Prosthodontic Considerations In Diabetes Mellitus

For Complete Dentures

8/7/2011 Dr. Prachi Agrawal PG Dept. of Prosthodontics Terna Dental College

Introduction to Diabetes Mellitus

Oral Manifestations of Diabetes Mellitus Prosthodontic Consideration (Complete denture) in treating a Diabetic Patient References

What is diabetes mellitus? According to Davidson, it is an Endocrine disorder characterized with hyperglycemia, where the fasting blood glucose level is equal to or more than 126mg/dl (7mmol/ltr) and random blood glucose level is equal to or more than 200 mg/dl (11.1mmol/ltr). Types of diabetes mellitus I. It is also known as insulin dependent diabetes mellitus or juvenile diabetes mellitus. It is due to cell mediated autoimmune destruction of insulin producing cells of islets of Langerhans in pancreas. It occurs in childhood between 12-15 years of age. It accounts for 10-20% of known diabetics It is also known as non insulin dependent diabetes mellitus or adult onset diabetes mellitus. It is due to increased peripheral resistance to insulin, impaired insulin secretion or increased glucose production in liver. It occurs in adults usually at age 35 years. It accounts for rest 80-90% of diabetics

II.

Diagnosis of Diabetes mellitus Fasting Normal Blood glucose level 65-104mg/dl 126md/dl
2

Post Prandial(2 HRs)

200mg/dl

Oral glucose tolerance

100-140 mg/dl

140-200mg /dl

Oral glucose tolerance test:

It is based on individuals' response to oral glucose load. Fasting blood sample and urine are collected. Patient is given 75gm oral glucose dissolved in 300ml of water. Blood and urine can be collected at an interval of 30 min for 2 hours or directly after 2 hours and plasma glucose is measured.

Glycated haemoglobin: It is post translation, non enzymatic

addition of sugar residue to amino acids of proteins (haemoglobin- HbA1c). It is used to monitor control diabetes. Synthesis of HbA1c is directly related to exposure of RBC to glucose. Normal HbA1c :3-5% total Hb Diabetic HbA1c : >7% of total Hb Oral manifestations of diabetes mellitus
1. 2. 3. 4. 5.

Rapid alveolar bone loss 6. Lichen Planus Xerostomia 7. Median Rhomboid Glossitis Oral candidiasis 8. Localized Osteitis Compromised Periodontal Health 9. Trigeminal Neuralgia Burning Mouth syndrome

Now lets go in details of each oral manifestation:

1.

Rapid alveolar bone loss: It is volume and size of residual alveolar portion of the maxilla or mandible. Mechanism of bone loss: Hyperglycemia results in i. Increase in osteoclastic function: it increases the number of osteoclasts, TNF- Factor and Macrophage
3

ii.

iii.
iv.

stimulating colony factor (which initiates proliferation of osteoclasts) Reduction in osteoblastic function: it decreases Runx-2 (runt related transcription factor), osteocalcin and osteopontin expression( which are extracellular matrix proteins) Reduce bone microcirculation by reducing neovascularization and thus bone repair. Increase in advanced glycated end products which reduce cross linking of collagen fibers and thus affect integrity of new bone formed.

To preserve alveolar bone after extraction, we have 3 options:

i.

ii. iii.

Immediate loading of the implants in the extraction socket provided blood sugar level is under adequate metabolic control Placement of bone grafts E.g.: DM bone, Biograft, Novabone dental putty Collagen plugs: Derived from bovine Achilles tendon. Collagen is a connective tissue protein which forms fibres. E.g.: Kolspon plug, Ace resorbable collagen plug, Bicon RC

1.

Xerostomia: Cause is unknown, but nay be due to polyuria or alterations in basement membrane of salivary gland. Saliva is thick and ropy. This results in poor retention of complete dentures.

Treatment: i. Ask the patient to sip water throughout the day ii. Wet the dentures before placing them in mouth iii. Chew on sugar free sialagogues like Orbit White, Biotene iv. Take salivary stimulants like: 1. Muscarinic agent pilocarpine. E.g., salagen 2. Vitamin C chewable tablets e.g.: Trenvit Cee Chewable Tab, Vitamin C Chewtab, Vitcee Chewable Tab.
5

3. Cievimline (Evoxac) 30mg, 3 times per day v. Salivary substitutes or artificial saliva: mimic natural saliva, but not stimulate salivary gland production. They include carboxymethylcellulose or hydroxyethylcellulose, minerals such as calcium and phosphate ions and fluoride, preservatives such as methyl- or propylparaben, and flavoring and related agents. E.g. Moi-Stir Oral Swabsticks ; Optimoist spray; Saliva Substitute liquid; and Xero-Lube Artificial Saliva sodium-free spray. vi. Salivary Reservoir: It is incorporation of artificial saliva reservoir in denture base. Preparatory stage Make primary and secondary impression. Duplicate the secondary model. Articulate both the original and duplicate models in 2 separate articulators with same maxillomandibular relationship. Split denture is required for placement of the reservoir. Hence, the mandibular denture base is made in 2 sections: lower clear acrylic and upper pink acrylic.

