Mehmood Hussain, Nazia Yazdanie, Jodat Askari
How to CITE:
J Pak Dent Assoc 2010;19(1): 46 - 48
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.
Diabetes Mellitus, Clinical features, Prosthodontics Management.
iabetes Mellitus is a clinical syndrome Dcharacterized by hyperglycemia due to absolute or relative deficiency of insulin.1 The two main categories of Diabetes Mellitus include Type I or Insulin dependent Diabetes Mellitus and Type II or Non insulin dependent Diabetes Mellitus. The former is a result of absolute deficiency of insulin with its onset occurring before adulthood. In contrast, Type II results because of insulin resistance with an insulin secretary defect with its onset usually occuring in mid or later life although it can occur earlier as well.2
Regarding pathogenesis, Type I Diabetes Mellitus results from immunological destruction of pancreatic beta cells, while Type II results from combination of impairment of insulin resistance and defective secretion of insulin by beta cells. Contributing factors include genetics, obesity, physical inactivity and advancing age. 3 Diabetes Mellitus is becoming a common disease of today’s world, in United Kingdom one in twenty people over the age of 65 has diabetes and this rises to one in five people over the age of 85 years. The World Health Organization predicts that the global prevalence of diabetes will increase from 135 million to 300 million in 2025.4 Even in developing countries like Pakistan, the incidence of diabetes is increasing rapidly and most of the cases are undiagnosed as well. People mostly consult their physician when typical symptoms of diabetes like polyuria, polydipsia, polyphagia occur.5 Considering oral health in diabetic patients, they are more prone to develop caries, periodontitis, xerostomia, oral ulcers, burning mouth syndrome, candidiasis, loss of resilience of oral mucosa, residual bone resorption, periodontal abscess, gingival overgrowth and poor tolerance to prosthesis especially for complete dentures. 6 Oral manifestations are most likely due to increase glucose concentration in saliva, polyuria, impaired host resistance due to defective function of polymorphonuclear leucocyte (PMN) and microvasculsar changes.7
Management Considerations: General Dental Considerations
It is better to arrange appointment in the morning and avoiding lengthy appointments. All procedures should be done involving minimal possible trauma and should be carried in stress free environment. Maintenance of good oral hygiene is a prerequisite for all dental procedures. In this regard application of topical agents like chlorhexidine, fluoride gel is found very useful. The use of prophylactic medication to avoid postoperative infection and pain is recommended in certain cases. For management of xerostomia, diet counseling, medication, artificial salivary substitutes are helpful. Before starting any procedure consultation with patient’s physician or endocrinologist is also beneficial for the diabetic patients.8
Dentist should also be able to know about the diagnosis and management of hypoglycemic shock. It is characterized by hunger, nausea, perspiration, pallor, and tachycardia. In severe condition seizure may occur and patient may undergo in state of unconsciousness
Management depends upon the severity of the shock. Initially treatment should be deferred and to monitor vital signs and administer glucose orally if possible otherwise intravenous administration of glucose should be done.
