2. INTRODUCTION Diabetes is a common disorder showing an exponential increase. It has various oral manifestations that impact the overall level of oral care. Physicians play an important role in optimising metabolic control in diabetic patients, thereby controlling the progression of oral complications. Diabetes can have a number of complications such as candidiasis, dental caries, tooth loss, gingivitis, mucosal lesions, neurosensory disorders, periodontitis, xerostomia, etc

3. NEED FOR ORAL HEALTH IN DIABETES There is robust evidence to support the relationship between oral health and diabetes. Despite the availability of data, oral health awareness is lacking among patients with diabetes People with diabetes have two times higher chances of getting mouth problems like gum disease and mouth infection

4. LINK BETWEEN DIABETES AND ORAL HEALTH Diabetes can affect the mouth and teeth in the following ways: High blood sugar affects small blood vessels contributing to periodontal disease and delayed healing Diabetics have a difficulty in warding off infections probably due to diminished capacity of the white blood cells (WBCs) to fight bacteria Xerostomia or dry mouth can occur due to autonomic neuropathy and further accentuate caries and infections

5. LINK BETWEEN DIABETES AND ORAL HEALTH Diabetes is a major risk factor for oral diseases like periodontitis and increases the susceptibility to periodontitis by approximately 3-fold Periodontitis tends to be more severe in patients with type 2 diabetes compared to those with type 1 diabetes Diabetes may also cause some changes in the salivary factors related to gingivitis in children Children and adolescents with diabetes may have a higher risk of periodontal disease

6. EPIDEMIOLOGY OF ORAL DISEASES IN DIABETES PATIENTS – INDIAN SCENARIO Oral disease distribution in diabetics

7. ORAL SYMPTOMS AWARENESS IN DIABETES PATIENTS Periodontitis is the most common oral disease seen in diabetic patients There is poor awareness regarding increased risk of oral diseases among diabetes patients

8. ORAL MANIFESTATIONS OF DIABETES

9. PERIODONTAL DISEASE The term ‘periodontal diseases’ includes gingivitis (reversible inflammation confined to the gingiva) and periodontitis (extension of inflammation to the tissues beyond gingiva resulting in tissue destruction and alveolar bone resorption) The tissue destruction results in the formation of a periodontal pocket between the gingiva and the tooth Early periodontitis is typically asymptomatic and painless and many patients are unaware of the condition Smoking is a major risk factor that significantly increases risk for periodontitis and severity

10. CHARACTERS OF ADVANCED PERIODONTITIS

11. PREVALENCE OF PERIODONTAL DISEASE IN DIABETICS Periodontal status was compromised in diabetics (92.6%) There was more need of a complex treatment in the diabetic population (58%).

12. PATHOGENESIS OF PERIODONTITIS IN DIABETES There has been growing emphasis on the ‘two-way’ relationship between diabetes and periodontitis Not only is diabetes a risk factor for periodontitis, but periodontitis can also have a negative effect on glycaemic control Periodontitis causes inflammation in the periodontal tissues stimulated by the long-term presence of the subgingival biofilm (dental plaque)

13. PERIODONTITIS AND DIABETES – A VICIOUS CYCLE

14. SIGNS AND SYMPTOMS OF PERIODONTITIS

15. MANAGEMENT OF PERIODONTITIS IN DIABETICS Oral hygiene maintenance Mouthwashes Referral to dentist

16. PREVENTION OF PERIODONTITIS IN DIABETICS Strict glycaemic control Advise regular brushing 2 times a day Advise use of dental floss and interdental cleaning aids Mouth washes Regular dental check-ups

17. DENTAL CARIES Dental caries is a chronic, microbial, multifactorial disease involving an interaction between the host, the substrate and alteration of the immunological system It primarily affects the calcified tissues of the teeth

18. PATHOGENESIS OF CARIES

19. DIABETES AND DENTAL CARIES Saliva has the capacity to buffer the acid produced by the action of bacteria on fermentable carbohydrates Saliva production has been reported to be reduced in patients with diabetes with poor metabolic control, may be as a consequence of peripheral neuropathy in these patients

20. PREVENTION OF DENTAL CARIES AMONG DIABETICS Strict glycaemic control Dietary modification: Avoiding intake of refined carbohydrates and other cariogenic foods Oral hygiene maintenance: Brushing twice a day Rinsing after meals Flossing and use of interdental cleaning aids Use of fluoride toothpastes and mouthwashes Regular visits to the dentist

21. WHO GUIDELINES ON SUGAR INTAKE IN CARIES PREVENTION FOR ADULTS AND CHILDREN WHO recommends: A reduced intake of free sugars throughout the life course Reducing the intake of free sugars to less than 10% of total energy intake (strong recommendation) Reduction of the intake of free sugars to below 5% of total energy intake (conditional recommendation)

22. CANDIDIASIS It is seen that diabetes patients with poor glycaemic control are prone to severe and/or recurrent bacterial or fungal infections It has been documented that candidiasis and other opportunistic fungal infections are early signs of diabetes Diabetes is a precipitating factor for increased oral mucosal colonisation of Candida The glycaemic control status i.e., glycated haemoglobin percentage (HbA1c %) of diabetes patients may directly influence candidal colonisation and various oral manifestations

23. CANDIDIASIS An Indian study showed that oral candidal carriage was observed in 76.47% diabetes patients having good glycaemic control; 69.69% in patients with moderate control; and 82.50% in poorly controlled diabetes patients

