Oral Health and Diabetes Chat Archive 05/14/08 - American Diabetes Association

Oral Healthand Diabetes Archive, Wednesday, May 14, 2008

ADA Live!

Dr. Maria Ryan ORAL HEALTH 101

During this chat Maria Emanuel Ryan, DDS, PhD, Director of Clinical Research, Professor Oral Biology & Pathology School of Dental Medicine SUNY at Stony Brook, will address questions about diabetes and its relation to oral disease, why it affects those with diabetes, and the overall importance of taking good care of your mouth.

The "Oral Health and Diabetes" series is brought to you by an unrestricted educational grant from Colgate.

ADA_Moderator: Welcome to ADA Live. Today our guest is Maria Emanuel Ryan, DDS, PhD, Director of Clinical Research, Professor Oral Biology & Pathology School of Dental Medicine SUNY at Stony Brook. Dr. Ryan will address questions about diabetes and its relation to oral disease, why it affects those with diabetes, and the overall importance of taking good care of your mouth. Welcome Doctor Ryan!

Dr__Ryan: Thank you for inviting me to answer questions regarding oral health and diabetes.

dee: what problems can occur with oral heath if you have diabetes?

Dr__Ryan: Dear Dee,

Oral health problems related to poorly controlled diabetes include:

Increased risk for oral infections.

Delayed wound healing.

Xerostomia or dry mouth leading to symptoms such as burning mouth or tongue.

Increased incidence of gingivitis or inflammation of the gums, periodontitis or breakdown of the connective tissue and bone supporting the teeth, oral candidiasis or yeast infections and caries or cavities.

john: I'm a Type 2 diabetic and notice a little blood after I brush my teeth. Is this normal? Should I be concerned?

Dr__Ryan: Dear John, Normal healthy gingival tiisues or gums do not bleed when you brush or floss. If you notice blood when brushing or flossing your teeth you should be concerned about the presence of inflammation of the gums that is either associated with gingivitis which is a reversible form of gum disease or more advanced forms of the disease known as periodontitis. Both of these conditions are more common in poorly controlled people with diabetes. If periodontitis is present and is left untreated it can lead to tooth loss and may contribute to insulin resistance in people with type 2 diabetes making it far more difficult for them to achieve optimal glycemic control.

Jackie: My husband was just recently diagnosed with Type 2 diabetes and we're trying to determine all the potential complications....can you tell me what are they key ones for his mouth?

Dear Jackie,

Some of the more common oral complications of long-term diabetes in individuals with poor glycemic control include:

Increased risk for oral infections.

Delayed wound healing.

Xerostomia or dry mouth leading to symptoms such as burning mouth or tongue.

Aaron: Hi Dr. Ryan. My gums are receding and I have Type 1 diabetes. Am I brushing too hard or is this a complication of diabetes?

Dr__Ryan: Dear Aaron,

Recession of the gums even in people without diabetes can be exacerbated by the use of hard toothbrushes or by bad brushing technique. However, with poorly controlled diabetes this loss of connective tissue attachment and bone can be even more prevalent. I would suggest that you see your oral healthcare provider to determine the cause of your gingival recession so that it can be addressed as soon as possible to prevent further loss of bone and connective tissue supporting the teeth.

Scott: I'm an occasional smoker (couple packs a month) and know it's not good for my overall health but I'm wondering because I have diabetes, if this will damage my mouth?

Dr__Ryan: Dear Scott, Smoking is one of the most significant risk factors for periodontal disease and oral cancer. This risk is compounded by the presence of other risk factors such as poorly controlled diabetes. These risk factors are actually more than additive and can act synergistically to significantly increase your risk for developing severe periodontitis and possibly for developing oral cancer. May I suggest a visit to your oral healthcare provider to assess your currently oral condition and to discuss smoking cessation, which will not only help with your oral health but is also key to your overall health.

