Dental considerations for the treatment of patients with diabetes mellitus

Association of the Life's Essential 8 cardiovascular health score with periodontitis among US adults

AIM

To investigate whether cardiovascular health (CVH) is associated with periodontitis.

MATERIALS AND METHODS

We used data from the 2009 to 2014 National Health and Nutrition Examination Survey. We quantified CVH using Life's Essential 8, which includes four health behaviours (diet, smoking, physical activity and sleep) and four health factors (body mass index, blood cholesterol, glucose and pressure). We categorized scores as low (0-49), moderate (50-79) and high (80-100). We calculated subscores of health behaviours and factors and categorized them as low, moderate and high. We used logistic regression to assess the association of CVH with periodontitis, adjusting for age, gender, race/ethnicity, education, poverty index, marital status and health insurance. We computed odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

This study included 9296 adults ≥30 years old. Multivariable-adjusted models showed that subjects with moderate (OR, 0.62; 95% CI: 0.52-0.74) or high (OR, 0.43; 95% CI: 0.33-0.57) CVH had significantly lower odds of periodontitis compared to those with low CVH. These results were consistent in the health behaviours model, but the estimates in the health factors model were not significant.

CONCLUSIONS

Improving CVH may help prevent periodontitis. Longitudinal studies are needed to confirm our findings.

Oral Manifestations: A Reliable Indicator for Undiagnosed Diabetes Mellitus Patients

OBJECTIVES

 This article identifies undiagnosed DM (UDM) cases in the Pakistani population by perceiving the signs and symptoms of DM and associating them with oral manifestations.

MATERIAL AND METHODS

 In this cross-sectional study, patients showing at least three or more classical or warning signs like polydipsia, polyuria, polyphagia, and general weakness were considered UDM cases. Detailed oral examination for gingivitis, periodontitis, halitosis, xerostomia, and tongue manifestations was done followed by the hemoglobin A1c (HbA1c) analysis.

RESULTS

 Out of 5,878 patients, 214 UDM cases were identified, where 31.8% and 39.7% of the patients were diagnosed as prediabetics and diabetics, respectively, based on HbA1c analysis. Prevalence of gingivitis (97.6%), fissured tongue (91.8%), generalized periodontitis (85.9%), thick saliva (87.1%), xerostomia (84.7%), burning mouth syndrome (63.5%), yellow discoloration of tongue (57.6%), and ecchymosis/ulcers (43.5%) were more in diabetics as compared to prediabetic patients and normal population.

CONCLUSION

 The oral manifestations can be crucial for identifying UDM cases. Dentists can play a pivotal role by taking detailed history and thorough oral examination. If three or more symptoms as concluded above are present, an HbA1c analysis should be conducted to prevent preop and postop complications associated with DM.

Efficacy of nonsurgical periodontal therapy affecting salivary biomarkers in non-diabetic and type 2 diabetic periodontitis patients. An observational study

Objectives

To assess the effects of non-surgical periodontal therapy on salivary biomarkers in non-diabetic and type 2 diabetic periodontitis patients and to investigate if saliva may be used to monitor glucose levels in type 2 diabetes.

Material and methods

250 participants with chronic generalized periodontitis aged 35-70 years were divided into two groups: test group with type 2 diabetes (125 subjects with 64 males & 61 females) and control group with non-diabetic (125 subjects with 83 males & 42 females). Participants received non-surgical periodontal treatment. Pre-NSPT and 6-week post-NSPT saliva glucose, amylase, total protein, and C-reactive protein (CRP) levels were measured. Intergroup correlations were assessed using Karl Pearson's correlation coefficient and paired t-test.

Results

Non-surgical periodontal therapy significantly decreased CRP (p < 0.05) in diabetics and non-diabetics. CRP mean values changes from baseline 1.79 to post op 1.5 and baseline 1.5 to post-op 1.24 in males and females of test group, respectively. In control group males and females, mean values change from baseline 1.48 to post-op 1.42 and 1.499 to 1.40. Other parameters Glucose, amylase & total protein showed improvement in the level, but statistically non-significant (p > 0.05). Salivary glucose levels corresponded favorably with HbA1C levels.

Conclusion

In individuals with type 2 diabetes and non-diabetic generalized chronic periodontitis, non-surgical periodontal therapy may play a role in lowering the level of significant salivary biomarkers. Saliva can be utilized as a non-invasive approach for monitoring glucose levels in people with type 2 diabetes and chronic periodontitis.

Multi-functional nanogel with cascade catalytic performance for treatment of diabetic oral mucosa ulcer

Introduction: Diabetic oral mucosa ulcers face challenges of hypoxia, hyperglycemia and high oxidative stress, which result in delayed healing process. Oxygen is regarded as an important substance in cell proliferation, differentiation and migration, which is beneficial to ulcer recovery. Methods: This study developed a multi-functional GOx-CAT nanogel (GCN) system for the treatment of diabetic oral mucosa ulcers. The catalytic activity, ROS scavenge and oxygen supply ability of GCN was validated. The therapeutic effect of GCN was verified in the diabetic gingival ulcer model. Results: The results showed that the nanoscale GCN was capable of significantly eliminating intracellular ROS, increasing intracellular oxygen concentration and accelerating cell migration of human gingival fibroblasts, which could promote diabetic oral gingival ulcer healing in vivo by alleviating inflammation and promoting angiogenesis. Discussion: This multifunctional GCN with ROS depletion, continuous oxygen supply and good biocompatibility, which might provide a novel therapeutic strategy for effective treatment of diabetic oral mucosa ulcers.

Association between Endodontic Infection, Its Treatment and Systemic Health: A Narrative Review

The 'Focal Infection Era in Dentistry' in the late 19th and early 20th century resulted in widespread implementation of tooth extraction and limited the progress of endodontics. The theory proposed that bacteria and toxins entrapped in dentinal tubules could disseminate systemically to remote body parts, resulting in many types of degenerative systemic diseases. This theory was eventually refuted due to anecdotal evidence. However, lately there has been increased interest in investigating whether endodontic disease could have an impact on general health. There are reviews that have previously been carried out on this subject, but as new data have emerged since then, this review aims to appraise the available literature investigating the dynamic associations between apical periodontitis, endodontic treatment, and systemic health. The available evidence regarding focal infection theory, bacteraemia and inflammatory markers was appraised. The review also collated the available research arguing the associations of apical periodontitis with cardiovascular diseases, diabetes mellitus, adverse pregnancy outcome and autoimmune disorders, along with the effect of statins and immunomodulators on apical periodontitis prevalence and endodontic treatment prognosis. There is emerging evidence that bacteraemia and low-grade systemic inflammation associated with apical periodontitis may negatively impact systemic health, e.g., development of cardiovascular diseases, adverse pregnancy outcomes, and diabetic metabolic dyscontrol. However, there is limited information supporting the effect of diabetes mellitus or autoimmune disorders on the prevalence and prognosis post endodontic treatment. Furthermore, convincing evidence supports that successful root canal treatment has a beneficial impact on systemic health by reducing the inflammatory burden, thereby dismissing the misconceptions of focal infection theory. Although compelling evidence regarding the association between apical periodontitis and systemic health is present, further high-quality research is required to support and establish the benefits of endodontic treatment on systemic health.

