Mehmood Hussain by alicejenny


									                                                           REVIEW ARTICLE


Mehmood Hussain,                        BDS,
Nazia Yazdanie                          BDS,MSc, Ph.D
Jodat Askari                            BDS,FCPS

Diabetes Mellitus is a nutritional metabolic disorder characterize by various oral and systemic problems. These
patients when referred to dentist or prosthodontist for the provision of prosthetic treatment require multidisciplinary
approach. In this article special focus is emphasized on the various factors important factors to be kept in mind when
providing prosthodontic treatment for such patients. .
KEY WORDS: Diabetes Mellitus, Clinical features, Prosthodontics Management.
J Pak Dent Assoc 2010;19(1):46-48

                     INTRODUCTION                                             as well. People mostly consult their physician when
                                                                              typical symptoms of diabetes like polyuria, polydipsia,

         iabetes Mellitus is a clinical syndrome                              polyphagia occur. Considering oral health in diabetic
         characterized by hyperglycemia due to absolute                       patients, they are more prone to develop caries,
         or relative deficiency of insulin.1 The two main                     periodontitis, xerostomia, oral ulcers, burning mouth
categories of Diabetes Mellitus include Type I or Insulin                     syndrome, candidiasis, loss of resilience of oral mucosa,
dependent Diabetes Mellitus and Type II or Non insulin                        residual bone resorption, periodontal abscess, gingival
dependent Diabetes Mellitus. The former is a result of                        overgrowth and poor tolerance to prosthesis especially for
absolute deficiency of insulin with its onset occurring                       complete dentures. 6 Oral manifestations are most likely
before adulthood. In contrast, Type II results because of                     due to increase glucose concentration in saliva, polyuria,
insulin resistance with an insulin secretary defect with its                  impaired host resistance due to defective function of
onset usually occuring in mid or later life although it can                   polymorphonuclear leucocyte (PMN) and microvasculsar
occur earlier as well.2                                                       changes.7
Regarding pathogenesis, Type I Diabetes Mellitus results                                  Management Considerations:
from immunological destruction of pancreatic beta cells,
                                                                                        General Dental Considerations:
while Type II results from combination of impairment of
insulin resistance and defective secretion of insulin by                      It is better to arrange appointment in the morning and
beta cells. Contributing factors include genetics, obesity,                   avoiding lengthy appointments. All procedures should be
physical inactivity and advancing age. 3 Diabetes Mellitus                    done involving minimal possible trauma and should be
is becoming a common disease of today's world, in United                      carried in stress free environment. Maintenance of good
Kingdom one in twenty people over the age of 65 has                           oral hygiene is a prerequisite for all dental procedures. In
diabetes and this rises to one in five people over the age of                 this regard application of topical agents like
85 years. The World Health Organization predicts that the                     chlorhexidine, fluoride gel is found very useful. The use of
global prevalence of diabetes will increase from 135                          prophylactic medication to avoid postoperative infection
million to 300 million in 2025.4 Even in developing                           and pain is recommended in certain cases. For
countries like Pakistan, the incidence of diabetes is                         management of xerostomia, diet counseling, medication,
increasing rapidly and most of the cases are undiagnosed                      artificial salivary substitutes are helpful. Before starting
                                                                              any procedure consultation with patient's physician or
*   Incharge, Prosthodontics Department , Hamdard College of                  endocrinologist is also beneficial for the diabetic patients.

    Medicine & Dentistry Karachi.
** Former Head, Prosthodontics Department, & Principal                        Dentist should also be able to know about the diagnosis
    de’Montmorency College of Dentistry, Lahore                               and management of hypoglycemic shock. It is
*** Associate Professor, Dept of Prosthodontics, Sir Syed Institute of        characterized by hunger, nausea, perspiration, pallor, and
    Medical Sciences , Karachi.                                               tachycardia. In severe condition seizure may occur and
Correspondence: Dr. Mehmood Hussain <>                  patient may undergo in state of unconsciousness.

