1. Acute Infections and Insulin Requirements In pre-diabetic individuals acute infections may induce a temporary state of diabetes requiring short-term insulin therapy Pelvic inflammatory disease Pneumonia Encephalitis Nephritis Bacterial endocarditis Appendicitis

2. Insulin Resistance Atherosclerosis Study Provided information demonstrating that inflammation (CRP) is associated with insulin sensitivity even in people without diabetes Higher levels of CRP were associated with a greater degree of insulin resistance Serum levels of CRP and other markers of inflammation were significantly related to the development of type 2 diabetes in 1,047 non-diabetic subjects followed for 5 years The investigators concluded that chronic inflammation has emerged as a new risk factor for type 2 diabetes

3. An Investigation on the Contribution of Periodontal Disease to Insulin Resistance 10 subjects with varying degrees of insulin resistance, consented to a clinical periodontal evaluation, genetic testing for an IL-1 polymorphism and to biochemical analysis of oral mouth rinse samples –Insulin Resistance was measured using a hyperinsulinemic euglycemic clamp to determine RD values which is a measure of glucose uptake and insulin sensitivity Levels of IL-1 , IL-8 and VEGF in the mouth rinse samples were measured using Fluorokine Multi-analyte profiling (MAP) kits (R&D Systems) on a Luminex analyzer DNA analysis was performed to determine if these subjects had a specific variation in the genes that regulate IL-1 (Kornman et al.)

5. Findings 50% of the subjects tested positive for the IL-1 polymorphism These same 5/10 subjects had 35-83 sites with attachment loss >5mm and were qualified as very insulin resistant with an RD value of <8. 4 subjects had 15-32 sites of attachment loss >5mm and were qualified as insulin resistant with RD values of 8-10 1 subject had 10 sites with attachment loss of >5mm and was qualified as average with an RD value of 11.98

6. Periodontitis and Diabetes: A two-way street Diabetics are at an increased risk for developing infections –Periodontitis is known to be a complication of diabetes Infections lead to impaired diabetic control –Periodontitis can impair a diabetic patient’s ability to process and/or utilize insulin

7. Diabetes Mellitus Prevalence Approximately 20.8 million Americans –6-7% of the population –Half are unaware that they have the disease –Pre-diabetes is also on the rise The number of cases in the U.S. continues to rise –Due to increasing population and life expectancy –Increased prevalence of obesity The practicing dentist –Will encounter patients with diabetes and pre-diabetes –A practice of 2000 patients may have 120-140 diabetic patients –Approximately 50% will be aware of their condition –Practices being referred diabetic patients will have much higher numbers –Can oral health providers aid in the identification and management of people with diabetes?

8. Diabetes Mellitus Can Dentists Help? Identify the classic signs and symptoms Identify oral manifestations Perform a risk assessment Ask, advise and refer patients to the physician Laboratory Methods (to be confirmed on subsequent day) –Classic symptoms and casual (non-fasting) plasma glucose >200 mg/dL –Fasting plasma glucose >126 mg/dL Categories of fasting plasma glucose (FPG) –FPG <110 mg/dL = normal fasting glucose –FPG > 110 mg/dL and <126 mg/dL = Impaired fasting glucose (IFG) –FPG >126 mg/dL = provisional diagnosis of diabetes (confirmed on next day)

10. Diabetes Mellitus Classic Signs and Symptoms  Polydipsia, polyuria, nocturia, polyphagia  Unexplained weight loss  General fatigue  Increased infections  Leg cramps  Numbness in the extremities  Impotence  Blurred vision

11. Diabetes Mellitus Risk Assessment  > 45 years  Obesity  Family history of type 2 diabetes  Racial decent  History of GDM or a history of delivering a baby > 9 lbs  History of impaired glucose tolerance or impaired fasting glucose  Hypertension (>140/90)  Dyslipidemia (HDL cholesterol 250mgdL)

12. Gestational Diabetes Usually develops in 3rd trimester – 2-3% of pregnancies Similar pathophysiology to type 2 DM Requires intensive monitoring & treatment Patient returns to normal after delivery 30-50% develop type 2 within 10 years

13. Diabetes Mellitus Classic Complications Macrovascular disease (accelerated atherosclerosis) –Peripheral –Cardiovascular (coronary artery disease) –Cerebrovascular (stroke) Nephropathy –Renal failure Neuropathy –Sensory (peripheral is most common) –Autonomic (dysrhythmias, alterations in BP, genitourinary, gastroparesis) Retinopathy –Blindness, Blurred vision Altered Wound Healing Periodontitis