Diabetes Treatments

diabetes: type 1, which results from an absolute insulin Furthermore, because poorly controlled diabetes can counsel their patients with diabetes about …

ABSTRACT
Background Diabetes is a common disease with concomitant oral manifestations that impact dental care The purpose of this ADA J review is to summarize the prevalence, signs, symptoms, diagnosis and treatment of diabetes, as well as dental treatment considerations for the patient with diabetes N C Conclusions Safely managing the E D U A UING 1 RT patient with diabetes requires effective L E IC communication among multiple health care providers Dentists must be familiar with techniques to diagnose, treat and prevent stomatological disorders in patients with diabetes Practice Implications Dental practitioners will be treating more patients with diabetes in the future, and this article provides an overview of the systemic and oral aspects of the disease that impact dental treatment
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Diabetes and oral health
An overview
JONATHAN A SHIP, DMD

iabetes mellitus is a syndrome of abnormal carbohydrate, fat and protein metabolism that results in acute and chronic complications due to the absolute or relative lack of insulin There are three general categories of diabetes: type 1, which results from an absolute insulin deficiency; type 2, which is the result of insulin resistance
and an insulin secretory defect; and gestational, a condition of abnormal glucose tolerance during pregnancy Diabetes develops in people of all ages, although in greater frequency in African-Americans and Hispanics, and prevalences have Safely increased dramatically over the past managing the several decades Diagnosis is made on patient with the basis of a host of systemic and oral signs and symptoms, including gindiabetes givitis and periodontitis, recurrent oral requires fungal infections and impaired wound effective healing communication Approximately one-third of adults with diabetes in the United States are among multiple undiagnosed, and preventive care among patients with diabetes falls health care below national health objective standproviders ards1 Therefore, dental professionals

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tests and seeing medical professionals for routine care Owing to the increasing longevity of the American population and the growing prevalence of diabetes, as well as the increased effectiveness of diagnostic and therapeutic protocols, researchers have predicted that dental practitioners will be treating more patients with this disease2
PREVALENCE AND INCIDENCE OF DIABETES

can play an
important role in diagnosing and managing patients with diabetes Furthermore, because poorly controlled diabetes leads to significant morbidity and mortality, dentists can counsel their patients with diabetes about improving glucose regulation, maintaining oral and nutritional health, performing daily glucose monitoring
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In 1999, the National Centers for Health Statistics reported that more than 10 million Americans were living with diabetes distributed among white, black, Hispanic and other racial/ethnic groups3 In 1997, an estimated 124 million people worldwide were living with diabetes4 By the year 2010, the number of people with diabetes worldwide is projected to reach 221 million, and in certain regions of the world for example, Asia, Africa, diabetes rates could rise twofold or threefold4 People with diabetes have a substantially higher risk of mortality and shorter life expectancy than do those without diabetes5 Diabetes was the sixth most common cause of death in 2001, accounting for more than 71,000 deaths in the United States6 In