Prosthodontics Management Considerations:
Eradication of any disease/s that will affect the prognosis of any dental prosthesis will be the first line of action. Teeth requiring restoration must be restored by appropriate restorative procedures like filling, endodontic treatment etc. As previously mentioned restoration and the maintenance of good oral hygiene is mandatory before starting any prosthodontic procedures. On first visit, assessment of the patient should be done which include proper history and examination. Details regarding type of prosthesis, duration of treatment, number of appointments must be explained to the patient.10
Radiographic evaluation must be carried out. Patients is advised to bring reports of recently done and up to date laboratory investigation regarding blood sugar level. Secondly it is better to note blood sugar level before starting any dental procedure with the help of glucometer. Patient must be instructed to consult his or her physician before initiating any procedure, if needed then any alteration regarding patient’s medication must be discussed with the patient’s physician. 11
If patient is provided removable partial denture (RPD), then restoration and maintenance of good oral hygiene by any restorative procedures or root planning and scaling must be accomplished first. Health of abutment teeth is very important and will be achieved by various means for better prognosis of RPD treatment.12 All components of RPD must be tissue friendly by making appropriate design of the prosthesis. As diabetic patients are more prone to develop periodontal diseases, therefore in certain cases splinting of periodontalally compromised teeth is also a good option. Some times periodontal surgery may be indicated.13 Selection of particular type of RPD is also very important, in Diabetic patients. If an acrylic denture is a preferred option then the design should incorporate the principles of ‘Every Denture’ with wider self cleansing interdental spaces and embrasures areas, uncovered marginal gingiva, point contact between denture and natural abutment teeth, free gliding occlusion, maximum retention following complete denture making principles. These all factors are beneficial for the diabetic patients if they need RPD.14
When complete denture is fabricated for diabetic patients then always use tissue friendly material and technique, impression making will be done by mucostatic technique. Occlusal vertical dimension should be appropriate
Always use an occlusal scheme that has narrow bucco-lingual dimension and shortened mesiodistal length. This approach will decrease the stress on the underlying tissue to retard bone resorption, concept of neutral zone can also be employed. Denture flanges should be smooth and polished. There should be no working or non-working occlusal interference between opposing teeth.15
It is also mandatory for the dentist to fully educate and motivate the patient to the importance of maintaining good oral hygiene and towards the importance of regular follow-up visits to the dentist.
This will ensure the long term heath of the oral tissues by preventing chronic infection states such as denture related stomatitis and denture hyperplasia that could lead to more serious conditions. Diabetic patients are more susceptible to infections which in severe cases may lead to excessive oral tissue destructions, such patients may need obturators. Fabrication of obturator require special care in every patient and especially in diabetic patient.16
For patients requiring a fixed prosthesis like crown or fixed partial denture (FPD), the finish-line of the preparation should be placed supragingival and to provide chamfer finish-line on the facial aspect of prepared tooth as it is better than shoulder because shoulder can concentrate stresses on weakened tooth/ teeth. Ante’s law should be obeyed; minimal preparation like three quarter crown can be done on teeth like pre molar.
A narrow occlusal table, group function or mutually protected occlusal scheme is better choice for periodontally compromised teeth.17. In certain cases procedures like crown lengthening, periodontal surgery and orthodontic extrusion of tooth will further improve the quality of fixed prosthesis in diabetic patients.18 Implant supported prosthesis are not advised for patients whose blood sugar level remains uncontrollable but if conditions are favorable , then this type of prosthesis can be planned. Like any other dental surgical procedure, implant placement must be accomplished with least trauma under stress free environment.19
Proper medication must be provided before and after implant placement. Complete history and examination along with radiographic evaluation must be carried out for selection of type of dental implant, number of dental implants, site of implant placement, type of artificial prosthesis and occlusal scheme.
All these considerations will ensure better performance of implants supported prosthesis. 20, 21
Diabetes Mellitus is a complex disorder having many oral and systemic problems. Multi disciplinary approach is needed for the management of diabetes mellitus. Fabrication of dental prosthesis would only be started after complete evaluation of diabetic patients through history, examination and making diagnostic cast. Before embarking any procedure for dental prosthesis, oral hygiene of the diabetic patients must be evaluated and should be improved through different surgical and non-surgical periodontal therapies and restorative techniques. Apart from conventional removable or fixed dental prosthesis, introduction of dental implants helps to improve the quality of life of the patients by better masticatory ability of the dental prosthesis. In this article along with oral complications of Diabetes Mellitus, various Prosthodontics treatment options available for diabetic patients are discussed Management of diabetic patients in Prosthodontics should be done carefully. Before embarking dental treatment it is better to consult patient’s physician. Good oral and denture hygiene maintenance is a pre requisite for ensuring the long term successful Prosthodontics treatment. With an increasing incidence and prevalence of Diabetes Mellitus, the role of oral health care provider becomes very important
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