Mary: My 5 year old son was just diagnosed with type 1 diabetes and we are overwhelmed with trying to educate ourselves. Is there anything we need to be concerned about his teeth being so young?

Dr__Ryan: Dear Mary, I know how overwhelming this condition can be but prevention is critical in young people with diabetes so you are wise to be as informed as possible. Excellent oral hygiene and optimal control of his diabetes will be very important factors for your son. The risk for developing gingivitis is greater in people with type 1 diabetes. Children with poor metabolic control show a tendency towards a higher gingivitis score or more ginigival inflammation. The prevalence of gingivitis in children and adolescents with diabetes is nearly twice that observed in populations of children and adolescents without diabetes. Studies indicate that the severity and extent of gingivitis is significantly increased in young patients with diabetes. It appears that the degree of metabolic control of diabetes is an important factor in the development and progression of gingivitis. Unlike gingivitis, the more severe form of the disease periodontitis is uncommon in children under the age of 12, even among those with diabetes. In adolescence, periodontitis does occur but the extent of attachment or bone loss is usually minimal. The prevalence of periodontal disease in juveniles with type 1 diabetes has been reported to be 9.5% compared with 1.7% in those without diabetes.

Larry: I like to chew tobacco but after being told I have diabetes, I'm not sure how this will affect my diabetes. Can you tell me what will happen if I continue to do so?

Dr__Ryan: Dear Larry, Chewing tobacco can increase your risk for periodontal disease and oral cancer. This risk is compounded by the presence of other risk factors such as poorly controlled diabetes. These risk factors are actually more than additive and can act synergistically to significantly increase your risk for developing severe periodontitis and possibly for developing oral cancer. May I suggest a visit to your oral healthcare provider to assess your currently oral condition and to discuss strategies to quit chewing tobacco, which will not only help with your oral health but is also key to your overall health.

Kenny: Hi Maria. What's the best way to educate myself on keeping my mouth "healthy". Like everyone else, I brush my teeth a couple of times a day but because I have diabetes, I'm not sure this is enough. Is it?

Dr__Ryan: Dear Kenny, Excellent oral hygiene is extremely important in people with diabetes. It does not take a great deal of plaque to get periodontal disease if your diabetes is not well controlled. The American Dental Association suggests brushing twice a day for a period of 2 minutes which is 30seconds per quadrant of the mouth. They also recommend flossing once a day. Despite our best efforts we often miss some areas of plaque accumulation. To assist in this cleaning process antiseptics are available to help out in a toothpaste known as Colgate Total and in a number of over the counter mouthrinses. In addition, for those people with manual dexterity problems powered toothbrushes can help out as well.

Robert: Some of my teeth are loose and I'm wondering if this is because I have diabetes. What should I do?

A change in your bite.

Pus between the teeth and gums.

Dr__Ryan: Dear Robert, Loose teeth would certainly be of concern to me. Periodontal disease is a very common and often silent chronic dental disease. The risk and rate of periodontal disease progression are altered by diabetes. Some of the warning signs of periodontal disease include:

Gums that bleed easily.

Loose or separating teeth.

Persistent bad breath.

Gums that are pulled away from the teeth.

A change in the fit of partial dentures. Red, swollen or tender gums.

However, the only way that you can know for sure if you have periodontal disease is to visit with your dentist so that they can probe around the teeth and take radiographs or x-rays to determine if you have periodontal pockets around the teeth and radiographic evidence of bone loss which leads to a diagnosis of periodontitis. Once you are diagnosed your dentist can work with you to determine the optimal treatment plan to prevent further bone loss and to help you to maintain your teeth if the disease has not progressed too far.

Marcus: I think I have gum disease, but not sure. What are the warning signs if i have diabetes...the type 2 condition

Dr__Ryan: Dear Marcus,

Periodontal disease is a very common and often silent chronic dental disease. The risk and rate of periodontal disease progression are altered by diabetes. Some of the warning signs of periodontal disease include:

Loose or separating teeth.

