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Gum Disease

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Overview of Gum Disease

Periodontal problems can complicate the management of diabetes, and poorly controlled diabetes may aggravate periodontal diseases. About 85% of the U.S. population probably has some degree of periodontal disease, including the most common form, chronic adult periodontitis.

Because the prevalence of both chronic periodontitis and diabetes increases with age, establishing a relationship between them in the older age groups is extremely difficult. Recent studies in which the age relationship of periodontal disease is accounted for show that in type 2 diabetics, periodontal disease is more severe and more prevalent than in nondiabetics. These studies further show that adult diabetes patients have greater tooth loss from periodontal disease than nondiabetics of comparable age. However, it is generally accepted that adults whose diabetes is well-controlled do not have more gingivitis or destructive periodontitis than nondiabetics.

Although definitive proof of a cause-effect relationship between glycemic control and periodontal disease is not available, an increased susceptibility to acute lateral periodontal abscesses has been reported in uncontrolled diabetes mellitus. A study of patients with longstanding diabetes, accompanied by retinal changes, showed an increased severity of periodontal diseases.

Severity of Periodontal Disease Among Diabetic and Non-Diabetic Pima Indians
Severity of Periodontal Disease Among Diabetic And Nondiabetic Pima Indians
Periodontal tissue loss, measured in millimeters along the tooth root, is a key indicator of periodontal disease severity. For the Pima Indians of Arizona, a population with the highest rate of diabetes in the world, periodontal infection and tooth loss are significant complications of the diabetic condition.

Diabetes and periodontal disease do seem to be related in children and adolescents. The frequency and severity of gingivitis increase in prepubertal diabetic children, especially in those with poor metabolic control. In the l2- to l8-year-old age group in the United States, the prevalence of periodontitis in all forms is about 3%. However, the prevalence appears to be far higher, ranging from 11 to 16%, among those in the same group with insulin-dependent diabetes mellitus (IDDM).

In uncontrolled IDDM in both juveniles and adults, most observers agree that it is not unusual to find acute fulminating periodontitis, characterized by rapidly progressive pocket formation and bone loss, and frequently complicated by acute abscesses.

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Gingivitis/ Thrush/ Pathophysiology

Gingivitis

Gingivitis, characterized by inflamed and bleeding gums, is a precursor to chronic periodontitis, although not all gingivitis progresses to periodontitis. Gingivitis results from bacterial colonization at the gum margin and in the sulcus between the margin and the tooth. These bacteria and their products have direct inflammatory effects and also evoke an immunological response. Although these responses are mainly protective, they also cause progressive destruction of the connective tissue fibers, resorption of alveolar bone around the tooth, and deepening of the gingival sulcus or pocket. The resulting condition is called periodontitis, formerly known as pyorrhea.

Progress of Periodontal Disease
Image showing close up of normal, healthy gingiva Image showing close up of gingivitis
 Normal, Healthy
  Gingiva

 Gingivitis

image showing close up of periodontis image showing close up of advanced periodontis
 Periodontitis  Advanced
  Periodontitis

ADA, reprinted with permission

Thrush

Diabetics have elevated glucose levels in oral fluids when blood glucose is high, and these glucose elevations can influence the microbial flora, the composition of bacterial plaque, and the mixture of organisms at the bottoms of the periodontal pockets. Elevated glucose levels may in particular encourage the growth of Candida albicans, the causative agent in thrush, and oral C. albicans counts have been reported to be higher in diabetics than nondiabetics.

Pathophysiology

In addition to elevated glucose levels, other pathophysiological changes in diabetics may predispose the diabetic to periodontal disease. These changes include decreases in leukocyte chemotaxis, phagocytosis, and bactericidal activity, as well as decreased cellular immunity. Impaired neutrophil function may reduce resistance to periodontal infection during periods of poor diabetic control and local relative insulin insufficiency.

Other factors contributing to periodontal disease in diabetics may be vascular changes, including statis in the microcirculation, and altered collagen metabolism.

Dental infections themselves may worsen the diabetic state. As in other infections, dental infections result in hyperglycemia, mobilization of fatty acids, and acidosis. Exacerbation of dental infection may undermine good control that has been achieved in diabetes, and initial control may be difficult or impossible in a newly diagnosed diabetic with active dental infection.

Dental disease, especially severe periodontal disease, may also hamper systemic management by making chewing painful or difficult, leading the diabetic to select foods that are easier to chew but that may be dietetically inappropriate.

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Prevention

Diabetic Control

Dental infection in diabetes may rapidly cause a series of adverse metabolic consequences, including coma. Rapidly progressive periodontitis in adults, unlike the chronic form, is less responsive to conventional treatment such as subgingival scaling, debridement, and plaque control; and with continuing bone loss around the teeth, exacerbations may occur. Therefore, preventing infection through local measures and reducing susceptibility to infection by maintaining good control of diabetes are primary steps in the prevention of periodontal complications.

