|Year : 2015 | Volume
| Issue : 1 | Page : 72-79
Oral health management considerations in patients with diabetes mellitus
Sandeep Kaur1, Kirandeep Kaur2, Shalu Rai3, Rajat Khajuria4
1 Department of Oral Medicine and Radiology, Indira Gandhi Government Dental College and Hospital, Jammu, Jammu and Kashmir, India
2 Department of Periodontology, Institute of Dental Studies and Technologies, Kadrabad, Modi Nagar, Uttar Pradesh, India
3 Department of Oral Medicine and Radiology, Institute of Dental Studies and Technologies, Kadrabad, Modi Nagar, Uttar Pradesh, India
4 Department of Prosthodontics, Indira Gandhi Government Dental College and Hospital, Jammu, Jammu and Kashmir, India
|Date of Web Publication||13-Apr-2015|
Dr. Sandeep Kaur
Department of Oral Medicine and Radiology, Indira Gandhi Government Dental College and Hospital, Jammu - 180 001, Jammu and Kashmir
Source of Support: None, Conflict of Interest: None
Diabetes mellitus (DM) is one of the most serious diseases of metabolism. Long-term consequences of hyperglycemia are very heterogeneous and affect partially all tissues and organs of the organism. A number of oral diseases and disorders have been associated with DM, and periodontitis has been identified as a possible risk factor for poor glycemic control and the development of other clinical complications of diabetes. In this review article, we discuss the relevant information about DM associated oral conditions and role of dental practitioners to take the responsibility to develop programs to educate the public about the oral manifestations of diabetes and its complications on oral health in order to promote proper oral health and to reduce the risk of oral diseases.
Keywords: Blood glucose, diabetes, glycemic control, insulin, periodontitis
|How to cite this article:|
Kaur S, Kaur K, Rai S, Khajuria R. Oral health management considerations in patients with diabetes mellitus. Arch Med Health Sci 2015;3:72-9
| Introduction|| |
Diabetes Mellitus (DM) is a chronic disease that occurs when the pancreas does not produce enough insulin (a hormone that regulates blood sugar) or alternatively, when the body cannot effectively use the insulin it produces. The overall risk of dying among people with diabetes is at least double the risk of their peers without diabetes.  The term DM describes a metabolic disorder of multiple etiology characterized by chronic hyperglycemia with disturbances of carbohydrate, fat, and protein metabolism resulting from defects in insulin secretion, insulin action, or both. The effects of DM include long-term damage, dysfunction, and failure of various organs.
DM may present with characteristic symptoms such as polydipsia, polyuria, and polyphagia. In its most severe forms, ketoacidosis or a non-ketotic hyperosmolar state may develop and lead to stupor, coma and, in absence of effective treatment, death. Often symptoms are not severe, or may be absent, and consequently hyperglycemia sufficient to cause pathological and functional changes may be present for a long time before the diagnosis is made.
The long-term effects of DM include: ,
The American Diabetes Association provided the most recent classification of DM, in 1974 [Table 1].  The most common forms of diabetes are termed type 1 and 2. Type 1 diabetes was previously called insulin-dependent diabetes or juvenile diabetes, while type 2 diabetes was formerly known as noninsulin-dependent diabetes or adult-onset diabetes.
- Peripheral neuropathy, and
- Cardiovascular disease.
- The terms type 1 and 2 should be reintroduced. The etiological type named type 1 encompasses the majority of cases which are primarily due to pancreatic islet beta-cell destruction and are prone to ketoacidosis.
- Type 1 includes those cases attributable to an autoimmune process, as well as those with beta-cell destruction and who are prone to ketoacidosis for which neither an etiology nor a pathogenesis is known (idiopathic). It does not include those forms of beta-cell destruction or failure to which specific causes can be assigned (e. g., cystic fibrosis, mitochondrial defects, etc.). Some subjects with this type can be identified at earlier clinical stages than "diabetes mellitus".
- The underlying pathophysiologic defect in type 2 diabetes does not involve autoimmune beta-cell destruction. Rather, type 2 diabetes is characterized by the following three disorders:
- Peripheral resistance to insulin, especially in muscle cells;
- Increased production of glucose by the liver; and
- Altered pancreatic insulin secretion.