A change in your bite.

A change in the fit of partial dentures.

Persistent bad breath.

Christopher: What is thrush?

Dr__Ryan: Dear Christopher, Thrush is oral candidiasis or an oral yeast infection. People with poorly controlled diabetes are at greater risk for developing oral candidiasis due increase levels of glucose or sugar in the saliva. Some people will also experience xerstomia or dry mouth and may complain of burning mouth or tongue. It is important to hydrate by drinking water and using ice chips to address the dry mouth and in some cases antifungal agents need to be prescribed to address oral yeast infections.

Adam: What type of toothbrush do you recommend?

Dr__Ryan: Dear Adam, I recommend a soft toothbrush preferably with a tongue cleaner as well. It is important that you angle the brush at a 45 degree angle towards the gums so that you can get the brush in between the gum and the tooth and then brush with a rotating motion, not like a saw. Make sure to brush all tooth surfaces and to spend about 30 seconds in each quarter of the mouth for a total of 2 minutes for the entire mouth brushing twice a day. There are other brushes known as end tuft brushes and proxabrushes that can help to get into hard to reach areas behind the molars, etc. and in spaces that may form in between the teeth. If your manual dexterity skills are not good you man consider using a powered toothbrush.

Pam: Should I tell my dentist I have diabetes?

Dr__Ryan: Dear Pam, You should absolutely tell your dentist that you have diabetes because this is a very important piece of information for the dentist to consider in making a diagnosis and formulating a treatment plan. Your dentist should ask you about the date of your last medical evaluation. A thorough medical history will be taken and you should inform the dentist of all of your current medications. The dentist will need to determine your level of glycemic control. The dentist should also inform your physician of your dental diagnosis. The dentist will devlop an integrated treatment plan to treat any acute or chronic infections, promote a healthy lifestyle, encourage tobacco use cessation, educate you about the links between your oral health and your diabetes and modify your treatment plan based on your current diabetes status.

Donna: I take insulin and am wondering if I should schedule my upcoming dentist check-up in the morning or afternoon? Does it matter?

Dr__Ryan: Dear Donna, We typically like to schedule morning visits but what is most important for people who are taking insulin is to consider the time of peak activity of the type of insulin that you are taking. As you know, patients on insulin are susceptible to hypoglycemia or low blood glucose. This is particularly true of people being managed with intensive treatment regimens or "tight control" of their blood glucose. To prevent hypoglycemic events in the dental office we suggest avoidance of peak activity periods of insulin and the monitoring of blood glucose levels and dietary intake before treatment.

Thomas: I have a few dark spots on my teeth and thought they were just stains of some sort but now I'm not so sure. What do you think?

Dr__Ryan: Dear Thomas, If you have dark spots on your teeth of unknown origin you should see the dentist to determine if they are cavities or if there is dark calculus or hardened plaque on your teeth and if it is stain whether it is intrinsic or extrinsic in nature.

Sam: Can oral infections make it harder for me to control my blood sugar level?

Dr__Ryan: Dear Sam,

Yes oral infections can make it harder to control your blood sugar level. The reason for this is that bacterial infections and chronic inflammation decrease insulin-mediated glucose uptake by the skeletal muscle leading to a whole-body insulin resistance decreasing insulin action. So if you do not address an oral infection it will be extremely difficult to maintain glycemic control. If the glycemic control is impeded for extended periods of time by chonic oral infection and inflammation such as that caused by periodontitis studies have indicated that chronic periodontitis can increase the risk for mortality in people with diabetes due to the development of other concurrent complications such as cardiovascular disease and kidney disease.

Helen: I have arthritis in my hands and can't floss. Is there something else I can do instead?

Dr__Ryan: Dear Helen, If you have problems with manual dexterity consider a powered toothbrush and the additional use of antiseptic agents such as those found in the toothpaste Colgate Total or many over the counter mouthwashes such as Listerine.

tom: does gum disease hurt? how will i know if have it?

