TITLE:- DIABETES AND IT'S ORAL IMPLICATIONS AUTHORS:1- Dr. ANAND PRATAP SINGH PG STUDENT, DEPT.

OF ORAL MEDICINE & RADIOLOGY, KOTHIWAL DENTAL COLLEGE AND RESEARCH CENTRE, MORADABAD (UP)244001 anandsingh001@gmail.com, CONTACT No.- 9411097515 2- Dr. M. SRINIVASA RAJU PROF. & HEAD, DEPT. OF ORAL MEDICINE & RADIOLOGY, KOTHIWAL DENTAL COLLEGE AND RESEARCH CENTRE, MORADABAD (UP)244001. KEY WORDS: Diabetes mellitus, Periodontitis, Grinspans syndrome, Oral implications.

Introduction:Diabetes mellitus is a common and growing global health problem . It is a metabolic disorder of multiple etiology characterized by chronic hyperglycemia with disturbance of carbohydrate, fat and protein metabolism due to defect in insulin secretion, insulin action or both. Chronic hyperglycemia affects almost all tissue in the body and is associated with specific complication of multiple organ system, including eye, nerves, kidney and blood vessels. These complications are responsible for high degree of mortality or morbidity. Oral manifestations of diabetes generally seen in patients with type 1 diabetes mellitus2. There is no oral manifestation in patient of control diabetes but uncontrolled diabetes shows several oral manifestations4, primarily those related to inflammation, infection and poor wound healing. These complications have significant implication for dental care, so the dentists have responsibility to recognize signs and symptoms, facilitate early diagnosis, appropriate management of oral conditions to
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maximize oral functions, comfort and esthetics, with the help of physician to facilitate long term disease control. Periodontal Disease:It is most common oral disorder and called as sixth complication of diabetes mellitus5. It starts with gingivitis and with poorly controlled diabetes, changes to advance periodontal disease6. Periodontal disease in diabetic patient with poor oral hygiene are severe gingival inflammation,deep periodontal pockets, increased tooth mobility, rapid bone loss and frequent painful periodontal abscess. Periodontal disease in diabetic patient does not have a consistent or distinct pattern of disease presentation. Difference in the host response to the periodontal pathogens are related to increased tissue destruction, Angiopathy associated with hyperglycemia leading to altered tissue metabolism, increase salivary glucose leading to increased bacterial substrate and plaque formation. Macrophages and Neutrophils inhibition7 may also allow bacterial growth and plaque formation. Hyperglycemia causes increased gingival cervicular fluid glucose level8 and associated vascular wall changes inhibit blood flow and the transport of granulocytes to the area of injury, which may significantly alter periodontal wound healing events by changing the interaction between cells and their extra cellular matrix within the periodontium. The primary structural protein in the periodontium is collagen and changes in collagen metabolism contributes through wound healing alteration and periodontal destruction in diabetic patients9.

Alveolar Bone Loss :

In diabetic a quite severe generalized pattern of bone loss may be observed. Diabetes enhances periodontal bone loss through enhanced resorption and diminished bone formation by increasing osteoblastic apoptosis and prolongs osteoclast formation and activity.10

Attachment loss and probing depth:

Increased prevalence and extent of periodontal pocket seem to be inconsistent finding in studies of diabetes versus non-diabetes. Attachment loss occurred more frequently in moderated and poorly controlled diabetes with extensive plaque and calculus than good controlled diabetes.11

Gingival Inflammation:
Study reported more gingival bleeding as metabolic control worsened in diabetics despite similar plaque and calculus scores in the diabetic subgroups.12 Diabetes itself does not cause gingival changes but those changes are due to increase responsiveness of the tissue to local irritants. Gingival changes may be extensive gingival inflammation, enlarged gingiva, sessile or pedunculated gingival polyps, polypoid gingival proliferation and abscess formation.