The American Diabetes Association's Expert Committee on the Diagnosis and Classification of Diabetes Mellitus also recently approved new criteria for diagnosis of DM [Table 2]; 
Maintenance of proper oral hygiene for good oral health is an accepted part of the normal recommendations for a healthy lifestyle. Poor oral hygiene is associated with gingivitis, which can progress to more severe infection and inflammation leading to periodontitis. Infectious disease is known to be more common in people with diabetes if blood glucose control is poor, and inflammation is known to be associated with a decrease in insulin sensitivity, and thus potentially a worsening of blood glucose control. The dentist plays a major role with other members of the health team in helping a patient maintain glycemic control by achieving optimal oral health; and by referring undiagnosed patients with complications suggestive of diabetes to physicians for further evaluation.
- A casual plasma glucose level (taken at any time of day) of 200 mg/dl (11.1 mM) or greater when the symptoms of diabetes are present. Classic symptoms of diabetes include polydipsia, polyurea, and polyphagia.
- Fasting plasma glucose level of 126 mg/dl (7.0 mmol/l) or greater.
- An oral glucose tolerance test value in the blood of 200mg/dlor greater when measured.
| Diabetes and Oral Health Oral Complications of Diabetes: The Sixth Complication of Diabetes|| |
The most common oral health problems associated with diabetes are:
- Gum disease.
- Salivary gland dysfunction.
- Fungal infections.
- Oral burning and taste impairment.
- Oral mucosal diseases including lichen planus and recurrent aphthous stomatitis.
- Dental caries.
- Traumatic ulcers and irritation fibroma. 
Periodontitis has been referred to as the sixth complication of diabetes. Diabetes is believed to promote periodontitis through an exaggerated inflammatory response to the periodontal microflora. The subgingivalmicroflora in patients with periodontitis who have DM generally is equivalent to that observed in patients with periodontitis who do not have a diagnosis of diabetes , [Figure 1].
Understanding the pathway to periodontitis is essential because it enables clinicians, researchers, and patients to consider the possible mechanisms by which oral-systemic connections occur.  It is a microbial challenge to the host or person with poor oral hygiene that initiates the cascade of events that can result in periodontal breakdown. The presence of bacterial endotoxins, antigens, and other virulence factors stimulate the host immunoinflammatory response. Neutrophils are recruited to the site of the infection to address the pathogenicmicrobes, which then invoke an antibody response. In more resistant individuals, these events lead to the development of localized reversible inflammation, known as gingivitis. In more susceptible individuals, very high levels of proinflammatory mediators - known as cytokines, prostanoids, and matrix metalloproteinases - will be produced by the host, leading to connective tissue breakdown and bone metabolism changes associated with the bone loss that is pathognomonic to periodontitis. In the clinical setting, this cascade of events presents as the signs of disease: Increases in probing depth, loss of clinical attachment, and radiographic evidence of bone loss. Genetics plays a significant role in who may be susceptible. Studies have shown that at least 50% of all cases of periodontal disease have some genetic component.  In addition, there are a number of environmental and acquired risk factors that put patients at greater risk. Various risk factors for periodontal disease include hereditary, smoking, poor oral hygiene, diabetes, and certain medications like calcium channel blockers, dilantin, and cyclosporin.
Risk assessment is important because it has been recognized that the more risk factors a patient has, the more likely he or she is to develop the disease. There is often more than an additive effect, there is a synergistic effect between these risk factors. Identification and consideration of these risk factors is critical to successful periodontal treatment because they can affect the onset, the rate of progression, and the severity of periodontal disease. In addition, these risk factors may determine treatment strategies and explain variability in the therapeutic responses of patients. Risk factor assessments can alter the way patients are viewed by the practitioner, leading to a decision process based on risk. The primary goal of the practitioner would be risk reduction.
A number of studies found a higher prevalence of periodontal disease among diabetic patients than among healthy controls. However, a recent survey has indicated that most patients with DM are unaware of oral health complications of their disease.  In a large cross-sectional study, Grossi and others  showed that diabetic patients were twice as likely as nondiabetic subjects to have attachment loss. Firatli,  followed type 1 diabetic patients and healthy controls for 5 years. The people with diabetes had significantly more clinical attachment loss than controls. In another cross-sectional study, Bridges and others  found that diabetes affected all periodontal parameters, including bleeding scores, probing depths, loss of attachment, and missing teeth. In fact, one study has shown that diabetic patients are five times more likely to be partially edentulous than nondiabetic subjects.  People with type 1 and 2 diabetes appear equally susceptible to periodontal disease and tooth loss. Periodontitis is a clinical complication of DM. Furthermore, approximately 30% of people with DM have undiagnosed DM. Therefore, the dental office is a healthcare site that can help identify undiagnosed DM, which can lead to better management of the care of patients with diabetes.
