Dr Frank Varon, DDS has spent significant time working with diabetic dental patients and knows well the improvements that proper dental care can have on glucose control. His first feature for us Diabetes and the Dental Patient points out the oral conditions that affect diabetes and how we as medical professionals can help our patients.
Diabetes and the Dental Patient
Dr. Frank Varon, DDS
PERIODONTAL DISEASE AND DIABETES
Periodontal disease is a chronic bacterial infection that affects the gum and bone supporting the teeth. It is a serious infection that, if left untreated, will lead to tooth loss. In untreated cases, periodontal disease can be life threatening for diabetic patients. The disease can affect one tooth or many teeth. It begins when the bacteria in plaque—the sticky, colorless film that constantly forms on teeth— cause the gums to become inflamed.
In the mildest form of the disease, gingivitis, the gums redden, swell and bleed easily. Contrary to popular belief, bleeding gums are never normal. There is usually little or no discomfort. Gingivitis often is caused by inadequate oral hygiene and is reversible with professional treatment and good oral home care.
Untreated gingivitis can advance to periodontitis. Toxins produced by the bacteria in plaque irritate the gums. The toxins stimulate a chronic inflammatory response in which the body in essence turns on itself, and the tissues and bone that support the teeth are broken down and destroyed. Gums separate from the teeth, forming pockets—spaces between the teeth and gums—that become infected. As the disease progresses, the pockets deepen and more gum tissue and bone are destroyed. Often that destructive process has very mild symptoms. Eventually, teeth can be-come loose, the way the teeth bite together may change and teeth may be lost. The main cause of periodontal (gum) disease is bacterial plaque. However, there are many factors that influence the health of the gums:
• smoking and tobacco use
• pregnancy and puberty
• clenching and grinding the teeth
• poor nutrition
• other systemic diseases
Periodontal disease also has been linked to coronary artery disease, strokes, low birth weight and premature infants, and stroke. Also many medications directly and indirectly affect the gums. Those medications can cause a gingival hyperplasia and further complicate the treatment of gum disease. No one is in a better position to alert patients to potential oral health side effects than the pharmacist who dispenses those medications and is fully aware of the patient’s health profile. Consequently, he or she is in an excellent position to advise patients with diabetes about preventive strategies and OTC health care products available to minimize unwanted oral side effects.
The most studied medications are cyclosporine, phenytoin and calcium antagonists. The reasons are not well understood, but it is multifactorial. Among the factors are poor oral hygiene and the presence of dental plaque that may provide a reservoir for the accumulation of cyclosporine or phenytoin, the depth of the periodontal pocket on probing, and the dose and duration of cyclosporine therapy. With a population that is more aware of oral hygiene practices those problems are rare.
The hormonal effects resulting from pregnancy, puberty and the contraceptive pill also have been related to gingival hyperplasia. Increased progesterone secretion alters the gingival vasculature and the inflammatory response to accumulated plaque.
People with diabetes are more likely to have periodontal disease than are people without diabetes, probably because diabetics are more susceptible to contracting infections. In fact, periodontal disease often is considered the sixth complication of diabetes. Furthermore, studies have found a link between periodontal disease and coronary artery disease in adults with type 1 diabetes.
Those people who don’t have their diabetes under control are especially at risk. A recent study found that poorly controlled type 2 diabetic patients are more likely to develop periodontal disease than are well-controlled diabetics.
Research has emerged that suggests that the relationship between periodontal disease and diabetes goes both ways—periodontal disease may make it more difficult for people who have diabetes to control their blood sugar, and people with uncontrolled diabetes have difficulty in eliminating periodontal disease. The link between the two conditions is a two-way street.
Severe periodontal disease can increase blood sugar, contributing to increased periods of time when the body functions with a high blood sugar. That puts diabetics at increased risk for diabetic complications. It is thus even more important for people with diabetes to seek treatment to eliminate periodontal infection than it is for otherwise healthy persons.
That recommendation is supported by a study involving Pima Indians. The study in 1997 involved 113 Pima Indians with both diabetes and periodontal disease. The study found that when their periodontal infections were treated, the management of their diabetes markedly improved.
• More than half of all adults have at least the early stages of gum disease.
• About 90 percent of adults have gum disease at some time during their lives.
• People with diabetes are at higher risk for gum problems and tend to have more gum disease and infections.
• Poor blood glucose control makes gum problems more likely. Gum disease can start at any age. Children and teenagers who have diabetes are at greater risk than those who don’t have diabetes.
• Patients can be educated about gum disease and its prevention, and it is here that the medical professional plays an important role by encouraging meticulous daily oral hygiene practice.
