Orthodontic Considerations in the Diabetic Patient

Luc Bensch,* Marc Braem,* and Guy Willems†

Diabetes mellitus (DM) is a metabolic disorder diagnosed in approximately 3% to 4%

of the population. The disease is characterized by chronic hyperglycemia caused by a
deficient insulin management. Persistently elevated blood glucose concentration gives
rise to acute and chronic complications with damage to various organs. Two main types
of DM exist: type 1 DM, being a total deficiency in insulin secretion, and type 2 DM,
which is a combination of resistance to insulin action and inadequate compensatory
insulin secretion. Since DM cannot yet be cured, the symptoms of the disease and its
complications can only be treated. The sooner the disease is diagnosed, the better the
prognosis of the patient, since complications in the early stage of the disease are less
severe and more readily treated. As a member of the health care team, the dental
practitioner should have knowledge of oral manifestations of DM to recognize initial
symptoms of the disease. Also when treating DM patients, the practitioner must
understand the consequences of the controlled disease in relation to orthodontic
treatment.
Semin Orthod 10:252-258 © 2004 Elsevier Inc. All rights reserved.

T he majority of patients who are treated orthodonti-

cally are healthy young individuals. However, the last
20 years has seen a dramatic increase in the number of
adult patients seeking orthodontic treatment, many of
them suffering from chronic diseases. Advances in the
management of many of these maladies have allowed these
patients to pursue elective orthodontic procedures that
only years ago would have been considered contraindi-
cated. One such disease is diabetes mellitus (DM). The
practitioner should therefore understand the conse-
quences of DM in relation to dental and/or orthodontic
treatment and should have a basic knowledge and under-
standing of this disease and its impact on the oral cavity. A
complete medical description of DM is beyond the scope
of this paper, but information essential to an understand-
ing of the disease is briefly presented. The oral manifesta-
tions of DM and orthodontic treatment considerations are
then discussed.
*University Hospital Antwerp, Special Care Dentistry Unit, Edegem, Bel-
gium.
†Katholieke Universiteit Leuven, Faculty of Medicine, School of Dentistry,
Oral Pathology and Maxillo-Facial Surgery, Department of Orthodon-
tics, Leuven, Belgium.
Address correspondence to Prof. Dr. G. Willems, Katholieke Universiteit Leu-
ven, Faculty of Medicine, Department of Orthodontics, Kapucijnenvoer 7,
Leuven B-3000, Belgium; E-mail: guy.willems@med.kuleuven.ac.be
General Description
and Main Clinical
Features of Diabetes Mellitus
DM is one of the most common endocrine disorders. It is
characterized by persistently raised blood glucose levels (hy-
perglycemia), resulting from deficiencies in insulin secretion,
insulin action, or both. The classic symptoms of marked hy-
perglycemia include polyuria, polydypsia, weight loss, and
susceptibility to infections. Chronic hyperglycemia is associ-
ated with long-term damage, dysfunction, and failure of var-
ious organs. Long-term complications of diabetes include
retinopathy, nephropathy, peripheral and autonomic neu-
ropathy, and cardiovascular disease. Also, increased ten-
dency for periodontal disease is often found in people with
diabetes.1,2
Incidence and Prevalence
Diabetes affects individuals of all ages, with a peak incidence
in the fifth decade of life. The incidence of diabetes increases
with age and since the life expectation of the population
increases, the number of diabetes patients will increase as
well. In 1997, an estimated 124 million people worldwide
had been diagnosed as diabetics, and by the year 2010, the
total number of people with diabetes is expected to reach 221
million.3 Approximately 3% to 10% of all diabetics have type
1 diabetes.3,4 The incidence of type 1 diabetes varies dramat-

252 1073-8746/04/$-see front matter © 2004 Elsevier Inc. All rights reserved.