A recent study found that smoking increases the risk of periodontal disease by nearly 10 times in diabetic patients.  According to these results, the management of diabetic patients should include strong recommendations to quit smoking. For both type 1 and 2 diabetes, there does not appear to be any correlation between the prevalence or the severity of periodontal disease and the duration of diabetes. ,
This is a chronic bacterial infection that affects the gum tissue and bone that supports the teeth [Figure 2]. If left untreated, gum disease can result in abscesses or the complete destruction of the tooth's supporting tissues and, ultimately, tooth loss. Gum disease tends to be more severe among people who have diabetes because the disease lowers the ability to fight infection and slows healing. An infection causes blood sugar level to rise, which makes diabetes more difficult to control. Preventing and treating gum disease can help improve blood sugar control. 
The principles of treatment of periodontitis in diabetic patients are the same as those for nondiabetic patients and are consistent with our approach to all high-risk patients who already have periodontal disease [see [Table 3].
Salivary gland dysfunction
Dry mouth, or xerostomia, has been reported in 40-80% of diabetic patients. Salivary dysfunction, however, can be difficult to diagnose.  Salivary flow may be affected by a variety of conditions, including the use of prescription medications and increasing age, and it appears to be affected by the degree of neuropathy and subjective feelings of mouth dryness that may accompany thirst.  Diabetic patients with poorly controlled disease have been found to have lower stimulated parotid flow rates than people with well-controlled DM and nondiabetic control subjects.  Asymptomaticbilateral enlargement of the parotid glands has been reported in 24-48% of patients with DM, and patients with uncontrolled DM have exhibited a greater propensity for enlargement. , Uncontrolled diabetes can decrease the saliva flow and cause dry mouth. A lack of saliva in the mouth allows bacteria to accumulate. This increases the risk of developing halitosis (bad breath), tooth decay, and gum diseases. The most common complications of dry mouth or xerostomia include difficulty in chewing, speaking, swallowing, and the ability to taste. To help relieve dry mouth, sip water throughout the day, chew sugarless gum or suck on sugarless mints, or use a mouth moisturizer available over the counter. 
Several authors have reported that diabetic patient have increased predisposition to manifestation of oral candidiasis, including median rhomboid glossitis, denture stomatitis and angular cheilitis. Candidiasis has been found to be associated with poor glycemic control and use of dentures. ,, It could be due to xerostomia, increased salivary glucose levels or immune dysregulation.
Mucormycosis is a rare but serious systemic fungal infection that may occur in patients with uncontrolled DM which appears as palatal ulceration or necrosis. Treatment usually includes systemic antifungal therapy.  Oral fungal infections are treated with special mouthwashes and antifungal medication and by controlling blood sugar levels. 
Oral burning and taste disturbances
Clinician should consider DM in the diagnosis of problems like burning mouth or tongue. The burning may be due to peripheral neuropathy, xerostomia, or candidiasis. Good glycemic control may alleviate burning sensation. Reports have indicated that clonazepam may be beneficial in some patients with complain of oral burning sensation.  Taste disturbances have been reported in patients with DM,  but all investigators have not observed this finding. Perros and colleagues  reported that some diabetic patients have a mild impairment of the sweet taste sensation. This may be related to xerostomia or disordered glucose receptors.
Oral mucosal diseases
A number of types of oral mucosal lesions, including lichen planus and recurrent aphthous stomatitis, have been reported in people with DM [Figure 3]. Not all study results have showed this association, and these are relatively common disorders that often are observed in patients who do not have diabetes. Petrou-Amerikanou and colleagues  reported that the prevalence of oral lichen planus is significantly higher in patients with type I DM and slightly higher in patients with type 2 DM than in control subjects. However, this may be side effect of oral hypoglycemic agents or antihypertensive medicines.
