The incidence of diabetes has increased dramatically over the last few decades. It is notorious in affecting multiple systems within the body, one of which is the mouth. In fact, diabetes contributes a great extent to oral and dental disease requiring regular visits to the dentist for different multiple related complications. There is a robust database of clinical evidence that supports the impact of diabetes on oral health.
Unfortunately, despite this evidence, patients with diabetes rarely take good care of their oral health which is primarily because of lack of awareness.
This article aims to discuss diabetes and your mouth, and talk about some of the common oral problems seen in patients with diabetes.
Why do people with diabetes have poor oral health?
There are a number of different reasons why this may occur.
- The high blood sugar levels that are seen in diabetes can affect the small blood vessels that supply the surface of the tooth and gums. The reduced blood supply leads to increase the incidence of infections and poor healing.
- The immunity in individuals with diabetes is low. This means that the ability of the affected patient to ward off infections of the oral cavity is reduced.
- Saliva contains components within it that can fight infection. Patients with diabetes can develop a dry mouth – a condition called xerostomia. Xerostomia is a result of nerve damage from diabetes (called autonomic neuropathy). A dry mouth can increase the chances of developing infections.
The chances of developing oral diseases in Type II diabetes is three times more than those without diabetes. In children, the lack of saliva can cause gum inflammation and a painful oral cavity.
The Indian scenario
Studies in Indian population groups have shown that periodontal disease is the most common type of dental disease seen in patients with diabetes. The primary reason for this is poor awareness regarding oral hygiene practices.
What are the common oral diseases seen in diabetes?
If you suffer from diabetes, then there is always a chance that you may develop any of the following conditions.
Periodontal disease refers to inflammation of the gums (gingivitis) and extension of this inflammation into the tooth and underlying bone (called periodontitis). Studies have shown that the incidence of periodontal disease is significantly higher in patients with diabetes as compared to those who do not have diabetes.
Symptoms and signs
The condition is often painless in the early stages and many individuals are unaware that they suffer from it. However, as the disease progresses, the gums can become red and inflamed, swollen and tender. Bleeding or oozing may occur from the gums and gaps may form in between the teeth. The accumulation of pus and the presence of infection in between the teeth may also be seen. Smoking tends to contribute further to the development of periodontal disease.
Why it develops
The primary reason for the development of periodontitis is poor oral hygiene. Clinical studies have shown a ‘bidirectional relationship’ between periodontal disease and diabetes. In other words, not only does diabetes increase the risk of periodontal disease, but it appears that the presence of periodontal disease can affect how well blood sugars are controlled in individuals with diabetes.
Another factor that leads to periodontitis in diabetes is the presence of dental plaque. High blood sugars and advanced glycation end products (AGEs) in the gums and periodontal tissues can also worsen the inflammation.
The most common clinical symptom is bleeding gums. Bad breath and receding gums are other commonly noted symptoms. Pain may or may not be present and some individuals complain of loosening of their teeth.
So how can periodontal disease be managed in diabetes?
The first and most importantly is to maintain good oral hygiene. Brushing regularly (twice daily) with a good quality toothpaste and flossing the teeth is important. Using mouthwash is can help kill any germs that may remain in the mouth after brushing.
It is also important to visit the dentist on a regular basis to ensure your teeth are clean and healthy.
From diabetes point of view, it is important to make sure that your blood pressures are well controlled. This can be easily done through home monitoring of blood sugars. If you find that your blood sugars are constantly elevated or you are developing tooth pain, make sure you visit your Doctor or dentist as soon as possible.
Dental caries is a condition where the teeth are affected by the long-standing bacterial infection. If you open your mouth and stare into the mirror, you may be able to see small black spots within the grooves of the teeth. This is dental caries.
How does dental caries affect the tooth?
The mouth is probably the most infected part of the human body and is teeming with millions and millions of bacteria. It is therefore not surprising that the teeth in our mouth can get affected by infection and dental caries. The saliva in our mouth acts as a natural antiseptic agent and helps to keep the oral cavity and the teeth clean.
