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Journal of Pakistan Dental Association

Mehmood Hussain,


Nazia Yazdanie


Jodat Askari


Diabetes Mellitus is a nutritional metabolic disorder

characterize by various oral and systemic problems. These
patients when referred to dentist or prosthodontist for the
provision of prosthetic treatment require multidisciplinary
approach. In this article special focus is emphasized on the
various factors important factors to be kept in mind when
providing prosthodontic treatment for such patients. .

KEY WORDS: Diabetes Mellitus, Clinical features,

Prosthodontics Management.

J Pak Dent Assoc 2010;19(1):46-48

iabetes Mellitus is a clinical syndrome

characterized by hyperglycemia due to absolute or relative

deficiency of insulin.1 The two main categories of Diabetes
Mellitus include Type I or Insulin dependent Diabetes
Mellitus and Type II or Non insulin dependent Diabetes
Mellitus. The former is a result of absolute deficiency of
insulin with its onset occurring before adulthood. In
contrast, Type II results because of insulin resistance with
an insulin secretary defect with its onset usually occuring
in mid or later life although it can occur earlier as well.2

Regarding pathogenesis, Type I Diabetes Mellitus results

from immunological destruction of pancreatic beta cells,
while Type II results from combination of impairment of
insulin resistance and defective secretion of insulin by beta
cells. Contributing factors include genetics, obesity,
physical inactivity and advancing age. 3 Diabetes Mellitus is
becoming a common disease of todays world, in United
Kingdom one in twenty people over the age of 65 has
diabetes and this rises to one in five people over the age of
85 years. The World Health Organization predicts that the
global prevalence of diabetes will increase from 135 million
to 300 million in 2025.4 Even in developing countries like
Pakistan, the incidence of diabetes is increasing rapidly and
most of the cases are undiagnosed as well. People mostly
consult their physician when typical symptoms of diabetes
like polyuria, polydipsia, polyphagia occur. 5 Considering oral
health in diabetic patients, they are more prone to develop
caries, periodontitis, xerostomia, oral ulcers, burning mouth
syndrome, candidiasis, loss of resilience of oral mucosa,
residual bone resorption, periodontal abscess, gingival
overgrowth and poor tolerance to prosthesis especially for
complete dentures. 6 Oral manifestations are most likely
due to increase glucose concentration in saliva, polyuria,
impaired host resistance due to defective function of

polymorphonuclear leucocyte (PMN) and microvasculsar

Management Considerations: General Dental
It is better to arrange appointment in the morning and
avoiding lengthy appointments. All procedures should be
done involving minimal possible trauma and should be
carried in stress free environment. Maintenance of good
oral hygiene is a prerequisite for all dental procedures. In
this regard application of topical agents like chlorhexidine,
fluoride gel is found very useful. The use of prophylactic
medication to avoid postoperative infection and pain is
recommended in certain cases. For management of
xerostomia, diet counseling, medication, artificial salivary
substitutes are helpful. Before starting any procedure
consultation with patients physician or endocrinologist is
also beneficial for the diabetic patients. 8
Dentist should also be able to know about the diagnosis
and management of hypoglycemic shock. It is
characterized by hunger, nausea, perspiration, pallor, and
tachycardia. In severe condition seizure may occur and
patient may undergo in state of unconsciousness
Management depends upon the severity of the shock.
Initially treatment should be deferred and to monitor vital
signs and administer glucose orally if possible otherwise
intravenous administration of glucose should be done.
Prosthodontics Management Considerations:
Eradication of any disease/s that will affect the prognosis of
any dental prosthesis will be the first line of action. Teeth
requiring restoration must be restored by appropriate
restorative procedures like filling, endodontic treatment
etc. As previously mentioned restoration and the
maintenance of good oral hygiene is mandatory before
starting any prosthodontic procedures. On first visit,
assessment of the patient should be done which include