Some studies have demonstrated that diabetic patients have more active dental caries than control subjects  [Figure 4]. Furthermore, a reduction in salivary flow has been reported in people with diabetes who have neuropathy,  and diminished salivary flow is a risk factor for dental caries. The literature presents no consistent pattern regarding the relationship of dental caries and diabetes.  However, low carbohydrate diabetic diets should theoretically reduce caries prevalence.
Traumatic ulcers and irritation fibroma
Guggenheimer and colleagues,  recently reported that people with type 1 diabetes have a higher prevalence of oral traumatic ulcers and irritation fibromas than do nondiabetic control subjects. These findings may be related to altered wound healing patterns in these patients.
| Dental Management Consideration|| |
To minimize the risk of intraoperative emergency, clinicians need to consider a number of management issues before initiating dental treatment.
Prior to dental treatment, the dentist must obtain a good medical history which indicates the type of diabetes suffered and frequency of hypoglycemic episodes or complications. Antidiabetic medications, dosages times of administration, and status of diabetes control should be determined. According to the recent consensus of the American Diabetes Association (2010),  glycosylated hemoglobin, that is, HbA1c ≥6.5%, a preprandial glycemia of ≥126 mg/ dl and a postprandial glycemia ≥200 mg/dl are suggestive diagnostic values of diabetes.
Scheduling of visits
In general, morning appointments are advisable since endogenous cortisol levels are generally higher at this time (cortisol increases blood sugar levels). For patients receiving insulin therapy, appointments should be scheduled so that they donot coincide with peaks of insulin activity, since that is the period of maximal risk of developing hypoglycemia.
It is important for clinicians to ensure that the patients has eaten normally and taken medications as usual. If the patient skips breakfast owing to the dental appointment but stills takes the normal dose of insulin, the risk of a hypoglycemic episode is increased. For certain procedures (e. g., conscious sedation), the dentist may request that the patients alter his or her normal diet before the procedure. In such cases, the medication dose may need to be modified in consultation with patient's physician.
Blood glucose monitoring
Depending on the patient's medical history, medication regimen and procedure to be performed, dentists may need to measure the blood glucose level before beginning a procedure. This can be done using commercially available electronic blood glucose monitors, which are relatively inexpensive and have a high degree of accuracy. Patients with low plasma glucose levels (<70 mg/dl for most people) should be given an oral carbohydrate before treatment to minimize the risk of a hypoglycemic event. Clinician should refer patients with significantly elevated blood glucose levels for medical consultation before performing elective dental procedures.
Type 1 diabetic patients undergoing a dental procedure
Follow the considerations previously described.
Noninvasive dental procedures
Well-controlled patients can be treated similarly to nondiabetic individuals. Be aware of the increased susceptibility of these patients to infections and delayed wound healing. In poorly controlled patients, delay the dental treatment if possible until they have achieved good metabolic control.
Invasive dental procedures
Patients should ask their doctor for instructions concerning their medication (normally, if they have metabolic stability, they should take half their daily dose of insulin the morning of the treatment; then, after the intervention, the whole dose should be taken with a supplement of rapid-acting insulin). Blood glucose should be measured preoperatively. If it is between 100 and 200 mg/dl, the invasive dental procedure can be performed. If blood glucose is >200 mg/dl, an intravenous infusion of 10% dextrose in half-normal saline is initiated, and rapid-acting insulin is administered subcutaneously. If the treatment lasts more than 1 h, blood glucose should be measured hourly. If blood glucose is >200 mg/dl, rapid-acting insulin should be administered subcutaneously. Type 1 DM is considered a risk factor with regard to suffering infection. For that reason, when invasive dental procedures are going to be performed (as intraligamentous anesthesia, teeth extractions, biopsies, etc.), the usual guidelines for the antibiotic prophylaxis should be followed. 
Type 2 diabetic patients undergoing a dental procedure
Follow the considerations previously described.
Noninvasive dental procedures
People who control their disease well by diet and exercise require no special perioperative intervention. As in type 1 diabetic patients, be aware of their susceptibility to infections and delayed wound healing. In poorly-controlled patients, delay the dental treatment if possible until they have achieved good metabolic control.
Invasive dental procedures
Patients should ask their doctor for instructions regarding their medication (normally, those patients being treated with oral hypoglycemic agents should take their normal dose in the morning and eat their regular diet).