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TABLE 1996, nearly 3 percent of
the adult population NUMBER OF ADULTS PER 1,000 PERSONS REPORTING reported experiencing HAVING EXPERIENCED CHRONIC DIABETES-RELATED diabetes as a chronic condition, with rates PROBLEMS, 1996 increasing from less RACE AGE GROUP YEARS than 1 percent in people Younger 45-64 65-74 75 and Older younger than 18 years of Than 45 age to greater than 10 75 447 895 850 White percent in adults aged 75 years and older3 84 1495 1547 2818 African-American Diabetes has great 3 Source: Adams and colleagues racial discrepancies A survey conducted in 1996 found that 87 percent of whites aged 65 may have pruritus, peripheral neuropathy and years and older had diabetes compared with 199 blurred vision Opportunistic infections, percent of blacks,3 and the prevalence of diabetes including oral and vaginal candidiasis, can be among Hispanics in the United States is approxipresent Adults with long-standing diabetes, mately twice the prevalence among non-Hispanic especially those with poorly controlled hyperwhites7 Blacks aged 45 years and older report glycemia, may develop microvascular and higher rates of chronic diabetes-related problems macrovascular conditions that can produce irrethan do their white
counterparts Table Premaversible damage to the eyes retinopathy, ture death is a significant problem due to diacataracts, kidneys nephropathy, nervous betes, and the problem is getting worse with system neuropathy and paresthesias, and heart time In 1999, a nationwide survey estimated accelerated atherosclerosis, as well as recurrent that 180 years of potential life were lost per infections and impaired wound healing 100,000 Hispanics before the age of 75 years as a It is less common to encounter a dental patient result of diabetes, an increase from 134 years of with acute signs and symptoms of hyperpotential life lost per 100,000 Hispanics in 19808 glycemia, although glucose control worsens in the The burden of diabetes on the health care presence of an uncontrolled infection An insulindeficient patient with acute hyperglycemia often system is remarkable; in 2000, 236 million visits may have a fruity breath Alternatively, hypoto physicians offices were for diabetes-related glycemia is more commonly observed owing to an issues9 During the past two decades, the prevaimbalance of glucose intake and use of hypolence of diabetes has increased 30 to 40 percent,10 glycemic agents
Weakness, sweating, mental and the burden of diabetes and its complications confusion, incoordination and trembling occur are likely to increase as the population grows when a persons serum glucose level falls below older11 Obesity is a major risk factor in the 50 to 70 milligrams per deciliter, and symptoms development of diabetes at any age, and the become severe loss of consciousness and convulnumber of overweight children and adolescents sions when levels fall below 40 mg/dL in the United States has increased substantially Diagnosis The American Diabetes Associain the past two decades12 In summary, diabetes tions diagnostic criteria for diabetes require a represents a growing medical disorder, with concomitant morbidity and mortality that can affect fasting blood glucose level of 126 mg/dL or people of all ages greater13 The measurement of glycosylated hemoglobin, or HbA1c, is a good measure of longSYSTEMIC ASPECTS OF DIABETES term six to 12 weeks glucose regulation14 For Signs and symptoms The onset of symptoms is people with diabetes, the goal is to maintain rapid in type 1 diabetes, and includes the classic HbA1c levels below 7 percent normal levels fall triad of polyphagia,
polydipsia and polyuria, as between 4 and 6 percent HbA1c levels above well as weight loss, irritability, drowsiness and 9 percent reflect poorly controlled diabetes, and fatigue Symptoms of type 2 diabetes develop indicate the need for aggressive diabetic control more slowly, and frequently without the classic Treatment Diabetes is not a curable disease, triad; rather, these patients may be obese and and therapy has four goals:

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BOX

ORAL MANIFESTATIONS OF DIABETES
dBurning Mouth Syndrome dCandidiasis dDental Caries dGingivitis dGlossodynia dLichen Planus dNeurosensory Dysesthesias dPeriodontitis dSalivary Dysfunction dTaste Dysfunction dXerostomia

blood sugar levels due to diet, medications and physical and psychological stresses Many tools are available to help people with diabetes, including home-based urine and blood tests and glucometers Patients must undergo regular examinations by physicians to monitor triglyceride, fasting glucose and HbA1c levels Dentists should document their patients most recent home-based glucose and laboratory test results, and monitor blood pressure
levels in the dental office to assist in oral health supervision Nutritional supervision is a critical component of diabetes management, and dentists can assist in this endeavor Risk factors for impaired nutritional intake include gingivitis and periodontitis, oral microbial infections, poorly fitting or lack of removable prostheses, dysphagia and salivary dysfunction A realistic nutritional plan that includes regular oral hygiene and requisite dental treatment can help patients maintain good blood glucose control and nutritional status17
ORAL SIGNS AND SYMPTOMS OF DIABETES

