Beverley A. Crawford, DDS is an Associate Professor of Clinical Dentistry and Director of Student Diversity and Inclusion Initiatives at Penn Dental Medicine and Yu Cheng Chang, DMD is an Assistant Professor of Clinical Periodontics and Director of Predoctoral Periodontics at Penn Dental Medicine.

Over the last year, Impacto has provided information on diabetes as part of the project Champions of Hope: Latinos Preventing Diabetes. In this article we continue with a discussion of diabetes and oral health.

Hispanic or Latino people share a diverse history and many traditions, but according to the Center for Disease Control and Prevention (CDC) they are all more likely to have Type 2 diabetes. While all adults in the US have a 40% chance of developing diabetes, Hispanics have a 50% likelihood of developing the disease. Hispanics also tend to develop the disease at an earlier age, having higher rates of diabetes-related complications, including kidney failure and vision loss. In every aspect of diabetes and its complications, racial and ethnic minorities have higher rates.

The high prevalence of diabetes among the Hispanic group also corresponds to a high prevalence of periodontitis, an inflammation of the soft tissue (gums) around teeth, among the Hispanic population. The 2009–2014 National Health and Nutrition Examination Survey found that 42.2% of dentate adults 30 years or older in the United States have periodontitis. Of them, 7.8% have severe periodontitis and 34.4% have mild to moderate periodontitis. It is important to note that severe periodontitis was most prevalent among Mexican Americans, non-Hispanic blacks, smokers, and adults 65 years or older. Are these two diseases related?

As you may already know. Diabetes is a chronic metabolic disease that disrupts the way our body processes the food we eat, causing the blood sugar levels to be elevated. Glucagon and insulin are the hormones that keep sugar levels in our blood balanced. After a meal, blood sugar levels rise, and insulin is released from the pancreas in response, to bring the sugar to the body cells where it is needed for energy. Unfortunately, patients with diabetes do not produce sufficient insulin, or their cells stop responding to insulin appropriately to stabilize their blood sugar. The condition will affect many body organs, including the heart and blood vessels, nerves and brain, eyes, teeth, and kidneys. Elevated sugar levels in the blood damage the blood vessels, which can cause heart disease, stroke, or heart failure. Furthermore, injuries take longer to heal or even result in serious infection.

There are oral symptoms of diabetes. Recent studies have added gum disease or periodontal disease as the sixth major complication of diabetes. New research indicates that the connection between diabetes and oral health is a two-way street. Diabetes is not considered to cause the development of periodontal disease or gum inflammation, but because of the systemic problems associated with diabetes, there is a decreased resistance to infections. Diabetes can accelerate the progression of the condition, and periodontal disease can worsen the effect that food or a meal has on blood sugar levels and increase the risk of diabetes complications. A long-term study found that people with diabetes who had moderate or severe periodontitis were at least twice as likely to have kidney complications (including end-stage renal disease) than people with diabetes but without periodontitis.

Usually, your primary care doctor will screen for diabetes through blood work. However, the dentist, by documenting the number of missing teeth and measuring the depths of the openings between the tooth and gums, called periodontal pockets, can make an early diagnosis of diabetes. According to the American Dental Hygienist’ Association (ADHA), dental hygienists responsible for cleaning a patient’s teeth often detect symptoms of diabetes during routine six-month dental examinations. The patient may complain of cheilosis (scaling of the lips and cracks between the upper and bottom lip), dry mouth, bleeding gums, burning mouth and tongue, and bad breath. The hygienist may notice thick or ropey saliva and tooth decay due to high glucose levels in the saliva, some tell-tale signs of the condition. Why is the dry mouth a problem? With the decreased saliva you lose the natural barrier of the first immune protection. This may lead to further infection by fungus such as Candida albicans, or bacteria such as hemolytic streptococci, or staphylococci. The periodontium will respond to these pathogens and trigger a series of immune responses, which lead to advanced inflammation, bleeding gums, tooth mobility, or tooth loss which is periodontitis. Furthermore, decreased insulin production observed in diabetic patients, will impact the bloodstream traveling to tissues and impact the process of wound healing and even cause infection. The impairment of the wound healing process affects the body’s mechanism against infection and the repair of damaged tissue. Undiagnosed or untreated diabetes can also affect healing after tooth extractions.

How can an oral health provider help if I have Diabetes?

From another perspective, uncontrolled periodontitis is also associated with worsening glycemic control over time. The uncontrolled inflammation and systemic infections will increase serum levels of inflammatory molecules associated with increased insulin resistance. Another hypothesis is that the pathogens that trigger periodontitis (gram-negative bacteria) may contribute to increased insulin resistance and poor glycemic control. The connection between diabetes and oral health is the blood sugar level. If this is not controlled, then oral health problems can develop. Treatment includes nutritional counseling, good oral hygiene (brushing twice daily with a soft toothbrush and flossing to remove plaque build-up), and regular dental office visits at least every 3- 6 months. Limiting your intake of fried foods, foods high in salt, sweets, such as baked goods, candy, and ice cream, and drinking water instead of sweetened beverages is also very helpful in controlling the blood sugar level.

Epidemiology and numerous research on this topic have concluded that periodontal therapy is associated with a statistically significant and clinically relevant improvement in glycemic control in patients with diabetes and periodontitis. Both diabetes and periodontitis are inflammatory diseases; the disease severity and progression are impacted by the person’s immune response and the pathogens. Multiple studies suggest that periodontal therapy is most likely to result in short-term improvement in glycemia in those diabetic patients with severe periodontitis and poor metabolic control. Things may have sounded very complicated, but the actions are relatively simple. Routine periodontal treatment is usually referred to as teeth cleaning. Your dentist will evaluate your periodontal health and determine the treatment type most beneficial to you. It may be just regular prophylaxis (cleaning) to prevent periodontitis or teeth debridement (deep cleaning) to control the periodontitis. A surgical approach may be needed in some severe cases to avoid early teeth loss.

Overall, it’s essential to have your medical and dental providers evaluate your conditions and fabricate a comprehensive treatment plan to control your glucose sugar level and periodontal health. A regular visit with your dental provider is critical to maintaining your oral health and diabetic condition. Call your primary health provider and your dentist today.

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