Hypoglycemia is the major issue that confronts dental practitioners when treating diabetic patients, particularly if patients are fasting. The clinical presentation of hypoglycemia is very similar to hyperglycemia. If in doubt, it should be treated as a hypoglycemia. The characteristics and treatment of this complication are showed in [Table 2].  Hypoglycemia usually appears in response to the stress experienced before, during, or after the treatment, and has been shown to cause a significant increase in perioperative morbidity and mortality. ,
| Recommendations on Clinical Care for People with Diabetes|| |
- Education of people with diabetes should include explanation of the implications of diabetes, particularly poorly controlled diabetes, for oral health, especially.
- Look for early signs of gum disease:Report any signs of gum disease - including redness, swelling, and bleeding gums - to a dental hygienist. Also mention any other signs and symptoms such as dry mouth, loose teeth, or mouth pain. In those people with possible symptoms of gum disease, advise them to seek early attention from a dental health.
- Maintain good oral hygiene:
Professional education and awareness within the diabetes community will need to be enhanced before these recommendations are likely to be widely adopted. Healthcare professionals should be empowered to explain the need for oral hygiene and the background to their enquiries about gum disease. They should be aware that certain medications (notably calcium channel blockers, tricyclics) may result in dry mouth (xerostomia), which is likely to increase the accumulation of plaque and the risk of oral diseases. Communication between diabetes and oral healthcare professionals could facilitate this empowerment.
- Brush twice a day for 2 min with a soft toothbrush and fluoridated toothpaste.
- Clean or floss between teeth once a day to remove food and plaque.
- Clean or scrape the tongue daily.
- Avoid mouth rinses with alcohol, as they tend to make dry mouth worse.
- Remove and clean dentures daily.Implementation
Dental hygienists involved in diabetes care should:
- Update the client's medical history and any changes in medication.
- Devise a treatment plan and develop a customized homecare program.
- Give advice on the various types of oral care products and how to use them.
- Instruct clients on the most effective way to brush and floss.
- Provide information and counseling on tobacco cessation and dietary measures to support diabetic management.
- Refer clients to a physician/nurse practitioner if diabetes is suspected but not diagnosed.
| Conclusion|| |
DM is a disease of which the general public and practicing dentists and dental hygienists should be aware. On the basis of the available data, we can conclude that practicing dentists and dental hygienists can have a significant, positive effect on the oral and general health of patients with DM. It is important for the dentist to be aware with the medical management of the patients with DM, and to recognize the signs and symptoms of the undiagnosed or poorly controlled disease. By taking an active role in the diagnosis and treatment of oral conditions associated with DM, dentist may also contribute to the maintenance of optimal health in patients with this disease. Periodontal disease is the main oral clinical manifestation in diabetic patients. Periodontal treatment may eventually be covered by medical insurance, which could include consultations, diagnostics, and therapeutics. These patients should be aware of their increased susceptibility to infections and delayed wound healing. Well-controlled diabetics can be treated in the dental office similarly to nondiabetic patients, but morning appointments are preferable, and patients should be instructed not to fast, in order to reduce the risk of the occurrence of hypoglycemia.
| References|| |
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2010;33:62-9.
Kidambi S, Patel SB. Diabetes mellitus: Considerations for dentistry. J Am Dent Assoc 2008;139:8-18S.
Report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus. Diabetes Care 1997;20:1183-97.
Guggenheimer J, Moore PA, Rossie K, Myers D, Mongelluzzo MB, Block HM, et al
. Insulin dependent diabetes mellitus and oral soft tissue pathogenesis. I. Prevalence and characteristics non-candidial lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:563-9.
Ebersole JL, Holt SC, Hansard R, Novak MJ. Microbiologic and immunologic characteristics of periodontal disease in Hispanic Americans with type 2 diabetes. J Periodontol 2008;79:637-46.
Lalla E, Kaplan S, Chang SM, Roth GA, Celenti R, Hinckley K, et al
. Periodontal infection profiles in type 1 diabetes. J Clin Periodontol 2006;33:855-62.
Page RC, Kornman KS. The pathogenesis of human periodontitis: An introduction. Periodontol 2000 1997;14:9-11.
Michalowicz BS, Diehl SR, Gunsolley JC, Sparks BS, Brooks CN, Koertge TE, et al
. Evidence of a substantial genetic basis for risk of adult periodontitis. J Periodontol 2000;71:1699-707.