• Patients should be alerted to early signs of gum disease, such as bleeding or slight gum discomfort.
• Twice-yearly dental visits are important, more often if there are problems.
• For edentulous (without teeth) patients, yearly visits are recommended for checking the health of the tissues and to detect possible infections.
Xerostomia is a dryness of the mouth, having varied etiologies, resulting from diminished or arrested salivary secretion. There are many different salivary gland problems, of which diabetes is but one. The glands are found in and around the mouth and throat. The major salivary glands are the parotid, submandibular and sublingual glands. They all secrete saliva into the mouth, the parotid through tubes that drain saliva, called salivary ducts, near the upper teeth, sub-mandibular gland under the tongue and the sublingual through many ducts in the floor of the mouth. Besides those glands, there are many tiny glands called minor salivary glands located in the lips, in the inner cheek area (buccal mucosa) and extensively in other linings of the mouth and throat. Salivary glands
produce the saliva used to moisten the mouth, initiate digestion and help protect teeth from decay. The parotid gland has a higher frequency of problems than the other glands.
Salivary gland problems that cause clinical symptoms include:
Obstruction to the flow of saliva most commonly occurs in the parotid and submandibular glands, usually because stones have formed. Symptoms typically occur when one is eating. Saliva production starts to flow, but can-not exit from the ductal system, leading to swelling of the involved gland and significant pain, sometimes with an infection. Unless stones totally obstruct saliva flow, the major glands will swell during eating and then gradually sub-side after eating, only to enlarge again at the next meal. Infection can develop in the pool of blocked saliva, leading to more severe pain and swelling in the glands. If untreated for a long time, the glands may become abscessed.
It is possible for the duct system of the major salivary glands that connects the glands to the mouth to be abnormal. Those ducts can develop small constrictions, which decrease salivary flow, leading to infection and obstructive symptoms.
Infection: The most common salivary gland infection in children is mumps, which involves the parotid glands. While it is most common in children who have not been immunized, it can occur in adults. However, if an adult has swelling in the area of the parotid gland only on one side, it is more likely due to an obstruction or a tumor. Infections also occur because of ductal obstruction or sluggish flow of saliva be-cause the mouth has abundant
Patients may have a secondary infection of salivary glands from nearby lymph nodes, which are the structures in the upper neck that often become tender during a common sore throat. In fact, many of the lymph nodes actually are located on, within and deep in the sub-stance of the parotid gland or near the submandibular glands. When the lymph nodes enlarge through infection, patients may have a red, painful swelling in the area of the parotid or submandibular glands. Lymph nodes also enlarge be-cause of tumors and inflammation.
Tumors: Primary benign and malignant salivary gland tumors usually show up as painless enlargements of those glands. Tumors rarely involve more than one gland and are detected as a growth in the parotid, submandibular area, on the palate, floor of the mouth, cheeks or lips. An otolaryngologist-head and neck surgeon should check those enlargements.
Malignant tumors of the major salivary glands can grow quickly, may be painful and can cause loss of movement of part or all of the affected side of the face. Those symptoms should be investigated immediately.
Other Disorders: Salivary gland enlargement also occurs in autoimmune diseases such as HIV and Sjögren’s syndrome, where the body’s immune system attacks the salivary glands, causing significant inflammation. Dry mouth or dry eyes are common. That may occur with other systemic diseases, such as rheumatoid arthritis. Diabetes may cause enlargement of the salivary glands, especially the parotid glands. Alcoholics may have salivary gland swelling, usually on both sides.
Another rare sign of uncontrolled or poorly controlled diabetes is a bilateral enlargement of the parotid glands. While that may look like a mild case of the mumps, it is usually a visual sign of problems with disease management for these patients.
For the person with poorly controlled diabetes, a dry mouth is commonplace. It may be due to an autonomic neuropathy (a diabetes complication), medication side effects or infections in the salivary glands caused by poor flow levels. It also may be known as secondary xerostomia while primary xerostomia is due to direct diseases of the glands.
The most frequent medication causing those secondary problems are the anti-hypertensives and anti-psychotics. High blood pressure is a common diabetes complication, and while it is imperative that it be treated pharmacologically, one must be aware of the potential oral side effects those medications may cause. Many studies have shown a relationship between calcium channel blockers and periodontal problems. There are more than 400 medications, both over and under the counter, that list dry mouth as a possible side effect. For patients receiving the medications, advice about potential oral health problems is important, as is emphasis on the need for regular dental visits.
