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                                                        DR. DAN PETERSON

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Here is some of the newest updates on the connection of dental health and diabetes.

National Diabetes Education Program

Extra Care
Assess the level of control of diabetes.

bulletWhat was your last level of glycosylated hemoglobin (Hb1Ac)? (More than 6% means poorly controlled diabetes)
bulletHave you changed medications lately?
bulletWhat is the name and phone number of your endocrinologist and physician?
bulletAre you taking insulin? 

Treatment of periodontal disease improves metabolic control of diabetes

Diabetes is a complex disease with both vascular and metabolic components. A back and forth connection exists between diabetic control and oral infections. When periodontal infection is established, metabolic control of diabetes is worsened. When diabetesis exacerbated, periodontal infection progresses. During the 3-month study, subjects in the control group received no periodontal treatment. Test group subjects received oral hygiene
instructions and scaling and root planing with local anesthesia.

Baseline, post-treatment and three-month data included clinical
indices and blood tests. Only a few in the test and control groups had moderately deep pockets. The others had gingivitis. Following treatment statistically significant differences were observed between the groups. The differences were not large, but did show evidence of
improved glycemic control following non-surgical therapy.

Clinical Implications: Oral hygiene instructions and non-surgical treatment of periodontal disease in type 2 diabetics can result in better metabolic control of the diabetes.

Kiram, M., Arpak, N., Ünsal, E., Erdogan, M.: The Effect of Improved Periodontal Health on Metabolic Control Type 2 Diabetes Mellitus. J
Clin Perio 32: 266-272, 2005. Cited: Perio Reports 2005 April

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Poorly Controlled Diabetes Can Lead To Tooth Loss
Americans with poorly controlled diabetes are at higher risk for severe periodontal disease, which can lead to tooth loss.

Researchers from the Harvard School of Dental Medicine and the University of Michigan School of Dentistry analyzed national data on more than 4,300 adults ages 45 to 90 with type 2 diabetes. They found that people with poorly controlled diabetes were nearly three times more likely than those with better-controlled diabetes to have severe periodontal disease.

Periodontal disease is an infection of the gums, ligaments and bone surrounding the teeth. It can lead to bleeding gums, receding gums and loose teeth. Teeth eventually may fall out or need to be removed.

People with diabetes also can be at increased risk for other oral problems — including gingivitis (the first stage of periodontal disease), dry mouth, fungal infections and slow wound healing — if they do not take steps to control their blood-sugar levels.

The study was published in the June issue of Community Dentistry and Oral Epidemiology. By Nancy VolkersInteliHealth News Service. June 2002

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         Gum disease may even be more important than obesity or age as a factor in the onset of diabetes in adults,  Adult-onset diabetes, or Type 2 diabetes, accounts for 90 percent of the estimated diabetes cases in the United States and is almost always caused by lifestyle.   
     This study along with 2 others revealed results that blood sugar levels could be reduced and kept at a lower level most effectively with a single dose of oral antibiotic and repeated application of a topical antibiotic to the gums.    
     "The study shows that in this group of severe diabetics we were able to increase glucose control with repeated treatment of their periodontal infection".  This study underscores the importance of prevention and early treatment of gum disease in people who are at risk of developing diabetes.       In a third study, the University of Buffalo researchers showed that using antibiotics to treat gum disease decreases two markers of inflammation throughout the body.  The inflammatory markers area associated with the development of arteriosclerosis and other chronic diseases. 
Sara Grossi, clinical assistant professor of oral biology at the University of Buffalo in New York. March 2002

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Most Adult Diabetics In United States Have Hypertension
Nearly three-quarters of adult diabetics in the United States have hypertension. Regardless of age, sex, race or ethnic origin, all may benefit from efforts to prevent it.

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Dry Mouth More Common in People with Diabetes

This study established a link between diabetes, neuropathy and dry mouth.  Diabetics according to this study report:


 More symptoms of dry mouth and impaired salivary flow. 


 Diabetes who smoke and snack frequently had more symptoms of dry mouth.


Those taking mediations that tend to dry mouth had lower salivary flow.


Those who were not well controlled reported more dry mouth symptoms.

These observations could be due to a decreased responsiveness of the nerves that stimulate the production of saliva.  Saliva washes the sugar out of the mouth after eating and when this ability is decreased it can lead to:

  1. dry mouth

  2. tooth loss

  3. gingivitis

  4. periodontists

  5. abscesses originating in a tooth 

  6. soft tissue lesions in the mouth and tongue.