dto normalize blood glucose levels; dto prevent acute complications and eliminate symptoms; dto maintain ideal body weight; dto prevent or minimize chronic complications Oral hypoglycemic medications depend on functioning pancreatic beta cells to stimulate insulin secretion and, therefore, are used to treat many patients with type 2 diabetes Insulin is required for patients with type 1 diabetes, as well as for patients with type 2 diabetes who do not respond to dietary therapy alone or in combination with oral hypoglycemic therapy Diet and physical exercise are a necessary component of therapy for patients with
both type 1 and type 2 diabetes Dentists should be familiar with the medications used for diabetes; updated lists of common therapies are available15,16 Oral hypoglycemic agents include sulfonylureas which enhance insulin secretion, biguanides which reduce hepatic glucose production, alpha-glucosidase inhibitors which delay glucose adsorption and thiazolidinediones which enhance insulin sensitivity Insulin is available in short-acting one to 11/2 hours, regular-acting four to six hours, intermediate-acting eight to 12 hours and longacting 24-36 hours formulations Insulin pumps provide a continuous burst of insulin to help control serum glucose levels Home glucose monitoring is recommended several times daily to help regulate rapid fluxes in
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Oral signs and symptoms Box Gingivitis and periodontitis Persistent poor glycemic control has been associated with the incidence and progression of diabetes-related complications, including gingivitis, periodontitis and alveolar bone loss18,19 Figures 1 and 2 Nationwide surveys have demonstrated that people with diabetes, especially poorly controlled diabetes, have a significantly higher prevalence of severe
periodontitis20 Several mechanisms have been proposed to explain the increased susceptibility to periodontal diseases, including alterations in host response, subgingival microflora, collagen metabolism, vascularity, gingival crevicular fluid and heredity patterns Multiple pathophysiological mechanisms compromised neutrophil function, decreased phagocytosis and leukotaxis also have been implicated in the increased alveolar bone loss found in patients with diabetes18,21 Furthermore, poorly controlled diabetes, particularly in connection with tobacco use, is a risk factor for periodontal disease22 In addition, evidence supports the observation that periodontal infections contribute to problems with glycemic control23 For example, adults with diabetes who received ultrasonic scaling and curettage in combination with systemically administered doxycycline therapy demonstrated, at three months, significant reductions in mean

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HbA1c, reaching nearly 10 percent from the pretreatment values24 The mechanisms for this relationship are undergoing investigation and require validation25 However, evidence suggests that
periodontitis-induced bacteremia will cause elevations in serum proinflammatory cytokines, leading to hyperlipidemia, and ultimately causing an insulin-resistance syndrome and contributing to destruction of pancreatic beta cells26 Treating chronic periodontal infections is essential for managing diabetes19 Dental caries The relationship between diabetes and dental caries has been investigated, but no clear association has been clarified It is important to note that patients with diabetes are susceptible to oral sensory, periodontal and salivary disorders, which could increase their risk of developing new and recurrent dental caries For example, several studies have reported a greater history of dental caries in people with diabetes27,28 Factors for caries development include the traditional elements for example, Streptococcus mutans levels, previous caries experience, as well as poor metabolic control of diabetes,29 underscoring the need for dental professionals to follow up all patients with diabetes on a regular basis for new and recurrent dental decay Salivary dysfunction People with diabetes have been reported to complain of dry mouth, or xerostomia,30 and experience salivary
gland dysfunction31-33 Figure 3 A recent study detected impaired salivary uptake and excretion by salivary scintigraphy in adults with type 2 diabetes34 The cause is unknown, but may be related to polyuria or to alterations in the basement membranes of salivary glands35 Xerostomic complaints may be due to thirst, a common manifestation of diabetes Saliva may be useful to diagnose and/or monitor systemic diseases,36 and it may be possible in the future to evaluate glucose levels37 or diabetes-specific autoimmune markers38 from oral fluids, thus eliminating the need for serum blood evaluation for diagnosis and monitoring Oral mucosal diseases Diabetes is associated with a greater likelihood of developing certain oral mucosal disorders39 There are reports of greater prevalences of lichen planus40 Figure 4 and recurrent aphthous stomatitis,41 as well as oral fungal infections While these associations have not been found consistently in all populations of subjects with diabetes,39 they may be due to chronic immunosuppression and require con-