Mediacl Practitioners who prescribe those drugs to their patients on a regular basis should therefore alert patients to the potential problems and reassure their patients that appropriate OTC oral health care products are available to relieve the symptoms.
Persistent dry mouth will result in problems with recurrent decay and gum disease as well as bad breath. Root caries is especially prominent in those patients, who are often elderly, owing to normal gum recession and the exposure of the root surface to the oral environment.
DENTAL CARIES AND DIABETES
Dental caries or tooth decay is caused by a bacterial infection of the hard tissue of the tooth. A few hours after teeth are brushed, bacteria and food particles will form plaque on the tooth surfaces. Those bacteria produce an acid that erodes the calcium in the tooth’s enamel and leads to the formation of minute cavities. If left untreated, the acid eventually will eat through the tooth enamel and begin eroding the dentin layer beneath it. Owing to the porosity of the dentin layer, it is eroded much faster than the overlying enamel; hence, a large cavity could be forming inside the tooth without showing many visible signs.
As the decay continues, bacteria migrate through the porous dentin layer and infect the pulp inside the tooth. The pulp contains nerves and blood and lymph vessels. When the body launches an immune response to the infection, the blood vessels around the tooth enlarge and press against the nerves entering the tooth, causing the tooth to ache.
If the infection proceeds and a significant number of bacteria invade the pulp, then the tooth and nerve may die. That may stop the pain; however, because the body still is fighting the infection, an abscess may form. A tooth abscess forms around the tip of the tooth’s root. It will cause the tooth to ache constantly and will be extremely painful to chew on. If the abscess is left untreated, it will begin to erode the bone around the tooth and may lead to the formation of a small fistula, or canal, through the bone and its overlying gum. Just before the fistula reaches the surface of the gum, a swelling, or boil, may form. It can persist or burst, releasing foul-tasting pus into the mouth.
Tooth decay usually does not pose a serious health risk if treated early. How-ever, if the decay progresses, the tooth will likely die. The spreading infection may enter the bloodstream, causing septicemia, a swelling in the face and neck, and a general feeling of malaise.
The best advice the medical professional can give to a patient who presents for advice with such signs and symptoms of a serious spreading infection, is an immediate referral to a dentist or physician.
The subsequent need for an extraction is not without hazard for patients with diabetes. The medical professional should re-mind the obviously stressed patient or caregiver of the need to inform the dentist that the patient has diabetes. Should conscious sedation requiring a skipped meal be planned, the patient will need the physician’s advice regarding medication and diet management.
Should the medical professional be told that extensive surgery is planned for one of his or her diabetic patients, he or she can perform an important service by reminding the patient or caregiver to watch caloric and carbohydrate intake following surgery. That is especially important if chewing becomes painful after the
procedure, in which case a liquid food substitute, readily found on the pharmacy shelf, may be needed.
Patients with diabetes are not good candidates for glucocorticosteroids, which sometimes are prescribed after surgery to reduce swelling. The medical professional, aware that those drugs raise blood glucose levels, is in a position to discuss the matter with the prescribing dentist before dispensing the medication.
The best treatment to control or avoid dental caries is prevention. Through proper brushing, flossing, a low carbohydrate diet and dental visits the chances of significant dental decay are reduced greatly. Dental sealants also can be used as a good preventative measure. If tooth decay exists, then the decay can be removed and a filling placed in the tooth. More advanced decay involving the pulp may require the dentist to per-form a root canal. If an abscess has formed, an apicoectomy also may be necessary. The goal of that surgical procedure is to remove the infected tissue at the base of the root. If the tooth and underlying bone is decayed severely, the tooth may need to be extracted.
For the person with diabetes, studies have not found a good relationship between the incidence of dental decay and diabetes. However, the effects of primary and secondary xerostomia will increase the rate of decay if it exists.
The incidence of various other oral infections, however, is related directly to the level of glycemic control in the patient. The most frequent infection is Candida. Also known as oral thrush, that condition is commonly found in many immune-compromised hosts. Sites of infection include the internal oral mucosa and the lips.
For infections of the oral cavity, it can be best treated with a 14-day course of fluconazole (Diflucan 100mg bid). That may have to be repeated depending on the response. It also can be found on the corners of the mouth and lip. That frequently happens when a denture prosthesis does not fit properly. The anti-candida
rinses have limited efficacy owing to low con-tact time and are falling out of favor with dentistry.
Other problems include mucormycosis, a rare fungal infection; necrotizing cellulitis; and deep neck infections of dental origin. Those problems, though rare, can be life-threatening and will re-quire immediate medical attention. Oral infections also can be caused by ill-fitting dentures. Some patients will wear their dentures day
and night, and the gum tissue under the denture becomes an ideal site for a yeast infection. Denture wearers should remove their pros-theses at night.
