By Dr Emmanuel W Francis
What is diabetes?
Diabetes is a noncontagious, systemic disease characterised by sustained high blood sugar due to problems with insulin production or action. Insulin is a hormone produced by the pancreatic gland (pancreas) to remove sugar from the blood when levels become too high. Excess sugar removed from the blood is stored by the liver for release by a feedback mechanism when blood sugar levels drop too low. However, sugar overload from excess dietary consumption is stored as fat.
How common is diabetes?
The incidence of diabetes in the Bahamas was estimated at about 10 per cent by the Minister of Health in 2006. It is interesting to note that Dr Kirtland Culmer, in a 2000 Bahama Health article on diabetes, reports that 50 – 60 per cent of Bahamians will have diabetes in their life time, and that 50 – 60 per cent of these will have high blood pressure (HBP) as well. The incidence of diabetes is on the increase as more and more young people are affected, and sugar and refined food consumption escalates.
What are the complications of diabetes?
• Heart disease is the leading cause of diabetic death
• Risk of stroke is 2 – 4 times higher
• Leading cause of blindness in adults 24 – 74 years (retinopathy)
• One of the leading causes of end stage kidney disease resulting in need for dialysis.
• Severe forms of nerve disorders (neuropathy)
• Majority of limb amputations
• Increased infections
• Dental diseases
What are the dental diseases caused by diabetes?
This is an inflammatory condition where the gingival tissues (gums) become red, swollen, shiny, painful and prone to bleeding due to decreased resistance to infection from bacterial plaque on tooth surfaces.
- Periodontal disease:
This is an advanced inflammatory disease (periodontitis) which affects the supporting tissues of the teeth (periodontium), and includes gums, periodontal ligament and jaw bone. It is characterized by bleeding, pus, loose and drifting teeth, halitosis (bad breath), pain, swelling, bone loss and tooth loss. The susceptibility to periodontal disease, often called the “sixth complication of diabetes mellitus”, is the most common oral complication of diabetes.
- Salivary gland dysfunction and xerostomia (dry mouth):
Diabetics are reported to have decreased salivary gland function resulting in dry mouth (xerostoma). Decreased flow of saliva fosters tooth decay, poor denture adhesion to the gums, dry atrophic and cracking oral mucosa, yeast infection (candidiasis), ulcers and desquamation, as well as an inflamed depapillated tongue (loss of taste buds). All of these complications lead to difficulty in eating and poor nutrition.
- Burning mouth syndrome:
Burning of the mouth and tongue are common symptoms of diabetics which adversely affect their quality of life. 5. Acute oral infections:
These include recurrent bouts of herpes simplex virus (painful mouth/facial sores), periodontal abscesses and palatal ulcers. Case reports have been published on life-threatening deep neck infection from a periodontal abscess and on fatal palatal ulcers in patients with diabetes.
What can be done to prevent and control dental diseases in diabetics?
• Diabetics must keep current with their medical treatment to control their diabetes.
• The dentist plays a major role in referral of patient with diabetes to physicians for additional evaluation and is often the first medical practitioner the patient sees.
• All patients with diagnosed diabetes must be identified by history. A thorough understanding of their medical treatment – including medications, including regimen and the degree of glycemic (sugar) control, as well as any systemic complications resulting from diabetes—then must be methodically established.
• In general, adults with well-controlled type 1 or type 2 diabetes may have no more significant risk of experiencing oral disease progression than do those without diabetes, and can therefore be treated similarly.
• Typically, patients should receive short morning appointments to reduce stress. The release of endogenous epinephrine from stress stimulates the release of stored sugar into the blood from the breakdown of glycogen in muscle (and to a lesser extent in liver) leading to hyperglycaemia (elevated blood sugar).
• Profound anaesthesia is mandatory to reduce stress released epinephrine.
• The longer the duration of the diabetes, the greater the likelihood of the patient’s developing periodontal disease.
• Supportive periodontal therapy (teeth cleaning) at relatively close intervals (two to three months).
• Periodontal infections may complicate the severity of diabetes mellitus and inhibit metabolic control of blood sugar. However, the use of tetracycline antibiotic in the treatment of periodontal infections is associated with improvement in the glycaemic (sugar) control.
• Teeth with dental caries should be restored (filled) to prevent spread of dental infection.
• Missing teeth should be replaced to avoid teeth migration into edentulous areas.
• Splinting of mobile teeth can keep them from drifting when they become loose from the destructive effects of periodontal disease.
• Surgical procedures should not be performed on patients with uncontrolled diabetes. These patients must be referred to their physician for diabetic control prior to treatment.
• Dry mouth can be treated with the use of saliva substitutes and stimulants; this can reduce the risk for dental caries from decreased salivary flow.
• Candidiasis (yeast infection) can be reduced as the dry mouth is corrected, but can be treated with antifungal drugs as well.
• Burning mouth syndrome can be controlled as the dry mouth and candidiasis are effectively managed. Oral topical anaesthetics can help with symptomatic relief.
• Cigarette smoking must be discouraged as it has been implicated in the vascular complications of diabetes and oral cancer.
• Alcohol consumption also adversely affects diabetes and must also be discouraged.
• Nutritional counselling to reduce dietary sugars and foods with a high glycaemic index.
The dentist plays a significant role with allied members of the health team in helping a patient maintain diabetic control by properly treating oral infections, and by instructing the patient with diabetes to exercise meticulous oral hygiene and sensible nutritional habits.