Figure 1 Periodontal abscess in a mandibular right first molar in a patient with type 1 diabetes

Figure 2 Radiograph of the patient in Figure 1
demonstrating rapid and aggressive periodontitis-associated alveolar bone loss

Figure 3 Salivary hypofunction, xerostomia and dental caries in a patient with long-standing type 1 diabetes

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Figure 4 Oral reticular lichen planus in a patient with type 2 diabetes

Figure 5 Oral pseudomembraneous candidiasis in a patient with poorly controlled type 1 diabetes

tinued follow-up by health care practitioners In patients with type 1 diabetes, chronic immunosuppression most likely is a sequelae of the disease, whereas in patients with type 2 diabetes, acute hyperglycemia causes alterations in immune responsiveness Oral mucosal disorders represent an opportunity to coordinate diabetes care between physicians and dentists, which can improve the referral of patients to oral health practitioners42 Oral infections candidiasis Another manifestation of diabetes and an oral sign of systemic immunosuppression is the presence of opportunistic infections, such as oral candidiasis Fungal infections of oral mucosal surfaces and removable prostheses ar e more commonly found in adults with diabetes Figure 5
Candida pseu8S JADA, Vol 134, October 2003

dohyphae, a cardinal sign of oral Candida infection, have been associated significantly with cigarette smoking, use of dentures and poor glycemic control in adults with diabetes43 Salivary hypofunction also may increase the oral candidal carriage state in adults with diabetes44 The oral health care professional can readily make the diagnosis of oral candidiasis and provide therapy,45 but most importantly, he or she should pursue the infections etiology, which could include a diagnosis of diabetes mellitus Taste disturbances Taste is a critical component of oral health46 that is affected adversely in patients with diabetes47 One study reported that more than one-third of adults with diabetes had hypogeusia or diminished taste perception, which could result in hyperphagia and obesity48 This sensory dysfunction can inhibit the ability to maintain a proper diet and can lead to poor glycemic regulation Neurosensory and visual disorders Patients with diabetes have reported increased complaints of glossodynia and/or stomatopyrosis A common, yet poorly understood, orofacial neurosensory disorder, burning mouth syndrome,49 has been associated with
diabetes mellitus50 Patients may experience long-lasting oral dysesthesias, which could adversely affect oral hygiene maintenance Peripheral neuropathies can impair the use of oral hygiene devices, and diabetic retinopathy can produce visual disturbances, ultimately leading to blindness,51 which, in turn, also could impair daily oral and prosthesis hygiene Dysphagia, another sequelae of diabetes, is caused by altered strength, speed and/or coordination of the cranial nerve musculature52 Dental treatment considerations for the patient with diabetes Antibiotic coverage Patients with poorly controlled diabetes are at risk of developing oral complications because of their susceptibility to infection and sequelae, and likely will require supplemental antibiotic therapy15 Anticipation of dentoalveolar surgery involving mucosa and bone with antibiotic coverage may help prevent impaired and delayed wound healing Orofacial infections require close monitoring Cultures should be performed for acute oral infections, antibiotic therapy initiated and surgical therapies contemplated if appropriate for example, incision and drainage, extraction, pulpectomy In cases of poor response to the first
antibiotic administered, dentists can select a more effective antibiotic

