UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 FOUSP - MINISTRY OF HEALTH, BRAZIL
Oral Health in the Diabetic Patient The diabetic patient presents a chart that requires care and may even prove to be diagnosed in the dental office. Chapters
Updating and Illustrating
1. Introduction
2. Complications of diabetes mellitus interfering in dental treatment
Page 1
3. Glycemia and blood pressure in diabetes mellitus
Page 3
Page 2
no
5. References and Credits Page 4
Page 3
1. Introduction
4. Dental treatment of the diabetic patient
control
of
the
filtration done by ADH.
glomerular DM. There are other categories mentioned as pre-diabetes that are
The word diabetes comes Diabetes mellitus (DM) is the not clinical entities but risk factors to from the Greek and means “siphon” epidemic manifestation of diabetes, the development of DM and or “keep the legs apart”. The word mainly characterized by polyuria cardiovascular diseases. makes reference to the presence of and hyperglycemia. In Brazil, it is Type 1 DM is the result of the beta polyuria that is a great amount of estimated that there are 8 million pancreatic cells destruction with a !
liquid
produced
by
the
body people with DM, causing consequent insulin deficiency. In metabolism that quickly crosses the considerable impact in the Brazilian most cases, this destruction is kidneys originating urine that, in the mortality rate, as well a high cost to autoimmune by nature but there are past, was eliminated by the the public health system due to its situations where this autoimmunity individual standing on his legs apart chronic character and control (SBD, is not apparent and becomes (Rezende, 2007).
2006). DM includes a variety of idiopathic. Type 1 corresponds from Diabetes may be insipidus and metabolic disorders that have 5 to 10% of DM cases. mellitus. Diabetes insipidus has its hyperglycemia in common. In ! Type 2 DM is characterized origins in the ADH (antidiuretic general, there is insulin deficiency, by defects in insulin action and hormone) deficiency or by the non- generating an increase of glucose secretion. The individual may have sensitivity of this hormone in the rates in the blood. an insufficient insulin rate in relation kidneys. It is produced by the The classification accepted by WHO to the glucose load or the inability adeno-hypophysis and characterized and the American Association of peripheral tissues have to respond to by polyuria, excessive thirst and Diabetes considers the process insulin, becoming resistant to it. polydipsia. The body fluids cross the etiology that includes 4 clinical Most of the time, both phenomena kidneys and are quickly eliminated classes: type 1 DM, type 2 DM, other are observed in the individual. as very liquid urine because there is specific types of DM and gestational
UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 - FOUSP - Ministry of Health
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UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 FOUSP - MINISTRY OF HEALTH, BRAZIL
Other specific types of mainly
due
to
nephropathies, frequent endothelial injury caused
DM include people that systemic arterial hypertension and by glycated proteins, as well as present genetic defects in beta dyslipidemias (Gross, Nehme, 1999). protein deposits in the vascular wall pancreatic cells and pancreatic Diabetic retinopathy attacks about (arteriolosclerosis); alterations (pancreatitis, neoplasia, 40% of diabetic patients and is the acromegaly) that can be secondary main cause of blindness in type 2 to
drugs
and
chemical
agents DM patients from 24 to 72 years of
(glucocorticoids, interferon alpha, age. thyroid hormone, etc.) or infections ! Diabetic foot presents a high (congenital rubella, incidence in type 2 diabetic patients, cytomegalovirus, etc.). being the cause of frequent hospital !
!
Decrease
differentiation fibroblasts,
in
and
the
migration
endotheliocytes
of and
bone stem cells and, consequently, less collagen production, blood vessels and bone tissue (Graves et al., 2006).
Gestational DM is similar to admissions and amputations. The
! type 2 DM but diagnosis is made great majority (85%) of severe cases during gestation. It does not exclude that require hospitalization originate ! If bacteremia and septicemia the possibility of the patient having from superficial ulcers associated to are present, infectious foci in the oral it before pregnancy. In general, the the patient
becomes
decrease
normoglycemic diabetic
in
by cavity, minor cause
sensitivity
neuropathy
and
after delivery but many reports have trauma (Gross, Nehme, 1999). demonstrated a risk of developing ! In Dentistry, one should pay type 2 DM from 5 to 16 years after specific attention to alterations in the delivery (SBD, 2006). repair process of the DM patient, as well as to the risk of bacteremia and
2. Complications of diabetes mellitus interfering in dental treatment
alterations,
periodontopathies,
important such
as
systemic increase
in
cytokines and growth factors, that indicate general inflammatory response
contributing
to
the
development of vascular diseases
(Graves et al., 2006). Bacteremia septicemia originated from derived from periodontal pathogens infectious foci in the oral cavity. contributes to insulin resistance and !
