DENTAL PROBLEMS AND DENTAL CARE IN
DIABETES
Diabetes mellitus is a common
endocrine disease characterized by chronic hyperglycaemia and
abnormalities of carbohydrate and lipid metabolism. These are
caused by either an absolute or relative deficiency of insulin
produced by the pancreas. Consequently there are high blood glucose
levels and excretion of sugar in the urine.
Classification
Two basic types of primary Diabetes Mellitus
are
-
Median rhomboid glossitis,
which is a well demarcated, central, nonulcerated, smooth pink/red
area on the middle third of the dorsum of the tongue, is often
associated with diabetes.
-
Oral conditions
exacerbated by diabetes are:-
(a) Gingivitis and periodontal disease
(b) Oral candidiasis (Fungal disease)
(c) Localized osteitis after exodontia
(d) Burning tongue
-
Microflora from IDDM
has more of gram negative rods and bacteria
-
Cheilosis (Bad breath)
-
A tendency towards
drying and cracking
-
Burning sensation
in the mouth
-
Decrease in salivary
flow-dry mouth
-
Oral thrush seen
more in diabetics.
The increased incidence
of dry sockets mainly associated with mandibular extractions is
thought to be related to a reduced blood supply to the mandible
caused by atherosclerosis in long standing diabetes. Epinephrine
will further reduce the blood supply to the area and may increase
the likelihood of dry socket. Following extractions, suturing
of sockets to aid homeostasis is recommended.
Effect of diabetes on the periodontium
(mainly affected structure)
1) Greater loss of
attachment.
2) Increased bleeding on probing.
3) Increased tooth mobility.
4) Insulin dependent diabetic children tend to have more destruction
around the first molars and incisors.
5) Increased bone loss and retardation of post surgical healing
of periodontal tissues seen.
6) Frequent periodontal abscess is another feature of diabetes.
7) IDDM patients have sub gingival flora composed mainly of anaerobic
organisms.
8) Increased susceptibility to infection is seen in these patients
due to leukocyte deficiencies.
Perhaps the most striking changes in
uncontrolled diabetes are,
(i) The reduction
in defense mechanism
(ii) The increased susceptibility to infection leading to destructive
periodontal disease.
In juvenile diabetics,
there is often extensive periodontal destruction, which is noteworthy
because of the age of the patients.
Bio - chemical Studies:
The glucose content of the
gingival fluid is higher in diabetics. The increased glucose in
the gingival fluid and blood of diabetics could change the environment
of the microflora , inducing qualitative changes in bacteria that
could affect periodontal changes.
Uncontrolled Diabetes and
Dental Septic focus
An important aspect of diabetes
control in a person whose blood sugars are not getting under expected
`Control' despite adequate dieting, exercise and drugs: it should
alert the doctor to look for evidence of chronic dental septic
(infective) focus. Usually stumps of broken teeth are infected,
particularly in many elderly diabetics who do not bother to get
them removed. In such instances, control of their blood sugars
(if necessary with addition of small doses of insulin) and removal
of the infected roots/teeth would bring down their blood sugars
and enable them to be taken off insulin.
ORAL CARE SCHEDULE FOR
DIABETICS:
Meticulous oral hygiene
measures to be observed through proper brushing, twice a day.
- Inter dental aids
like dental floss or interdental brushes to be used as indicated.
- Antiseptic mouth wash, preferably chlorohexidine to be used
as a maintenance procedure with professional
advice from a dental surgeon.
- Oral hydration to be maintained to prevent drying of gingival
tissue.
- Periodic visits to a dentist once in every six months.
- Dental treatment to be carried out in stages to avoid complications.
PRECAUTIONS TAKEN
IN DENTAL MANAGEMENT OF DIABETIC PATIENT.
Patient's physician is
to be consulted. Laboratory tests such as fasting blood glucose,
postprandial blood glucose,glycosylated hemoglobin (HbA1c), glucose
tolerance test and urinary glucose, bleeding time, clotting time
etc. must be obtained.
Acute oro-facial or severe
dental infection must be ruled out. Vital signs especially blood
pressure must be monitored closely. Glucose levels should be continuously
monitored and periodontal treatment should be performed when the
disease is in a well - controlled state.
Prophylactic antibiotics,
started 2 days preoperatively and continued through the immediate
postoperative period should be administered. Penicillin will be
the drug of choice.
Persons (especially
with cardiac problems) taking aspirin and anticoagulant medication
should stop these well before any oral/dental surgery, after consulting
their cardiologists.
DENTAL MANAGEMENT
Morning appointment after
breakfast is ideal because of optimal insulin levels The clinician
should make certain that the prescribed insulin has been taken,
followed by a meal.
If
general anesthesia, intravenous procedures/ surgical procedures
are performed that alter the patient's ability to maintain
a normal caloric intake, postoperative insulin doses should be
altered.
Diabetics are to be handled
as atraumatically and as minimally as possible. Anesthetics should
contain epinephrine in concentrations not greater than 1:1,00,000.
Endogenous epinephrine may increase insulin requirement. Diet
recommendations are made to enable the patient to maintain a proper
glucose balance.
Diabetes may be considered
not as a disease but as a disorder. With proper control of diabetes,
oral health also may be normally maintained and all dental procedures
may be gone through.
SPECIALLY CONTRIBUTED
BY
DR. S. RAMACHANDRAN, M.D.S., PRINCIPAL
PROF. DEPT. OF CONSERVATIVE DENTISTRY & ENDODONTICS.
RAGAS DENTAL COLLEGE & HOSPITAL, CHENNAI
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