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DIABETES AND DENTAL COMPLICATIONS

By Joseph M. Shurina III
Community Dental Hygienist, U.S. Public Health Service, Ft. Belknap, Montana

Within the diabetic population, there is a serious risk of dental complications. It has long been known that having diabetes increases the risk of severe periodontal disease. Poorly controlled type 2 diabetics are more likely to develop periodontal disease than are well-controlled diabetics. Why?

Studies conclude that poorly-controlled diabetics respond differently to bacterial plaque at the gum line than do well-controlled diabetics and non-diabetics. Having poorly-controlled diabetes correlates with having more harmful proteins (cytokines) in their gingival tissue -- and that can cause destructive inflammation of the gums. In turn, beneficial proteins (growth factors) are reduced, which interferes with the healing response to infection.

Diabetics tend to lose collagen, a protein that supports gums, skin, tendon cartilage, and bone, in their gum tissue, thus increasing periodontal destruction. Diabetic vascular disorders, such as reduced circulation in tiny blood vessels in the gums, interfere with nutrition and healing in the gum tissues. Young people with type 1 diabetes, especially those with poor control, are very vulnerable to early-onset periodontal disease as they reach puberty.

Current research in the September 2002 issue of Diabetes Research and Clinical Practice looked at 102 patients with type 2 diabetes, average age 65. In this Swedish study, the researchers conducted a comprehensive dental examination, and then compared these results with the same battery of tests given to a control group without diabetes but otherwise the same in terms of age and gender. The results showed that diabetic subjects had more periodontal gum disease pockets between teeth, which indicate moderate to advanced gum disease. These pockets also tended to be deeper than in non-diabetics.

The diabetic group had more plaque on their teeth and experienced more bleeding of their gums while being examined. The 22 subjects taking insulin had more cavities than those who were controlling diabetes with diet only. Overall, the diabetic group also had problems with dry mouth, and those with poor control had worse problems.

In an article in the Journal of Periodontology, author Christopher Cutler, DDS, states: "Increased serum triglyceride levels in uncontrolled diabetics seem to be related to greater attachment loss and probing depths, which are measures of periodontal disease."

For this reason, the article stresses diabetics should work with their health care team to keep cholesterol levels and triglyceride levels normal. "Reducing ... [these two levels], preferably through diet and exercise, may be the most important changes that diabetics can make to improve their life, as well as their oral health."

How can diabetes affect your teeth and gums? We all know these problems can happen to anyone. That's why we go to the dentist on a regular basis. Plaque builds up on everybody’s teeth, but diabetic high blood glucose helps germs build up on teeth and gums, and make these problems worse, to the point it could cause tooth loss.

What does this look like, if it's happening to you? The first signs are red, sore, and bleeding gums. This can progress to periodontitis, which is an infection in the gums and the bone that holds the teeth in place. Pockets form between the teeth, and they fill with germs and pus. If the infection is allowed to get worse, your gums may pull away from your teeth, making the teeth look very long, and your teeth will loosen.

Sometimes when I write these articles, I think that diabetics are singled out for many diseases, but not here. Eighty-five percent of all adults develop it. Ten percent have lost all of their teeth to it. Diabetes just makes it worse.

It is difficult to get people to brush and floss as often as they should, and many people do not go to the dentist when their gums bleed as they brush or floss. This bleeding is not normal, and needs to be addressed. If the plaque is not brushed and flossed away, it hardens into tartar and collects under the gum line. To make matters worse, more plaque forms over the tartar, so you can imagine how this problem can escalate.

Tartar, calcified bacterial plaque, harbors soft surface bacteria, and worsens the disease below the gum-line. As this process accelerates, more and more tissue becomes diseased, and more plaque accumulates. Once the bone begins to be destroyed, you know the rest: the teeth loosen, and false teeth are around the corner.

The prospects for fighting periodontal disease are excellent, as there are many things that someone with diabetes can do to stop the process or correct the disease, once it starts. The first goal is easy.

1. Good blood glucose control

The degree to which a person exercises good diabetes control appears to have a direct relationship to the severity of periodontal disease. This is clearly a very good thing to know, especially on those mornings when you think you are running too late to brush and floss. Among poorly-controlled diabetics, bone loss from periodontal disease is particularly severe.

2. Oral hygiene

Make sure you schedule regular dental check-ups. For a diabetic this may mean every six months, or, if you have periodontal disease, more often, until you get it under control. According to many periodontists, revisiting a dental hygienist every three months (“periodontal recall,”) may ensure problems can be controlled with relatively minor procedures.

Brush and floss the proper way. If you are not sure, the hygienist, the person who regularly cleans your teeth at the dentist's office, can help show you the right way. Now that you've read this article, you know brushing and flossing are important tools to help remove bacteria before it can cause damage. If necessary, your dentist may recommend mouthwashes that use chemicals to destroy plaque-forming bacteria and neutralize their toxins.

3. Watch for warning signs.

We've gone over these in the article, but, one more time let's list them: Bleeding gums while you eat or brush and floss, abnormal changes in your mouth such as soreness, sores, bright red gums and tenderness. Also look for gums pulling away from your teeth, making your teeth look long. Also, see the dentist if you have chronic bad breath or your bite feels different.

Run -- don't walk to the dentist, if your dentures do not fit well or if you experience any of these symptoms. At the same time throw away any cigarettes you have in the house. Smoking, diabetes, and dental hygiene do not go together -- smoking escalates the severity of the periodontal disease process. White patches on your gums might indicate the presence of thrush, a fungal infection requiring treatment.

If you have to visit the dentist because of periodontal disease, you will likely receive an extended gum-line cleaning called a root plane. The dental hygienist can probe the periodontal pockets and remove plaque and tartar. Once these are removed, the inflammation of the gums should subside and the gums should re-adhere to the teeth.

Why do diabetics need to care about controlling periodontal disease? First, dental infections may worsen your diabetes by causing hyperglycemia (high blood sugar), causing mobilization of fatty acids, and ultimately leading to acidosis. As we know, all of these conditions make it very difficult to control blood glucose levels.

Proper nutrition is essential to good control of diabetes. When gums are tender, a diabetic may opt for foods that are not appropriate for a diabetic diet.

To summarize, we hope that reading this article has helped you understand the importance of caring for your teeth and gums, as well as your blood glucose levels. Most people know that when diabetes is poorly controlled, they will eventually have problems with their extremities, particularly toes and feet. But the same type of damage can occur to the salivary glands. Without those protective proteins we spoke of, diabetic people are at a higher risk for dental problems. In people with well-controlled diabetes, there really is no difference in oral health, compared to those without diabetes. But, as we have explained, those with poor control or poor oral hygiene run the risk of cavities and periodontal disease. Don’t become a statistic ... Visit Your Dental Clinic Today!

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If you or a friend would like to remember the Diabetes Action Network of the National Federation of the Blind in your will, you can do so by employing the following language:

“I give, devise, and bequeath unto the Diabetes Action Network of the National Federation of the Blind, 1800 Johnson Street, Baltimore, Maryland 21230, a District of Columbia nonprofit corporation, the sum of $_____” (or “_______ percent of my net estate” or “the following stocks and bonds: ________”) to be used for its worthy purposes on behalf of blind persons.

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