DIABETES AND DENTISTRY

8/2/2019 DIABETES AND DENTISTRY

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June 2008

Wil l iam Beaumont Army Medical Center El Paso , Tx 79920-5001

VOLUME 6 ISSUE 2

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 tocomplications.

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 2007'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 FlowPatients 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 2) that can help keep the

mouth moist. ( Cont. on page 2)

Diabetes and Dentistry

Take Charge with Case Management:

Diabetes and Oral Health

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.

Defining PeriodontitisPeriodontitis 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. Thisresponse 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 Blood Glucose (BG) ControlBG 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.


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Diabetes and Dentistry (Cont. from page 1)

PAGE 2 TAKE CHARGE WITH CASE MANAGEMEN T: FOCUS ON DIABET ES & ORAL HEALTH VOLUME 6, ISSUE 2

It's All ConnectedThe development of periodontal disease may reflect the

presence of other problems related to BG control such as

retinopathy or eye disease.

"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 other health problems. The presence of

microalbuminuria and neuropathy are signals to check the

mouth for potential complications.

PreventionAs 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 todiscuss 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 ChairPrevention 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 ahalf 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.

Treatment

If an infection is already present, it must betreated before any significant procedures can be

attempted. Once diabetes is under good control, oral surgery

can be performed without complication.

Dentures

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 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.

Taking PrecautionsDental 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 forpatients 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 break-

fast 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.

Be AwareThe 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 causeadditional 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.

Product Options

Cleaning:

The Sonicare with Quadpacer at-home sonic toothbrush by

Optiva. Call (800) 682-7664 for more information.


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PAGE 3TAKE CHARGE WITH CASE MANAGEMENT: FOCUS ON DIABETES & ORAL HEALTHVOLUME 6, ISSUE 2

Tooth TipsThe following tips are from the National Institute of Dental Health:

Controlling your blood glucose is the most important step you can take to preventtooth and gum problems. People with diabetes, especially those whose blood glucose

levels are poorly controlled, are more likely to get gum infections than non-diabetics. A severe gum infec-

tion can also make it more difficult to control your diabetes. Once such an infection starts in a person with

diabetes, it takes longer to heal. If the infection lasts for a long time, the diabetic person may lose teeth.

Much of what you eat requires good teeth for chewing, so it is extremely important to try to preserveyour teeth. Because the bone surrounding the teeth may sometimes be damaged by infection, dentures

may not always fit properly and may not be perfect substitutes for your natural teeth.

Taking good care of your gums and teeth is another important measure. Use a soft-bristle brush be-

tween the gums and the teeth in a vibrating motion. Place the rubber tip of the toothbrush between theteeth and move it in a circle.

If you notice that your gums bleed while you are eating or brushing your teeth, see a dentist to deter-

mine if you have a beginning infection. You should also notify your dentist if you notice other abnormalchanges in your mouth, such as patches of whitish-colored skin.

Have a dental checkup every six months. Be sure to tell your dentist that you have diabetes and ask him orher to demonstrate procedures that will help you maintain healthy teeth and gums.

Clean Those Choppers: Periodontal Disease May Accelerate Pre-Diabetes

Its already clear that people with type 2 diabetes are more susceptible to periodontal

disease than people without diabetes. Now researchers at the University of Copenha-

gen School of Dentistry have found that periodontal disease may contribute to pre-

diabetes, at least in rats.

Their study examined fat pre-diabetic rats and lean rats, both with artificially inducedperiodontal disease. Compared to control rats without periodontal disease, the fat rats

experienced greater deterioration in glucose metabolism, and even the lean rats showed increased fasting

glucose and insulin resistance. Whether the rats brushed their little teeth was not reported.

"Oral infections have systemic effects," said Dr. Thomas Van Dyke, a professor of periodontology and oral

biology, speaking to the Baltimore Sun about a study linking cancer and gum disease. Chronic inflamma-

tion anywhere, including swollen gums, causes the release of cytokines that can trigger insulin resistance.And obesity, a major cause of diabetes, is also now seen as a direct risk factor for periodontal disease .

(From Diabetes Health. 05 April 2007.)


