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 β 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
II. 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

Diagnosis of Diabetes mellitus

Fasting Post Prandial(2

HRs)
Normal 65-104mg/dl
Blood glucose level ≥126md/dl ≥200mg/dl

2
 Oral glucose 100-140 mg/dl 140-200mg /dl
tolerance

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. Rapid alveolar bone loss 6. Lichen Planus

2. Xerostomia 7. Median Rhomboid
Glossitis
3. Oral candidiasis 8. Localized Osteitis
4. Compromised Periodontal Health 9. Trigeminal
Neuralgia
5. Burning Mouth syndrome

Now let’s 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-α Factor and Macrophage

3
 stimulating colony factor (which initiates proliferation of
osteoclasts)
ii. Reduction in osteoblastic function: it decreases Runx-2
(runt related transcription factor), osteocalcin and
osteopontin expression( which are extracellular matrix
proteins)
iii. Reduce bone microcirculation by reducing
neovascularization and thus bone repair.
iv. 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. Immediate loading of the implants in the extraction

socket provided blood sugar level is under adequate
metabolic control
ii. Placement of bone grafts E.g.: DM bone, Biograft,
Novabone dental putty
iii. 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

4
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

1. 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)

6
 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.

7
 b

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. Cut the internal surface of reservoir smoothly with big
diameter (2mm), on each posterior surface, maintaining
sufficient thickness of denture walls for strength.
2. Drill 0.5 mm drainage hole from the inferior aspect of
lingual flange of denture into the reservoirs.
3. 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
 I. 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.

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, Sjogren’s
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, Moi-
Stir, Salivart, Oralube, Plax, Oral balance
B) Treat oral candidiasis
C) Relieve anxiety or depression by anticonvulsant
medication- clonazepm (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:

1. 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.

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