Oral Factors

Local factors, such as smoking and wearing dentures, particularly when dentures are worn continuously, may promote candidal colonization in the mouth. Attention to these predisposing factors could reduce the incidence of thrush in diabetes.

Natural Dentition

Because of the importance of diet in diabetes, diabetic patients need to be aware of the desirability of maintaining their own teeth. Most diabetic patients who lose their teeth become edentulous because of periodontal disease. Dentures may not be completely satisfactory replacements because the size and form of the remaining alveolar ridge for proper fit may be diminished. In addition, diabetic individuals may not tolerate full dentures well, especially when diabetes is poorly controlled, because of mucosal soreness and the need for frequent relining of the dentures. Every effort should therefore be made to preserve a healthy, functional, natural dentition so that diabetics may chew proper foods efficiently and comfortably.

As noted above, teenage diabetics may be at increased risk for periodontal infections and need to be especially counseled about preventive measures. Diabetes in the mother may have an influence on tooth development in the offspring, resulting in disturbances of mineralization of the primary dentition (hypoplasia of the enamel). There may also be a correlation between congenital dental defects and degree of diabetic control during pregnancy.

Oral Hygiene

Periodontitis can be arrested by local treatment aimed at plaque and calculus removal and improved oral hygiene, all of which are directed toward eradicating pathogenic bacteria that cause periodontal disease. Periodontitis is a bacterial infection strongly correlated with poor oral hygiene, and proper care of the mouth, teeth, and gums is especially important for diabetic patients.

Diabetic patients should have a dental examination every 6 months and should be sure to tell their dentists that they are diabetic.

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Detection and Monitoring

Signs and symptoms related to dental structures may furnish clues about the presence of diabetes. Dry mouth and thirst are classic symptoms of diabetes mellitus, and an increased incidence of thrush is considered a complication of diabetes. Rapid alveolar bone loss and acute or multiple periodontal abscesses suggest the presence of uncontrolled diabetes.

In screening for periodontal disease, the gums adjacent to the teeth should be examined for bright red or magenta tissue or purulence emanating from the margins. The outer and inner surfaces of the dental arches should be observed for fluctuence and purulence emanating from the crevices.

Self-Examination

Patients should be counseled to monitor themselves for the beginning of periodontal disease and to see a dentist if the gums bleed upon eating or brushing the teeth.

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Treatment and Referral

Acute Infections

When a patient with diabetes is found to have advanced periodontal disease, most dental treatment should be deferred until the diabetes is reasonably controlled. Acute infections, however, require immediate attention, including draining acute abscesses and administering broad-spectrum antibiotics. Complete metabolic control of diabetes may not be possible while dental infection is still present. However, if blood glucose can be reduced, the acute periodontal condition may subsequently improve.

Oral Surgery

Once infection has subsided, any necessary tooth extractions can be performed. When diabetes is under good control, oral surgery can be carried out as in a nondiabetic. Dental appointments should be scheduled in the morning, generally about an hour and a half after breakfast and the morning insulin.

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Patient Education Principles

Diabetes Control

Patients should be informed that periodontal infection may make it more difficult to control diabetes and conversely, poor diabetic control may increase susceptibility to periodontal infection.

Risk of Infection

Patients should know that diabetics may be more likely to get gum infections than nondiabetics, and the infections may take longer to heal. Long standing infection may lead to loss of teeth.

Natural Dentition

Because of the importance of proper diet in helping control diabetes, the desirability of maintaining natural dentition should be emphasized. Diabetics may have problems in wearing dentures.

Oral Hygiene

Patients should be informed that good oral hygiene will help prevent many periodontal problems. Bleeding gums may be a sign of infection, and diabetics who notice this or other unusual lesions in the mouth should see a dentist.

Dental Checkups

Because diabetics may often be unaware that they have periodontal disease, they should be encouraged to have a dental checkup every 6 months. Patients should make certain that the dentist knows about their diabetes.

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Dental Tips for Diabetics

  • Controlling your blood glucose is the most important step you can take to prevent tooth and gum problems. People with diabetes, especially those whose blood glucose levels are poorly controlled, are more likely to get gum infections than nondiabetics. A severe gum infection 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 preserve your 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 between the gums and the teeth in a vibrating motion. Place the rubber tip on the toothbrush between the teeth 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 determine if you have a beginning infection. You should also notify your dentist if you notice other abnormal changes in your mouth, such as patches of whitish-colored skin.

  • Have a dental checkup every 6 months. Be sure to tell your dentist that you have diabetes and ask him or her to demonstrate procedures that will help you maintain healthy teeth and gums.

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Gum Disease