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based on the patients sensitivity test results15 Adjustment of insulin or hypoglycemics Most forms of dental therapy should not interfere with the medical control of diabetes However, dentoalveolar surgery, orofacial infections and the stress of dental procedures can increase serum glucose levels and metabolic insulin requirements Therefore, dentists must consider modifying medical therapy in consultation with the patients physicians For example, patients whose condition is controlled with insulin usually will require increased insulin dosages in the presence of an acute oral infection15 Medications used by dental professionals may require adjustment of diabetes-associated therapies For example, large amounts of epinephrine can antagonize the effects of insulin and result in hyperglycemia Small amounts of systemic corticosteroids can severely worsen glycemic control; patients taking oral hypoglycemic agents who are placed on steroid therapy may require short-term insulin therapy to maintain glycemic control Alternatively, hypoglycemia can be
promoted by aspirin, sulfa antibiotics and antidepressants Monitoring glycemic control Two critical steps are involved in treating patients with diabetes: establishing the diagnosis type 1 or type 2 diabetes, and the form of therapy and the level of disease control well-controlled or poorly controlled Most commonly, blood glucose or HbA1c levels will be available from the physicians office Medical updates must be recorded in the dental record at each visit to guide the clinicians treatment decisions The dentist should be able to use a glucometer to measure blood glucose levels rapidly from a patients fingertip53 Finally, the dental office should be equipped with immediate sources of glucose in case a diabeticinduced hypoglycemic event occurs One study determined that the risk of infections was directly related to fasting blood glucose levels Patients with levels below 206 mg/dL had no increased risk, whereas patients with fasting blood glucose levels above 230 mg/dL had an 80 percent increased risk of developing infection54 Therefore, dentists must be familiar with the diabetic status of their patients, and make appropriate accommodations to prevent and treat effectively
diabetes-associated oral and systemic disorders Communication with physicians Regular communication with physicians is a critical component of safely treating patients with diabetes

Communication must be bidirectional: physicians must be apprised of oral manifestations of the disease to help them regulate blood glucose levels, and dentists must be updated on glycemic control to help them maintain a patients oral health Treating patients with diabetes also represents an opportunity to expand a dentists referral base Physicians who treat children and adults with diabetes could be a good referral source of patients whose oral health care needs may not be satisfied adequately42 Treatment of oral complications of diabetes Dentists must be cognizant of the various methods of treating effectively the oral complications of diabetes mellitus15,53 Many treatments are no different from those recommended for patients without diabetes However, managing patients with diabetes does require more rigorous follow-up, more aggressive interventional therapy rather than observation, regular communication with physicians and greater attention to prevention Patients with diabetes, particularly those
with a history of poor glycemic control and oral infections, require more frequent recall visits and fastidious attention to acute oral infections
CONCLUSION

Diabetes mellitus affects people of all ages, and its prevalence has been increasing Providing safe and effective oral medical care for patients with diabetes requires an understanding of the disease and familiarity with its oral manifestations The goal of therapy is to promote oral health in patients with diabetes, to help prevent and diagnose diabetes in dental patients receiving routine stomatological care and to enhance the quality of life for patients with this incurable disease s
Dr Ship is a professor, Department of Oral Medicine, and director, Bluestone Center for Clinical Research, New York University College of Dentistry, 421 First Ave, 2nd Floor, New York, NY 10010-4086, e-mail jonathanship@nyuedu Address reprint requests to Dr Ship 1 Levels of diabetes-related preventive-care practices–United States, 1997-1999 MMWR Morb Mortal Wkly Rep 2000;49:954-8 2 Lalla RV, DAmbrosio JA Dental management considerations for the patient with diabetes mellitus JADA 2001;132:1425-32 3 Adams PF, Hendershot GE, Marano MA Current
estimates from the National Health Interview Survey, 1996 Hyattsville, Md: National Center for Health Statistics, Vital Health Statistics; 1999:10200 4 Amos AF, McCarty DJ, Zimmet P The rising global burden of diabetes and its complications: estimates and projections to the year 2010 Diabet Med 1997;14supplement 5:S1-85 5 Gu K, Cowie CC, Harris MI Mortality in adults with and without diabetes in a national cohort of the US population, 1971-1993 Diabetes Care 1998;21:1138-45 6 Arias E, Smith BL Deaths: preliminary data for 2001 Natl Vital Stat Rep 2003;515:1-44 7 Self-reported prevalence of diabetes among Hispanics–United