doi:10.1053/j.sodo.2004.09.005
Diabetic patient
ically among racial groups and countries.5,6 There is a clear
difference between the northern and southern hemispheres,
with a high incidence for the people of Europe and North
America. In Europe there is a large intracontinental variation
ranging from the highest in Finland (35.3 per 100,000) to the
lowest in northern Greece (4.6 per 100,000). In general, boys
and girls are at equal risk of developing type 1 diabetes. A
small percentage of individuals, however, do develop this
type of diabetes during adulthood.7 It can occur even in the
eighth and ninth decade of life. Type 2 diabetes is a global
health problem of enormous magnitude that is calculated to
affect 5% to 7% of the world’s population.1,8-10 This preva-
lence may be an underestimate, because many cases, even up
to 50% in some populations, remain undiagnosed. Type 2
diabetes in children was thought to be rare and to account for
less than 5% of all cases of childhood diabetes.11 Recently,
however, there have been reports of an increasing incidence
of type 2 diabetes in childhood from the United States, Japan,
Singapore, and Australia.12-16 In the United States, 10% to
20% of diabetic children and adolescents now have type 2
diabetes.17 High caloric diet, decrease in physical activity,
and mental stress may contribute to this increase of type 2
diabetes in children and adolescents.
Etiology and Classification
of Diabetes Mellitus
Several pathogenetic processes may be involved in the devel-
opment of diabetes such as:
● genetic defects,
● primary destruction of islet cells by inflammation, can-
cer, surgery, and trauma,
● a complication of endocrine disorders such as anterior
pituitary hyperfunction (overproduction of growth hor-
mone, acromegaly), Cushing disease, and pheochromo-
cytoma,
● iatrogenesis after the administration of corticosteroids.
In addition to these, there are many other factors involved.
Due to this enormous variety and also for better treatment
options, an international committee of experts in 1997 pub-
lished a review of the scientific literature to decide if changes
in classification and diagnosis of diabetes were needed.18
Whereas previously the classification of the disease, insulin
dependent or noninsulin dependent, was merely based on a
combination of clinical manifestations or treatment require-
ments, the new classification is now based on the etiology of
the disease (Table 1).
The vast majority of cases of diabetes fall into two broad
etiopathogenetic categories. In one category, type 1 diabetes,
the cause is an absolute deficiency of insulin secretion. The
pancreatic islets are usually destroyed, mostly as a result of a
T cell-mediated autoimmmune pathologic process, leaving
the patient totally dependent on exogenous insulin. Autoim-
mune destruction of the ␤ cells of the pancreas has multiple
genetic predispositions. This can also be caused by environ-
mental factors such as a viral infection, for example congen-
253
Table 1 Recent Classification of Diabetes Mellitus Based on
the Etiology of the Disease
I. Type 1 diabetes (␤-cell destruction, usually leading to
absolute insulin deficiency)
A. Immune mediated
B. Idiopatic
II. Type 2 diabetes (may range from predominantly insulin
resistance with relative insulin deficiency to a
predominantly secretory defect with insulin resistance)
III. Other specific types
A. Genetic defects of ␤-cell function
B. Genetic defects in insulin action
C. Diseases of the exocrine pancreas
D. Endocrinopathies
E. Drug- or chemical-induced
F. Infections
G. Uncommon forms of immune-mediated diabetes
H. Other genetic syndromes sometimes associated with
diabetes
IV. Gestational diabetes mellitus
ital rubella or cytomegalovirus. Due to the rapid and severe
onset of symptoms, type 1 diabetes is often diagnosed at
adolescence and was therefore previously termed “juvenile-
onset diabetes.” Type 1 diabetes is the most common endo-
crine-metabolic disorder of childhood and adolescence19 and
has a peak incidence at the age of 10 to 14 years.20,21
In the other, much more prevalent category, type 2 diabe-
tes, the cause is a combination of resistance to insulin action
and an inadequate compensatory insulin secretor response.
In this type of diabetes, the hyperglycemia develops gradu-
ally and starts usually at the age of 40 or later. Many patients
have only moderately raised blood glucose levels. In the early
stage of the disease, classic symptoms of diabetes are usually
not severe enough to alert the patient. Due to this slow rate of
clinical onset, type 2 diabetes often remains undiagnosed for
many years. The disease is therefore occasionally diagnosed
during a routine medical checkup. A striking feature of type
2 diabetes is the strength of its genetic component, which is
much greater than in type 1 diabetes and is estimated to
account for 40% to 80% of total disease susceptibility. Type 2
diabetes is highly concordant, being 60% to 90% in monozy-
gotic twins, but less so in nonidentical twins,17% to
37%.22-26 For example, if one of two identical twins develops
type 1 diabetes, the other twin has only about a 50% chance
of developing diabetes; but if one twin develops type 2 dia-
betes, the other twin has about a 100% chance of also becom-
ing diabetic. This suggests that there is a difference in genetic
as well as environmental factors in the etiology and patho-
genesis of diabetes between these two groups of identical
twins. However, the genetics of type 2 diabetes are complex
and still not clearly defined.18 At the onset of type 2 diabetes,
more than 90% of patients are either overweight or obese,27
so obesity must be considered as an important environmental
factor in the origin of type 2 diabetes. Diabetic proneness is
considered in obese individuals with a positive family history
of diabetes. Therefore, efforts should be made to inform those
persons with an increased risk of developing type 2 diabetes.
