Long back a famous European diabetologist was asked about his success. He said humorously, it was very simple as he was sending all his patients to his next-door friend’s dental clinic. It sounds funny, but present scenario suggests dentistry is almost mandatory in diabetes care. It is factual treating gum disease in diabetic patients can help them keep their diabetes under control. Thus I believe dentists are well positioned to help, prevent and combat the complications of diabetes!
In case of diabetes, elevated blood sugar levels can damage many parts of human body specially heart, kidney, eyes, nerves and blood vessels, including our mouth and teeth. Diabetes increases risk of gum disease, cavities and tooth loss, dry mouth, and a variety of oral infections. In other way, poor oral health can make diabetes more difficult to control. Infections may cause stiff rise in blood sugar and require more insulin or tablets to keep it under control.
In addition, diabetes can diminish our ability to taste sweets. Although this change may not be noticeable, it can influence our food choices in favour of additional sweeter tasting foods, thereby affecting our dental health, as well as our ability to control diabetes. Constant high blood sugar for a longer period of time caused by diabetes can contribute to progressive damage to the teeth and gums, which may cause tooth loss.
Plaque: The teeth are covered normally by an invisible film of bacteria, saliva and food particles called dental plaque. The bacteria feed on the sugars and starches in the foods and beverages we consume and subsequently produce acids that damage the hard enamel coating of our teeth. Higher blood sugar that accompanies diabetes gives the bacteria a greater supply of sugars and starches, leading to production of even more acid. Thus damage from this acid increases the risk of tooth decay, known as cavities. Junk foods and beverages are causing excessive fats, both pre-diabetes and diabetes, dental complains and what not! It’s high time for the parents to stop feeding those to their children!
Gum disease: If dental plaques are not removed from our teeth with regular brushing and flossing, it hardens under gum line into a substance called tartar or calculus. It irritates the gums and causes gingivitis. This makes the gums tender, swollen and red, and they may bleed when you brush your teeth. Fortunately, your dentist or dental hygienist can prevent or treat gingivitis by removing tartar during a professional dental cleaning. Here again diabetes plays a crucial role in disease exacerbation. Dentist are thus in a much better position to detect either new onset diabetes or poorly controlled diabetes by their clinical experiences.
Periodontitis: Untreated gingivitis leads to a more serious condition when bacteria infect our gums and the bones around our teeth, which is known as periodontitis. This can cause gums to pull away from our teeth and that makes teeth to loosen and even fall out. Gingivitis and periodontitis are the most common oral complications of diabetes. Diabetes predisposes patients to development of severe and progressive forms of periodontal disease(1), which in turn is a serious concern of present days clinical practice. In case of type 2 diabetes, the risk of developing such dental complications are three times higher comparing with someone who doesn’t have diabetes. Diabetes lowers our body’s resistance to many infections and slows the healing rate. Several studies suggested that people with gum infections might be at increased risk of cardiovascular disease. The Dental Atherosclerosis Risks in Communities Study has shown evidence of relationship between periodontal infections and presence of sub-clinical atherosclerosis(2). Researchers have given strong evidences that dental infections are closely associated with coronary atherosclerosis as some local bacterial DNA has been identified in distant atherosclerotic plaques(3),(4).
Diabetes and periodontitis are supposed to share a common pathogenesis that involves an enhanced inflammatory response that can be observed at the local and systemic level. A number of reviews and studies have proposed mechanisms to explain the relationship, which includes a) microvascular disease, b) changes in components of gingival cervicular fluid, c) changes in collagen metabolism, d) an altered host response, e) an altered subgingival flora, f) genetic predisposition and g) non-enzymatic glycation. Undoubtedly there are genetic connections to diabetes and periodontitis. However there is strong evidence of the bacterial and host contributions.
In the presence of hyperglycaemia, due to altered inflammatory response, there is an increase in innate immune responses and periodontal tissue destruction. The inflammatory response is mainly caused by the chronic effect of high plasma glucose and the formation of biologically active glycated proteins and lipids that promote inflammatory responses.
Diabetes and the rest of the mouth: Our teeth and gums aren’t the only parts of our mouth at risk, the following problems can also occur:
Dry mouth: Dry mouth (xerostomia) occurs when our salivary glands don’t produce sufficient saliva to keep our mouth moist. Dryness contributes to cavities and gum diseases because lack of saliva does not help to wash away the bacteria that contribute to these conditions. Dry mouth also causes tissues in our mouth to become inflamed and sore. As chewing, tasting and swallowing become difficult it may reduce our interest in eating, so it can make diabetes control more challenging, since patient may not eat properly to keep blood sugars in control.