proper history and examination. Details regarding type of

prosthesis, duration of treatment, number of appointments
must be explained to the patient.10
Radiographic evaluation must be carried out. Patients is
advised to bring reports of recently done and up to date
laboratory investigation regarding blood sugar level.
Secondly it is better to note blood sugar level before
starting any dental procedure with the help of glucometer.
Patient must be instructed to consult his or her physician
before initiating any procedure, if needed then any
alteration regarding patients medication must be
discussed with the patients physician. 11
If patient is provided removable partial denture (RPD), then
restoration and maintenance of good oral hygiene by any
restorative procedures or root planning and scaling must
be accomplished first. Health of abutment teeth is very
important and will be achieved by various means for better
prognosis of RPD treatment.12 All components of RPD must
be tissue friendly by making appropriate design of the
prosthesis. As diabetic patients are more prone to develop
periodontal diseases, therefore in certain cases splinting of
periodontalally compromised teeth is also a good option.
Some times periodontal surgery may be
indicated.13 Selection of particular type of RPD is also very
important, in Diabetic patients. If an acrylic denture is a
preferred option then the design should incorporate the
principles of Every Denture with wider self cleansing
interdental spaces and embrasures areas, uncovered
marginal gingiva, point contact between denture and
natural abutment teeth, free gliding occlusion, maximum
retention following complete denture making principles.
These all factors are beneficial for the diabetic patients if
they need RPD.14
When complete denture is fabricated for diabetic patients
then always use tissue friendly material and technique,
impression making will be done by mucostatic technique.
Occlusal vertical dimension should be appropriate

Always use an occlusal scheme that has narrow buccolingual dimension and shortened mesiodistal length. This
approach will decrease the stress on the underlying tissue
to retard bone resorption, concept of neutral zone can also
be employed. Denture flanges should be smooth and
polished. There should be no working or non-working
occlusal interference between opposing teeth. 15
It is also mandatory for the dentist to fully educate and
motivate the patient to the importance of maintaining good
oral hygiene and towards the importance of regular followup visits to the dentist.
This will ensure the long term heath of the oral tissues by
preventing chronic infection states such as denture related
stomatitis and denture hyperplasia that could lead to more
serious conditions. Diabetic patients are more susceptible
to infections which in severe cases may lead to excessive
oral tissue destructions, such patients may need
obturators. Fabrication of obturator require special care in
every patient and especially in diabetic patient. 16
For patients requiring a fixed prosthesis like crown or fixed
partial denture (FPD), the finish-line of the preparation
should be placed supragingival and to provide chamfer
finish-line on the facial aspect of prepared tooth as it is
better than shoulder because shoulder can concentrate
stresses on weakened tooth/ teeth. Antes law should be
obeyed; minimal preparation like three quarter crown can
be done on teeth like pre molar.
A narrow occlusal table, group function or mutually
protected occlusal scheme is better choice for periodontally
compromised teeth.17. In certain cases procedures like
crown lengthening, periodontal surgery and orthodontic
extrusion of tooth will further improve the quality of fixed
prosthesis in diabetic patients.18 Implant supported
prosthesis are not advised for patients whose blood sugar
level remains uncontrollable but if conditions are
favorable , then this type of prosthesis can be planned. Like

any other dental surgical procedure, implant placement

must be accomplished with least trauma under stress free
Proper medication must be provided before and after
implant placement. Complete history and examination
along with radiographic evaluation must be carried out for
selection of type of dental implant, number of dental
implants, site of implant placement, type of artificial
prosthesis and occlusal scheme.
All these considerations will ensure better performance of
implants supported prosthesis.20, 21

Diabetes Mellitus is a complex disorder having many oral
and systemic problems. Multi disciplinary approach is
needed for the management of diabetes mellitus.
Fabrication of dental prosthesis would only be started after
complete evaluation of diabetic patients through history,
examination and making diagnostic cast. Before embarking
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. Apart
from conventional removable or fixed dental prosthesis,
introduction of dental implants helps to improve the quality
of life of the patients by better masticatory ability of the
dental prosthesis. In this article along with oral
complications of Diabetes Mellitus, various Prosthodontics
treatment options available for diabetic patients are
discussed Management of diabetic patients in
Prosthodontics should be done carefully. Before embarking
dental treatment it is better to consult patients physician.
Good oral and denture hygiene maintenance is a pre
requisite for ensuring the long term successful
Prosthodontics treatment. With an increasing incidence and
prevalence of Diabetes Mellitus, the role of oral health care
provider becomes very important

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