The Provision of Dental Care to Post COVID-19 Survivors. A Concise Review

Aims

It has been reported that there are a certain percentage of COVID-19 patients who recover but suffer from devastating permanent organ damage or failure. Others suffer from long Covid syndrome, with prolonged symptoms that persist more than 12 weeks. However, there is scarcity of literature regarding the provision of dental treatment for these two groups of patients. This manuscript reviews the impact of multi-system involvement on the provision of dental care to these patients.

Materials and methods

A search of literature was done in PubMed-Medline and Scopus databases to review the available literature on COVID-19 impacts on pulmonary, cardiovascular, haematologic, renal, gastrointestinal, endocrine, and neurologic systems and respective management in dental clinical settings.

Results

The literature search from PubMed-Medline and Scopus databases resulted in 74 salient articles that contributed to the concise review on COVID-19 effects on pulmonary, cardiovascular, haematologic, renal, gastrointestinal, endocrine, and neurologic systems and/or its respective dental management recommendations.

Conclusions

This concise review covers the management of post COVID-19 patients with pulmonary, cardiovascular, haematologic, renal, gastrointestinal, endocrine, or neurologic system complications.

The Complex Interrelationship between Diabetes Mellitus, Oral Diseases and General Health

There is emerging evidence that several oral diseases and conditions can be associated with DM. Dental caries, hyposalivation, fungal diseases and endodontics lesions may represent potential oral complications that can be aggravated by chronic hyperglycemia. Individuals with DM have a low perception of oral diseases which can lead to clinically important oral and systemic complications. This review aims to provide data on the most common oral signs and symptoms related to DM and to explore the mechanisms that might explain associations between DM and oral diseases in order to clarify the risks posed by poor oral health in DM. Since the linkage between oral diseases and DM is part of multifactorial aspects related to chronic hyperglycemic status and several common conditions affecting the whole body, both require rigorous self-control from patients and attention from medical and dental professionals.

Effect of Acrylic Removable Partial Denture in Caries Prevalence Among Diabetic and Non-Diabetic Patients

Background:

Dental caries is the most prevalent dental disease affecting human race. The etiology and pathogenesis of dental caries are known to be multifactorial. Studies have shown that removable partial dentures in the oral cavity increases the biofilm formation and consequently an increase in the occurrence of caries and periodontal diseases. There is a complex relationship between diabetes mellitus and dental caries. Patients with diabetes are more susceptible to oral sensory, periodontal, and salivary disorders which could increase the risk of developing new and recurrent dental caries. Therefore, the aim of the study was to assess the prevalence of dental caries among diabetic and non-diabetic acrylic removable partial denture wearers.

Materials and Methods:

Individuals participating in the study were partially edentulous and aged between 18 and 64 years. Patients were screened at Out patient department (OPD) in the Department of Prosthodontics JSSDCH, among which 60 patients were diabetic based on the random blood sugar level more than 160 mg/dl—30 patients were wearing RPD and 30 were without RPD. And 60 non-diabetic patients were selected among which 30 were wearing RPD and 30 without RPD. A total 120 patients were screened. Dental caries prevalence was assessed using Decayed, Missing, Filled (DMFT) index.

Results:

Diabetic group unrehabilitated with removable partial prosthesis showed significant difference in the number of missing teeth when compared to non-diabetic patients without removable prosthesis (P < 0.05).

Conclusion:

Removable partial denture prosthesis had less impact on prevalence of dental caries with good oral hygiene, following post insertion RPD instructions and regular dental visits irrespective of diabetes.

Prevalence of species-specific candidiasis and status of oral hygiene and dentition among diabetic patients: A hospital-based study

Objective

The study was undertaken to estimate the species-specific prevalence of oral candidiasis in diabetic individuals in India, and further find the relationship of oral carriage of Candida in diabetes with degree of diabetic control, duration of disease, type of diabetes and its effect on the status of oral hygiene status and decayed, missing and filled teeth (DMFT) score.

Methodology

The prospective cross-sectional study involved 900 individuals (470 diabetic and 430 non-diabetic) visiting a tertiary care hospital. Informed consent was obtained from all the individuals participating in the study. The demographic details, medical history and oral cavity examination were recorded in a specially designed proforma. Swabs were taken for microbiological evaluation for specific prevalence of Candida.

Results

The overall prevalence of Candida in diabetics was 22.1% as compared to 9.7% in non-diabetic individuals. However, among the type 1 and type 2 diabetics, the prevalence of Candida was equally distributed as 22.6% and 20.8%, respectively. C. albicans was the most common species (97.1%), while isolated cases of other species like C. rugosa, C. tropicalis, C. glabrata were also observed. The individuals with higher glycaemic score (HbA1c >7) showed higher prevalence of oral candidiasis. Oral hygiene status was observed to be lower among diabetics as compared to non-diabetic individuals.

Conclusion

Oral candidiasis was more prevalent in diabetic patients, and C. albicans was the most common species. The diabetics also showed higher mean DMFT with lower oral hygiene status as compared to non-diabetic individuals.

The role of primary care providers in oral health education for patients with diabetes

OBJECTIVE

In this manuscript, we provide information and guidance on oral health education for diabetes care management, which will be beneficial to primary care providers and educators as it serves to fill a current knowledge gap.

RESULTS

There is a lack of awareness on the relationship between diabetes mellitus and oral health complications along with less frequent dental visits by adult patients with diabetes, which can be attributed to the great variation in the volume and intensity of training on oral health information between current diabetes education programs.

CONCLUSIONS

There is a general lack of reliable oral health assessment tools incorporated in diabetes education curricula in addition to a lack of familiarity and time to complete the existing tools among diabetes patient educators in the busy primary care setting.