Moore PA, Orchard T, Guggenheimer J, Weyant RJ. Diabetes and oral health promotion: A survey of disease prevention behaviours. J Am Dent Assoc 2000;131:1333-41.
Grossi SG, Zambon JJ, Ho AW, Koch G, Dunford RG, Machtei EE, et al
. Assessment of risk for periodontal disease. I. Risk indicators for attachment loss. J Periodontol 1994;65:260-7.
Firatli E. The relationship between clinical periodontal status and insulin-dependent diabetes mellitus. Results after 5 years. J Periodontol 1997;68:136-40.
Bridges RB, Anderson JW, Saxe SR, Gregory K, Bridges SR. Periodontal status of diabetic and non-diabetic men: Effects of smoking, glycemic control, and socioeconomic factors. J Periodontol 1996;67:1185-92.
Moore PA, Weyant RJ, Mongelluzzo MB, Myers DE, Rossie K, Guggenheimer J, et al
. Type 1 diabetes mellitus and oral health: Assessment of tooth loss and edentulism. J Public Health Dent 1998;58:135-42.
Moore PA, Weyant RJ, Mongelluzzo MB, Myers DE, Rossie K, Guggenheimer J, et al
. Type 1 diabetes mellitus and oral health: Assessment of periodontal disease. J Periodontol 1999;70:409-17.
Sandberg GE, Sundberg HE, Fjellstrom CA, Wikblad KF. Type 2 diabetes and oral health. A comparison between diabetic and non-diabetic subjects. Diabetes Res Clin Pract 2000;50:27-34.
Dental Hygienists: Your partners in oral health. Available from: www.odha.on.ca
[Last accessed on 2014 Mar 18].
Quirino MR, Birman EG, Paula CR. Oral manifestation of diabetes mellitus in controlled and uncontrolled patients. Braz Dent J 1995;6:131-6.
Moore PA, Guggenheimer J, Etzel KR, Weyant RJ, Orchard T. Type 1 diabetes mellitus, xerostomia, and salivary flow rates. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;92:281-91.
Chavez EM, Taylor GM, Borell LN, Ship JA. Salivary function and glycemic control in older persons with diabetes control. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:305-11.
Russotto SB. Asymptomatic parotid gland enlargement in diabetes mellitus. Oral Surg Oral Med Oral Pathol 1981;52:594-8.
Guggenheimer J, Moore PA, Rossie K, Myers D, Mongelluzzo MB, Block HM, et al
. Insulin dependent diabetes mellitus and oral soft tissue pathogenesis, II: Prevalence and characteristics of candida and candidial lesions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:570-6.
Hill LV, Tan MH, Periara LH, Embil JA. Association of oral candiasis with diabetic control. J Clin Pathol 1989;42:502-5.
Jones AC, Bentsen TY, Freedman PD. Mucormycosis of the oral cavity. Oral Surg Oral Med Oral Pathol 1993;75:455-60.
Grushka M, Epstein J, Mott A. An open-label, dose escalation pilot study of the effect of clonazepam in burning mouth syndrome. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1998;86:557-61.
Ship JA. Diabetes and oral health: An overview. J Am Dent Assoc 2003;134:4-10S.
Perros P, Mac Farlane TW, Counsell C, Frier BM. Altered taste sensation in newly-diagnosed NIDDM. Diabetes Care 1996;19:768-70.
Petrou-Amerikanou C, Markopolous AK, Belazi M, Karamitsos D, Papanayotou P. Prevalence of oral lichen planus in diabetes mellitus according to the type of diabetes. Oral Dis 1998;4:37-40.
Lalla Rajesh V, D′Ambrosio Joseph A. Dental management considerations for the patients with diabetes mellitus. J Am Dent Assoc 2001;132:1425-32.
Taylor GW, Manz MC, Borgnakke WS. Diabetes, periodontal diseases, dental caries, and tooth loss: A review of the literature. Compend Contin Educ Dent 2004;25:179-84, 186-8.
Gutiérrez JL, Bagán JV, Bascones A, Llamas R, Llena J, Morales A, et al
. Consensus document on the use of antibiotic prophylaxis in dental surgery and procedures. Med Oral Patol Oral Cir Bucal 2006;11:E188-205.
Bergman SA. Per ioperative management of the diabetic patient. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2007;103:731-7.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3]