William Beaumont Army Medical Center

El Paso, Tx 79920-5001

Take Charge with Case Management:

Diabetes and Oral Health

VOLUME 6 ISSUE 2
June 2008

Diabetes and Dentistry

No one enjoys going to the dentist, but for people with diabetes, getting that cleaning and check-up are especially important. The link between diabetes and oral health can't be ignored. In fact, dental problems in people with diabetes are so rampant that Mark Finney, DDS, believes oral disease should be referred to as "the sixth 'opathy' of diabetes," deserving of the attention given to retinopathy, neuropathy, nephropathy and the like. While everyone is prone to periodontitis, or diseases of the tissues surrounding the teeth and gums, people with diabetes often have more severe cases that can both cause and predict additional diabetic complications. Defining Periodontitis Periodontitis or periodontal diseases involve inflammation and destruction of the tissues supporting and surrounding the teeth, including the gums and supporting bone. Periodontitis destroys the periodontal ligaments or connective tissue fibers that attach the tooth to the bone causing resorption of the alveolar bone (tooth socket). Consequently, the gums swell, redden, change shape, bleed, teeth loosen and pus forms. With the loss of soft tissue and bony support, deep periodontal pockets may form that foster bacterial growth. The formation of plaque on the teeth is the first step toward periodontal disease. Plaque, the white sticky substance that collects between teeth, is often the start of periodontitis. Made of microorganisms, dead skin cells and leukocytes (infection fighting white blood cells), it can be removed by brushing and flossing regularly. If it is allowed to build up, it will harden and turn into tartar. Tartar can only be removed with a professional cleaning at the dentist's office. Both plaque and tartar make the gums vulnerable to infection. If an infection enters the gums it is referred to as gingivitis, the first stage of periodontitis. Bacteria that collect and breed at the gum line and the groove between the gum and the tooth cause the gums to redden, swell and bleed. This response is normal but can also lead to periodontitis. Gums affected by gingivitis often bleed and are sensitive, but not always. Other signs include swollen gums, loose teeth, a bad taste in the mouth and persistent bad breath. The Relationship to Blood Glucose (BG) Control BG control and good oral hygiene seems to be the key to avoiding most dental complications. Everyone is at risk of developing periodontal disease, but all people with diabetes, regardless of age or type of diabetes, are more susceptible. There are several reasons for this. For one, people with diabetes have more sugar in the mouth which provides a more hospitable environment for hostile bacteria. This makes all forms of periodontal disease more likely. High and fluctuating BGs are also a big factor in the increased risk of periodontal disease. Poor BG control means higher degrees of periodontitis and more vulnerability to complications. It also makes healing more difficult once an infection sets in. Just like diabetics with poor BG control have a hard time healing wounds and infections on their feet, their bodies have a hard time fighting infections and healing wounds in the mouth. At the same time, on-going infections may make BG control more difficult. Inflammation and infection affect BG control no matter where they occur. But the mouth is often overlooked as most doctors do not look in the mouth. Once an infection takes root a vicious cycle ensues making metabolic and infection control a struggle. This cycle can have drastic consequences. If oral infections get out of control they can lead to BG control problems serious enough to land a person with diabetes in the hospital, to say nothing of the damage to the teeth and gums. Gum infections can also impact insulin needs. Authors of a study cited in September's 2007's Practical Diabetology concluded that when an infection is rampant, patients with diabetes often have increased insulin requirements. If periodontal disease is treated and gingival inflammation is eliminated, these insulin needs often decrease. Collagen, which is a building block of the tissue that attaches teeth to bones and the surrounding soft tissue, is also affected by diabetes. Diabetes' effect on collagen metabolism, according to Finney, "may make an infection potentially more destructive." Reduced Salivary Flow Patients with diabetes may also experience dry mouth as a result of reduced saliva. Neuropathy and certain medications may be the cause of reduced salivary flow. Finney says that saliva is important to wash residue off teeth and gums and prevent tooth and gum disease. Ask your dentist about products that moisten the mouth or increase saliva. Drinking lots of fluids may help alleviate the problem and there are products available (see page 2) that can help keep the mouth moist. ( Cont. on page 2)

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V OLUME 6 , I SSUE 2

Diabetes and Dentistry (Cont. from page 1)