254
A recent study in 3234 nondiabetic persons with the pres-
ence of risk factors such as overweight or a sedentary lifestyle
showed a 58% reduction in the incidence of type 2 diabetes
when a lifestyle intervention program was followed.28
Healthy lifestyle measures such as exercise, appropriate nu-
trition, and maintenance of normal body weight have proved
to delay the onset of type 2 diabetes and decrease its inci-
dence by 40% to 60% in high-risk individuals.29,30 At least
initially, and often throughout life, type 2 diabetics do not
need insulin treatment to survive. Regulation of diet and
activity, and oral hypoglycemic drugs such as sulfonylurea or
biguanides, are current forms of appropriate medical treat-
ment in type 2 diabetes. If all these treatment modalities fail,
type 2 diabetes patients must rely on insulin.
In addition to these two types, there are other specific
types of DM including gestational DM (Table 1). These are
not discussed in this paper.
Diagnosis and Monitoring
of Diabetes Mellitus
Symptoms such as polyuria, polydypsia, weight loss, recur-
rent infection, and ketone breath are encountered in patients
with fully developed DM. If symptoms such as these are
found during medical history examination at the start of or
during the orthodontic treatment, the patient should always
be referred to his or her physician for further evaluation.
The determination of urinary glucose (glycosuria) is of
limited value in detecting diabetes: finding glucose in the
urine is not diagnostic of diabetes because of varying kidney
thresholds to glucose and, in addition, the absence of glyco-
suria in a patient suspected of being diabetic does not rule out
diabetes.31 Determination of the glucose concentration in a
properly obtained venous blood sample is the only reliable
criterion to establish the diagnosis of DM.18 The diagnosis
must be confirmed by repeated testing on a different day.
Once the diagnosis of diabetes is confirmed, the patient
must remain under control to prevent further deterioration of
the disorder and aggravation of its complications. Because of
improved therapy and monitoring, diabetes patients have a
longer life expectancy. However, with increased longevity,
the occurrence of chronic complications of the disease has
become a major concern. Diabetes Control and Complica-
tions Trial (DCCT) studies revealed that long-term compli-
cations can be reduced by 50% to 60% if DM is properly
managed.32
The treatment objectives are to control the blood glucose
at near normal levels and to avoid acute or chronic compli-
cations. Control of the diabetic state can be performed by the
patient himself and by the physician. To establish the effec-
tiveness of the hyperglycemia control, patients taking insulin
therapy often use self-glucose monitoring. This is done by
placing a small drop of blood obtained from a finger prick on
the end of a plastic strip that is inserted into a battery-oper-
ated device. This provides a meter reading of the blood glu-
cose concentration. This capillary blood glucose monitoring
provides an immediate result of the glycemia at the moment
L. Bensch, M. Braem, and G. Willems
of measurement and is very useful to these patients who can
alter their insulin dosage based on the results of the test. The
disadvantage of this method is that sometime severe hypo-
and hyperglycemic episodes can be missed. For better con-
trol, patients are urged to test more often, but the pain, in-
convenience, and costs of this type of blood measurements
are barriers to increased testing. Therefore, research has been
undertaken to develop more comfortable, noninvasive pro-
cedures for blood glucose monitoring. Based on impedance
spectroscopy technology, a noninvasive “sensor wristwatch”
that monitors glucose levels continuously was recently devel-
oped for self-monitoring of blood glucose. Besides the advan-
tage of continuously monitoring, this device also contains
adjustable alarm functions for upcoming hypo- and hyper-
glycemic conditions and therefore can contribute to a sus-
tainable improvement in the care of diabetics.
For professionals, the method of choice in monitoring the
treatment of diabetes is the determination of the glycosylated
hemoglobin concentration (HbA1c). Glycosylated hemoglo-
bin is an irreversible adduction of glucose to hemoglobin.