In patients with diabetes, the high blood sugar levels act like a food for these bacteria and help them grow even further. Furthermore, the amount of saliva that is present in the mouth is less. Bacteria such as Streptococcus grow in the dental plaque and release weak acids into the oral cavity. These weak acids render the oral cavity acidic which can lead to loss of tooth material and demineralisation of the tooth structures. This results in dental caries.
Studies have shown that nearly 42% of patients with diabetes suffer from dental caries.
Managing dental case in diabetic patients
As always, maintaining good oral hygiene by brushing twice daily, rinsing the mouth after meals and using a good quality mouthwash are extremely important. Regular visits to the dentist can pick up dental caries at a very early stage and treatments can be started sooner rather than later and stop
The World Health Organisation recommends reducing the amount of simple sugars (sweets, sugary drinks etc) to less than 10% of the total energy intake. This is clearly an easy thing to do.
Remember, dental caries can be prevented very easily by being very strict with regards to your oral hygiene.
Burning mouth syndrome
Many patients with diabetes who visit our clinic complain of a burning sensation in the mouth when they eat their food. This is because diabetes can affect the nerve fibers that supply the inner aspect of the mouth and irritation of these nerve fibers from the food can cause a burning sensation. This condition is sometimes called burning mouth syndrome or BMS.
BMS is very similar to the burning sensation that diabetic patients experience in their feet (called peripheral neuropathy). This similarity means that treatments offered for peripheral neuropathy will also help manage burning mouth syndrome. Painkillers such as Pregabalin and Gabapentin have been proven to be of some benefit. Multivitamin supplements that contain vitamin B6 and B12 are also helpful.
There are other conditions that affect the mouth that are particularly common in diabetic patients. One such condition that links diabetes and oral health is oral candidiasis, which is a fungal infection of the inner surface of the mouth. This condition can even be seen in patients with well controlled diabetes (76.47%). However, the incidence is higher in those with poor control (82.5%). Antifungal therapy is often needed.
Another condition, as mentioned previously, is dry mouth, also called xerostomia. This condition occurs as the salivary glands do not function well. This is because the nerves that supply these glands are affected by diabetes. Altered taste sensation and bad breath are common symptoms. Certain sprays and drugs are available that can increase saliva production.
The link between oral health, diabetes and heart disease
Did you know that your heart may be affected by poor oral hygiene?
There is sufficient clinical evidence to suggest that oral infections are directly linked to the development of atherosclerosis.
In fact, within the atherosclerotic plaque are present bacterial DNA which have emerged from the oral cavity.
Bacterial infection within the mouth can increase the release of certain inflammatory products such as cytokines into the circulation. Cytokines are responsible for initiating the process of atherosclerosis. The level of cytokines in the blood stream in patients with diabetes is significantly higher than those without diabetes.
Interestingly, there appears to be a link between periodontal disease and heart disease. Patients who have suffered from ischemic heart disease (such as angina or heart attacks) seem to have a higher mortality rate if they have accompanying severe periodontitis.
So what are the recommendations regarding maintaining good oral health?
Maintaining good oral health is very simple. The steps below should guide you with regards to what you must be doing.
- Brush your teeth twice daily regularly with a good quality fluoride toothpaste.
- Floss your teeth when brushing to remove any food particles that may be stuck in between the teeth.
- Use a good toothbrush that also massages the gums while brushing your teeth.
- Visit your dentist regularly and always keep your follow-up appointments. Never ignore the warning signs such as bleeding gums or tooth pain.
- Make sure that your blood sugar levels are adequately controlled and that you are continuing to get plenty of exercise whilst maintaining a regular healthy diet.
Taylor, George W. “Bidirectional interrelationships between diabetes and periodontal diseases: an epidemiologic perspective.” Annals of periodontology 6.1 (2001): 99-112.