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States, 1994-1997 MMWR Morb Mortal Wkly Rep 1999;481:8-12 8 Pastor PN, Makuc DM, Reuben C, Xia H Health United States, 2002: Chartbook on trends in the health of Americans Hyattsville, Md: National Center for Health Statistics; 2002 9 Cherry DK, Woodwell DA National ambulatory medical care survey: 2000 summary Adv Data 2002;328:1-32 10 Halter JB Diabetes mellitus In: Hazzard WR, ed Principles of geriatric medicine and gerontology 4th ed New York: McGraw-Hill;
1999:991-1011 11 Geiss LS, Herman WH, Goldschmid MG, et al Surveillance for diabetes mellitus–United States, 1980-1989 MMWR CDC Surveill Summ 1993;422:1-20 12 Prevalence of overweight among third- and sixth-grade children– New York City, 1996 MMWR Morb Mortal Wkly Rep 1998;47:980-4 13 Report of the expert committee on the diagnosis and classification of diabetes mellitus Diabetes Care 1997;20:1183-97 14 McCance DR, Hanson RL, Charles MA, et al Comparison of tests for glycated haemoglobin and fasting and two hour plasma glucose concentrations as diagnostic methods for diabetes Br Med J 1994;308:1323-8 15 Little JW, Falace DA, Miller CS, Rhodus NL Diabetes In: Little JW, ed Dental management of the medically compromised patient 6th ed St Louis: Mosby; 2002:248-70 16 Robertson C, Drexler AJ, Vernillo AT Update on diabetes diagnosis and management JADA 2003;134supplement:16S-23S 17 Stanley K Assessing the nutritional needs of the geriatric patient with diabetes Diabetes Educ 1998;241:29-30, 35-7 18 Taylor GW, Burt BA, Becker MP, Genco RJ, Shlossman M Glycemic control and alveolar bone loss progression in type 2 diabetes Ann Periodontol 1998;31:30-9 19 Grossi S Treatment of
periodontal disease and control of diabetes: an assessment of the evidence and need for future research Ann Periodontol 2001;61:138-45 20 Tsai C, Hayes C, Taylor GW Glycemic control of type 2 diabetes and severe periodontal disease in the US adult population Community Dent Oral Epidemiol 2002;30:182-92 21 Oliver RC, Tervonen T Diabetes: a risk factor for periodontitis in adults? J Periodontol 1994;65supplement 5:530-8 22 Moore PA, Weyant RJ, Mongelluzzo MB, et al Type 1 diabetes mellitus and oral health: assessment of periodontal disease J Periodontol 1999;70:409-17 23 Taylor GW Periodontal treatment and its effects on glycemic control: a review of the evidence Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:311-6 24 Grossi SG, Skrepcinski FB, DeCaro T, et al Treatment of periodontal disease in diabetics reduces glycated hemoglobin J Periodontol 1997;68:713-9 25 Taylor GW Bidirectional interrelationships between diabetes and periodontal diseases: an epidemiologic perspective Ann Periodontol 2001;61:99-112 26 Iacopino AM Periodontitis and diabetes interrelationships: role of inflammation Ann Periodontol 2001;61:125-37 27 Moore PA, Weyant RJ, Etzel KR, et al Type 1 diabetes
mellitus and oral health: assessment of coronal and root caries Community Dent Oral Epidemiol 2001;29:183-94 28 Lin BP, Taylor GW, Allen DJ, Ship JA Dental caries in older adults with diabetes mellitus Spec Care Dent 1999;191:8-14 29 Twetman S, Johansson I, Birkhed D, Nederfors T Caries incidence in young type 1 diabetes mellitus patients in relation to metabolic control and caries-associated risk factors Caries Res 2002;361:31-5 30 Field EA, Longman LP, Bucknall R, Kaye SB, Higham SM, Edgar WM The establishment of a xerostomia clinic: a prospective study Br J Oral Maxillofac Surg 1997;352:96-103 31 Chavez EM, Borrell LN, Taylor GW, Ship JA A longitudinal analysis of salivary flow in control subjects and older adults with type 2

