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No one enjoys going to the dentist, but for people with diabetes, getting that cleaning and check-up are especially important. The link between diabetes and oral health can't be ignored. In fact, dental problems in people with diabetes are so rampant that Mark Finney, DDS, believes oral disease should be referred to as "the sixth 'opathy' of diabetes," deserving of the attention given to retinopathy, neuropathy, nephropathy and the like.
While everyone is prone to periodontitis, or diseases of the tissues surrounding the teeth and gums, people with diabetes often have more severe cases that can both cause and predict additional diabetic complications.
Periodontitis or periodontal diseases involve inflammation and destruction of the tissues supporting and surrounding the teeth, including the gums and supporting bone. Periodontitis destroys the periodontal ligaments or connective tissue fibers that attach the tooth to the bone causing resorption of the alveolar bone (tooth socket). Consequently, the gums swell, redden, change shape, bleed, teeth loosen and pus forms. With the loss of soft tissue and bony support, deep periodontal pockets may form that foster bacterial growth.
The formation of plaque on the teeth is the first step toward periodontal disease. Plaque, the white sticky substance that collects between teeth, is often the start of periodontitis. Made of microorganisms, dead skin cells and leukocytes (infection fighting white blood cells), it can be removed by brushing and flossing regularly. If it is allowed to build up, it will harden and turn into tartar. Tartar can only be removed with a professional cleaning at the dentist's office. Both plaque and tartar make the gums vulnerable to infection.
If an infection enters the gums it is referred to as gingivitis, the first stage of periodontitis. Bacteria that collect and breed at the gum line and the groove between the gum and the tooth cause the gums to redden, swell and bleed. This response is normal but can also lead to periodontitis. Gums affected by gingivitis often bleed and are sensitive, but not always. Other signs include swollen gums, loose teeth, a bad taste in the mouth and persistent bad breath.
The Relationship to BG Control
BG control and good oral hygiene seems to be the key to avoiding most dental complications. Everyone is at risk of developing periodontal disease, but all people with diabetes, regardless of age or type of diabetes, are more susceptible. There are several reasons for this.
For one, people with diabetes have more sugar in the mouth which provides a more hospitable environment for hostile bacteria. This makes all forms of periodontal disease more likely.
High and fluctuating BGs are also a big factor in the increased risk of periodontal disease. Poor BG control means higher degrees of periodontitis and more vulnerability to complications.
It also makes healing more difficult once an infection sets in. Just like diabetics with poor BG control have a hard time healing wounds and infections on their feet, their bodies have a hard time fighting infections and healing wounds in the mouth.
At the same time, on-going infections may make BG control more difficult. Inflammation and infection affect BG control no matter where they occur. But the mouth is often overlooked as most doctors do not look in the mouth.
Once an infection takes root a vicious cycle ensues making metabolic and infection control a struggle. This cycle can have drastic consequences. If oral infections get out of control they can lead to BG control problems serious enough to land a person with diabetes in the hospital, to say nothing of the damage to the teeth and gums.
Gum infections can also impact insulin needs. Authors of a study cited in September's 1997's Practical Diabetology concluded that when an infection is rampant, patients with diabetes often have increased insulin requirements. If periodontal disease is treated and gingival inflammation is eliminated, these insulin needs often decrease.
Collagen, which is a building block of the tissue that attaches teeth to bones and the surrounding soft tissue, is also affected by diabetes. Diabetes' effect on collagen metabolism, according to Finney, "may make an infection potentially more destructive."
Reduced Salivary Flow
Patients with diabetes may also experience dry mouth as a result of reduced saliva. Neuropathy and certain medications may be the cause of reduced salivary flow. Finney says that saliva is important to wash residue off teeth and gums and prevent tooth and gum disease. Ask your dentist about products that moisten the mouth or increase saliva.
Drinking lots of fluids may help alleviate the problem and there are products available (see page 18) that can help keep the mouth moist.
It's All Connected
The development of periodontal disease may reflect the presence of other problems related to BG control such as retinopathy.
"Retinopathy and dental problems are closely related. If you look at a population that is having eye problems, that same population is likely to have dental problems. If a person is diagnosed with retinopathy, they should make sure that their mouth is being examined and the gums are healthy. Conversely, if there is serious gum disease there may be other diabetic complications taking place in the body," says Finney.