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PAGE 4 TAKE CHARGE WITH CASE MANAGEMEN T: FOCUS ON DIABET ES & ORAL HEALTH VOLUME 6, ISSUE 2

We often take our teeth for granted, but the mouth is the

first part of the digestive process. Its amazing how what

we put into it and what comes out of it can get us in so

much trouble.

Most of us dont realize that the health of our mouths

affects our diabetes control, and that our diabetes control

affects our oral health.

Dry Mouth

One of the most common oral health problems for

diabetics is dry mouth or altered salivary flow (or

xerostomia, if you like medical terms). The teeth and

muscles in the mouth, face and jaw chew the food into

smaller pieces to facilitate digestion in the stomach and

intestine. The saliva has several functions. It prevents

infection by controlling bacteria in the mouth. It moistens

and cleanses the mouth by neutralizing acids produced by

dental plaque, and it washes away the dead skin cells that

accumulate on the gums, tongue and cheeks. It helps with

the digestion, making it possible to chew, taste andswallow food. Dry mouth occurs when there is not enough

saliva (real or perceived) to keep your mouth moist, which

is important for health, comfort and for speaking.

Diagnosis of dry mouth is difficult due to the subjective

nature of this condition.

In most cases, dry mouth is due to side effects of

medications. There are over 500 prescription and

nonprescription medications that have been found to cause

dry mouth. Medications that treat high blood pressure or

other heart problems are used by many patients to manage

complications of diabetes. Other drug groups that cause

dry mouth are those used for depression, anxiety and

allergies, as well as diuretics, anti-psychotics, musclerelaxants, sedatives and anti-inflammatory medications.

Caffeinated beverages also cause dry mouth, and these

should be limited.

Precautions

Ask your pharmacist about side effects of your medica-

tions in order to avoid any possible problems. It is impor-

tant that diabetes patients drink water frequently while on

these medications, as well as for their general health. Also,

be sure to see your dentist and dental hygienist for an oral

examination and dental prophylaxis at least every six

months to minimize or prevent the development of oral

health problems. Optimal oral health will improve yourdiabetes control and your

quality of life.

Editors Note: If a patient has dry

mouth, then it is not recom-

mended to use mouthwash with

alcohol. However, if dry mouth is

NOT a problemand not all

diabetes patients have this problemthen the most

effective mouthwash is one with alcohol, per dental

research on controlling oral diseases.

Dental Care for Dry Mouth PatientsThe diabetes patient with dry mouth along with his or her oral

health team will have to develop a routine for optimal oral health.

Here are some simple ways to accomplish that goal:

Perform oral hygiene at least four times daily, after each

meal and before bedtime Rinse and wipe the mouth immediately after meals.

Brush and rinse removable dental appliances after meals.

Use only toothpaste with fluoride. Some toothpastes (such as

Biotene) are formulated for dry mouth.

Keep water handy to moisten the mouth at all times.

Apply prescription-strength fluoride at bedtime as

prescribed.

Avoid liquids and foods with high sugar content.

Avoid overly salty foods.

Limit citrus juices (orange, grapefruit, tomato), as well as

diet sodas. Avoid rinses containing alcohol. Several nonalcoholic

mouthwashes are now available on the market.

Use a lip balm or moisturizer regularly.

Try salivary substitutes, gels or artificial saliva preparations.

These may relieve discomfort by temporarily wetting the mouth

and replacing some of the saliva constituents.

In severe cases, use of pilocarpine might be used under a

physicians care. Source: www.oncolink.org

The most common reasons for a dry mouth in a diabetes

patient are

Side effects of medication

Neuropathy (autonomic)

Lack of hydration

Kidney dialysis

Hyperglycemia

Mouth breathing

Smoking

Some clinical signs of dry mouth

Loss of moisture, glistening of the oral mucosa

Dryness of the oral membranes

Irritated corners of the mouth (cheilitis)

Gingivitis

Difficulty wearing dentures

Mucositis

Mouth sores

Yeast infection (Candidiasis), especially on the tongue and

palate.

Dental cavities: increased prevalence and located in sites

generally not susceptible to decay

Dry Mouth and Diabetes


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VOLUME 6, ISSUE 2TAKE CHARGE WITH CASE MANAGEMENT: FOCUS ON DIABETES & ORAL HEALTHPAGE 5

The sixth major complication of diabetes is periodontal disease.

