Dental care is an important part of diabetes care. Lack of attention to your oral health can impact your diabetes and vice versa.
According to Amy Wachter, MD, clinical leader of Christiana Care Endocrinology Specialists in Wilmington, DE, oral health among those with diabetes does not get enough attention. “Typically people think that diabetes only negatively impacts the eyes, kidneys, feet, and vascular system. But diabetes can also severely harm oral tissue.”
What are the risks of poor dental care?
People managing diabetes are at higher risk for several oral diseases.
Infections: If you frequently take antibiotics to fight infections there is an increased risk for developing fungal infections of the mouth and tongue. Called “thrush,” the fungus feeds on high levels of glucose.
Dry mouth from decreased saliva flow: This can lead to soreness, ulcers, fungal infections, and increased tooth decay.
Poor healing of oral tissues: Incisions from surgeries or injuries do not heal as quickly because blood flow to the area may be restricted.
Perhaps the biggest concern for your overall health is periodontal disease (PD). This is a chronic, low-grade infection caused by bacteria collecting around the gums and teeth. If not treated, the bacteria produce chemicals that can affect your jaw and gums, resulting in loosened or missing teeth. Symptoms include bleeding and swelling in your gums, bad breath, a constant bad taste, frequent abscesses, loose teeth, and receding gums.
Especially for individuals with diabetes, a periodontist is part of the treatment team early on. Periodontists treat those with severe gum disease and complicated medical histories.
“The periodontist has additional training beyond dental school (2–3 years) in treating periodontal disease and diseases affecting the jaw bone,” says Sally J. Cram, DDS, a consumer advisor and spokesperson for the American Dental Association. “They have the training and skills to do more complex treatments including surgery, bone grafting, and implants.”
It is important to ask if your general dentist feels comfortable treating your periodontal problems. If he or she is unable to answer your questions, address your concerns, and provide education around controlling periodontal disease, then you may want to see a specialist.
The impact of periodontal disease on diabetes control
“The biggest risk factor for PD is control of the diabetes,” says Cram, who is also in private practice in the Washington, DC, area. “On the other side, those with untreated gum disease have a much harder time controlling their blood sugar levels because of the constant challenge of inflammation. The non-controlled diabetes can put you at higher risk for PD, but having untreated PD can make it much more difficult to control your diabetes.”
There are indications that severe inflammation linked to PD may increase insulin resistance and has the potential to destroy insulin-producing cells. Either of these can make diabetes worse.
The changes diabetes brings about in the blood vessels also play a part in periodontal disease. With less circulation to the gums, fewer white blood cells are drawn to the area to fight the infection. The lack of adequate circulation also brings about an increase in the activity of collagenase. Since the gums mainly consist of collagen, a substance essential for gum healing, they are more actively being broken down.
Other risk factors at work (in addition to diabetes) include: smoking; poor oral hygiene; stress; heredity; crooked teeth; underlying immune system disorders such as AIDS; bridges or dental appliances that no longer fit properly; and female hormonal changes, such as with pregnancy or the use of oral contraceptives.
Diabetes type not important difference
Presently, there are no indications that one type of diabetes puts you at higher risk for dental problems than the other. “We have always assumed that Type 1 diabetes was medically more severe than Type 2,” says Miriam R. Robbins, DDS, chair of the Department of Dental Medicine at NYU Winthrop Hospital in Mineola, NY, and president of the American Academy of Oral Medicine. “What we are finding is that the length of time you have diabetes increases the likelihood of these complications. In the past, Type 1 was most often seen in younger patients who had it for longer times. As we see more and more patients with Type 2 at earlier ages, this difference will probably diminish.”
The earlier onset also means that dental health care becomes important at younger ages. Parents and guardians should remember that even children need to be watched and treated for oral health the same as adults.
Robbins also suggests being seen as soon as possible after the initial diagnosis of diabetes to get a good baseline of your dental health. Since there can be a delay between onset of the disease and diagnosis, it is important to make sure that PD hasn’t already established itself.
