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  Diabetopaedia.com---Dental Care(Oral Hygeine)



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
  • IDDM (Type 1) or Juvenile Diabetes or Juvenile - onset diabetes (onset usually below the age of 15 years)
  • NIDDM (Type 2) or adult type (onset usually after 25 years)

Oral Manifestations:

  • 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 - 119.



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