Systemic Risk factor 2

Question 1

define DIABETES MELLITUS (DM)

Answer 1

A common group of metabolic disorders characterised by chronic hyperglycaemia resulting from insulin deficiency or impaired utilisation of insulin (insulin resistance)

Question 2

Diagnosis

Answer 2

Venous plasma glucose
Random venous plasma glucose >= 11.1 mmol/litre, ot fasting venous plasma glucose >= 7.0 mmol/l plus
Unexplained weight loss, polyuria, polydipsia
Normal blood glucose 4-5.5 mmol/l before meals. <8mmol/l two hours after meals

Haemoglobin A1c may be used for diagnosis
Cut off point 48mmol/mol (6.5%)

Question 3

Types of diabetes

Answer 3

○ Type 1 10%  
○ Type 2  90% 
○ Other 
	§ Maturity Onset Diabetes in the Young 1-2% (20-40k)
Gestational diabetes 3.5% of pregnancies

Question 4

Type 1 dibetes

Answer 4

• Destruction of ß cells in pancreas
○ Autoimmune process
○ Islet cell antibodies at time of diagnosis
• Genetic predisposition
Abrupt onset, most often in children/teens

Question 5

Type 2 diabetes

Answer 5

• Defect in ß cell and insulin resistance
• Usually manifests mid life
○ Small number of children affected
• Genetic influence
• á risk if obese, sedentary lifestyle, close relative with DM, Asian/Afro-Caribbean
Complications possible before diagnosis

Question 6

Control/diagnosis of diabetes is important,

Answer 6

…implications of poor control or undiagnosed DM include: diabetes complication/ risk factor for periodontal disease

Question 7

Control of Type 2 diabetes

Answer 7

Type 2
Treat by diet or diet and oral - hypoglycaemic drugs plus exercise
25% may go on to need insulin injections
Balancing act

Question 8

Control of Type 1 diabetes

Answer 8

Type 1
Treat by insulin injections/insulin pump
Balance carbohydrate intake and insulin
New technology includes transplantation of pancreatic islets of langerhans cells

Question 9

Home blood glucose monitoring

Answer 9

Simple finger prick
Drop of blood on strip
Direct reading in secs
Aim for 4-7mmol/ litre

Question 10

Complications of diabetes commonly cited
Macrovascular

Micro vascular

Answer 10

Macrovascular: cardiovascular disease-
the major cause of death
peripheral vasular disease- amputation,
cerebrovascular disease and stroke

Microvascular:
retinopathy- blindness,
Nephropathy- renal failure,
Neuropathy- painful nerve damage

Question 11

Systemic inflammation,Strong evidence periodontal infections induce systemic inflammatory response
Evidence of increase levels of…..

Answer 11

acute phase proteins (eg C-reactive protein) and pro-inflammatory cytokines

Question 12

What may play a role in the devlopment of type 1 DM?

Answer 12

Increased IL-1Beta may result in pancreatic Beta cell destruction (i.e role in type 1 DM)

Question 13

how does obesity play a role in development of type 2 DM? (interlukein)

Answer 13

In obesity IL-6 stimulates TNF-alpha

Increse IL-6 and increase TNF-alpha may result in insulin resistance (i.e role in type 2 DM)

Question 14

BMI linked to……

Obesity significant predictor of…….

Answer 14

……severity of attachment loss in NHANES III

……… periodontal disease; insulin resistance may mediate link

Question 15

Adipocyte production of proinflammatory cytokines (adipokines) may link……….

Answer 15

obesity to diabetes and periodontitis

Question 16

Hyperglycaemia may result in collagen to undergo non-enzymatic glycation to Advanced End Products (AGEs) leading to…..

linked to……

Answer 16

Increased collagen cross-linking, increased cytokine production,
linked to- microvascular complications, atherosclerosis, decreased production bone matrix

Question 17

AGES activate Receptor for AGES=RAGES

Interaction of RAGEs and AGES perturb vascular and inflammatory cell function

Answer 17

Microvascular and macrovascular diabetes complications

Accelerated periodontal tissue destruction

Question 18

Polymorphonuclear leukocyte (PMN’s) is first line of defence, but in DM…

Answer 18

Decreased PMN function, increased periodontitis
Enhanced respiratory burst
Delayed apoptosis, increased tissue desruction