diabetes Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:166-73 32 Gilbert GH, Heft MW, Duncan RP Mouth dryness as reported by older Floridians Community Dent Oral Epidemiol 1993;21:390-7 33 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 34 Kao CH, Tsai SC, Sun SS Scintigraphic evidence of poor salivary function
in type 2 diabetes Diabetes Care 2001;24:952-3 35 Murrah V, Crosson JT, Sauk JJ Parotid gland basement membrane variation in diabetes mellitus J Oral Pathol 1985;14:236-46 36 Malamud D Saliva as a diagnostic fluid Br Med J 1992;305: 207-8 37 Belazi MA, Galli-Tsinopoulou A, Drakoulakos D, Fleva A, Papanayiotou PH Salivary alterations in insulin-dependent diabetes mellitus Int J Paediatr Dent 1998;81:29-33 38 Todd AL, Ng WY, Lee YS, Loke KY, Thai AC Evidence of autoantibodies to glutamic acid decarboxylase in oral fluid of type 1 diabetic patients Diabetes Res Clin Pract 2002;57:171-7 39 Guggenheimer J, Moore PA, Rossie K, et al Insulin-dependent diabetes mellitus and oral soft tissue pathologies, part I: prevalence and characteristics of non-candidal lesions Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:563-9 40 Petrou-Amerikanou C, Markopoulos AK, Belazi M, Karamitsos D, Papanayotou P Prevalence of oral lichen planus in diabetes mellitus according to the type of diabetes Oral Dis 1998;41:37-40 41 Lorini R, Scaramuzza A, Vitali L, et al Clinical aspects of coeliac disease in children with insulin-dependent diabetes mellitus J Pediatr Endocrinol Metab 1996;9supplement
1:101-11 42 Levin RP How treating the patient with diabetes can enhance your practice: recommendations for practice management JADA 2003;134supplement:49S-53S 43 Guggenheimer J, Moore PA, Rossie K, et al Insulin-dependent diabetes mellitus and oral soft tissue pathologies, part II: prevalence and characteristics of Candida and candidal lesions Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2000;89:570-6 44 Kadir T, Pisiriciler R, Akyuz S, Yarat A, Emekli N, Ipbuker A Mycological and cytological examination of oral candidal carriage in diabetic patients and non-diabetic control subjects: thorough analysis of local aetiologic and systemic factors J Oral Rehabil 2002;29:452-7 45 Willis AM, Coulter WA, Fulton CR, Hayes JR, Bell PM, Lamey PJ The influence of antifungal drugs on virulence properties of Candida albicans in patients with diabetes mellitus Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:317-21 46 Ship JA, Chavez EM Special senses: Disorders of taste and smell In: Silverman S Jr, Eversole LR, Truelove EL, eds Essentials of oral medicine Hamilton, Ontario: BC Decker; 2001:277-88 47 Settle RG The chemical senses in diabetes mellitus In: Getchell TV, ed Smell and
taste in health and disease New York: Raven Press; 1991:829-43 48 Stolbova K, Hahn A, Benes B, Andel M, Treslova L Gustometry of diabetes mellitus patients and obese patients Int Tinnitus J 1999;52:135-40 49 Ship JA, Grushka M, Lipton J, Mott A, Sessle B, Dionne R Burning mouth syndrome: an update JADA 1995;126:842-53 50 Grushka M, Epstein JB, Gorsky M Burning mouth syndrome Am Fam Physician 2002;65:615-20 51 Kalina RE Seeing into the future: vision and aging West J Med 1997;167:253-7 52 Ship JA, Duffy V, Jones JA, Langmore S Geriatric oral health and its impact on eating J Am Geriatr Soc 1996;44:456-64 53 Vernillo AT Dental considerations for the treatment of patients with diabetes mellitus JADA 2003;134supplement:24S-33S 54 Golden SH, Peart-Vigilance C, Kao WH, Brancati FL Perioperative glycemic control and the risk of infectious complications in a cohort of adults with diabetes Diabetes Care 1999;22:1408-14

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