PRACTICE IMPLICATIONS

We propose a simplified, more feasible oral health assessment tool that can be incorporated in office visits of primary care educators and providers. The intention of this manuscript is to generate sufficient awareness to motivate a follow-up effectiveness study to test the validity and use of the proposed tool.

Attitude of Physicians towards Periodontal Disease and Diabetes Mellitus Screening in Dental Clinics in Thailand

BACKGROUND

Diabetes mellitus (DM) is one of the top causes of death in many places of the world. Diagnosing DM in the early stage is necessary to avoid severe cases and death.

OBJECTIVES

To evaluate the knowledge of association between DM and periodontal disease (PD) among Thai physicians and assess their attitudes towards DM screening in dental clinics in Thailand.

METHODS

Online survey of currently practicing physicians in Thailand was conducted on voluntary basis using the newly developed questionnaire.

RESULT

We received 403 responses that are statistically sufficient to represent the entire population of currently practicing physicians in Thailand. A total of 97.3% of all responses indicate that Thai physicians have knowledge about the association between DM and PD. More than 90% know that DM has an effect on PD; however, 70% know about the effect of untreated PD in DM patients. Most of physicians think that DM screening in dental clinics is important (79.1%) and are ready to accept referred cases for definite DM diagnosis from a dentist (84.1%). The concerned issues among the participants were the accuracy of the test results in DM screening (73%) and ability of a dentist to perform the screening (71.5%).

CONCLUSIONS

The majority of participating physicians have adequate knowledge about the bidirectional relationship between DM and PD. They have a positive attitude towards DM screening in dental setting. The collaboration between physicians and dental professionals should be established to reduce the number of undiagnosed DM patients and enhance the medical care of DM patients.

Periodontal disease, undiagnosed diabetes, and body mass index: Implications for diabetes screening by dentists

BACKGROUND

Periodontal disease and diabetes are widespread comorbid conditions that are detrimental to oral and overall health. Dentists' performing chairside screenings for undiagnosed diabetes mellitus (UDM) can be beneficial to both patients and providers. The authors determined UDM rates in a population-based study and whether UDM and periodontal disease were independently associated.

METHODS

Data from 7,343 participants in the Atherosclerosis Risk in Communities study visit 4 were used to determine rates of UDM by periodontal status, edentulism, and body mass index. The authors used a χ2 test or analysis of variance, along with a 2-stage logistic regression model, to determine relationships with UDM. UDM was defined as no self-reported diabetes and blood glucose levels (fasting glucose ≥ 126 milligrams/deciliter or nonfasting glucose > 200 mg/dL). Periodontal disease was defined using the Periodontal Profile Classes system adapted to stages and the Centers for Disease Control and Prevention and American Academy of Periodontology index.

RESULTS

UDM rates overall were 5.6%. The highest rates occurred in patients who were obese and edentulous (12.6%) and obese and had severe periodontal disease (12.2%). Significant associations were found for UDM and severe periodontal disease (Periodontal Profile Classes system stage IV) (odds ratio, 1.78; 95% confidence interval, 1.10 to 2.88). Edentulism was significantly associated with UDM in the Periodontal Profile Classes system model (odds ratio, 1.87; 95% confidence interval, 1.27 to 2.75) and Centers for Disease Control and Prevention and American Academy of Periodontology index (odds ratio, 1.70; 95% confidence interval, 1.08 to 2.67). Hyperglycemia was found in participants of all body mass index categories.

CONCLUSIONS

UDM is significantly associated with obesity, edentulism, and periodontitis. These characteristics could help dentists identify patients at higher risk of developing DM. Patients without these characteristics still have UDM, so dentists performing chairside diabetes screening for all patients would yield additional benefit.

PRACTICAL IMPLICATIONS

Dental offices are a major point of contact within the US health care system. Diabetes screening in this setting can provide important health information with direct relevance to patient care.

Management of periodontal disease in patients with diabetes- good clinical practice guidelines: A joint statement by Indian Society of Periodontology and Research Society for the Study of Diabetes in India

There is a huge body of literature suggesting an association and a bidirectional relationship between periodontal disease and diabetes. Diabetes and periodontal diseases are both chronic diseases with a high prevalence. Dentists/periodontists, in their daily clinical practice, very often attend to diabetes patients with diverse oral health conditions and cater to their dental treatment needs. Safe and effective periodontal therapy in this population requires a broad understanding of diabetes, medical management of diabetes, and essential modifications to dental/periodontal therapy that may be required. This paper describes a joint statement put forth by the Indian Society of Periodontology and the Research Society for the Study of Diabetes in India aiming to provide expert consensus and evidence-based guidelines for optimal clinical management of periodontal conditions in diabetes patients or patients at risk for diabetes. Although this paper is not envisioned to be a comprehensive review of this topic, it intends to provide the guidelines for dental professionals and periodontists.

Salivary Fructosamine as a Noninvasive Glycemic Biomarker: A Systematic Review

BACKGROUND

Standard diagnostic and monitoring methods for glycemic status involve invasive sample collection through venous puncture or fingerstick. Recent attention has been focused on exploring noninvasive methods through oral biofluids. Specifically, serum fructosamine has been established as a short-term (2- to 3-wk) marker of disease status in patients with diabetes. Fructosamine measured through noninvasive means such as saliva has shown promise, but its clinical applicability is unknown.

OBJECTIVE

Evaluate the available evidence on using salivary fructosamine as a reliable noninvasive marker to screen and diagnose patients with diabetes mellitus in the clinical setting. A comparative analysis of the correlative accuracy of salivary fructosamine measurements with established blood glycemic biomarkers such as serum fructosamine, blood glucose, and HbA1c will be conducted.

METHODS

Six electronic databases (PubMed, PubMed Central, MEDLINE, EMBASE, Scopus, Cochrane Library) were searched for original research papers (clinical and animal studies) that were relevant to the objective of this systematic review. The search was initiated on May 28, 2020. The systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Bias risk assessment, overall quality, and level of evidence were based on the Oxford Centre for Evidence-Based Medicine, Appraisal Tool for Cross-Sectional Studies, and Collaborative Approach to Meta-Analysis and Review of Animal Data from Experimental Studies tool. Heterogeneity was assessed using the National Institutes of Health quality assessment tool for cross-sectional studies.

