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1

define DIABETES MELLITUS (DM)

A common group of metabolic disorders characterised by chronic hyperglycaemia resulting from insulin deficiency or impaired utilisation of insulin (insulin resistance)

2

Diagnosis

Venous plasma glucose
Random venous plasma glucose >= 11.1 mmol/litre, ot fasting venous plasma glucose >= 7.0 mmol/l plus
Unexplained weight loss, polyuria, polydipsia
Normal blood glucose 4-5.5 mmol/l before meals. <8mmol/l two hours after meals

Haemoglobin A1c may be used for diagnosis
Cut off point 48mmol/mol (6.5%)

3

Types of diabetes

○ Type 1 10%
○ Type 2 90%
○ Other
§ Maturity Onset Diabetes in the Young 1-2% (20-40k)
Gestational diabetes 3.5% of pregnancies

4

Type 1 dibetes

• Destruction of ß cells in pancreas
○ Autoimmune process
○ Islet cell antibodies at time of diagnosis
• Genetic predisposition
Abrupt onset, most often in children/teens

5

Type 2 diabetes

• Defect in ß cell and insulin resistance
• Usually manifests mid life
○ Small number of children affected
• Genetic influence
• á risk if obese, sedentary lifestyle, close relative with DM, Asian/Afro-Caribbean
Complications possible before diagnosis

6

Control/diagnosis of diabetes is important,

...implications of poor control or undiagnosed DM include: diabetes complication/ risk factor for periodontal disease

7

Control of Type 2 diabetes

Type 2
Treat by diet or diet and oral - hypoglycaemic drugs plus exercise
25% may go on to need insulin injections
Balancing act

8

Control of Type 1 diabetes

Type 1
Treat by insulin injections/insulin pump
Balance carbohydrate intake and insulin
New technology includes transplantation of pancreatic islets of langerhans cells

9

Home blood glucose monitoring

Simple finger prick
Drop of blood on strip
Direct reading in secs
Aim for 4-7mmol/ litre

10

Complications of diabetes commonly cited
Macrovascular

Micro vascular

Macrovascular: cardiovascular disease-
the major cause of death
peripheral vasular disease- amputation,
cerebrovascular disease and stroke

Microvascular:
retinopathy- blindness,
Nephropathy- renal failure,
Neuropathy- painful nerve damage

11

Systemic inflammation,Strong evidence periodontal infections induce systemic inflammatory response
Evidence of increase levels of.....

acute phase proteins (eg C-reactive protein) and pro-inflammatory cytokines

12

What may play a role in the devlopment of type 1 DM?

Increased IL-1Beta may result in pancreatic Beta cell destruction (i.e role in type 1 DM)

13

how does obesity play a role in development of type 2 DM? (interlukein)

In obesity IL-6 stimulates TNF-alpha
Increse IL-6 and increase TNF-alpha may result in insulin resistance (i.e role in type 2 DM)

14

BMI linked to......
Obesity significant predictor of.......

......severity of attachment loss in NHANES III
......... periodontal disease; insulin resistance may mediate link

15

Adipocyte production of proinflammatory cytokines (adipokines) may link..........

obesity to diabetes and periodontitis

16

Hyperglycaemia may result in collagen to undergo non-enzymatic glycation to Advanced End Products (AGEs) leading to.....

linked to......

Increased collagen cross-linking, increased cytokine production,
linked to- microvascular complications, atherosclerosis, decreased production bone matrix

17

AGES activate Receptor for AGES=RAGES
Interaction of RAGEs and AGES perturb vascular and inflammatory cell function

Microvascular and macrovascular diabetes complications
Accelerated periodontal tissue destruction

18

Polymorphonuclear leukocyte (PMN's) is first line of defence, but in DM...

Decreased PMN function, increased periodontitis
Enhanced respiratory burst
Delayed apoptosis, increased tissue desruction

19

Effect of periodontal diseases on diabetes control (HbA1c)

Systematic review of current evidence suggests that periodontal diseases adversely affect diabetes outcome:
-Control
-Complications
-Incidence

20

Decreased HbA1c of 1% associated with decreased risk of:

Deaths related to diabetes
Myocardial infarction
Microvascular complications

21

Recent systematic reviews/ meta analyse on the effect of periodotnal treatment on Diabetes control

Improvement in HbA1c significant 0.4% after non-surgical treatment but after non-surgical therapy and antibiotic not significant
In type 2 DM, equivalent to single extra drug effect
Need more studies with larger samples

22

Periodontal care for patients with diabetes

Check HbA1c with diabetes care team
Follow 3 principles of 3 stages of therapy
Initial therapy: GDP can undertake; if poor response, consider specialist referral
Corrective therapy: consider adjunctive systemic antibiotics (but more research needed)
Supportive therapy: GDP can undertake

23

Managment of 'hypo'

Hypoglycemia: pale, shaky, clammy, may be aggreessive/confused; blood glucos <4mmol/l
Give 3-6 glucose tablets (3g each) i.e 10-20g
Or give glucose drink e.g Lucozade 150-200ml

24

Managemnet of severe 'hypo'

Give glucogon IM, SC or IV injections (1mg if adult or child over 8yrs; 0.5mg if under8 yrs)
Plus further carbohydrate on recovery
Advice: get doctor/ dial 999 if no recovery in 10 minutes
If still unconscious, will need glucose IV

25

Diabetes:
Loe in 1993 proposed


Lamster & Lalla after reviewing the evidence concluded

What is most important

periodontal disease as the sixth complication of diabetes
Loe 1993

periodontal disease is a clinical complication of diabetes

Diabetes control is critical

26

Genetic factors may increase the susceptibility to other associated chronic conditions: cancer/ heart disease/ diabetes.
A study of shred genetics risk factors between cancer and periodontal disease in monozygotic twins found

associataion between periodontal disease and several cancers
Hypothesis that inflammation underlines the association and IL-1 gene polymorphisms associated with increased levels of periodontal disease may be associated with icnreased cance

27

How is progresion of periodontits linked to genetics

Periodontitis that occur early in age and progresses fast has shown familial aggregation
In the more common form of periodontal disease seen in older patients with slower progression the picture is less clear

28

Conclusion

Several systemic risk factors where some evidence of a link to periodontitis
Potentially bi-directional relationship
Evidence for diabetes as risk factor is insignificant
Patients should be informed about the relationship of diabetes and periodontitis for optimum management of both conditions
Some other potential risk factors require further research to establish the relationship and its extent

29

Periodontitis

Initial therapy: GDP can undertake; if poor response, consider specialist referral
Corrective therapy: consider adjunctive systemic antibiotics (but more research needed)
Supportive therapy: GDP can undertaker

30

Guidelines for dental practice- EFP/AAP workshop & manifesto (part one)

If periodontitis, need:
Therapy (IT, CT, SPT) ; OHE
-manage acute, infections, oral complications; dental rehabilitation if tooth loss