It's All Connected The development of periodontal disease may reflect the presence of other problems related to BG control such as retinopathy or eye disease. "Retinopathy and dental problems are closely related. If you look at a population that is having eye problems, that same population is likely to have dental problems. If a person is diagnosed with retinopathy, they should make sure that their mouth is being examined and the gums are healthy. Conversely, if there is serious gum disease there may be other diabetic complications taking place in the body," says Finney. Problems that begin elsewhere in the body should also provide clues for other health problems. The presence of microalbuminuria and neuropathy are signals to check the mouth for potential complications. Prevention As with all diabetic complications, an ounce of prevention is worth its weight in gold. By far the most important step that can be taken is to brush and floss regularly. It is advisable to discuss proper brushing and flossing techniques with your dental team. Some of the fundamentals might surprise you. For example, it is recommended that you brush for a minimum of three minutes, which, when put into practice, is longer than one might imagine. In the Chair Prevention also includes making and keeping the often dreaded dental appointment. Finney suggests seeing the dentist twice a year, or as often as necessary. If you are avoiding the dentist due to fear and or loathing, see below for some strategies to make it a little easier to deal with. It is best to schedule dental appointments, about an hour and a half after breakfast so that the appointment does not interfere with regular meal times. Test your BGs before you go to the dentist and test them while you are at the dentists office. Make sure to stick to your regular insulin and/or oral medication schedule to avoid BG problems. It is also important to discuss your diabetes with your dental team. Once at the dentist, voice concerns and report any abnormality, such as gingival bleeding. Healthy gums are usually light-pink, snug around the tooth and don't bleed. Treatment If an infection is already present, it must be treated before any significant procedures can be attempted. Once diabetes is under good control, oral surgery can be performed without complication. Dentures Since periodontal disease can lead to tooth loss, many patients are fitted for dentures. Patients wearing complete dentures should see the dentist once a year to examine all soft tissue areas. Partial dentures require attention to hygiene just like real teeth. They need to be removed and cleaned daily. Wearing dentures continuously and failing to take the proper precautions can promote the growth of mouth fungus leading to thrush. Dentures may also be ill-fitting and uncomfortable. This is because the gums of people with diabetes may be especially sensitive. This in turn makes eating, and maintaining good health and proper BG control more difficult. Dental implants can be another viable option for tooth replacement for people with diabetes. Taking Precautions Dental therapy for people with diabetes does not have an established criteria, although dental offices record medical conditions such as diabetes they may not be prepared for an emergency resulting from diabetes. It is important to discuss your diabetes and possible low and high blood sugar scenarios with your dental team. According to Finney, the dental team needs to know if their patients take oral agents or insulin because that means special precautions must be taken. He advocates that dentists caring for patients with diabetes have a calibrated glucose meter, glucose tablets or fruit juice, and a glucagon kit available. They should also be familiar with the common signs of hypoglycemia such as loss of coordination, blurry vision, palpitations, rapid heart rate, sweating and shaking. He also suggests finding out if a patient with diabetes has hypoglycemic unawareness, a condition in which they experience few if any signs and symptoms of low blood sugars. According to Finney, a common situation leading to hypoglycemia at the dental office is a patient skipping breakfast before an appointment but taking the regular amount of insulin. Severe hyperglycemia may occur as well, but less frequently. Acetone breath and dehydration, dry mucous membranes and changes in mental status are signs that blood glucose is too high and dental procedures should be postponed. Be Aware The relationship between diabetes and periodontal disease is well-established. Since periodontal disease can be prevented, education should start in childhood. Organizations such as the National Oral Health Information Clearinghouse can offer valuable information on dental health and diabetes. They can be contacted at 1 NOHIC Way, Bethesda, MD, 20892-3500 or call 301-402-7364. "The key thing to remember is that diabetes can cause additional problems so those with diabetes need to take additional care to keep their teeth and gums healthy," says Finney. Fortunately, this care is simple and inexpensive compared to the pain and cost of replacing lost teeth. Product Options Cleaning: The Sonicare with Quadpacer at-home sonic toothbrush by Optiva. Call (800) 682-7664 for more information.