JPDA Vol.19 No.1 Jan-Mar 2010                                            45
               Hussain M, Yazdanie N, Askari J                        Management of Diabetes Mellitus Patient in Prosthodontics

Management depends upon the severity of the shock.                   Always use an occlusal scheme that has narrow bucco-
Initially treatment should be deferred and to monitor vital          lingual dimension and shortened mesiodistal length. This
signs and administer glucose orally if possible otherwise            approach will decrease the stress on the underlying tissue
intravenous administration of glucose should be done.                to retard bone resorption, concept of neutral zone can also
  Prosthodontics Management Considerations:                          be employed. Denture flanges should be smooth and
                                                                     polished. There should be no working or non-working
Eradication of any disease/s that will affect the prognosis          occlusal interference between opposing teeth.15
of any dental prosthesis will be the first line of action.
Teeth requiring restoration must be restored by                      It is also mandatory for the dentist to fully educate and
appropriate restorative procedures like filling, endodontic          motivate the patient to the importance of maintaining
treatment etc. As previously mentioned restoration and the           good oral hygiene and towards the importance of regular
maintenance of good oral hygiene is mandatory before                 follow-up visits to the dentist.
starting any prosthodontic procedures. On first visit,               This will ensure the long term heath of the oral tissues by
assessment of the patient should be done which include               preventing chronic infection states such as denture related
proper history and examination. Details regarding type of            stomatitis and denture hyperplasia that could lead to more
prosthesis, duration of treatment, number of appointments            serious conditions. Diabetic patients are more susceptible
must be explained to the patient.10                                  to infections which in severe cases may lead to excessive
Radiographic evaluation must be carried out. Patients is             oral tissue destructions, such patients may need
advised to bring reports of recently done and up to date             obturators. Fabrication of obturator require special care in
laboratory investigation regarding blood sugar level.                every patient and especially in diabetic patient.
Secondly it is better to note blood sugar level before               For patients requiring a fixed prosthesis like crown or
starting any dental procedure with the help of glucometer.           fixed partial denture (FPD), the finish-line of the
Patient must be instructed to consult his or her physician           preparation should be placed supragingival and to provide
before initiating any procedure, if needed then any                  chamfer finish-line on the facial aspect of prepared tooth
alteration regarding patient's medication must be
                                        11                           as it is better than shoulder because shoulder can
discussed with the patient's physician.                              concentrate stresses on weakened tooth/ teeth. Ante's law
If patient is provided removable partial denture (RPD),              should be obeyed; minimal preparation like three quarter
then restoration and maintenance of good oral hygiene by             crown can be done on teeth like pre molar.
any restorative procedures or root planning and scaling
                                                                     A narrow occlusal table, group function or mutually
must be accomplished first. Health of abutment teeth is
                                                                     protected occlusal scheme is better choice for
very important and will be achieved by various means for
                                      12                             periodontally compromised teeth.17. In certain cases
better prognosis of RPD treatment. All components of
                                                                     procedures like crown lengthening, periodontal surgery
RPD must be tissue friendly by making appropriate design
of the prosthesis. As diabetic patients are more prone to            and orthodontic extrusion of tooth will further improve the
develop periodontal diseases, therefore in certain cases             quality of fixed prosthesis in diabetic patients.18 Implant
splinting of periodontalally compromised teeth is also a             supported prosthesis are not advised for patients whose
good option. Some times periodontal surgery may be                   blood sugar level remains uncontrollable but if conditions
indicated.13 Selection of particular type of RPD is also             are favorable , then this type of prosthesis can be planned.
very important, in Diabetic patients. If an acrylic denture          Like any other dental surgical procedure, implant
is a preferred option then the design should incorporate             placement must be accomplished with least trauma under
the principles of 'Every Denture' with wider self                    stress free environment.19
cleansing interdental spaces and embrasures areas,                   Proper medication must be provided before and after
uncovered marginal gingiva, point contact between                    implant placement. Complete history and examination
denture and natural abutment teeth, free gliding occlusion,          along with radiographic evaluation must be carried out for
maximum retention following complete denture making                  selection of type of dental implant, number of dental
principles. These all factors are beneficial for the diabetic        implants, site of implant placement, type of artificial
patients if they need RPD.                                           prosthesis and occlusal scheme.
When complete denture is fabricated for diabetic patients            All these considerations will ensure better performance of
then always use tissue friendly material and technique,              implants supported prosthesis. 20, 21
impression making will be done by mucostatic technique.
Occlusal vertical dimension should be appropriate.

                                                                46                                 JPDA Vol.19 No.1 Jan-Mar 2010
                  Hussain M, Yazdanie N, Askari J                                Management of Diabetes Mellitus Patient in Prosthodontics