ORAL CARE FOR PEOPLE WITH DIABETES
Long-term studies have proven the value of consistent and regular oral hygiene care routines. Regular and timely dental visits are imperative to reinforce those habits and to minimize oral health problems.
The basics of oral care for all people include brushing, flossing, mouth rinsing and tongue cleaning. Special care in many of those areas is important for people with diabetes.
Teeth should be brushed at least twice daily with a soft brush. If possible, teeth also should be brushed after meals. The use of a brush with soft bristles is very important. Stiff bristles or too rigorous brushing can damage the gums and in-crease the potential for problems.
The variety of brushes available in-creases on an almost daily basis. Choices exist with regard to the size of the brush head, shape of the brush, and shape and flexibility of the handle. Patients should be encouraged to try different brushes so they can identify the one they find most comfortable. Consideration also may be given to electric brushes. A good-quality electric brush may make it easier for many people to brush more effectively without exerting unnecessary pressure that is potentially damaging.
Patients also should be encouraged to floss. Ideally, teeth should be flossed at least once daily. Again, a wide array of flossing products is available in most pharmacies. And, again, patients should be encouraged to try various flossing products so that they find one they like and will use. Several types of flossing tools designed to make flossing easier are also available.
Mouth rinsing also can be part of good oral health, but care should be taken to select a mouth rinse that meets the patient’s specific needs. Some mouth rinses have fluoride and are intended to decrease cavities. Those mouth rinses typically have little effect with regard to gum disease and bad breath. Other products are
intended to be used before brushing and are for the purpose of increasing the effectiveness of brushing. For people with diabetes the greatest areas of concern tend to be with gum disease and bad breath. Those people need a mouth rinse that addresses bacteria and the by-products of bacteria that contribute to gum
disease and bad breath.
A key area of concern for people with diabetes is the amount of alcohol in a mouth rinse. Of particular concern is the drying effect of alcohol. As indicated above, saliva plays an important role in oral health. Anything that has a drying effect on oral tissues is likely to increase oral health problems, including the potential for bacterial growth. Increasingly, attention is being given to the role of bacteria with anaerobic activity and their output of volatile sulfur compounds. Mouth rinses containing oxidizing agents are recommended in that regard. It also is recommended that mouth rinses be sugar free and alcohol free.
While attention has long been given to the importance of the gums in oral health, the tongue largely has been overlooked. Recently, there has been greater recognition of the role of tongue cleaning in maintaining good oral health. There are a variety of approaches to tongue cleaning. The simplest is to clean the tongue
using a toothbrush. However, for many people, the use of a regular toothbrush to clean the tongue will be limited by the size of the toothbrush and its potential to produce a gag reflex when it is used on the back of the tongue. Increasingly tongue scrapers and cleaners are coming into common usage. Tongue brushes also
have been well received by many patients.
People with diabetes are more likely to have periodontal disease than are people without diabetes. Furthermore, studies have found a link between
periodontal disease and coronary artery disease in type 1 diabetic adults.
Those people who don’t have their diabetes under control are especially at risk. A recent study found that poorly controlled type 2 diabetic patients are more likely to develop periodontal disease than are well-controlled diabetics. And periodontal disease may make it more difficult for people who have diabetes to control their blood sugar.
Medical professionals have an opportunity to improve the health care of their patients by educating them about the relationship between diabetes and oral health and by encouraging good oral health care.
Frank Varon has been a general dentist since 1985 graduating from the University of Texas Dental Branch, Houston. He maintains a general dental practice in Omaha, Nebraska. He has strong interests in oral medicine especially diabetes care and women’s health issues. He is a member of the American Dental Association, Nebraska Dental Association, Omaha District Dental Society, and the Academy of General Dentistry. He is the NDA dental representative to the Nebraska Diabetes Control
He maintains his interest in diabetes care issues as a professional section member of the American Diabetes Association, Councils on Complications and Clinical Endocrinology, Health Care Delivery & Public Health. He currently is a participating partner with the National Diabetes Education Program, a joint program of the National Institute of Diabetes, Digestive, and Kidney Disorders and the Centers for Disease Control and Prevention Diabetes Translation Division. He has previously served on the Heartland Chapter of the American Diabetes Association Board for Nebraska, Western Iowa, and South Dakota. He was appointed to serve as the Dental representative for the Sarpy/Cass County Department of Health and Wellness.