The concentration of this compound is directly related to the
rise in blood glucose over an interval of time. There is a linear
rise in HbA1c as the blood sugar increases in diabetic pa-
tients. Since the lifespan of the erythrocyte is about 120 days,
a change in HbA1c can be observed only after several weeks
if the ambient blood sugar concentration is changed. There-
fore, HbA1c is extremely useful for the assessment of glyce-
mic control over a 6- to 12- week period in patients with
either type 1 or type 2 diabetes. An HbA1c of less than 7.5%
or of more than 9% indicates, respectively, a good or a poor
control of diabetes.31
Hypoglycemic Reaction
and Insulin Shock
Patients who require large doses of insulin can have periods
of extreme hyper- and hypoglycemia, called brittle diabetes,
even with the best medical management. They are even more
prone to developing a so-called hypoglycemic reaction. A
study of Davis and colleagues33 revealed that 8.5% of 675
children with type 1 diabetes had severe hypoglycemic epi-
sodes resulting in seizure or coma, and 26.9% had moderate
episodes requiring the assistance of another person, but not
with seizure or coma. If patients fail to eat normally but
continue to take their regular insulin dosage, a hypoglycemic
reaction may occur because of excess insulin, yielding to
insulin shock, an acute complication of diabetes. When a
hypoglycemic reaction occurs in the dental office, the dentist
should recognize the prodromes and act in an appropriate
way. Loss of consciousness in insulin shock can occur quite
rapidly, within minutes after the appearance of the first
symptoms. At the onset, patients appear weak, nervous, and
confused. Their skin is moist and pale, and they exhibit ex-
cessive flow of saliva. Respiration is normal, the pulse is full
and pounding, and blood pressure is usually normal. Fre-
quently, a tremor may be noted. Most patients are familiar
with these symptoms and will inform the dentist in time. The
Diabetic patient
patient experiencing such signs of a hypoglycemic reaction in
the dental office should be taken care of immediately. The
still cooperative and conscious patient with these clinical
symptoms should be administered a high-carbohydrate bev-
erage such as orange juice or cola (not diet). When treating a
diabetic patient, it is advised to have a source of sugar avail-
able in the office that is handy for quick and easy use. The
patient will respond within a few minutes and should then
remain under observation until all signs and symptoms have
disappeared. If the state of hypoglycemia continues, the pa-
tient will soon become unconscious unless a 50% dextrose
solution (50 mL) is administered intravenously at once. Man-
agement of the unconscious patient also includes airway
maintenance, oxygen administration, and monitoring of vital
signs. Another drug that can be administered is glucagon
(1 mg intramuscularly), which is also preferable if the patient
is conscious but uncooperative to take carbohydrates orally.
Oral Manifestations
of Diabetes Mellitus
Knowledge of the oral manifestations of DM is of great im-
portance to the dentist. As approximately half of the patients
with diabetes are undiagnosed, a dental examination may
provide the first indication of the disease. Important clues are
dry mucous membranes (xerostomia), oral candidiasis, burn-
ing mouth or tongue (glossopyrosis), impaired wound heal-
ing, recurrent oral infections, and ketone breath. Any patient
suspected of diabetes should be referred to a physician for
further medical evaluation.
Oral manifestations associated with diabetes are in most
cases restricted to the uncontrolled or poorly controlled pa-
tient.34-36 Factors that may contribute to oral complications
in diabetes include decreased polymorphonuclear (PMN)
leukocyte function and abnormal collagen metabolism. PMN
dysfunction leads to impaired resistance to infections. Al-
tered protein metabolism resulting from impaired utilization
of glucose can contribute to increased breakdown of collagen
in the connective tissues. In addition, impaired neutrophil
chemotaxis and macrophage function may add to the im-
paired wound healing responses in diabetic patients.37
Diminished salivary flow is a common oral feature of DM,
sometimes causing symptoms of xerostomia like burning
mouth or tongue and dry oral mucosa.38 Occasionally, en-
largement of the parotid salivary gland can be noticed. The
occurrence of decreased salivary flow may contribute to an
increase in caries susceptibility.39 Also, increased exposure to
bacteria, as a consequence of elevated salivary glucose levels,
noticed mainly in poorly controlled or uncontrolled patients
with DM, results in increased bacterial substrate and altered
plaque microflora, favoring caries and periodontal dis-
ease.40-42 As a consequence, an increased incidence of dental
caries has been reported among uncontrolled or poorly con-
trolled patients with DM 43 and, conversely, well-maintained
patients with DM with good oral health measures show a
reduced incidence of dental caries. This is due to dietary
restrictions, effective metabolic control, and effective oral hy-
255
giene measures in combination with dental recall appoint-
ment schedules.44
Patients with well-controlled diabetes without local factors
such as subgingival calculus have a periodontium compara-
ble with nondiabetics.45 Several studies show that gingivitis is
more severe in children with diabetes and increases in sever-
ity with increasing blood glucose levels.45-48 Even in well-
controlled diabetics there is more gingival inflammation,
probably due to the impaired neutrophil function.21 Vascular
changes, such as diabetes-related microangiopathies, are re-
sponsible for complications in many organs such as the retina
(retinopathy) and the kidney (nephropathy). Vascular
changes also seem to favor progression of periodontal dis-
ease.35 This was also confirmed by Rylander and colleagues,49
who compared the periodontal condition of 46 insulin-con-
trolled young diabetics with 41 healthy young adults. They
reported significantly more gingival inflammation in those
young diabetics with retinopathy and nephropathy com-
pared with diabetics with no complications such as retinop-
athy and nephropathy.
