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Diabetes Mellitus and Gum Disease

Having been in dental practice for over 35 years, I’ve met numerous people whom I consider mentors in the dental profession. But none of them exceeds the brilliance of the one teacher which not even the wittiest mind could match, and this teacher’s name is “WISDOM”. I’ve always believed that “What the eyes cannot see, the mind cannot know…”

Through the decades, I’ve had the privilege of treating people from all walks of life with a wide variety of dental conditions, along with their respective underlying systemic disabilities. Not surprisingly, most adult patients I’ve treated (which form approximately about 95 percent of my patient pool) fall in the category of those with underlying systemic conditions such as cardiovascular diseases, pulmonary diseases, diabetes mellitus, nerve dysfunctions, bone diseases, etc.

Majority of that number have one, if not a combination of the diseases I just mentioned. The dangerous part is that, roughly 50 percent were not even aware they had those diseases.

When it comes to diagnosing and treating the more commonly known gum disease (gingivitis), and the gum and bone disease (periodontitis), in my clinical experience and as verified through research, patients suffering from diabetes have a more increased risk of periodontal disease (American Academy of Periodontology — Commissioned Review of over 200 published articles for the past 50 years).

The International Journal, Journal of Periodontology, attempted to tackle and compile a comprehensive review on this issue of Diabetes as it relates to the gum and bone disease (periodontitis). I will be discussing the 4 most frequently asked questions about this topic.

Question #1: What is gum disease and what are its signs and symptoms?
Gum disease, in dental nomenclature is gingivitis, per ‘se. If broken apart, would refer to two things, gingiva = soft tissue surrounding the tooth or part of the investing structures of the tooth; and the word —itis = inflammation. Obviously, we know that when a portion of our bodies is inflamed, the five cardinal signs of inflammation would indicate that something is not normal, and these are the following: 1. Redness (rubor), 2. Pain (dolor), 3. Swelling (tumor), 4. Heat (calor), and 5. Loss of function (functio laesa). The cause of all these when referring to the “gums”, is usually plaque (whitish/yellowish sticky substance which remains around the neck area of our teeth after we eat).

However, there is also a long list of other causes which play a part in its onset, such as certain chemicals, drugs, hormonal imbalances, eating habits, malocclusion, heredity, etc.

Having these five signs of inflammation in mind, there are criteria to differentiate a normal from an unhealthy gum.

Question #2: Are people with diabetes more likely to have gum disease? If so, why?
There is strong evidence that diabetes is a risk factor for gingivitis and periodontitis, and the level of glycemic control (blood sugar level) appears to be an important determinant in this relationship.

The reason why people with diabetes are more likely to have gingivitis and to a certain extent even periodontitis is their suboptimal glycemic control (control of blood sugar). Studies have shown that adults with type 2 diabetes have had the highest occurrence of gingivitis with poor glycemic control. The control of one’s blood sugar level is significant for diabetic patients for they may play a role in the gingival response to bacterial plaque, which causes the gum disease.

The relationship between metabolic control of diabetes and periodontal disease is very important. Research suggests that it is relative and it is similar to the association between glycemic control and the classic complications of diabetes such as retinopathy and neuropathy. There is significant heterogeneity in the diabetic population. Thus, although poor control of diabetes clearly increases the risk of diabetic complications, there are many poorly controlled diabetic individuals who are not suffering from major complications of the disease. Conversely, good control of diabetes greatly decreases the risk of diabetic complications, but there are people with well-controlled diabetes who suffer major diabetic complications nonetheless.

Studies suggest that some diabetic patients with poor glycemic control develop extensive periodontal destruction (extensive gum disease). On the other hand, many well-controlled diabetic patients have excellent periodontal health, but others may develop periodontitis. Thus, this is where the role of the patient’s immune response comes in and how it deals with particular bacteria in the body. There is variability in each person.

For diabetic patients, it is important to maintain a consistent and controlled blood sugar level in order not to develop systemic complications and catch infections due to their low immune response.

Effects of periodontal disease on the diabetic state
Periodontal diseases can have a significant impact on the metabolic state in diabetes. The presence of periodontitis increases the risk of worsening glycemic control over time, as well as increased risk of other diabetic complications.

Studies have shown that there has been marked improvement of glycemic control following scaling and root planing with adjunctive systemic antibiotic therapy.

Periodontal diseases may induce or perpetuate an elevated systemic chronic inflammatory state. Acute bacterial and viral infections, as well as chronic gram-negative periodontal infections increase insulin resistance in people with diabetes, thus, greatly aggravate glycemic control. Treatment that reduces periodontal inflammation may restore insulin sensitivity, resulting in improved metabolic control.

Question #3: Why is mporto to take care of one’s gums?
As I’ve mentioned earlier, we all have the obligation to maintain a clean bill of health. May it be so with the “simplest” things as keeping our gums healthy and normal. But we should be more vigilant when it comes to acquiring gingivitis, or worse, periodontitis when we have diabetes. Not only do we “belittle” these diseases which affect our mouths and bodies, but they might also affect the people we love. As the maxim goes: “Spread love and not the disease”.

Recent studies have also shown that preventing gum disease would put us at less risk of developing cardiovascular diseases.

Question#4: How can gum disease be prevented and treated in people with diabetes?
You’ve heard it time and again, the best treatment is always through prevention. You don’t have to be diabetic, or have any of those numerous diseases, which would compromise the body’s immune level just so you’d be compelled to be aware of these oral health precautions. If you notice any signs or symptoms of gum disease which

I clearly tabulated for you earlier or if you haven’t gone to your periodontist (dental specialist on gum diseases) or your general dentist for the past three to six months since your last visit, I believe this is the time to make that appointment.

However, one must understand that having gingivitis does not always lead to periodontitis. Although genetic factors and bacterial plaque play an important role in the etiology of both gingivitis and periodontitis, the host’s immune response is a major factor whether gingivitis will progress into periodontitis later on. On the other hand, gingivitis always precedes periodontitis. It means that one cannot have bone loss and loss of attachment without signs of gum inflammation.

It is also very important to note that the diabetic patient’s blood sugar level be regulated and controlled before any gum treatment like the conventional oral prophylaxis (teeth cleaning) and deep scaling and root planing (subgingival cleaning of the roots and crown of teeth) be performed. A clearance from the patient’s endocrinologist is required prior to proceeding to the mentioned treatments if the patient’s condition presents inversely otherwise.

Meanwhile, proper oral health care must be performed in order to prevent the onset of gum disease. I strongly advise the following preventive measures (in sequence):

  1. Swish/gargle with a plaque softening agent or rinse
  2. Floss carefully around all your teeth
  3. Use of medium to soft bristled toothbrush (brushing in the correct fashion) with toothpaste preferably those prescribed for gum problems.
  4. Finish off with a 30-second gargling with a mouth rinse.

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