Daily dental care recommendations
Standard daily care is basically the same as the general population. Brush your teeth after every meal. You should brush at a 45-degree angle against the gums and move it back and forth in short strokes. Make sure you clean the front, back and chewing surfaces of your teeth. Use the brush’s tip to clean the inside of the front teeth.
Flossing is another important part of the process. You should: pull off enough floss to wind it around the middle fingers of each hand; hold the floss tightly between your thumbs and forefingers; curve it into a C shape against one tooth and gently move the floss back and forth across the tooth and then the side of the tooth in an up and down motion; and repeat until you have flossed all your teeth.
Before using any kind of mouthwash, check with your dentist to see what, if any, he or she recommends. Anti-bacterial mouthwash can contain up 20 percent alcohol, which can further dry out your mouth. If your dental care professional thinks it is needed, medicated mouthwashes such as Peridex may be prescribed. Many dentists will suggest fluoride supplements to help keep the teeth stronger.
“Part of the prevention of periodontal disease is knowing how to take care of your gums and teeth,” says Cram. “We can do all of the best treatments in the world, but if you aren’t doing what you need to do every day at home, this disease won’t get better.”
Choosing your dental professional
If you are successfully controlling your diabetes and have no problems with your eyes, kidneys, or heart, then you can probably see any general dentist in the community. How often will be decided based on your dental condition. Referral to a periodontist will also be a joint decision. Those who have uncontrolled diabetes, have medical problems, or may have hypoglycemia unawareness (a complication where a person is unaware of a deep drop in blood sugar) should consider a dentist who has additional training and experience in treating medically complicated patients.
Your endocrinologist is often a good source for referrals and likely to have other patients who need more specialized dentists. Check with your local hospital to see if they offer a medical dental service. While they may not be the best option for a dentist, they should know those in the area with extra training. A local dental society is another good resource.
“Make sure you tell your dental care professionals that you have diabetes,” says Wachter. “Find out if they can accommodate special needs such as stopping the examination long enough to check blood sugars and respond as needed. And ask if they are taking care of other diabetic patients.”
Other question to ask your dentist include:
* Are you able to recognize low blood sugar during the appointment and can you treat it if it happens?
* What special training or education do you possess? Was it a structured residency?
* Have you completed seminars or other postgraduate work focusing on medical dentistry?; and
* Are you a member of any interest groups or professional organizations?
There is little research backing up the idea that you should see the dentist twice a year. This is mostly the result of insurance companies long ago saying they will pay for two visits. How often you will need to see the dental health professional depends on your specific situation. Some may only need to be seen annually, while others will visit as often as every two or three months.
The power of brushing and flossing
Cleaning your teeth is important because PD is a bacterial infection. The bacteria in your mouth spin out sticky proteins that cause pieces of food and debris to attach to your teeth. This film is plaque, and it is what makes your teeth feel fuzzy when you wake up in the morning. It remains soft for 48–72 hours and can be brushed off before it starts to harden.
“This hardened material is called calculus or tartar and contains bacteria,” said Robbins. “I tell my patients that this is like a pebble in your shoe that causes your foot be to inflamed and raw. The calculus becomes a site of inflammation.”
It is the combination of the immune response to the bacteria in the tartar and the toxins generated as waste products by the bacteria that destroys the hard and soft tissues around the gum and teeth.
Even if you are the most careful and aggressive brusher and flosser, you will always miss a little plaque, and calculus will build up. Scraping your teeth is what removes it, making the dental visit a critical part of diabetes care.
“An important takeaway is that [people with diabetes] should realize that somehow the mouth has gotten disconnected from the rest of the body,” says Robbins. “It is vitally important that you get regular checkups and cleaning, stop smoking, and have a conversation with your dental health providers about risk factors and things you can do to lessen that risk.”