As periodontal disease tends to be more common and
more extensive in patients with uncontrolled or poorly con-
trolled diabetes, one could hypothesize that normalizing
blood glucose levels should stop the progression of periodon-
tal disease. This is, however, not true, since Sastrowijoto and
colleagues50 demonstrated that an improved metabolic con-
trol in diabetes type 1 patients did not improve the clinical
periodontal condition. The periodontal condition only ame-
liorates when local oral hygiene measures are intensified.
One must realize, however, that the periodontal condition
will continue to deteriorate when the blood glucose level is
not well controlled.35
Orthodontic
Treatment Considerations
Nowadays, there is no age limit for orthodontic treatment.
The practitioner will therefore be confronted in his office
with type 1 as well as type 2 diabetes patients. Diabetes type
2 patients can be considered more stable when compared
with type 1 patients (Table 2). The latter can be presumed to
be “brittle”: strict compliance with the medical regimen is of
utmost importance to maintain control of blood glucose lev-
els. Deviations from appropriate diet and the schedule of
insulin injections will result in distinct changes in the serum
glucose level.51 Hypoglycemic reactions may thus occur
more often in these patients. Diabetes type 1 is more often
encountered in younger patients who will be more frequently
selected for orthodontic treatment. Morning appointments
are preferable. If a patient is scheduled for a long treatment
session, that is, longer than 1½ hours, the patient should be
advised to eat their usual meal and take their medication as
usual. Before the dental procedure starts, the dental team
should check whether the patient has fulfilled these recom-
mendations or not. In this way a hypoglycemic reaction in the
office can readily be avoided.
Having knowledge of the oral complications of diabetes,
256 L. Bensch, M. Braem, and G. Willems

Table 2 Type of Diabetes, Medical Treatment, Considerations in Orthodontic Treatment

Type of diabetes Type 1 diabetes Type 2 diabetes
Medical treatment Insulin Lifestyle changes to promote weight loss: diet, physical exercise
Oral hypoglycemic agents: biguanides, sulfonylurea
Insulin
Considerations in Medical anamnesis at the first appointment.
orthodontic Check for HbA1c or contact the patient’s physician to verify the control of the disease.
therapy Type 1 DM patients are presumed to be more brittle: check for the frequency of
hypoglycemic reactions.
Type 2 DM patients are presumed to be more stable.
At each appointment evaluate the oral cavity for signs of deterioration of glycemic control.
Advise the maintenance of good oral hygiene.
During treatment, monitor the periodontal condition and keep control over the inflammation.
Apply light forces and check on a regular basis the vitality of the teeth involved.
Summary Patients with well-controlled diabetes are no contraindication for orthodontic treatment.
Avoid orthodontic treatment in uncontrolled or poorly controlled diabetes patients.

the dental practitioner should take them into account when
treating the diabetic patient. The key to any orthodontic
treatment for a patient with diabetes is good medical control.
Orthodontic treatment should not be performed in a patient
with uncontrolled diabetes. If the patient is not in good met-
abolic control (HbA1c ⬎ 9%), every effort should be made to
improve the diabetic state before starting orthodontic treat-
ment. For diabetes patients under good medical control, all
dental procedures can be performed without special precau-
tions unless complications of diabetes are present.
