Some people call periodontal disease the sixth complication of diabetes after retinopathy, nephropathy, neuropathy, cardiovascular disease and poor wound healing.
By Shelley Diamond, BScPhm
Illustration by Martin Bregman
Several epidemiological studies have shown that the incidence of periodontal disease in people living with diabetes is three-fold compared to people without diabetes. The reason for this is not exactly clear, but many studies have shown that inflammatory mediators and proteins which are modified by hyperglycemia, such as advanced glycated end products (AGES), may be the cause. There is a clear relationship between the degree of hyperglycemia and the severity of periodontitis.
Periodontitis is a chronic inflammatory disease which results in periodontal pocket formation, loss of connective tissue attachment and alveolar bone resorption, all which can lead to eventual tooth loss. Without proper oral hygiene, oral bacteria form plaque which is resistant to immune cells and chemicals. Mechanical debridement is required to remove the plaque, and without this, gingivitis results within a few days. Gingivitis is chronic but reversible with appropriate plaque removal. Gingivitis takes months or years until it becomes irreversible.
There appears to be a two-way relationship between gum disease and diabetes. Studies have shown that people with periodontal disease, who do not have pre-existing diabetes, have a higher incidence of uncontrolled blood glucose levels and/or higher A1C levels.
What can your patients with diabetes expect in terms of their periodontal care?
Like diabetes, periodontal disease is a chronic condition that needs to be managed and cannot be cured. Treatment of periodontitis has been shown to be associated with an A1C reduction of approximately 0.4%. When people with diabetes visit their dentist, they can expect that they will require scaling to remove plaque and calculus (hardened plaque), which harbour anaerobic bacteria that are difficult to remove with self-care.
It is this bacterial colonization in deep pockets that leads to the progressive destruction of the ligaments and bone that hold the teeth in place. With inflammatory disease and depending on the severity, antibiotics or antiseptics may be used locally or a patient may start on a low dose of an oral antibiotic for several months. In some cases, surgical intervention may be required, such as contouring of the gingiva to provide better access for scaling, or bone grafts when there is bone loss.
Not all people with diabetes are aware of the need to have extra preventative oral care. The cost associated with extra visits can be a barrier. While most people visit their dentist every six months, people living with diabetes with signs of periodontal disease are usually seen every three to four months.
- Diabetes is a significant risk factor for periodontitis
- The risk of periodontitis is greater if glycemic control is poor
- People with poorly controlled diabetes are at an increased risk of periodontitis (and also most at risk for the other macrovascular and microvascular complications)
The link between oral and systemic health has been firmly established. Like the chicken and the egg story, oral complications can be an indicator of uncontrolled blood glucose levels. At the same time, diabetes can result in increased oral complications.
So how will you prepare your patients with diabetes so they can reduce their risk of periodontal issues? And will you refer your patients who may have existing periodontal disease to have their blood glucose checked? Y
You can have a large impact on improving oral health by recommending your patients with diabetes have regular dental visits, which in turn can have an impact on their long-term complications.
It is also important to be aware of those patients who may be picking up a prescription for painkillers following gum surgery, and who may be already receiving an antihypertensive or cholesterol-lowering medication. It wouldn’t be unrealistic to suggest that they ask their physician for a blood glucose test.
Shelley Diamond BScPhm is the president of Pedipharm Consultants and Diabetes Care Community Inc. (www.diabetescarecommunity.ca)