RESULTS

A total of 174 records were identified. Full-text articles screened for eligibility (n = 21) identified only 6 original research articles relevant to the research question and were thus included in the systematic review. The types of studies identified were cross-sectional and in vivo studies. Three studies (3/6) showed positive correlation of salivary fructosamine with blood glucose levels, while 1 study (1/6) demonstrated a positive correlation with glycated hemoglobin (HbA1c). Limitations related to sample size and selection were identified along with a fair level of interstudy heterogeneity.

CONCLUSION

Based on the evidence evaluated, the utility of salivary fructosamine as a noninvasive marker to screen and diagnose patients with diabetes is doubtful. The overall level of evidence was low (IIIB) and the risk of bias was determined to be high.

KNOWLEDGE TRANSFER STATEMENT

Further evidence in the form of large-scale well-controlled studies is needed prior to recommending salivary fructosamine as a noninvasive diagnostic tool for glycemic status in patients with diabetes mellitus.

Efficacy of non-surgical treatment accompanied by professional toothbrushing in the treatment of chronic periodontitis in patients with type 2 diabetes mellitus: a randomized controlled clinical trial

Purpose

The present study aimed to evaluate the clinical benefit of additional toothbrushing accompanying non-surgical periodontal treatment on oral and general health in patients with type 2 diabetes mellitus (T2DM).

Methods

We conducted a doubled-blind randomized controlled trial in 60 T2DM patients between June 2013 and June 2014. The patients were randomly assigned to the scaling and root planing (SRP) group; the scaling and root planing with additional toothbrushing (SRPAT) group, in which additional toothbrushing was performed by toothpick methods; or the control group. Microbiological and oral examinations were performed for up to 12 weeks following treatment. Non-surgical treatment was conducted in the experimental groups. The SRP group received scaling and root planing and the SRPAT group received additional toothbrushing with the Watanabe method once a week from the first visit through the fifth visit. The primary outcomes were changes in haemoglobin A1c (or glycated haemoglobin; HbA1c) levels, serum endotoxin levels, and interleukin-1 beta levels. Periodontal health status was measured by periodontal pocket depth, the calculus index, and bleeding on probing (BOP).

Results

Both the SRP and SRPAT groups showed improvements in periodontal health and HbA1c, but the SRPAT group showed significantly less BOP than the SRP group. Furthermore, only the SRPAT group showed a statistically significant decrease in serum endotoxin levels.

Conclusions

Non-surgical periodontal treatment was effective in improving HbA1c and serum endotoxin levels in T2DM patients. Furthermore, non-surgical treatment with additional tooth brushing had a more favourable effect on gingival bleeding management.

Trial Registration

Clinical Research Information Service Identifier: KCT000416

Gastrointestinal symptoms in pediatric patients with type 1 diabetes mellitus

Background Various gastrointestinal (GI) symptoms are associated with diabetes. Common GI complaints associated with the manifestation of the disease include abdominal pain, diarrhea, nausea, bloating and vomiting. There have been very few studies examining GI problems of pediatric patients with type 1 diabetes mellitus (T1DM). The aims of this study were to find out the prevalence of GI symptoms in pediatric patients with T1DM and to determine the correlation among such symptoms, duration of diabetes and glycemic control. Methods One hundred and thirty-seven (median age 13.2 years, female 45.3%) patients with T1DM were examined. Demographic features, GI symptoms, signs and physical examination findings of the patients were recorded by pediatric gastroenterology specialists for the differential diagnosis and exclusion of other etiologies. Complete blood count, blood glucose, lipid profile, electrolytes, amylase, lipase, celiac antibodies and glycated hemoglobin (HbA1c) levels were evaluated and stool examination was performed. Endoscopy was performed on the patients who had refractory GI complaints. Gastric emptying (GE) time was evaluated using GE scintigraphy. Results Overall, 74 (54%) patients had ≥1 GI complaints. Patients often reported gastroesophageal reflux (32.8%) and abdominal pain (18%). The most significant findings in terms of GI symptoms were determined when patients were classified according to the glycemic control status. Reflux and dyspeptic symptoms were significantly more common in poorly or very poorly controlled diabetic patients (p=0.003 and p=0.004, respectively). Conclusions Diabetes can affect the entire GI tract, and GI symptoms are common in pediatric patients. We recommend that T1DM patients be evaluated for GI symptoms.

Associação entre condições sistêmicas e gravidade da doença periodontal em pacientes atendidos na Clínica-Escola da UFCG

Resumo Introdução A doença periodontal é uma doença inflamatória crônica dos tecidos de proteção e suporte dos dentes. As doenças ou alterações de ordem sistêmica, como diabetes, alterações cardiovasculares e pulmonares, distúrbios hormonais e outras, não iniciam a doença periodontal, mas podem acelerar uma doença preexistente, aumentando sua progressão e destruição tecidual. Objetivo O presente estudo teve como objetivo avaliar, por meio de prontuários clínicos, uma possível associação entre as condições sistêmicas e a gravidade da doença periodontal em pacientes atendidos na Clínica-Escola de Odontologia da Universidade Federal de Campina Grande, campus CSTR (UFCG-CSTR). Material e método Para o estudo, foram avaliados 1.035 prontuários clínicos dos pacientes que procuraram atendimento na Clínica-Escola de Odontologia da UFCG-CSTR durante os anos de 2012 a 2017. Resultado A população estudada apresentou prevalência do sexo masculino (50,9%) e diagnóstico de doença gengival (63,6%) e periodontal (35,8%). As condições sistêmicas mais prevalentes foram hipertensão (15%), diabetes (7,5%) e cardiopatias (5,8%). Além disso, 20,2% relataram ser fumantes ou ex-fumantes, enquanto o uso de medicação foi observado em 28,3% dos casos. Foi verificada associação estatisticamente significativa entre doença periodontal, sexo masculino, faixa etária mais avançada, hipertensão arterial, tabagismo ou histórico de tabagismo e diabetes. Conclusão Foi observada uma quantidade de dentes igual ou menor do que 10 com maior frequência entre os pacientes com idade igual ou superior a 60 anos, hipertensos, diabéticos, cardiopatas e fumantes ou ex-fumantes, sugerindo, desse modo, uma maior gravidade da doença periodontal nesses indivíduos.

Awareness of population regarding the effects of diabetes on dental implant treatment in Jeddah, Saudi Arabia

OBJECTIVE

Diabetes mellitus (DM) has several complications. Delayed wound healing, microvascular disease and an impaired response to infections are complications that can have a direct bearing on dental implant therapy. This paper studies the awareness of the population with regard to the effect of DM on dental implant treatment.