There is no treatment preference with regard to fixed or
removable appliances. It is important to stress the mainte-
nance of good oral hygiene, especially when fixed appliances
are used. Indeed such appliances may give rise to increased
plaque retention, which may in these patients more easily
cause tooth decay and periodontal breakdown. Adjuvant
daily rinses with a fluoride-rich mouth rinse, preferably be-
fore bedtime, can provide further preventive benefits. Can-
dida infections may occur and, if present, blood glucose lev-
els should be monitored to rule out deterioration of the
diabetic state. Diabetes-related microangiopathy can occa-
sionally occur in the periapical vascular supply, resulting in
unexplained odontalgia, percussion sensitivity, pulpitis, or
even loss of vitality in sound teeth.52,53 Especially in an orth-
odontic treatment where forces are applied to move teeth
over a significant distance, the practitioner should be alert to
this phenomenon and check on a regular basis the vitality of
the teeth involved. It is advisable to apply light forces and not
to overload the teeth.
Periodontal reactions to orthodontic forces were studied
by Holtgrave and Donath.54 They found a retarded osseous
regeneration, a weakening of the periodontal ligament, and
microangiopathies in the gingival area. The authors con-
cluded that the specific diabetic changes in the periodontium
are more pronounced following orthodontic tooth move-
ment. Since diabetes patients and, more specifically, uncon-
trolled or poorly controlled diabetic patients have an in-
creased tendency for periodontal breakdown, these patients
should be considered in the orthodontic treatment plan, as
periodontal patients and treatment considerations must ac-
cordingly be made. Especially in adults, it is important before
the start of the orthodontic treatment to obtain a full mouth
periodontal examination including probing, plaque and gin-
givitis score, and to evaluate the necessity for periodontal
treatment. First, the periodontal condition must be improved
before any orthodontic treatment can take place. During
orthodontic treatment the orthodontist should monitor the
periodontal condition of patients with diabetes and keep
control over the inflammation. As with all orthodontic pa-
tients, maintaining strict oral hygiene is very important. If
plaque control is difficult to achieve with mechanical aids
such as toothbrush and interdental brush, the use of a disin-
fectant mouth rinse of the chlorhexidine type, as an adjuvant
chemical plaque control, can be considered. To minimize the
neutralizing effect of the toothpaste on the chlorhexidine
molecule,55,56 there should be at least a 30-minute interval
between toothbrushing and a chlorhexidine rinse.57,58 Chlo-
rhexidine is cationic and forms salts of low solubility with
anions, resulting in a reduced antimicrobial effect. Sodium
lauryl sulfate, which is widely used as a detergent in tooth-
paste, is anionic.
Conclusion
Diabetes mellitus is a common medical disorder that will be
encountered by every practicing dentist. For dental practitio-
ners it is essential to recognize oral signs and symptoms of
undiagnosed or poorly controlled diabetes and to understand
the diagnostic and treatment aspects of this disease, and to
take appropriate actions when necessary. The practitioner
must be prepared to manage diabetes emergencies should
they occur in the dental office. Medical anamnesis of the
patient therefore plays a crucial role as part of the clinical
examination. Any patient suspected of diabetes should be
referred for medical evaluation.
Patients with well-controlled diabetes are not contraindi-
cated for orthodontic treatment. During treatment, special
attention is required with regard to periodontal problems.
Patients should be informed about the greater propensity for
gingival inflammation when fixed appliances are planned as
Diabetic patient
well as the importance of maintaining good oral hygiene to
prevent progression of periodontal breakdown. Especially in
type 1 diabetes patients, who are presumed to be more brit-
tle, the oral cavity must be monitored on a regular basis
because these patients are more prone to gingivitis, periodon-
tal breakdown, and candida infections. When type 1 diabetes
patients frequently exhibit a hypoglycemic coma, one can
assume that the diabetic state is less controlled. Efforts
should be taken by the physician to obtain better glycemic
control. If during orthodontic treatment signs of deteriora-
tion of the glycemic control are noticed, the orthodontist
should inform the patient and advise consultation with his or
her physician.
As a general conclusion, it can be stated that orthodontic
treatment should be avoided in patients with uncontrolled or
poorly controlled diabetes and that patients with good met-
abolic control, without local factors such as calculus, and
with good oral hygiene, show a similar oral status as healthy
patients and thus can be treated orthodontically as nondia-
betics.
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