It is now well recognised that a healthy mouth is necessary for complete overall general health and that oral health can have a significant impact upon our quality of life. Diabetes affects many parts of the body, but the impact on the oral cavity is often neglected. Research has shown that having diabetes increases the susceptibility to various diseases of the mouth. In addition, it has also been shown that improving the health of your mouth can help to regulate blood sugar.
High blood sugars can increase the risk of developing gum disease, dry mouth, dental decay, dental abscesses and oral thrush. It is important to understand these increased risks and learn how their prevention, and if necessary treatment, can improve general health. This should form part of an overall diabetes self-management programme.
Perhaps the most significant, yet least recognised result of high blood sugars on the mouth is its effect upon the gums and tissues that support the teeth. Periodontal or gum disease is one of the most widespread diseases of mankind – almost all of the adult population has experienced gingivitis (inflammation of the gums), and periodontitis (inflammation and subsequent loss of the supporting tissues of the teeth), or both. This can result in loose, mobile teeth which can eventually be lost all together. Therefore, periodontal disease can have a profoundly negative impact upon daily life affecting social interactions, confidence and food choices, which are of particular importance in the management and control of diabetes.
For a person with diabetes, the risk of developing periodontal disease is approximately three times that of a person without diabetes. The level of glycaemic (blood sugar) control has been found to be a major factor in determining this increased risk. The diabetes population also have a more severe gingivitis than those without diabetes, even if they have similar plaque levels. (Plaque is a sticky film made up of bacteria, saliva and food that constantly forms on teeth.) Adults, especially those with complications affecting their blood vessels, are also prone to greater periodontal destruction. This may be due to changes within the blood vessels and a change in the immune response to the plaque bacteria and their irritants, which are associated with high blood sugar levels. Therefore, it is important that people with diabetes are aware of their particular susceptibility to periodontal destruction. They should also have regular dental examinations and receive advice on oral hygiene (plaque removal).
The good news is that the treatment of periodontal disease can have a beneficial effect upon glycaemic control. One study in 2010 identified that 3-4 months after periodontal treatment in people with diabetes, a mean reduction in HbA1C approaching 0.5% (or 5.5mmol/mol) could be demonstrated. This was even more pronounced in people with severe periodontitis.
People with diabetes also show an increased susceptibility to oral thrush (candidiasis). This is an infection in the mouth caused by a yeast fungus, Candida albicans. This fungus is present in the mouths of almost half of the population without causing any problems. However, when there is a change in the environment or chemistry that favours the growth of Candida over the other micro-organisms (bacteria, fungi and viruses) that are present in the mouth, its proliferation can result in unpleasant, although rarely painful, symptoms. These can include erythema (redness) and soreness of the mucosa (lining of the oral cavity), and erythema, soreness and cracking at the corners of the mouth. Often there are no symptoms of a candidal infection and it is diagnosed following an oral examination.
People with diabetes can develop clinical signs of infection at lower candidal loads than patients without diabetes. Once again, the occurrence seems to be related to glycaemic control. Glucose levels in saliva mirror blood glucose levels, and raised glucose levels in the saliva increase the ability of the candidal organism to adhere to the skin inside the mouth. Poor glycaemic control can also lead to difficulties in clearing the infection. Predisposition to candidal infection is also increased by a reduction in the flow of saliva and subsequently a dry mouth, a frequent finding in people with diabetes.
A dry mouth (or xerostomia) can be a result of dehydration due to frequent urination or, in long standing diabetes, related to damage to the blood vessels and nerves affecting the major salivary glands. The problems of a dry mouth, which can also be further complicated by the side effects of certain medications, include increased plaque accumulation, fungal infections, dental decay (caries), thin, ulcerated or peeling mucosa (lining of the oral cavity), and reduced ability to chew and eat foods (for example difficulty in swallowing) and impaired taste sensation. Treatments include ensuring good hydration, artificial salivas and drug treatments. For everyone with a dry mouth and natural teeth, fluoride (via toothpastes, mouthwashes and professionally applied varnishes) is essential to reduce the risk of dental decay.
Dental decay, which is a common problem, develops only in the presence of three interacting substances – bacterial plaque, a food source for the bacteria (particularly sugar) and a susceptible tooth surface. Various studies have reported conflicting views on the prevalence of decay in people with diabetes. Surprisingly, despite the reduced intake of refined carbohydrates for diabetes self-management, the observed rate of dental decay appears to be no less than for the general population.
People with diabetes are also more susceptible to infections, including those in the mouth. Pain and infection can increase insulin resistance and make glycaemic control more difficult. Therefore, any infections need to be treated promptly and vigorously. People with diabetes also exhibit delayed wound healing which has obvious consequences following surgical procedures in the mouth. The delay in healing is again related to glycaemic control and poor control is often quoted as a reason for not going ahead with more complex dental procedures such as the provision of implants.
Therefore, it can be seen that high blood sugar levels present an adverse environment to tissues in the mouth, as it does elsewhere. However, there is every reason to expect that with good self-management of your diabetes and care of your mouth, you should be able to reduce the risk of unwanted consequences. Regular visits to the dentist for dental and oral health examinations are recommended: Dental care should focus upon the prevention of oral disease with a special emphasis upon periodontal disease. The dental care team can advise on the most appropriate techniques of plaque removal for each person including brushing, flossing and the use of brushes that clean in-between the teeth.
People with diabetes should be empowered to know how the health of their mouths and their diabetes are linked. They should be given the knowledge and skills to enable them to keep their teeth, gums and mouth healthy and for their oral health to have a positive effect on their general health and quality of life.
Judith Deeprose, General Dental Practitioner
Professor Mike Cummings