Question 19

Effect of periodontal diseases on diabetes control (HbA1c)

Answer 19

Systematic review of current evidence suggests that periodontal diseases adversely affect diabetes outcome:

• Control
• Complications
• Incidence

Question 20

Decreased HbA1c of 1% associated with decreased risk of:

Answer 20

Deaths related to diabetes
Myocardial infarction
Microvascular complications

Question 21

Recent systematic reviews/ meta analyse on the effect of periodotnal treatment on Diabetes control

Answer 21

Improvement in HbA1c significant 0.4% after non-surgical treatment but after non-surgical therapy and antibiotic not significant
In type 2 DM, equivalent to single extra drug effect
Need more studies with larger samples

Question 22

Periodontal care for patients with diabetes

Answer 22

Check HbA1c with diabetes care team
Follow 3 principles of 3 stages of therapy
Initial therapy: GDP can undertake; if poor response, consider specialist referral
Corrective therapy: consider adjunctive systemic antibiotics (but more research needed)
Supportive therapy: GDP can undertake

Question 23

Managment of ‘hypo’

Answer 23

Hypoglycemia: pale, shaky, clammy, may be aggreessive/confused; blood glucos <4mmol/l
Give 3-6 glucose tablets (3g each) i.e 10-20g
Or give glucose drink e.g Lucozade 150-200ml

Question 24

Managemnet of severe ‘hypo’

Answer 24

Give glucogon IM, SC or IV injections (1mg if adult or child over 8yrs; 0.5mg if under8 yrs)
Plus further carbohydrate on recovery
Advice: get doctor/ dial 999 if no recovery in 10 minutes
If still unconscious, will need glucose IV

Question 25

Diabetes: Loe in 1993 proposed Lamster & Lalla after reviewing the evidence concluded What is most important

Answer 25

periodontal disease as the sixth complication of diabetes Loe 1993 periodontal disease is a clinical complication of diabetes Diabetes control is critical

Question 26

Genetic factors may increase the susceptibility to other associated chronic conditions: cancer/ heart disease/ diabetes. A study of shred genetics risk factors between cancer and periodontal disease in monozygotic twins found

Answer 26

associataion between periodontal disease and several cancers Hypothesis that inflammation underlines the association and IL-1 gene polymorphisms associated with increased levels of periodontal disease may be associated with icnreased cance

Question 27

How is progresion of periodontits linked to genetics

Answer 27

Periodontitis that occur early in age and progresses fast has shown familial aggregation In the more common form of periodontal disease seen in older patients with slower progression the picture is less clear

Question 28

Conclusion

Answer 28

Several systemic risk factors where some evidence of a link to periodontitis Potentially bi-directional relationship Evidence for diabetes as risk factor is insignificant Patients should be informed about the relationship of diabetes and periodontitis for optimum management of both conditions Some other potential risk factors require further research to establish the relationship and its extent

Question 29

Periodontitis

Answer 29

Initial therapy: GDP can undertake; if poor response, consider specialist referral Corrective therapy: consider adjunctive systemic antibiotics (but more research needed) Supportive therapy: GDP can undertaker

Question 30

Guidelines for dental practice- EFP/AAP workshop & manifesto (part one)

Answer 30

If periodontitis, need: Therapy (IT, CT, SPT) ; OHE -manage acute, infections, oral complications; dental rehabilitation if tooth loss

Question 31

Guidelines for dental practice- EFP/AAP workshop & manifesto (part 2)

Answer 31

If no periodontitis and no DM (yet!) need Prevention, monitor If risk for type 2 DM, inform patient, do chairside HbA1c or refer to GP

Question 32

Guidelines for dental practice- EFP/AAP workshop and manifesto Patients with DM should be told:

Answer 32

At higher risk of periodontitis Gylycamic control may be difficult At higher risk of other complications At higher risk of other complication e.g cardiovascular disease And should: Receive a thorough oral/perio exam (adults and children)

Question 33

Osteoporosis

Answer 33

Reduced bone mineral density Most common in post-menopausal women but does occur in men Leads to increase risk of fracture; typically hip fractures after a fall Reduced oestrogen production after menopause results in increased bone resorption Systemic bone resorption associated with mandibular bone resorption Some studies show a correlation between systemic bone loss and periodontal disease

Question 34

Other risk factors

Answer 34

Dietary calcium Vitamin D obesity