Dental Product Report, Dr Trevor Orchard, NIH, pg 30, Dec 2001

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November is National Diabetic Month


When you have diabetes, your chances of getting gum disease increase.

There are more bacteria in your mouth right now than there are people on Earth. 

If those germs settle into your gums, you've got gum disease. "Not me?" you say. Here are the facts:

bulletMore than half of all adults have at least the early stages of gum disease.
bulletAbout 90 percent of adults have gum disease during their lives.
bulletIf you have diabetes, you are at higher risk for gum problems. People with diabetes tend to have more gum disease and infections. Poor blood sugar control makes gum problems more likely.
bulletGum disease can start at any age. Children and teenagers who have diabetes are at greater risk than those who don't have diabetes. Just when you thought the news was all bad, remember, there is a lot you can do to fight gum disease:
bulletLearn how gum problems start.
bulletBrush your teeth twice a day.
bulletFloss you teeth every day.
bulletLook for early signs of gum disease.
bulletVisit your dentist at least twice a year.

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A Big Plaque Attack

When you have gum disease, germs work to destroy your gums (gingiva) and the bone around your teeth. It starts with plaque. Plaque is a sticky film of food, saliva, and germs. Plaque loves to settle in at the gum line. There germs get busy making your gums red, tender, and likely to bleed.

The goal of your daily tooth brushing and flossing is to clean away plaque. When plaque stays put, it hardens into tartar. Tartar builds up under the gum line. More plaque forms over the tartar. Only your dentist can get tartar off your teeth.

If plaque and tartar are not cleaned away, even gentle brushing can cause your gums to bleed. This is called gingivitis. It is the first stage of gum disease. You can fight gingivitis with:

bulletdaily good brushing and flossing habits
bulletgetting your teeth cleaned at least twice a year at your dentist's office

If you ignore gingivitis, the gum disease gets worse.

The more severe form of gum disease is called periodontitis. When you reach this stage, your gums begin to pull away from your teeth. Pockets form between your teeth and gums. These fill with germs and pus and deepen. When this happens, you may need gum surgery to save your teeth. If nothing is done, the infection goes on to destroy the bone around your teeth. The teeth may start to move or get loose. Your teeth may fall out or need to be pulled.

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Warning Signs

As if this is not enough, diabetes can make things worse. Plaque is the main bad guy of gum disease. But diabetes can also be a culprit. Diabetes may weaken your mouth's germ-fighting powers. High blood sugar levels can help the gum disease get worse. At the same time, gum disease can make diabetes harder to control.

Often gum disease is painless. You may not even know you have it until you have some serious damage. Regular dentist visits are your best weapon. 

Regular testing of your blood sugar is important for good control

When you schedule your visit to the dentist, plan to:

bulletTell your dentist you have diabetes. Also, share any problems with infections or trouble keeping your blood sugar levels under control.
bulletEat before you go to see your dentist. The best time for dental work is when your blood sugar level is in a normal range and your diabetes medicine action is low. If you take insulin, a morning visit after a normal breakfast is best.
bulletTake your usual medicines before your dentist visit, unless your dentist or doctor tells you to change your dose for dental surgery. Your dentist should consult with your doctor to decide about adjustments in your diabetes medicines or to decide if an antibiotic is needed before surgery to prevent infection.
bulletStick to your normal meal plan after dental work. If you can't chew well, plan how to get the calories you need. You may need to use your sick-day meal plan that uses more soft or liquid foods.
bulletWait to have dental surgery until your blood sugar is in better shape, if your diabetes is in poor control. If your dental needs are urgent (pain or swelling), talk to your dentist and doctor about having dental treatment in a hospital or special setting where you can be checked on during and after surgery.

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More on the Mouth

Diabetes also makes you prone to other mouth problems.

Oral infections. An oral infection is a cluster of germs causing problems in one area of your mouth. Here are some warning signs:

bulletSwelling or pus around your teeth or gums or any place in your mouth. Swelling can be large or as small as a pimple.
bulletPain in the mouth or sinus area that doesn't go away.
bulletWhite or red patches on your gums, tongue, cheeks, or the roof of your mouth.
bulletPain when chewing.
bulletTeeth that hurt when you eat something cold, hot, or sweet or when you chew.
bulletDark spots or holes on your teeth.

Infections can make your blood sugar hard to control. By planning ahead and discussing a plan of action with your dentist, you will be prepared to handle needed adjustments.

Fungal infections. Having diabetes means you are more prone to fungal infections such as thrush. If you tend to have high blood sugar levels or take antibiotics often, you are even more likely to have this problem. Thrush makes white (or sometimes red) patches in areas of your mouth. These can get sore or turn into ulcers. If you think you have a fungal infection, talk to your dentist.