24. CLINICAL FEATURES OF CANDIDIASIS White patches (plaques) that can be rubbed off Loss of taste or unpleasant taste in the mouth Redness Cracks at the corners of the mouth Burning sensation in the mouth

25. PREVENTION AND MANAGEMENT OF CANDIDIASIS Strict glycaemic control Antifungal therapy Using mouthwash Oral hygiene maintenance

26. XEROSTOMIA Xerostomia is a conventional term used to describe the subjective complaint of dry mouth, whereas hyposalivation is an objective reduction in salivary secretion Both xerostomia and hyposalivation are associated with diabetes Studies have shown that diabetes patients reported symptoms of dry mouth more frequently than controls (24% vs. 18%, respectively)

27. XEROSTOMIA It is seen that the salivary flow rates are impaired in subjects with type 1 diabetes, especially in those with neuropathy In type 2 diabetes patients, unstimulated and stimulated salivary flow rates are also significantly reduced

28. CLINICAL FEATURES OF XEROSTOMIA Oral mucosal dryness and redness Difficulty in chewing, swallowing and speaking Pain in the mouth Oropharyngeal burning Increased fungal infections Increased caries Dysgeusia Halitosis Difficulty in wearing dentures

29. MANAGEMENT OF XEROSTOMIA Local salivary stimulation, e.g., use of a sugarless chewing gum Systemic salivary stimulation using bromhexine, anetholetrithione, pilocarpine and cevimeline, etc. Sprays or gels with lubricating properties to provide symptomatic relief Use of artificial saliva and saliva substitutes Oral hygiene maintenance

30. BURNING MOUTH SYNDROME The higher prevalence of burning mouth syndrome (BMS) found among the patients with diabetic peripheral neuropathy supports the fact that a neuropathic process may be the underlying cause of BMS It may be prudent to screen patients with a recent onset of BMS for presence of diabetes. There exist similarities between BMS and peripheral diabetic neuropathy These include the description of clinical symptoms that characterise both the conditions, specifically burning, tingling, numbness, pain, scalding and itching Both BMS and diabetic neuropathy respond to similar classes of drugs that interrupt or modulate these symptoms

31. ORAL MUCOSAL LESIONS Oral mucosal lesions (OMLs) show high prevalence in diabetes patients. The presence of OMLs such as lichen planus and recurrent aphthous ulceration have frequently been diagnosed in diabetes patients A study showed that the most common lesions in the oral mucosa were ulcerative lesions (traumatic and aphthous ulcers) Higher occurrence of OMLs was significantly associated with poor metabolic control

32. ORAL HEALTH AND HEART DISEASE There is evidence that oral infection is associated with coronary atherosclerosis and that bacterial DNA has been identified in atherosclerotic plaques Clinical evidence has shown that there is a relation between dental infection and incidence of coronary events Data available from the Insulin Resistance Atherosclerosis Study showed that chronic hyperglycaemia was positively associated with increased intimal–medial wall thickness (IMT)

33. ORAL HEALTH AND HEART DISEASE

34. RECOMMENDATIONS ON DENTAL CARE FOR PEOPLE WITH DIABETES Enquire annually if a diabetes patient follows local recommendations on day-to-day dental care and attends a dental professional regularly for oral health check-ups Enquire at least annually for symptoms of gum disease (including bleeding when brushing teeth and gums which are swollen or red) In patients not performing adequate day-to-day dental care, remind them that this is a normal part of diabetes self-management and provide general advice as needed

35. RECOMMENDATIONS ON DENTAL CARE FOR PEOPLE WITH DIABETES In patients with possible symptoms of gum disease, advise them to seek early attention from a dental health professional Education of diabetes patients should include explanation of the implications of diabetes, particularly poorly controlled diabetes, for oral health, especially gum disease

36. ORAL HYGIENE PRACTICES IN INDIA Various oral hygiene practices are used in India There is scarce awareness with regard to the use of correct brushing methods and agents used in oral hygiene maintenance Majority of the people are unaware about the relationship between oral hygiene and systemic diseases or disorders Most diseases show their first appearance through oral signs and symptoms and they remain undiagnosed or untreated because of this missing awareness

37. ORAL HYGIENE PRACTICES IN INDIA Diabetic individuals should be educated to refrain from hazardous practices that can do harm to oral structures Improper brushing techniques and cleaning agents can have detrimental effects on teeth and surrounding structures causing trauma, infections and wasting diseases

38. MANAGEMENT CONSIDERATIONS FOR A DIABETES PATIENT BEFORE DENTAL PROCEDURES It is essential to obtain a thorough history of the patient along with the details of any complications, hypoglycaemic episodes, etc Generally morning appointments should be advised For patients on insulin, the appointment should not clash with the peak insulin activity thereby precipitating hypoglycaemia Advise the patient to eat normally and take all the medications as per advise Postponing non-emergency dental care procedures if the blood sugar is too high

39. MANAGEMENT CONSIDERATIONS FOR A DIABETES PATIENT BEFORE DENTAL PROCEDURES People with diabetes wearing orthodontic appliances like braces should contact their orthodontist immediately if a wire or bracket results in a cut inside their tongue or mouth The dentist may record the blood glucose prior to the procedure using blood glucose monitors Well controlled diabetics can be treated like non-diabetic patients Keeping the dentist up-to-date on the patient's diabetic condition and treatment and also the physician about his/her oral condition and treatment, so that they can work together as a team to help one control diabetes and periodontal disease