MATERIALS AND METHODS

A validated, close-ended questionnaire was distributed to 506 randomly selected mall-goers in the city of Jeddah. Responses were coded and entered into spreadsheet software (SPSS, IBM). The frequency distribution of the responses was calculated, and inferences were drawn.

RESULTS

The study revealed that the majority of the sample were females (62.8%), did not have diabetes (80.4%) and reported a positive family history of diabetes (87.4%). Most of the respondents (56%) believed that uncontrolled diabetes can lead to implant loss and that diabetes affects the healing process (91.6%). Many patients (42%) responded that diabetes could be treated with dental implants if the blood sugar level was controlled.

CONCLUSION

The studied sample revealed a satisfactory level of awareness regarding the association of diabetes and oral hygiene in dental implant therapy. However, there is less than adequate knowledge about the effects of diabetes on dental implants, as the majority of the respondents believe that only controlled diabetics can avail dental implant treatment.

Evaluation of Knowledge, Attitudes and Oral Health-related Nutritional Performance of Diabetic Patients Referred to the Diabetes Research Center in Isfahan-Iran, 2016

Background:

Type II diabetes is a chronic disease, with an ever-increasing incidence, concomitant with an increase in the number of the elderly. It is one of the conditions that can affect the orodental health. In general, the diabetes-related oral problems include dental caries, xerostomia, oral candidiasis, periodontal diseases and consumption of inappropriate foodstuff.

Objective:

The aim of this study was to evaluate knowledge, attitudes and oral health-related nutritional performance of diabetic patients referred to the diabetes center research in Isfahan-Iran, 2016.

Methods:

In the present cross-sectional study, 362 diabetic subjects (142 females and 220 males) referred to the Research Center for Endocrine Glands and Metabolism in Isfahan, were evaluated after being selected by simple random sampling technique. The frequency distribution of demographic data (gender, marital status, occupation, affliction with orodental diseases, disease history, and use of medications and supplements) were evaluated. The relationships of the variables above and the knowledge, attitude and performance scores of the subjects were evaluated. Data were analyzed with independent t-test, Pearson’s correlation coefficient and Spearmen’s correlation coefficient.

Results:

There were no significant relationships between orodental diseases and the mean scores of knowledge, attitudes and performance of the subjects. The mean scores of knowledge, attitudes and performance of the subjects were 33.8 ± 11.2, 53.311.01 and 53.7 ± 6.9 out of 100, respectively.

Conclusion:

The oral-health related nutritional knowledge of diabetic subjects was poor. Programs should be prepared to improve the knowledge and oral health-related nutritional performance of diabetic patients.

Salivary flow and xerostomia in patients with type 2 diabetes

BACKGROUND

Saliva is secreted by the major and minor salivary glands. There are a number of physiological factors that can reduce this secretion such as age, sex, body weight, number of teeth present in the mouth or time of day. This decrease may also be caused by the use of certain drugs, radiotherapy for head and neck cancer, chronic rheumatic diseases such as Sjögren's syndrome and other systemic disorders such as diabetes mellitus (DM). Objective of this study was to investigate the effect of type 2 DM on salivary secretion and its relation to the sensation of xerostomia.

METHODS

Forty-seven patients with type 2 DM and 46 healthy individuals, aged 40-80, participated in the study. Samples of saliva were collected, at rest and after stimulation, at baseline and after the administration of a meal. A questionnaire of 10 items was used to define the patients' sensations of xerostomia. For statistical analysis, the Mann-Whitney test was used to assess the difference in salivary flow between the two groups and the relationship between the response to each of the questions and salivary flow levels. The degree of the patients' sensation of xerostomia was analysed by the Fisher test.

RESULTS AND CONCLUSIONS

There was a significant decrease in total saliva levels at rest in patients with type 2 DM compared to the control group. The study group also experienced higher levels of dryness at night and on waking as well as a greater sensation of lingual burning compared to the control group.

Identification of Candida species in the oral cavity of diabetic patients

Background and Purpose:

Diabetic patients are more susceptible to oral candidiasis infection than non-diabetics due to the factors promoting oral carriage of Candida. Several factors can increase colonization of Candida species in the oral cavity such as xerostomia, which reduces the salivary flow and is a salivary pH disorder. In the current study, we aimed to identify and compare the colonization level of Candida spp. in the oral cavity of diabetic and non-diabetic groups.

Materials and Methods:

Swabs were taken from the mouth of 106 participants and were cultured on Sabouraud dextrose agar (SDA) medium. Likewise, the saliva samples were collected for salivary glucose and pH measurements. The study was performed during June 2014-September 2015 on two groups of diabetic patients (n=58) and non-diabetics (n=48) as the control group. The Candida spp. were identified with PCR-restriction fragment length polymorphism (RFLP) using the restriction enzymes HinfI and MspI and were differentiated by culture on CHROMagar Candida medium.

Results:

The frequency of Candida spp. was higher in diabetic patients compared to non-diabetics. The most frequent Candida spp. in the diabetic patients were Candidaalbicans (%36.2),C. Krusei (%10.4), C. Glabrata (%5.1), and C. tropcalis .(%3.4)Likewise, C. albicans was the most frequent species (%27) in the non-diabetic individuals. In this study, the results of both methods for identification of the isolates were consistent with each other.

Conclusion:

Xerostomia and disturbance of physiological factors including pH and glucose can promote overgrowth of Candida flora in the oral cavity. These factors are considered important predisposing factors for oral candidiasis in diabetic patients. In the present study, it was observed that application of CHROMagar Candida and PCR-RFLP methods at the same time contributes to more accurate identification of isolates.

Salivary profile in diabetic patients: biochemical and immunological evaluation

BACKGROUND

The aim of this study was to evaluate the biochemical and immunological characteristics of saliva from diabetic patients compared to non-diabetic adults.

METHODS

Eighty-eight diabetic adults and 39 non-diabetic adults (control) were included in the study. Glucose, urea, calcium, total protein and amylase were determined by a colorimetric method. The levels of secretory IgA and the IgA anti-Streptococcus mutans and anti-insulin IgA antibodies were measured by enzyme-linked immunosorbent assay (ELISA). Caries status was evaluated using the DMFT index.