Fungal infection: Candida albicans is a fungus that normally lives inside our mouth without causing any problems. But in the case of diabetes, deficient saliva in the mouth and extra sugar in the saliva may allow the fungus to cause an infection called candidiasis (thrush), which appears as sore white or red areas in our mouth.
Smoking and wearing dentures all day and night increase the risk of thrush. Not smoking and limiting the time dentures are worn can reduce the risk of getting thrush.
Burning mouth syndrome: When we have this condition, we may feel severe burning and pain in our mouth even though we don’t see any problems in our mouth that could be causing it. Dry mouth and candidiasis can cause burning mouth syndrome. Diabetic neuropathy may lead to oral symptoms of tingling, numbness, burning or pain in the oral region.
Dangers of acute oral infection: Any diabetic patient with acute dental or oral infection presents a problem in management of both diabetes and dental management. The infection will often cause loss of control of the diabetic condition, and as a result the infection is not handled by the body’s defences as well as it would be in a non-diabetic patient. So infection control has to be aggressive here, along with tight glycaemic control.
Oral surgery and diabetes: Like all surgical procedures here we need cautious handling of the case, as diabetes can complicate surgery. Diabetes retards healing and increases risk of post-operative infection. If a patient needs oral surgery, they should follow the American Diabetes Association’s recommendations:
- Remind dentist that you have diabetes. Patient should discuss any problems regarding infections or about controlling blood sugar with the dentist.
- Eat before your dental visit. The best time for dental work is when you know that your blood sugar is in a normal range, which allows for better healing. If your blood sugar level is out of control when you have a dental surgery scheduled, you may need to postpone the procedure until it’s in control.
- Take your usual medications. Unless your dentist or doctor tells you to change your medication schedule, continue taking your medications.
- Plan for your eating needs after surgery. If you’re having any dental work done that may leave your mouth sore, plan to eat soft or liquid foods that will allow you to eat without pain. Do not skip a meal.
- Wait until your blood sugar is under control. It’s best to have surgery when your blood sugar levels are within your goal range. If your dental needs are urgent and your blood sugar is poorly controlled, talk to your dentist and diabetes doctor both for better care in a single possible time.
The protocol of regular dental care in a diabetic person should be tighter enough as our mouth is the common source of infection causing concerns for disturbed glycaemic control.A diabetic person should follow these steps:
- Control your blood glucose.
- See dentist at least twice a year, and make sure dentist knows about your diabetes.
- Brush twice a day, using a soft nylon toothbrush. Also clean the tongue.
- Floss every day.
- Look for early signs of gum disease, such as bleeding gums, redness and swelling.
- Inform dentist if dentures (false teeth) do not fit right or if gums are sore.
- Quit smoking.
In view of the relationship between infection, inflammation and cardiovascular disease, Howe G D et al suggested periodontal disease as the sixth diabetic complication, after nephropathy, neuropathy, retinopathy and microvascular and macrovascular complications(5). I personally feel dentistry should get equal importance in regular diabetes screening and management protocol. More information from prospective long term clinical trials targeted to answer many unanswered questions regarding diabetes and dental problems should help to guide therapy in future. It will have immense impact in reducing additional health-related economic burden, potentially preventing diabetes by early case detection at the dentist’s clinic, preventing cardiovascular disease by avoiding or early intervention to periodontitis and other co-morbidities. Awareness among population is the key to success; it’s applicable here too.
- Campus G. et al: Diabetes and periodontal disease: a case control study. J Periodontal 76: 418-425, 2005.
- Nichols TC. et al: Role of nuclear factor Kappa B (NF/Kappa B) in inflammation, periodontitis and atherogenesis. Ann Periodontal 6: 20-29, 2001.
- Poligon B. et al: Elevated NF-Kappa B activation in nonobese diabetic mouse dendritic cells results in enhanced APC function. J. Immunol 168: 188-196, 2002.
- Liu J. et al: Distant pathways for NF-Kappa B regulations are associated with aberrant macrophage IL-12 production in lupus- and diabetes prone mouse stains. J Immunol 170: 4489-4496, 2003.
- Lowe GD: The relationship between infection, inflammation and cardiovascular disease: an overview. Ann Periodontal 6: 1-8, 2001.
Dr Basab Ghosh [MBBS, MDRC (Chennai), Dip Diab]
Dr Basab’s Diabetes Care
Opposite Ramnagar 3,
T G Road Extn, Krishnanagar