                           Conclusion:                                               Medicine and Treatment Planning. 2nd ed. Canada: BC Decker Inc
                                                                                      2002; 421-470.
Diabetes Mellitus is a complex disorder having many oral                        11. Habib SS, Almas K. Management of Diabetic patients in dental
and systemic problems. Multi disciplinary approach is                                 practice. J Pak Dent Assoc 2002; 11: 101-106.
                                                                                12. Carr AB, McGivney GP, Brown DT. McCracken's Removable
needed for the management of diabetes mellitus.
                                                                                      Partial Prosthodontics. 11th ed. India: Elsevier 2005; 145-162.
Fabrication of dental prosthesis would only be started                          13. Stewart KL, Rudd KD, Kuebker WA. Clinical Removable Partial
after complete evaluation of diabetic patients through                                Prosthodontics. 2nd ed. India: AIPD 2005; 97-116.
history, examination and making diagnostic cast. Before                         14. Walmsley AD. Acrylic Partial Dentures. Dent Update 2003; 30:
embarking any procedure for dental prosthesis, oral                                   424-9.
hygiene of the diabetic patients must be evaluated and                          15. Zarb GA, Bolender CL. Prosthodonticc Treatment for Edentulous
                                                                                      Patients. 12th ed. USA: Mosby 2004; 298-328.
should be improved through different surgical and non-                          16. Sykes LM, Sukha A. Potential risk of serious oral infections in the
surgical periodontal therapies and restorative techniques.                           diabetic patient: A clinical report. J Prosthet Dent 2001; 86: 569-
Apart from conventional removable or fixed dental                                    573.
prosthesis, introduction of dental implants helps to                            17. Shillingberg HT, Hobo S, Whitsett LD, Jacobi R, Brackett SE.
improve the quality of life of the patients by better                               Fundamentals of Fixed Prosthodontics. 3rd ed. India: Quintessence
                                                                                    2002; 211-224.
masticatory ability of the dental prosthesis. In this article                   18. Ziada H, Irwin C, Mullaly B, Byrne PJ, Allen E. Periodontics:
along with oral complications of Diabetes Mellitus,                                 Surgical Crown Lengthening. Dent Update 2007; 34: 462-8.
various Prosthodontics treatment options available for                          19. Hobkrik JA, Watson RM, Searson LJJ. Introducing Dental Implant.
diabetic patients are discussed Management of diabetic                              1st ed. USA: Elsevier 2003; 19-28.
patients in Prosthodontics should be done carefully.                            20. Scortecci GM, Misch CE, Benner KU. Implants and Restorative
                                                                                    Dentistry. 1st ed. UK: Martin Dunitz 2001; 141-165.
Before embarking dental treatment it is better to consult                       21.Roumanas FD, Garrett NR, Hamada MO, Diener RM, Kapur KK. A
patient's physician. Good oral and denture hygiene                                   randomized clinical trial comparing the efficacy of mandibular
maintenance is a pre requisite for ensuring the long term                           implant supported overdenturtes and conventional dentures in
successful Prosthodontics treatment. With an increasing                             Diabetic patients. Part V: Food preference comparisons. J Prosthet
incidence and prevalence of Diabetes Mellitus, the role of                          Dent 2002; 87: 62-73.
oral health care provider becomes very important.

1. Frier BM, Truswel AS, Shepherd J, Jung R. Diabetes mellitus
     nutritional and metabolic disorders. Davidson's Principles and
    Practice of Medicine. 18th ed. UK: Churchill Living stone 2001;
2. Rhodus NL, Vibeto BM, Hamamoto DT. Glycemic control in
    patients with diabetes mellitus upon admission to a dental clinic:
    Considerations for dental management. Quintessance Int 2005; 36:
3. Ghom AG. Text book of Oral Medicine. 1st ed. India: Jaypee
    Brothers 2005; 764-781.
4. Fiske J. Diabetes Mellitus and Oral Care. Dent Update 2004; 31:
5. Basit A, Hydrie MZI, Ahmed K, Hakeem R. Prevalence of diabetes,
    impaired fasting glucose and associated risk factors in a rural area
    of Balochistan province acoording to new ADA criteria. J Pak Med
    Assoc 2002; 52: 357-360.
6. Soell M, Hassan M, Miliauskaite A, Haikel Y, Selimovick D The
    oral cavity of elderly patients in diabetes. Diabetes Metab 2007; 33
    Suppl 1: 10-18.
7. Lima DC, Nakata GC, Balducci I, Almeida JI. Oral manifestations
    of Diabetes Mellitus in complete denture wearers. J Prosthet Dent
    2008; 99: 60-65.
8. Miley DD, Terezhalmy GT. The patients with Diabetes Mellitus:
    Etiology, epidemiology, principles of medical management, oral
    disease burden and principles of dental management. Quintessance
    Int 2005; 36: 779-795.
9. Hupp JR. Prevention and management of medicalemergencies. 4th
    ed. USA: Mosby 2000; 221-241.
10. Bricker SL, Langlais RP, Miller CS. Oral Diagnosis, Oral

JPDA Vol.19 No.1 Jan-Mar 2010                                              47

To top