As to the impaired repair to beta pancreatic cells destruction.
process (Brem, Tomic-Canic, 2007), it Inflammatory foci in the oral cavity can be observed:
are a risk factor to the development
of inflammatory responses that may ! Vast release of procontribute to chronic complications inflammatory factors, originated at a systemic level. from intense oxidative stress; this
diabetes leads to an increase in inflammatory ! mellitus (DM) can be acute or intensity deregulating the ! Besides severe periodontitis chronic. Acute include coma by inflammation-repair binomial; it is possible to mention as oral ketoacidosis or coma by Decrease in angiogenesis; the manifestations of DM the bacterial hypoglycemia. Chronic are ! !
Complications
mainly
characterized
by
macroangiopathies,
of
and DM patient shows less endothelial plaque accumulation, gingivitis, dry diabetic cell migration to the injury, leading mouth sensation with xerostomia
micro
retinopathy, diabetic nephropathies to less neovascularization and, (due to the salivary glands and systemic arterial pressure. consequently, to a delay in the repair impairment and dehydration caused by hyperglycemia) and recurrent Vascular diseases such as process; infections by Candida. atherosclerosis are the main cause of ! P r e s e n c e o f death in type 2 diabetic patients, microangiopathies characterized by UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 - FOUSP - Ministry of Health
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A R A L SC AER E Q N OU T EÓB OI O KA 2 0 1 2 U P D A T ICN G L O FU T BH E E B A S IDC O FOUSP - MINISTRY OF HEALTH, BRAZIL
3. Glycemia and blood pressure in diabetes mellitus !
Nível de HG Glicemia média (mg/ Nível de HG Glicemia média (mg/ (%)
According to the Brazilian Society of Diabetes
there are three criteria to DM diagnosis: •
dl)
(%)
dl)
5
100
9
240
6
135
10
275
7
170
11
310
8
205
12
345
Symptoms of polyuria, polydipsia and weight loss, Adapted from SBD, 2006. with casual glycemia above 200 mg/dl;
•
Fasting glycemia ≥ 126mg/dl (7 millimoles);
!
The
arterial
hypertension
is
frequently
2-hour glycemia after overload of 75g glucose above associated to DM. In type 1 DM the pressure starts rising 3 years after the beginning of microalbuminuria 200mg/dl. that derives from nephropathy in initial stages; in type 2 The table below summarizes the glycemic levels DM, 40% of the patients are already hypertensive when •
accepted as DM identifiers.
diabetes is diagnosed (SBD, 2006). Hypertension may predispose to diabetic nephropathy, as well as to
Categoria Glicemia normal
Jejum* < 100
2 horas após 75 g de glicose < 140
Tolerância à glicose > 100 e < 126
≥ 140 a < 200
diminuída Diabetes mellitus
≥ 200
≥ 126
Casual**
important cardiovascular diseases. To prevent these complications it is necessary to keep the patient’s pressure in lower levels than the usual. Blood pressure levels lower than 130/80 mmHg should be maintained;
≥ 200 (sintomas clássicos)***
*Fasting is defined as the absence of caloric intake for minimum 8 hours; **casual plasma glycemia is performed at any time during the day without following the interval from the last meal; ***the DM classic symptoms include polyuria, polydipsia and non-explained weight loss.
Note: DM diagnosis should always be confirmed by the test repetition in another day, unless there is unequivocal hyperglycemia with acute metabolic decompensation or DM obvious symptoms. Adapted from SBD, 2006.
!
if there is proteinuria and renal insufficiency, the pressure should come to 120/75 mmHg. (See more information on arterial hypertension).
4. Dental treatment of the diabetic patient !
Dental treatment of diabetes mellitus (DM)
patients should contemplate, first of all, research as to the patients’ glycemia and the therapy, mainly the recommended nutritional habits and drugs. The
principal objective is to prevent the episodes of The test to detect the levels of glycated hypoglycemia due to the non-ingestion of food because hemoglobin (GH) is also recommended. This test shows it is difficult to eat after dental procedures (McKenna, !
the mean glycemic levels the patient had 2 or 3 months 2006). from the date of the GH test. It is very useful in ! As a treatment plan, it is advisable to remove glycemic control and to the treatment efficacy. The table infectious foci as soon as possible. It has been proved below relates the GH values with those from glycemia; that bacteria from the oral cavity, particularly from values above 7% indicate the need to review the present periodontal disease, cause an increase in tumoral α therapy scheme, as the patient is exposed to necrosis factor in blood plasma that may contribute to complications, such as cardiopathies, nephropathies insulin resistance (Engebretson et al., 2007). and retinopathies. A DM patient with chronic oral infections possibly
UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 - FOUSP - Ministry of Health
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UPDATING OF THE BASIC ORAL CARE NOTEBOOK 2012 FOUSP - MINISTRY OF HEALTH, BRAZIL
possibly shows insulin resistance and, once The prescription of non-steroidal anti-inflammatory treated, should be submitted to medical drugs (NSAIDs) must be shared with the physician as it evaluation again to adjust hypoglycemic therapy. !
