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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
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
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, 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.
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.
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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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.
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.
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
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.
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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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.
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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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
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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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.
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.
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.
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.
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
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- 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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