Periodontal disease, or pyorrhea, is a painless disease of the supporting tissues of the teeth,

gums and bones of the mouth.

It is estimated that 80 percent of the adult population in the United States has periodontaldisease.

Once you have periodontal disease, it is almost impossible to eradicate it completely.

However, with the help of your dentist and hygienist, you can slow down its progression with early detection and

aggressive treatment.

Aside from periodontal disease, the mouth is vulnerable to these other problems that can affect people with

diabetes:

Altered taste often affects people with diabetes; it may result from a change in salivary chemistry, dry mouth

or the presence of yeast.

Dryness of the mouth may result from inactive or defective salivary glands. Dryness is also a manifestation of

poorly controlled diabetes. Yeast (candida) in the mouth is a fungal infection associated with elevated glucose levels and is a frequent

complication of diabetes.

Oral neuropathy, or numbness of the mouth, is a rare complication characterized by a burning sensation in the

mouth or on the tongue.

Halitosis, or bad breath, often occurs when periodontal disease is present. Bad breath is worsened by dry

mouth. Strong breath mints may help, but they only mask the problem, not solve it.

Ask Yourself About These Warning Signs of Periodontal Disease

Do your gums bleed easily when brushing or flossing?

Do you have loose teeth?

Are your gums red, swollen or tender?

Do you have unusually bad breath?

Do you have tartar formation (creamy brown, hard masses on tooth surfaces)?

Have you noticed a change in the way your teeth fit together when you bite?

Do you feel pain when you chew?

Are your teeth sensitive to temperature?

Guidelines for Basic Oral Hygiene

1. Brush your teeth at least twice a day2. Floss your teeth at least once a day

3. Avoid harsh mouthwashes4. Have your teeth cleaned regularly

Precautions for Visiting the Dental Office

Be sure your dentist knows you have diabetes and what medications you take.

Make your appointment at an appropriate time to avoid hypoglycemia (for those on insulin therapy).

Bring your glucose meter to your appointment.

Try to have your blood glucose levels in goal range during dental office visits.(From Diabetes Health. 01 March 2005.)

Caring for Your Teeth and Gums


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Take Charge with Case Management: Focus on Diabetes & Oral Health

Toni Badillo, RN., Chief, Medical Mgt Section/MCD, WBAMCDr Cecilia Del Moral, MD., Diabetes Champion, PAMC, WBAMC

Jean Bernardini, RN., CMC., Outpatient Case Manager, WBAMC

WI LL IAM BEA UMON T ARM Y MED ICAL CEN TE R

EL PASO, TX 79920-5001

Phone: (915) 569-3423

Fax: (915) 569-2712Email: [email protected]

To be the Standard Bearer for

Excellent Healthcare in theDepartment of Defense

On the Lighter Side . . .

How Much Do You Know About the Tooth Fairy? A Quiz with Answers

1. Should everyone be using a tartar control toothpaste?

A. False. Studies find that using tartar control tooth-

paste causes many peoples teeth to become sensitive to cold

(particularly if they have gum recession). The teeth

sensitivity stopped within a few weeks after discontinueduse of the tartar control toothpaste with very little change

in the amount of tartar buildup.

2. Raisins are a good snack and do not promote tooth

decay.

A. False. Raisins are very high in sugar and their

stickiness causes the sugar to stay on the teeth for long

periods of time. You should brush your teeth thoroughly

after eating raisins.

3. Diet sodas can cause tooth decay.

A. True. You may think that be-

cause diet sodas dont contain sugar,

that they are safe for your teeth as

they are for your waistline. Many diet

sodas contain phosphoric acid which

is a known cause of tooth decay.

4. In terms of cavity prevention, drinking tap water is

usually better than drinking bottled water.

A True. Most tap water now contains added

fluoride. Most bottled water does not contain

Fluoride.

5. Some toothpastes can whiten your teeth.

A. False. No toothpaste available contains any

bleaching ingredient which can whiten your teeth.

6. If you want to enjoy a sugary treat, when is the

most tooth-friendly time to eat it?

A. It is better to eat sugary foods along with a

meal to minimize the risk of tooth decay. Snacking

on sugary treats between meals is the worst for teeth.However, a high sugar diet is never great for teeth so

you should try to cut down your intake of sugary

foods.

DIABETES AND DENTISTRY

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