Construction of the clear acrylic mandibular base section Determine height clear acrylic base section(c) 2. This is done by measuring the anterior height of the mandibular wax denture (a) 3. Then measure the height of the lower anterior teeth add 3mm to allow for sufficient Acrylic under the teeth for strength (b) 4. Subtract This height from the height of the denture(a-b=c)
1.

5. Now keep original b mandibular a wax denture c base aside and Construct new wax denture base of height c 6. Place 3 Three double-toothed LegoTM blocks in the wax, One was anteriorly and two posteriorly, one on each side 7. The Lego blocks are placed exactly in the centre of the wax base, kept parallel to each other and waxed in such a way that only the teeth of the Lego blocks were above the wax 8. Now seal the rim to the model and perform flasking, counter flasking, dewaxing, packing with CLEAR heat cure acrylic and acrylization.

Construction of the upper mandibular section 1. Place upper waxed denture on the duplicate articulated upper model 2. Place clear acrylic base on the duplicate articulated lower model. 3. Duplicate the clear acrylic base with impression made of the occlusal surface in a custom made tray and pour in stone. 4. A wax squash bite is made on the articulator between upper wax denture and clear acrylic base 5. Now remove the clear acrylic and place the duplicated stone in its place and plaster it.

6. Now set teeth and wax in normal manner. 7. Now flask and process the denture in pink, heat cure acrylic. 8. After deflasking, attach both upper and lower segments to ensure a flush and smooth finish.

Reservoir placement:
8

1.

2. 3.

Cut the internal surface of reservoir smoothly with big diameter (2mm), on each posterior surface, maintaining sufficient thickness of denture walls for strength. Drill 0.5 mm drainage hole from the inferior aspect of lingual flange of denture into the reservoirs. Test drainage by filling the reservoirs with water and denture placed on paper towel.

Cleanliness of dentures: 1. Weekly flush with 1% sodium hypochlorite solution. 2. Use Orthodontic wire to clean the drainage holes. 3. Candidiasis: It has generally been assumed that oral candidiasis occurs with increased frequency in patients with diabetes mellitus. Candidiasis is of 2 types: i. Oropharyngeal ii. Esophageal Oral manifestations of candidiasis are:
i.

Oral thrush: Thrush is an yeast Infection of the mucous membrane lining the mouth and the tongue.
9

People who have diabetes and high blood sugar levels are more likely to get thrush in the mouth, because the extra sugar in saliva acts like food for candida. Site: roof of the mouth, mucobuccal fold and retromolar area Appearance: multiple, curdy, loosely attached patches on mucous membrane
ii.

Denture sore mouth (Denture Stomatitis): also known as chronic atrophic candidiasis. Denture wearers are the most common group to be affected by candida albicans. It also affects people with poor oral hygiene, diabetics or denture wearer on steroids(any form) Site: mucosal surface covered by denture. Appearance: patchy distribution associated with speckled curd like white lesion.

Care for candidiasis:

10

The patient should maintain effective oral hygiene. E.g.: rinse mouth after every meals, clean the dentures every morning. II. Place the dentures in 0.2% chlorhex solution or 1%hypochlorite solution. E.g.: sanidyl, Chlorhexidine mouthwash, chlorhex 150, orathex. III.Antimycotic treatment: a. Sustained drug delivery by coating lacquer miconazole on fitting denture surface. E.g.: Daktarin Gel, Decanazole Gel, Fungitop Gel b. Topical treatment with Nystatin Suspension, Ointment or Gel. E.g.: Fongistat, Mystatin- OS, Devnyst Nystatin OS c. Amphotericin B- Lozenge, suspension or gel. E.g.: fungizone, AmB, Ambisome, Amphotec, Tegopen d. Ketokonazole lozenge for 2 weeks. E.g. : Fungitop Lotion, Kalzep Z lotion, Nizral solution, Sarot lotion.
I. 1.

Denture sore spot ( Traumatic Ulcers): A painful ulcer on the denture bearing area of oral tissues of short duration. Etiology: denture irritation, biting injuries.

