Download prevention of periodontitis in diabetics

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 mouth
problems 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 CHILDREN
WHO 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