RESULTS

Glucose, urea, calcium, anti-S. mutans IgA, total IgA, and anti-insulin IgA were significantly higher in diabetic patients, whereas total protein and amylase levels were lower in these patients. There was no positive correlation between blood and salivary glucose levels in either group. Diabetic patients had a higher DMFT index.

CONCLUSIONS

The present study showed for the first time that IgA levels in diabetic patients'saliva, shows correlation with systemic biochemical parameters. Thus the saliva is an useful tool to follow the systemic health status in these patients.

Prevalence of oral mucosal lesions among patients with diabetes mellitus types 1 and 2

BACKGROUND

Patients with diabetes mellitus have been associated with a number of changes in the oral cavity, such as gingivitis, periodontitis, mucosal diseases, salivary dysfunction, altered taste, and burning mouth.

OBJECTIVES

To determine the prevalence of oral mucosal lesions in patients with diabetes mellitus.

METHODS

A cross-sectional observational study between August and October 2012 with a convenience sampling was performed for 51 patients with diabetes mellitus (type 1 and type 2). The study consisted of two phases: 1) a questionnaire application; 2) intraoral clinical examination. For the analysis of data, we used descriptive statistics, Fisher's exact test in bivariate analysis (significance level of 0.05), and Poisson Regression.

RESULTS

The prevalence of oral lesions was 78.4%. Traumatic ulcers (16.4%) and actinic cheilitis (12.7%) were the most prevalent lesions. The lips (35.3%) and tongue (23.5%) were the most common location. The bivariate analysis showed an association with the type of diabetes, and two variables (age and comorbidity) were quite close to the significance level. In the Poisson Regression analysis, only diabetes type 2 remained significant after adjusting the model.

CONCLUSIONS

The results of this study show a high prevalence of oral mucosal lesions in diabetic patients. The oral mucosal lesions are mostly associated with diabetes type 2.

Local anesthesia with epinephrine is safe and effective for oral surgery in patients with type 2 diabetes mellitus and coronary disease: a prospective randomized study

OBJECTIVE

To investigate the variations in blood glucose levels, hemodynamic effects and patient anxiety scores during tooth extraction in patients with type 2 diabetes mellitus T2DM and coronary disease under local anesthesia with 2% lidocaine with or without epinephrine.

STUDY DESIGN

This is a prospective randomized study of 70 patients with T2DM with coronary disease who underwent oral surgery. The study was double blind with respect to the glycemia measurements. Blood glucose levels were continuously monitored for 24 hours using the MiniMed Continuous Glucose Monitoring System. Patients were randomized into two groups: 35 patients received 5.4 mL of 2% lidocaine, and 35 patients received 5.4 mL of 2% lidocaine with 1:100,000 epinephrine. Hemodynamic parameters (blood pressure and heart rate) and anxiety levels were also evaluated.

RESULTS

There was no difference in blood glucose levels between the groups at each time point evaluated. Surprisingly, both groups demonstrated a significant decrease in blood glucose levels over time. The groups showed no significant differences in hemodynamic and anxiety status parameters.

CONCLUSION

The administration of 5.4 mL of 2% lidocaine with epinephrine neither caused hyperglycemia nor had any significant impact on hemodynamic or anxiety parameters. However, lower blood glucose levels were observed. This is the first report using continuous blood glucose monitoring to show the benefits and lack of side effects of local anesthesia with epinephrine in patients with type 2 diabetes mellitus and coronary disease.

Salivary alkaline phosphatase and calcium in caries-active type II diabetes mellitus patients: An in vivo study

Background:

Diabetes Mellitus is a metabolic syndrome, affecting the oral health in various ways with dental caries being one of the most common problems encountered. Saliva is one of the most abundant secretions in the human body with a variety of natural protective and defence molecules bathing the oral cavity maintaining equilibrium. Its collection is easy and non-invasive.

Aims:

To compare and evaluate salivary alkaline phosphatase levels and calcium ion levels between caries active type II diabetes mellitus patients and non-diabetics.

Materials and Methods:

This study was carried out on caries-active age and gender matched 60 non-diabetic and 60 patients with known Type II diabetes mellitus subjects of age group 25-50 years with DMFT index >10. Saliva sample was collected to analyse for alkaline phosphatase enzyme and concentration of calcium ions using Agappe kits.

Statistical Analysis:

Student ‘t’ test was used to correlate the salivary electrolyte concentration in non- diabetic and diabetic patients with dental caries. A ‘P’ value of 0.05 or less was considered significant. Results are presented as mean ± standard deviation (X ± SD).

Results:

The alkaline phosphatase (ALP) activity in saliva was higher in diabetic patients when compared to that of non-diabetic patients with salivary calcium ions were significantly higher in non-diabetic individuals.

Conclusion:

Diabetes Mellitus patients are more prone to dental caries, hence require intervention to improve the quality of saliva.

An influence of adrenaline (1:80,000) containing local anesthesia (2% Xylocaine) on glycemic level of patients undergoing tooth extraction in Riyadh

OBJECTIVE

Aim is to compare the glycemic level among patients before, and after local anesthesia containing adrenaline 1:80,000 among patients who need dental extraction.

MATERIALS AND METHODS

60 patients were randomly selected including 30 healthy and 30 with a diabetes history for this study in Riyadh city. First the blood glucose level was measured before administering local anesthesia containing adrenaline after taking their history with glucocheck according to instructions, then blood Sugar level was recorded after administering local anesthesia containing adrenaline 1:80,000 concentrations. Blood sugar level was also checked 5 min after the tooth extraction procedure.

RESULTS

There were no significant results found after the administration of local anesthesia containing adrenaline in both healthy and diabetic patients (p > 0.05). However, change of significance (p < 0.05) was noticed in diabetic patients who had not taken their hypoglycemic medication; there was a rise in their blood glucose level after extraction.

CONCLUSION

The study concluded no significant effect on the glycemic level of patients after the administration of local anesthesia containing adrenaline 1:80,000 in healthy and diabetic patients whether hypoglycemic medication was taken or not but a rise in blood sugar level was found among diabetic patients who did not take their hypoglycemic medications undergoing tooth extraction.

Oral health-related quality of life in diabetic patients: comparison of the Persian version of Geriatric Oral Health Assessment Index and Oral Health Impact Profile: A descriptive-analytic study

BACKGROUND

Diabetes mellitus is one of the systemic disease which is show important oral manifestation and influence oral health. This study describes how diabetes mellitus affects oral health and oral health-related quality of life. The aim of this study was to evaluate the oral health and oral health-related quality of life of diabetic patients and compare the discriminative capability of Persian versions of two GOHAI and OHIP-14 questionnaires in these patients.