Como plano de tratamento, é recomendável a
remoção de focos infecciosos o mais rapidamente possível. Tem sido evidenciado que bactérias da cavidade oral, particularmente da doença periodontal, provocam aumento de fator de necrose tumoral α no plasma sanguíneo, o qual parece contribuir para a resistência à insulina (Engebretson et al., 2007). Assim, um paciente com DM e infecções crônicas bucais
is known that these drugs interfere with those that control glycemia. Some drugs that increase the hypoglycemic
action
are
NSAIDs,
beta-blockers,
antifungal agents and cyclic antidepressants. Some drugs that decrease the hypoglycemic action are corticoids, estrogens, calcium blockers and rifanpicin.
5. References and Credits
possivelmente apresenta resistência à insulina e, uma
Bergman SA. Perioperative management of the diabetic vez tratado, deve ser submetido novamente a avaliação médica, para adequação da terapêutica hipoglicemiante. patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2007 Jun;103(6):731-7. ! It is advisable to provide preventive therapeutic measures against periodontal diseases as the severity of Brem H, Tomic-Canic M. Cellular and molecular basis periodontal pathogenic bacterial infections and alveolar of wound healing in diabetes. J Clin Invest. 2007 May;117(5):1219-22. bone loss are more pronounced in DM (Graves et al., 2006). Engebretson S, Chertog R, Nichols A, Hey-Hadavi J,
As to surgical procedures, if the patient has controlled Celenti R, Grbic J. Plasma levels of tumour necrosis glycemia and will not be submitted to general factor-alpha in patients with chronic periodontitis and anesthesia, these should be performed in the morning type 2 diabetes. J Clin Periodontol. 2007 Jan;34(1):18-24.
period after taking oral hypoglycemic medications. The Graves DT, Liu R, Alikhani M, Al-Mashat H, Trackman post-op approach must be routine with no need of PC. Diabetes-enhanced inflammation and apoptosis-prophylactic antibiotic therapy. To the type 1 DM impact on periodontal pathology. J Dent Res. 2006 Jan; patients who will be submitted to minor oral surgery 85(1):15-21. without general anesthesia it is necessary to know the Gross JL, Nehme M. Detecção e tratamento das patient’s hypoglycemic regimen (Bergman, 2007); the complicações crônicas do diabetes melito: Consenso da contact with the physician is fundamental as it is Sociedade Brasileira de Diabetes e Conselho Brasileiro advisable to give half the daily dose of insulin in the de Oftalmologia. Rev Ass Med Brasil 1999; 45(3): 279-84. morning period previous to surgery. If the patient’s glycemia is between 100 and 200 mg/dl, surgery can be Rezende. Diabetes. http://usuarios.cultura.com.br/ performed; if values exceed 200 mg/dl, insulin is jmrezende/diabetes.htm necessary previous to surgery, reducing the values to SBD. Sociedade Brasileira de Diabetes. Tratamento e 150 mg/dl (Bergman, 2007). In the post-op, the glycemic acompanhamento do diabetes mellitus. Diretrizes da control in 4-hour-interval is important (Bergman, 2007). Sociedade Brasileira de Diabetes, 2006. In patients who have unfavorable glycemic control, prophylactic antibiotic therapy should be performed (McKenna, 2006). Surgical procedures and anesthesia cause hormonal alterations stimulating gluconeogenesis and glycogenolysis, accounting for an increase in the glucose levels in the blood (Bergman, 2007).
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A R A L SC AER E Q N OU T EÓB OI O KA 2 0 1 2 U P D A T ICN G L O FU T BH E E B A S IDC O FOUSP - MINISTRY OF HEALTH, BRAZIL
Updating of the Notebook on Oral Health Basic Care – 2012: Profa. Dra. Luciana Corrêa – FOUSP Profa. Dra. Marina Helena C. Gallotini de Magalhães – FOUSP Layout: Profa. Dra. Mary Caroline Skelton-Macedo Translation: Flávia Egner - Intertrad, SP - Brazil.
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