic Control State of Diabetes
Patients with diabetes at High-Risk Group
–
–
–
-O
Fasting blood glucose level > 240 mg/dl
HbA1C level > 10%
DM with complications Management Considerations in the
– Risk of ketoacidosis and hypoglycaemia
Oral Treatment Process
Treatment Plan
1. Medical consultation is required.
2. All restorative treatments must be performed only in the presence
of glycaemic controls.
3. Acute infections must be treated by administering antibiotics and
abscess drainage when they disrupt diabetes regulation.
4. Detailed medical consultation is required for complicated surgical
procedures.

Restorative Treatments and Minor/Major Surgical Procedures Restorative Treatments and Minor/Major Surgical Procedures
under Local Anaesthesia for Patients with type 1 diabetes under Local Anaesthesia for Patients with type 1 diabetes

=
• The blood glucose level must be measured before the
procedure. The procedure can proceed if blood glucose is
• Since infection is likely, antibiotics must be used as
-
prophylactic measure prior to procedures such as
-
between the values of 100 and 200 mg/dl; if it exceeds 200 intraligamentary-
anaesthesia, tooth extraction, biopsy,
mg/dl, a specialist must be consulted. -
endodontic treatment,-
subgingival curettage and other
• In the case that treatment continues for a longer-than- surgical operations.
expected period of time, the blood glucose value must be • Atraumatic methods must be used due to the high probability
monitored every hour. of fracture or complications during tooth extractions
performed to prevent the risk of osteoporosis.

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 21.02.22

Restorative Treatments and Minor/Major Surgical Procedures Prophylactic Approaches with regard to Oral
under Local Anaesthesia for Patients with type 2 diabetes Health in Patients with Diabetes

• No special measures are required for diabetic patients • Daily and regular oral and dental care is essential for
(HbA1C 6-8%) with (regulated) metabolic control. the treatment and metabolic control of diabetes.
• Caution must be taken against infection and (impaired) • Diabetic patients must be educated regarding the
wound healing. impact of oral hygiene on the treatment of diabetes
• Concerning nonregulated patients, intervention needs to be • Diabetic patients without metabolic control must be
delayed until metabolic control is achieved informed of the increased periodontal disease and
caries risk related to raised saliva glucose levels

Dietary Consultation/Advice
• Nutrition plays a crucial role in the regulation of • Oral hygiene must be maintained after snack meals. If not possible, xylitol
diabetes, so any oral rehabilitation that the patient gum must be chewed 3 times/20 minutes a day
needs for a healthy diet must be promoted/induced • Fiber-rich carbohydrates with low glycaemic index and cariogenic
immediately. characteristics are recommended.
• Patients at risk of developing diabetes who have not • Sweeteners like sorbitol, xylitol and mannitol are sugar alcohols. They
been diagnosed yet must be referred to a related contain calories and can be fermented. Therefore, they should only be
specialist. consumed as recommended.
• Cessation of smoking is a prerequisite to the control • Non-metabolic and non-calorie-containing synthetic sweeteners like
and treatment of diabetes as well as to ensure and sodium cyclamate, aspartame or saccharine should be preferred
maintain oral and dental health.