Diagnostic And Therapeutic Strategies For The Management Of The Diabetic Patient
Maria Emanuel Ryan, DDS, PhD
ABSTRACT The bridge between oral and systemic health exists and becomes more concrete as data continue to emerge in support of this relationship. The medical management of diabetes is affected by the presence of chronic infections, such as periodontitis. This article reviews the pathogenesis of periodontal disease as it relates to diabetes. The author discusses patient susceptibility in terms of risk and recommends risk assessment to determine optimal treatment strategies. Patients with poorly controlled diabetes are at greater risk for developing periodontitis. The opportunity for systemic exposure to periodontal pathogens and pro-inflammatory mediators associated with periodontitis is discussed relative to their specific effects on patients with diabetes. The importance of good metabolic control in terms of risk for developing long-term complications of diabetes is presented and the impact of periodontitis on achieving adequate metabolic control is described. Special considerations for the management of patients with diabetes in the dental office are reviewed, including the signs and symptoms of diabetes, risk assessment for diabetes, and the challenges of "tight control" with insulin and oral agents with regards to hypoglycemia. It is recommended by the author that a thorough medical history of the patient be obtained, that the patient's medications are known, that the dentist consults with the patient's physician to assess the patient's glycemic control, and that the patient's blood glucose levels and dietary intake be monitored before treatment. Finally, the author reviews the long-term complications of diabetes, particularly the oral complications that can affect overall health. The author concludes with the belief that the treatment of periodontal diseases should not be considered optional or elective but, instead, should be a necessary and integral part of a patient's overall health care program.
The bridge between oral and systemic health has been reinforced during the past decade by multiple publications describing this important connection in both dental and medical journals. The oral focus of these publications has been on periodontal diseases, which are the most common dental conditions. It is known that a number of systemic diseases, including diabetes, can increase an individual's risk for developing periodontitis, which is a chronic and progressive disease with no known cure. However, periodontal disease is certainly treatable and may even be prevented by appropriate risk assessment and risk reduction strategies. Conversely, untreated periodontal disease has been linked to an increased risk for developing certain systemic conditions as well as difficulties in managing certain systemic conditions. The medical management of diabetes is affected by the presence of chronic infections, such as those seen in patients with periodontitis. These links between oral and systemic health have led to the belief that the treatment of periodontal diseases should not be considered optional or elective but, instead, should be a necessary and integral part of a patient's overall health care program.
THE PATHWAY TO PERIODONTAL DISEASE
Understanding the pathway to periodontitis is essential because it enables clinicians, researchers, and patients to consider the possible mechanisms by which oral–systemic connections occur (Figure 1) (1). It is a microbial challenge to the host or person with poor oral hygiene that initiates the cascade of events that can result in periodontal breakdown. The presence of bacterial endotoxins, antigens, and other virulence factors stimulate the host immuno-inflammatory response. Neutrophils are recruited to the site of the infection to address the pathogenic microbes, which then invoke an antibody response. In more resistant individuals, these events lead to the development of localized reversible inflammation, known as gingivitis. In more susceptible individuals, very high levels of pro-inflammatory mediators–known as cytokines, prostanoids, and matrix metalloproteinases–will be produced by the host, leading to connective tissue breakdown and bone metabolism changes associated with the bone loss that is pathognomonic to periodontitis. In the clinical setting, this cascade of events presents as the signs of disease: increases in probing depth, loss of clinical attachment, and radiographic evidence of bone loss. So the question becomes, "Who are these susceptible individuals?"
Genetics plays a significant role in who may be susceptible. Studies have shown that at least 50% of all cases of periodontal disease have some genetic component (2). In addition, there are a number of environmental and acquired risk factors that put patients at greater risk (Table 1). Risk assessment is important because it has been recognized that the more risk factors a patient has, the more likely he or she is to develop the disease. There is often more than an additive effect, there is a synergistic effect between these risk factors.
Identification and consideration of these risk factors is critical to successful periodontal treatment because they can affect the onset, the rate of progression, and the severity of periodontal disease. In addition, these risk factors may determine treatment strategies and explain variability in the therapeutic responses of patients. Risk factor assessments can alter the way patients are viewed by the practitioner, leading to a decision process based on risk. The primary goal of the practitioner would be risk reduction. A simple example of this would be improvements in oral hygiene since it has long been known that poor oral hygiene increases the risk of disease. A clinician may proceed with caution if a patient presents with multiple risk factors. In addition, patients begin to be viewed in terms of risk when considering how treatment should proceed. Depending on the type of risk (eg, the presence of a systemic condition such as diabetes), the clinician will interact more with our medical colleagues in an attempt to reduce the risk.
Ultimately, as part of a risk assessment,risk reduction for periodontal disease needs to be considered. Risk reduction strategies are listed in Table 2. Obviously, the more risk factors a patient has, the more frequent his or her dental visits should be, including more intensive periodontal therapy and follow-up maintenance. Certain risk factors can be modified while others cannot (eg, heredity). Once this is determined, the appropriate therapeutic regimens can be utilized, including the use of adjunctive medications that may be administered to the patients that have been referred to as "perioceutics" in the past (3). Locally applied or systemically delivered antimicrobials may be one choice; host modulatory agents are another,which may be ideal for patients who cannot reduce their risk (such as patients who have a genetic predisposition). For smokers, smoking cessation is the obvious first step, but what if the patient will not stop smoking? Cutting back on tobacco use may help, but other strategies would need to be considered in those patients who cannot or will not stop smoking. In diabetic patients, the patient's physician should be consulted to help the patient achieve better metabolic control of his or her diabetes to facilitate an optimal response to periodontal therapy. Patients who are unable to control their diabetes will be much more difficult for the oral health care provider to manage and may require the use of adjuncts to traditional mechanical therapy, such as antimicrobials and host modulatory therapy as part of their treatment regimen.
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