METHODS

A total of 350 patients with Type II diabetes mellitus, referring to the Diabetes Clinic, were selected and data were collected by GOHAI and OHIP-14 questionnaires completed by patients and clinical examinations. Oral health parameters (CAL,BI,GI,PLI,DMFT and xerostomia) were measured, also concurrent validity and conformity of two questionnaires were assessed. In order to test Discriminant analysis capabilities of two questionnaires, ADD and SC scores of questionnaires were divided into two parts and a logistic regression model was designed, which included subjective and objective variables.

RESULTS

Mean patients age was 55 years (with 75.4% female patients). The results showed that some oral conditions such as xerostomia, clinical attachment loss, number of missing teeth and plaque index were correlated to diabetes control level (HbA1c) and type of anti-diabetic medication. ADD and SC scores of two questionnaires were at high level. However, the effect of oral problems on decreasing OHRQoL was evident. Both questionnaires had acceptable concurrent validity and conformity. Moreover, there was a strong correlation between GOHAI and OHIP-14. OHIP-14 questionnaire had a higher discriminant analysis capability compared to GOHAI and better diagnosed patients who needed dental treatments: patients with higher GI, xerostomia and those wearing partial dentures.

CONCLUSION

Diabetic patients did not show acceptable oral health status and in some extent, oral problems affected oral health-related quality of life. Psychotherapy courses and solving oral problems of the patients can improve OHRQoL. OHIP-14 had higher discriminant analysis capability and was more effective in diagnosing oral problems.

Are dentists interested in the oral-systemic disease connection? A qualitative study of an online community of 450 practitioners

Background

Dentists in the US see an increasing number of patients with systemic conditions. These patients are challenging to care for when the relationship between oral and systemic disease is not well understood. The prevalence of professional isolation exacerbates the problem due to the difficulty in finding expert advice or peer support. This study aims to identify whether dentists discuss the oral-systemic connection and what aspects they discuss; to understand their perceptions of and attitudes toward the connection; and to determine what information they need to treat patients with systemic conditions.

Methods

We retrieved 14,576 messages posted to the Internet Dental Forum from April 2008 to May 2009. Using natural language processing and human classification, we identified substantive phrases and keywords and used them to retrieve 141messages on the oral-systemic connection. We then conducted coding and thematic analysis to identify recurring themes on the topic.

Results

Dentists discuss a variety of topics on oral diseases and systemic health, with the association between periodontal and systemic diseases, the effect of dental materials or procedures on general health, and the impact of oral-systemic connection on practice behaviors as the leading topics. They also disseminate and share research findings on oral and systemic health with colleagues online. However, dentists are very cautious about the nature of the oral-systemic linkage that may not be causal. Nonetheless, they embrace the positive association as a motivating point for patients in practice. When treating patients with systemic conditions, dentists enquire about the cause of less common dental diseases potentially in relation to medical conditions in one-third of the cases and in half of the cases seek clinical guidelines and evidence-based interventions on treating dental diseases with established association with systemic conditions.

Conclusions

Dentists’ unmet information needs call for more research into the association between less studied dental conditions and systemic diseases, and more actionable clinical guidelines for well-researched disease connections. To improve dissemination and foster behavioral change, it is imperative to understand what information clinicians need and in which situations. Leveraging peer influence via social media could be a useful strategy to achieve the goal.

Risk assessment for periodontal disease

The prevention and treatment of periodontal disease is based on accurate diagnosis, reduction or elimination of causative agents, risk management and correction of the harmful effects of the disease. The practice of risk assessment involves dental care providers identifying patients and populations at increased risk of developing periodontal disease. This can have a significant impact on clinical decision making. Risk assessment reduces the need for complex periodontal therapy, improve patient outcome and, ultimately, reduce oral health care cost. The awareness of risk factors also helps with the identification and treatment of co-morbidities in the general population as many periodontal disease risk factors are common to other chronic diseases such as diabetes, cardiovascular diseases and stroke.

Diabetes mellitus and inflammatory pulpal and periapical disease: a review

Diabetes mellitus (DM) is one of the most common metabolic disorders. DM is characterized by hyperglycaemia, resulting in wound healing difficulties and systemic and oral manifestations, which have a direct effect on dental pulp integrity. Experimental and clinical studies have demonstrated a higher prevalence of periapical lesions in patients with uncontrolled diabetes. The influence of DM on periapical bone resorption and its impact on dental intervention of such patients are reviewed, and its aetiology and pathogenesis are analysed at molecular level. Pulps from patients with diabetes have the tendency to present limited dental collateral circulation, impaired immune response, increased risk of acquiring pulp infection (especially anaerobic ones) or necrosis, besides toothache and occasional tendency towards pulp necrosis caused by ischaemia. In regard to molecular pathology, hyperglycaemia is a stimulus for bone resorption, inhibiting osteoblastic differentiation and reducing bone recovery. The relationship between poorly controlled diabetes and bone metabolism is not clearly understood. Molecular knowledge about pulp alterations in patients with diabetes could offer new therapeutic directions. Knowledge about how diabetes affects systemic and oral health has an enduring importance, because it may imply not only systemic complications but also a higher risk of oral diseases with a significant effect on pulp and periapical tissue.

Periodontal disease: the influence of metabolic syndrome

Metabolic syndrome (MetS) is a cluster of cardiovascular risk factors that include obesity, impaired glucose tolerance or diabetes, hyperinsulinemia, hypertension, and dyslipidemia. Recently, more attention has been reserved to the correlation between periodontitis and systemic health. MetS is characterized by oxidative stress, a condition in which the equilibrium between the production and the inactivation of reactive oxygen species (ROS) becomes disrupted. ROS have an essential role in a variety of physiological systems, but under a condition of oxidative stress, they contribute to cellular dysfunction and damage. Oxidative stress may act as a common link to explain the relationship between each component of MetS and periodontitis. All those conditions show increased serum levels of products derived from oxidative damage, promoting a proinflammatory state. Moreover, adipocytokines, produced by the fat cells of fat tissue, might modulate the balance between oxidant and antioxidant activities. An increased caloric intake involves a higher metabolic activity, which results in an increased production of ROS, inducing insulin resistance. At the same time, obese patients require more insulin to maintain blood glucose homeostasis – a state known as hyperinsulinemia, a condition that can evolve into type 2 diabetes. Oxidation products can increase neutrophil adhesion and chemotaxis, thus favoring oxidative damage. Hyperglycemia and an oxidizing state promote the genesis of advanced glycation end-products, which could also be implicated in the degeneration and damage of periodontal tissue. Thus, MetS, the whole of interconnected factors, presents systemic and local manifestations, such as cardiovascular disease and periodontitis, related by a common factor known as oxidative stress.