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TA K E C H A RG E W I TH C A S E M A N A G E M E N T: F OC U S O N D I A B E T E S & ORA L H E A L TH

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Clean Those Choppers: Periodontal Disease May Accelerate Pre-Diabetes

Its already clear that people with type 2 diabetes are more susceptible to periodontal disease than people without diabetes. Now researchers at the University of Copenhagen School of Dentistry have found that periodontal disease may contribute to prediabetes, at least in rats. Their study examined fat pre-diabetic rats and lean rats, both with artificially induced periodontal disease. Compared to control rats without periodontal disease, the fat rats experienced greater deterioration in glucose metabolism, and even the lean rats showed increased fasting glucose and insulin resistance. Whether the rats brushed their little teeth was not reported. "Oral infections have systemic effects," said Dr. Thomas Van Dyke, a professor of periodontology and oral biology, speaking to the Baltimore Sun about a study linking cancer and gum disease. Chronic inflammation anywhere, including swollen gums, causes the release of cytokines that can trigger insulin resistance. And obesity, a major cause of diabetes, is also now seen as a direct risk factor for periodontal disease.
(From Diabetes Health. 05 April 2007.)

Tooth Tips
The following tips are from the National Institute of Dental Health: 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 non-diabetics. 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 of 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 six 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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V OLUME 6 , I SSUE 2

Dry Mouth and Diabetes

We often take our teeth for granted, but the mouth is the first part of the digestive process. Its amazing how what we put into it and what comes out of it can get us in so much trouble. Most of us dont realize that the health of our mouths affects our diabetes control, and that our diabetes control affects our oral health. Dry Mouth One of the most common oral health problems for diabetics is dry mouth or altered salivary flow (or xerostomia, if you like medical terms). The teeth and muscles in the mouth, face and jaw chew the food into smaller pieces to facilitate digestion in the stomach and intestine. The saliva has several functions. It prevents infection by controlling bacteria in the mouth. It moistens and cleanses the mouth by neutralizing acids produced by dental plaque, and it washes away the dead skin cells that accumulate on the gums, tongue and cheeks. It helps with the digestion, making it possible to chew, taste and swallow food. Dry mouth occurs when there is not enough saliva (real or perceived) to keep your mouth moist, which is important for health, comfort and for speaking. Diagnosis of dry mouth is difficult due to the subjective nature of this condition. In most cases, dry mouth is due to side effects of medications. There are over 500 prescription and nonprescription medications that have been found to cause dry mouth. Medications that treat high blood pressure or other heart problems are used by many patients to manage complications of diabetes. Other drug groups that cause dry mouth are those used for depression, anxiety and allergies, as well as diuretics, anti-psychotics, muscle relaxants, sedatives and anti-inflammatory medications. Caffeinated beverages also cause dry mouth, and these should be limited. Precautions Ask your pharmacist about side effects of your medications in order to avoid any possible problems. It is important that diabetes patients drink water frequently while on these medications, as well as for their general health. Also, be sure to see your dentist and dental hygienist for an oral examination and dental prophylaxis at least every six months to minimize or prevent the development of oral health problems. Optimal oral health will improve your diabetes control and your quality of life. Editors Note: If a patient has dry mouth, then it is not recommended to use mouthwash with alcohol. However, if dry mouth is NOT a problemand not all diabetes patients have this problemthen the most effective mouthwash is one with alcohol, per dental research on controlling oral diseases. Dental Care for Dry Mouth Patients The diabetes patient with dry mouth along with his or her oral health team will have to develop a routine for optimal oral health. Here are some simple ways to accomplish that goal: Perform oral hygiene at least four times daily, after each meal and before bedtime Rinse and wipe the mouth immediately after meals. Brush and rinse removable dental appliances after meals. Use only toothpaste with fluoride. Some toothpastes (such as Biotene) are formulated for dry mouth. Keep water handy to moisten the mouth at all times. Apply prescription-strength fluoride at bedtime as prescribed. Avoid liquids and foods with high sugar content. Avoid overly salty foods. Limit citrus juices (orange, grapefruit, tomato), as well as diet sodas. Avoid rinses containing alcohol. Several nonalcoholic mouthwashes are now available on the market. Use a lip balm or moisturizer regularly. Try salivary substitutes, gels or artificial saliva preparations. These may relieve discomfort by temporarily wetting the mouth and replacing some of the saliva constituents. In severe cases, use of pilocarpine might be used under a physicians care. Source: www.oncolink.org The most common reasons for a dry mouth in a diabetes patient are Side effects of medication Neuropathy (autonomic) Lack of hydration Kidney dialysis Hyperglycemia Mouth breathing Smoking Some clinical signs of dry mouth Loss of moisture, glistening of the oral mucosa Dryness of the oral membranes Irritated corners of the mouth (cheilitis) Gingivitis Difficulty wearing dentures Mucositis Mouth sores Yeast infection (Candidiasis), especially on the tongue and palate. Dental cavities: increased prevalence and located in sites generally not susceptible to decay