Poor healing. If your diabetes is poorly controlled, you heal more slowly and you increase your chance of infection after dental surgery. To give yourself the best shot at healing well, keep your blood sugar under control before, during, and after surgery.

Dry mouth. Some people with diabetes complain of dry mouth. This may be caused by medicines you take. You may notice a dry mouth if your blood sugar levels are high. A dry mouth can increase your risk of cavities, because there's less saliva to wash away germs and take care of the acids they create. 

Keeping your teeth and mouth healthy requires a team effort

You're the most important person on this team to do the day-to-day mouth care.  Remember, good dental health can create a healthy mouth and a smile that will last a lifetime.

Source: For more information on diabetes, visit American Diabetes Association Book Store or follow the hyperlinks to these related books : Complete Guide to Diabetes and The Uncomplicated Guide to Diabetes Complications.

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The oral complications of diabetes involve the teeth, periodontal tissues, oral soft tissues, salivary glands or temporomandibular joints (TMJ). 

Dental Caries can occur more often due to generalized lack of self-care or secondary to sustained hypoglycemia with low salivary flow and high salivary glucose levels.
Gum disease is know as the sixth clinical complication of DM which includes loss of gingival attachment, abnormal pockets around teeth, and gingivitis. Severity of periodontal disease appears to be related to age, duration of the DM and glycemic control.  Gum disease in patients with DM is approximately 2.6 time normal.   In both type 1 and type 2 DM, poor oral hygiene and poor control of DM appear to contribute to periodontal disease.
Oral Soft Tissue Lesions in type 1 DM have increased incidence of candidal and noncandidal lesions with candida albicans, glossitis, denture stomatis and angular cheilitis.
Xerostomia is due to changes in the composition of the saliva, salivary flow rates and an increase in salivary glucose levels in adults with Diabetes.  Poorly controlled patients have more impairment of salivary flow than better controlled patients.  Some diabetic medications cause dry mouth like ACE inhibitors.  Reduced salivary flow associated with DM may be a clinical manifestation of neuropathy.
Oral Neuropathies is burning tongue syndrome or burning mouth syndrome and can occur frequently in type 2 DM.
Once the diagnosis of DM is made, your goal is toward long term control of blood glucose, which can reduce or delay these complications.

Managing Patients with Diabetes, Part 2, Dr. Jerome Rothstein, Dentistry Today, July 2001 pgs 62-65.

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Relationship of Insulin-dependent Diabetes and Oral Soft Tissue Lesions

In a study that evaluated soft tissue lesions of Type 1 diabetes (early onset insulin-dependent diabetes) with non-diabetic patients, it was found that 45% of the 405 patients with type 1 diabetes had at least one lesion. Seven lesions were identified as appearing more frequently in this group.  Three of these lesions were non-candidal: fissured tongue, irritation fibroma and traumatic ulcer.  15 % of this group had Candidiasis. Thus the rate of soft tissue candidal lesions are greater with Type 1 diabetes. 
Dentistry Today April 2001 pg 44

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Study finds periodontal disease, diabetes connection

Bethesda, Md. — Study results from the Marquette University School of Dentistry suggest chronic periodontal disease may increase the risk of developing Type 2 diabetes.

The new research, presented at the Periodontal-Systemic Connection Symposium currently underway here, ties the incidence of diabetes in patients with periodontal disease to the release of bacteria into the bloodstream that triggers a reaction from the immune system

Immune system cells can release proteins called cytokines that can disrupt production of insulin, the hormone that is key to diabetes, the researchers said.

"In the pancreas, the cells responsible for insulin production can be damaged or destroyed by high levels of cytokines," said Dr. Anthony Iacopino from the Marquette University School of Dentistry. "Once this happens, it may induce Type 2 diabetes, even in otherwise healthy individuals with no other risk factors for diabetes."

The research also points to high cholesterol, or lipid, levels as a risk factor for people who are already diabetic developing periodontal disease. "Low fat diets, lipid lowering drugs and exercise are vitally important for diabetics who want to improve their quality of life, as well as their oral health," Dr. Iacopino noted. ADA Online News April 2001 

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More on: Chronic Periodontal Disease Could Lead to Diabetes 

Diabetes Information

Periodontal Disease is Associated with the Development of Glucose IntoleranceJ Dent Res 83(6): 485-490, 2004 The Severity of Periodontal Disease is Associated with theDevelopment  of Glucose Intolerance in Non-diabetics: The Hisayama Study September 14, 2007

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