Treatment: i. Removal of the cause, i.e. ill fitting denture should be replaced with new properly fitting dentures. ii.Apply benzocaine gels or orabase 2-3 times per day. Prognosis: Good if the cause is removed. If it fails to heal biopsy is required to be taken. Differential Diagnosis: a. Squamous Carcinoma
11

b. Ulcerative mucosal diseases such as lichen planus

1. Burning Mouth Syndrome Burning of the mouth has no detectable cause. It is of two types: i. Primary: the cause is unknown or idiopathic ii. Secondary: due to systemic factors like Diabetes, Vit B deficiency, Xerostomia Site: most commonly occurs on tongue, followed by denture bearing areas, lips and palate. 3 main features of burning mouth syndrome are: a. Dysgeusia: diminished taste perception due to atrophy of papillae. This in turn causes hyperphagia and consequently obesity. b. Dysesthesia: abnormal sensations in mouth. It can be tingling or numbness on the tip of the tongue or in mouth. It can be due to damage to nerves that carry pain and taste sensations. c. Dry mouth Treatment : i. Adjust or replace the ill fitting dentures. ii. Treat underlying disease like diabetes, Sjogrens syndrome iii. Recommend supplements for nutritional deficiency. E.g. : for vit B: Cobalvit, Mtild Forte, Mecobil OD, Zincobal. iv.Prescribe medications to:
12

A)

Relieve dry mouth. E.g. mouthwash like biotene or bioxtra, saliva substitutes like Glandosane, MoiStir, Salivart, Oralube, Plax, Oral balance

B) Treat oral candidiasis C) Relieve anxiety or depression by anticonvulsant medicationclonazepm (klonopin)- lozenge. D) Alpha Lipoic Acid: Strong Antioxidant- Biletan, Heparlipon, Thioctsan, Bolovit-FC v. Topical application of capsaicin, chemical derived from black pepper- It acts as a desensitizing agent. vi. Life style home remedies: a. Drink more water b.Suck ice chips c.No use of alcohol and tobacco products d.Avoid hot, spicy, acidic foods and liquids e.Brush dentures with baking soda and water f. Chew sugarless gum. g. Eat apple, carrot, celery, hard breads- these increase salivary stimulation.

General dental management: Put the patient on oral hypoglycemic (e.g. Betanase, Glucosafe, Glinil-M, Euclide)or insulin(e.g. B-D Microfine, Insucare-N, Insuman Rapid). 2. Diabetic patients should have morning appointments. 3. Procedures should be done with minimum possible trauma. 4. It should be carried out in stress free environment.
1. 13

5.

Patient should be treated under antibiotic coverage.

Special Prosthodontic Considerations( for Complete Denture) 1. We should examine the patient carefully and then arrive at appropriate diagnosis. 2. This will help to plan the treatment. 3. While making impression for complete dentures, Selective Pressure technique is used. It is as follows: i. Record preliminary impression in stock tray, with periphery adapted with compound and impression material being alginate. ii.Now pour cast with plaster. Make special tray of cold cure acrylic with a spacer of 2mm. iii.Make escape holes on tray overlying the ridge crest. iv. Load the impression compound material on special tray and make impression on the cast. Chill it (mucostatic). v.Now trim the peripheral impression compound with scalpel and apply tracing stick and adapt in mouth. Keep adapting till accurate fit is obtained. vi.Now cut the entire impression compound over crest of the ridge till the escape holes are exposed. vii.Load impression paste in the special tray and record the working surface with impression paste under heavy digital pressure (mucocompressive).

14

Conclusion:

Diabetes mellitus is a complex disorder affecting people of all ages. Providing safe and effective oral medical care for patient with diabetes requires an understanding of the disease and familiarity with its oral manifestations. Control of blood glucose level is of utmost importance for successful Prosthodontic treatment. Before starting any procedure for dental prosthesis, oral hygiene of the diabetic patients must be evaluated and should be improved through different surgical and non-surgical periodontal therapies and restorative techniques. Good oral and dental hygiene

15

maintenance is a pre requisite for ensuring the long term successful prosthodontic treatment .

References:
Mehmood Hussain, Nazia Yazdanie, Jodat Askari. Management of patient with Diabetes Mellitus in Prosthodontics. Journal of Pak dental association; 2010;19(1):46-48

A. Roy McGregor, Clinical dental Prosthetics, 3rd Edition, pg. no. 71, 77

Ejvind Budtz- Jorgensen, Dr. Odont, Prosthodontics for the Elderly Jonathan A. Ship. Diabetes and oral health an overview. Journal of American Dental Association; Oct 2003; vol 134

John J. Manappallil, Complete Denture Prosthodontics, 2nd ed

16