Problems that begin elsewhere in the body should also provide clues for health care professionals. The presence of microalbuminuria and neuropathy are signals to check the mouth for potential complications.
As with all diabetic complications, an ounce of prevention is worth its weight in gold. By far the most important step that can be taken is to brush and floss regularly. It is advisable to discuss proper brushing and flossing techniques with your dental team. Some of the fundamentals might surprise you. For example, it is recommended that you brush for a minimum of three minutes, which, when put into practice, is longer than one might imagine.
In the Chair
Prevention also includes making and keeping the often dreaded dental appointment. Finney suggests seeing the dentist twice a year, or as often as necessary. If you are avoiding the dentist due to fear and or loathing, see below for some strategies to make it a little easier to deal with.
It is best to schedule dental appointments, about an hour and a half after breakfast so that the appointment does not interfere with regular meal times. Test your BGs before you go to the dentist and test them while you are at the dentists office. Make sure to stick to your regular insulin and/or oral medication schedule to avoid BG problems. It is also important to discuss your diabetes with your dental team.
Once at the dentist, voice concerns and report any abnormality, such as gingival bleeding. Healthy gums are usually light-pink, snug around the tooth and don't bleed.
If an infection is already present, it must be treated before any significant procedures can be attempted. Once diabetes is under good control, oral surgery can be performed without complication.
Since periodontal disease can lead to tooth loss, many patients are fitted for dentures. Patients wearing complete dentures should see the dentist once a year to examine all soft tissue areas. Partial dentures require attention to hygiene just like real teeth. They need to be removed and cleaned daily.
Wearing dentures continuously and failing to take the proper precautions can promote the growth of mouth fungus (candidal colonization) leading to thrush.
Dentures may also be ill-fitting and uncomfortable. This is because the gums of people with diabetes may be especially sensitive. This in turn makes eating, and maintaining good health and proper BG control more difficult.
Dental implants can be another viable option for tooth replacement for people with diabetes.
Dental therapy for people with diabetes does not have an established criteria, although dental offices record medical conditions such as diabetes they may not be prepared for an emergency resulting from diabetes. It is important to discuss your diabetes and possible low and high blood sugar scenarios with your dental team.
According to Finney, the dental team needs to know if their patients take oral agents or insulin because that means special precautions must be taken. He advocates that dentists caring for patients with diabetes have a calibrated glucose meter, glucose tablets or fruit juice, and a glucagon kit available.
They should also be familiar with the common signs of hypoglycemia such as loss of coordination, blurry vision, palpitations, rapid heart rate, sweating and shaking. He also suggests finding out if a patient with diabetes has hypoglycemic unawareness, a condition in which they experience few if any signs and symptoms of low blood sugars.
According to Finney, a common situation leading to hypoglycemia at the dental office is a patient skipping breakfast before an appointment but taking the regular amount of insulin.
Severe hyperglycemia may occur as well, but less frequently. Acetone breath and dehydration, dry mucous membranes and changes in mental status are signs that blood glucose is too high and dental procedures should be postponed.
The relationship between diabetes and periodontal disease is well-established. Since periodontal disease can be prevented, education should start in childhood.
Organizations such as the National Oral Health Information Clearinghouse can offer valuable information on dental health and diabetes. They can be contacted at 1 NOHIC Way, Bethesda, MD, 20892-3500 or call 301-402-7364.
"The key thing to remember is that diabetes can cause additional problems so those with diabetes need to take additional care to keep their teeth and gums healthy," says Finney.
Fortunately, this care is simple and inexpensive compared to the pain and cost of replacing lost teeth.
The Sonicare with Quadpacer at-home sonic toothbrush by Optiva. Call (800) 682-7664 for more information.
The DenTrust three-sided, specially angled Ultralon non-scratching bristle toothbrush from Dental Health Way. Call (800) 345-1143 for more information.
Biotene antibacterial dry mouth toothpaste, dental chewing gum and alcohol-free mouth wash from Laclede. Oralbalance saliva substitute gel is also available from Laclede.
Call (888) BIOTENE (246-8363) for more information.