Periodontal Abscess:
Multiple periodontal abscesses are reported in uncontrolled diabetes mellitus.13

Cervicular fluid risk marker:

According to Lamster elevated -Glucuronidase predicts periodontal breakdown. Study shows the increase level of -glucuronidase and increased glucose content in cervicular fluid of diabetic patients.

Loosening Of Teeth:
More rapid periodontal breakdown leading to loosening of teeth and associated pain. Dental

Decay:-

Increased concentration of glucose present in the saliva and gingival crevicular fluid of diabetic patient, increases the risk of developing new and recurrent dental caries. The reduced buffering power of the saliva due to relatively reduced flow rates increases the risk of caries. Candidal

Infection:

Diabetes increases the adherence of candida to the oral epithelium and it occurs due to altered response to infection, xerostomia and altered oral flora. Candidal pseudohyphae, a cardinal sign of oral candida infection, have been associated significantly with cigarette smoking, use of denture and poor glycemic control in adult with diabetes.14 Median rhomboidal glossitis (central papillary atrophy of the tongue), now reported as Candidal infection is also common in uncontrolled diabetes mellitus. Antral mucormycosis is a rare but serious complication associated with immunocompromised and uncontrolled type1 diabetes mellitus. The signs and symptoms include nasal obstruction bloody nasal discharge, facial pain, swelling and visual disturbances leads to blindness, seizures and death.

Angular Cheilitis:Angular Cheilitis is common in uncontrolled diabetes mellitus and occurs due to xerostomia and Candidal infection. Lichen Planus And Oral Lichenoid Reaction: There are reports of greater prevalences of Lichen Planus in the diabetic patients.

It may be due to chronic immunosuppressant15. Triad of OLP, diabetes mellitus and systemic hypertension is called as Grinspans syndrome16, increases the risk of squamous cell carcinoma. It is recognized that lichenoid drug reaction may be seen in those patient treated with the sulphonylurea classes of drugs, specially chlorpropamid and tolbutamide. 17

Taste

Disturbances:

It is reported that hypogeusia or dysgeusia (diminished taste perception) is common in diabetes which results in hyperphagia and obesity. Burning Mouth syndrome [BMS] : BMS, an orofacial neurosensory disorder, has been reported in diabetic patients and this may be related to xerostomia, poor glycemic control and to local measure such as poor oral hygiene, candidiasis or peripheral neuropathy.18 Sylaviry Gland Dysfunction And Xerostomia : Diabetes mellitus is some time associated with diffuse, non tender, bilateral enlargement of parotid gland 19 called as diabetic sialadenosis. Patient with type1 diabetes who has developed neuropathy more often reported symptoms of dry mouth and decreased salivary flow20. the saliva in uncontrolled diabetic patient contains increased glucose level. Xerostomia may result from hyperglycemia and subsequent polyurea that depletes the extracellular fluid. The oral dryness is not associated with cardiovagal autonomic system dysfunction but may be due to disturbances in glycemic control.21

Localized Osteitis:Dry socket develop in uncontrolled diabetes hence they show delayed healing and impaired immunological balance.

Trigeminal nerve involvement:Diabetic neuropathy may also involve the trigeminal nerve. Tongue Pathologies: Both Median Rhomboid Glossitis and Geographic tongue are more common in diabetes.22

 Conclusion: Diabetes mellitus may affects the people of all ages, and its prevalence is increasing day by day. The intimate relationship between oral health and systemic health in individuals with diabetes suggested a need for good relationship between the dental and medical professionals for management of these patients. The dentist play a major role with physician in helping a patient to maintain glycemic control by proper treatment of oral infection, patient motivation to maintain good oral hygiene and a proper diet. Dentist play an important role in referring patients to a medical practitioner for additional evaluation of sign and symptoms suggesting undiagnosed diabetes. However, Dentist must be familiar with techniques to diagnose, treat and prevent stomatological disorders in patient with diabetes to enhance the quality of life for patient suffering from this incurable disease.

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