Protective effects of salivary factors in dental caries in diabetic patients of Pakistan

Salivary factors have been studied for their effects on the process of dental caries in patients of diabetes mellitus type 2. In this study, protective role of salivary pH, salivary flow rate, and salivary calcium is assessed in the patients of diabetes mellitus type 2 with dental caries. The samples of saliva were collected from 400 patients of diabetes mellitus type 2 and 300 age- and sex- matched controls after getting informed consent. All the subjects were classified into four groups according to age. The severity of dental caries was counted by decayed, missed, and filled teeth (DMFT) score. The salivary pH, flow rate, and calcium levels were found to be low in patients as compared to controls. The levels of fasting blood sugar, HbA1c, and DMFT score were found to be significantly high in patients than controls. The glycemic factors were significantly correlated with salivary factors indicating their influence on progression of caries in diabetes. On the basis of findings, it is concluded that the suitable salivary pH and flow rate may be regarded as main protective factors against dental caries in diabetes. Optimum level of salivary calcium may be responsible for continuous supply of calcium to arrest the demineralization and help reduce the occurrence of dental caries.

A novel intraoral diabetes screening approach in periodontal patients: results of a pilot study

BACKGROUND

This pilot study examines whether a novel diabetes screening approach using gingival crevicular blood (GCB) could be used to test for hemoglobin A1c (HbA1c) during periodontal visits.

METHODS

Finger-stick blood (FSB) samples from 120 patients and GCB samples from those patients with adequate bleeding on probing (BOP) were collected on special blood collection cards and analyzed for HbA1c levels in a laboratory. The Pearson correlation coefficient was used to measure correlation between FSB and GCB HbA1c values for 75 paired FSB and GCB samples. A receiver-operator characteristic curve (ROC) analysis was performed to determine an optimal GCB HbA1c criterion value for a positive diabetes screen.

RESULTS

For the 75 paired samples, the Pearson correlation coefficient was 0.842. The ROC analysis identified a criterion value of 6.3% for the GCB HbA1c test with high sensitivity (0.933) and high specificity (0.900), corresponding to FSB HbA1c values ≥6.5% (in the diabetes range). Using this GCB HbA1c criterion value for 27 additional paired samples, in which there was an unidentified component observed to coelute within the elution window of GCB HbA1c in the laboratory, there was agreement between FSB and GCB values for 24 of the pairs according to whether both were within or outside of the diabetes range.

CONCLUSION

Using a criterion value of 6.3%, GCB samples are acceptable for HbA1c testing to screen for diabetes in most persons with BOP at the GCB collection site.

In vitro antimicrobial effects of commercially available mouth-wetting agents

Products have been developed to provide palliation for persons with dry mouth. In addition to mouth-wetting agents, some products incorporate antimicrobial constituents with the goal of improving oral microbial defenses. The aim of this in vitro study was to investigate the potential antimicrobial and antifungal effects of two commercially available saliva substitutes on Streptococcus mutans, Lactobacillus acidophilus, and Candida albicans by using the agar-well diffusion method. Antimicrobial activity as measured by the size of the inhibition zone growth for S. mutans and L. acidophilus was observed only with Biotene Dry Mouth Oral Rinse® and BioXtra® gel. The zone of inhibition of Biotene Dry Mouth Oral Rinse was larger than that of BioXtra gel (p= 0.00, p < 0.01). No anticandidal effect was seen with any of the test products. The pH of the preparations, the variations between the amount of active ingredients within the products, and the potential antimicrobial effects of inactive ingredients should be investigated to determine the factors that impacted microbial inhibition.

Treatment strategies for oropharyngeal candidiasis

BACKGROUND

Oropharyngeal candidiasis (OPC) is a common oral disease that may cause oral symptoms, lead to regional infection (e.g., esophageal candidiasis) and increase the risk of systemic fungal infection in the compromised host.

OBJECTIVE

Critical review of the literature of prevention and therapy.

METHODS

The literature was reviewed using PubMed, and specific keywords from the MeSH Database were used.

RESULTS/CONCLUSION

Management of OPC requires that the underlying risk factors of infection be diagnosed and managed whenever possible. Antimicrobials may be provided as topical or systemic therapy. Topical therapies may provide effective management for candidiasis in the non-compromised host and increase the control of colonization in the compromised host. Advances in prevention and management include new agents and improved mechanisms of topical drug delivery.

Buccal alterations in diabetes mellitus

Long standing hyperglycaemia besides damaging the kidneys, eyes, nerves, blood vessels, heart, can also impair the function of the salivary glands leading to a reduction in the salivary flow. When salivary flow decreases, as a consequence of an acute hyperglycaemia, many buccal or oral alterations can occur such as: a) increased concentration of mucin and glucose; b) impaired production and/or action of many antimicrobial factors; c) absence of a metalloprotein called gustin, that contains zinc and is responsible for the constant maturation of taste papillae; d) bad taste; e) oral candidiasis f) increased cells exfoliation after contact, because of poor lubrication; g) increased proliferation of pathogenic microorganisms; h) coated tongue; i) halitosis; and many others may occur as a consequence of chronic hyperglycaemia: a) tongue alterations, generally a burning mouth; b) periodontal disease; c) white spots due to demineralization in the teeth; d) caries; e) delayed healing of wounds; f) greater tendency to infections; g) lichen planus; h) mucosa ulcerations. Buccal alterations found in diabetic patients, although not specific of this disease, have its incidence and progression increased when an inadequate glycaemic control is present.

Case assessment and treatment planning: what governs your decision to treat, refer or replace a tooth that potentially requires endodontic treatment?

Several factors determine whether a tooth will require treatment by a general dentist, treatment by an endodontist or whether prosthodontic care is necessary after the tooth in question is extracted. This paper will present and discuss those factors, which govern the decisions made by the general dentist, and the resultant treatment options ranging from conservative endodontic therapy to the extraction of the offending tooth and its prosthodontic replacement. The impact of prognosis during endodontic therapy will also be discussed.