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V OLUME 6 , I SSUE 2

Caring for Your Teeth and Gums

The sixth major complication of diabetes is periodontal disease. Periodontal disease, or pyorrhea, is a painless disease of the supporting tissues of the teeth, gums and bones of the mouth. It is estimated that 80 percent of the adult population in the United States has periodontal disease. Once you have periodontal disease, it is almost impossible to eradicate it completely. However, with the help of your dentist and hygienist, you can slow down its progression with early detection and aggressive treatment. Aside from periodontal disease, the mouth is vulnerable to these other problems that can affect people with diabetes: Altered taste often affects people with diabetes; it may result from a change in salivary chemistry, dry mouth or the presence of yeast. Dryness of the mouth may result from inactive or defective salivary glands. Dryness is also a manifestation of poorly controlled diabetes. Yeast (candida) in the mouth is a fungal infection associated with elevated glucose levels and is a frequent complication of diabetes. Oral neuropathy, or numbness of the mouth, is a rare complication characterized by a burning sensation in the mouth or on the tongue. Halitosis, or bad breath, often occurs when periodontal disease is present. Bad breath is worsened by dry mouth. Strong breath mints may help, but they only mask the problem, not solve it. Ask Yourself About These Warning Signs of Periodontal Disease Do your gums bleed easily when brushing or flossing? Do you have loose teeth? Are your gums red, swollen or tender? Do you have unusually bad breath? Do you have tartar formation (creamy brown, hard masses on tooth surfaces)? Have you noticed a change in the way your teeth fit together when you bite? Do you feel pain when you chew? Are your teeth sensitive to temperature? Guidelines for Basic Oral Hygiene Brush your teeth at least twice a day Floss your teeth at least once a day Avoid harsh mouthwashes Have your teeth cleaned regularly

1. 2. 3. 4.

Precautions for Visiting the Dental Office Be sure your dentist knows you have diabetes and what medications you take. Make your appointment at an appropriate time to avoid hypoglycemia (for those on insulin therapy). Bring your glucose meter to your appointment. Try to have your blood glucose levels in goal range during dental office visits.
(From Diabetes Health. 01 March 2005.)

WILLIAM BEAUMONT ARMY MEDICAL CENTER EL PASO, TX 79920-5001 Take Charge with Case Management: Focus on Diabetes & Oral Health Toni Badillo, RN., Chief, Medical Mgt Section/MCD, WBAMC Dr Cecilia Del Moral, MD., Diabetes Champion, PAMC, WBAMC Jean Bernardini, RN., CMC., Outpatient Case Manager, WBAMC

On the Lighter Side . . .

Phone: (915) 569-3423 Fax: (915) 569-2712 Email: Jean.Bernardini@amedd.army.mil

To be the Standard Bearer for Excellent Healthcare in the Department of Defense

How Much Do You Know About the Tooth Fairy? A Quiz with Answers
1. Should everyone be using a tartar control toothpaste? 4. In terms of cavity prevention, drinking tap water is usually better than drinking bottled water.

A. False. Studies find that using tartar control toothA True. Most tap water now contains added paste causes many peoples teeth to become sensitive to cold fluoride. Most bottled water does not contain (particularly if they have gum recession). The teeth Fluoride. sensitivity stopped within a few weeks after discontinued use of the tartar control toothpaste with very little change 5. Some toothpastes can whiten your teeth. in the amount of tartar buildup. 2. Raisins are a good snack and do not promote tooth decay. A. False. Raisins are very high in sugar and their stickiness causes the sugar to stay on the teeth for long periods of time. You should brush your teeth thoroughly after eating raisins. 3. Diet sodas can cause tooth decay. A. True. You may think that because diet sodas dont contain sugar, that they are safe for your teeth as they are for your waistline. Many diet sodas contain phosphoric acid which is a known cause of tooth decay. A. False. No toothpaste available contains any bleaching ingredient which can whiten your teeth. 6. If you want to enjoy a sugary treat, when is the most tooth-friendly time to eat it? A. It is better to eat sugary foods along with a meal to minimize the risk of tooth decay. Snacking on sugary treats between meals is the worst for teeth. However, a high sugar diet is never great for teeth so you should try to cut down your intake of sugary foods.