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
D

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 changes. 7
Management Considerations: General Dental Considerations
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 bucco-lingual 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
follow-up 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 environment. 19
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

Conclusion
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 nonsurgical 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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