Dr__Ryan: Dear Tom, Very often gum disease does not hurt until it is very advanced so it is often referred to as a silent disease. Periodontal disease is a very common dental condition. The risk and rate of periodontal disease progression are altered by diabetes. Some of the warning signs of periodontal disease include:

Gums that bleed easily.

Red, swollen or tender gums.

Gums that are pulled away from the teeth.

Persistent bad breath.

Pus between the teeth and gums.

Loose or separating teeth.

A change in your bite.

A change in the fit of partial dentures.

Jeff: My girlfriend says my bad breath is a sign of gum disease. I have been living with diabetes for over 10 years and this is never been a problem. Thoughts?

Dr__Ryan: Dear Jeff, Bad breath can be a sign of gum disease but is most often derived from bacteria found on the tongue. If you have been seeing your dentist regularly for periodontal examinations and there is no evidence of periodontal disease then perhaps the source of your bad breath is from the tongue. Tongue cleaners and mouth rinses can be used to improve on bad breath.

Bob: My dentist has led me to believe that, as I have t2 diabetes, he has to use a "lesser" numbing agent when working on my teeth. Is this true? I really want it to be the strongest it can be as I don't like pain.

Dr__Ryan: Dear Bob, This is a difficult question to answer not knowing your medical history but type 2 diabetes alone is not a reason for changing the type of anesthetic utilized in the dental office. It sounds as though your dentist may be using carbocaine rather than lidocaine as your local anesthetic and this is most likely due to a history of cardiovascular disease or the fact that you are on certain meds that may interact with the stronger anesthetic. Even with the use of alternative anesthetics we can often achieve profound anesthesia so give it a try and let your dentist know if the anesthetic being used is sufficient, if not there are other choices.

Joseph: Will a high A1c (more sugar in my blood) result in more tooth decay?

Dr__Ryan: Dear Joseph, The answer is yes, elevated blood glucose can lead to elevated levels of sugar in the saliva and therefore more tooth decay.

Dave: A relative told me to watch out for "oral candyitis". She said it was some kind of fungus that people with diabetes can get in their mouths! Is this true? ugh...

Dr__Ryan: Dear Dave, Yes people with poorly controlled diabetes can develop oral candidiasis or an oral yeast or fungal infection. People with poorly controlled diabetes are at greater risk for developing oral candidiasis due increase levels of glucose or sugar in the saliva. Some people will also experience xerstomia or dry mouth and may complain of burning mouth or tongue. It is important to hydrate by drinking water and using ice chips to address the dry mouth and in some cases antifungal agents need to be prescribed to address oral yeast infections.

Laila: Is there any direct connection between diabetes and gum disease?

Dr__Ryan: Dear Laila, The link between periodontitis is truly a two-way street. People with diabetes are at an increased risk for developing periodontitis or gum disease. If left untreated periodontitis can impair a person diabetes ability to process and/or utilize insulin thereby leading to impaired diabetic control.

ADA_Moderator: We're close to the end of our time here today. Do you have any thoughts you'd like to leave us with Dr. Ryan?

Dr__Ryan: Just remember that optimal oral health is extremely important to your overall health and the optimal metabolic control of your diabetes. If you haven't been to a dentist within the past year make sure that you make an appointment to visit the dentist to ensure that you have a healthy mouth. If you have oral infection or inflammation never consider its treatment as an option or an elective procedure. Make sure that oral disease is addressed as soon as possible, just as you would quickly address a non-healing chronic, infected area on your leg or anywhere in the body. As the old saying says an ounce of prevention is worth a pound of cure. Work hard to improve your oral hygiene at home by brushing twice daily, flossing once a day and use antiseptics in toothpastes such as Colgate Total or mouth rinses to reduce the levels of oral bacteria and to help to prevent the development of oral disease.

ADA_Moderator: That's it for today. Thanks so much for taking the time to be here Doctor Ryan. Thanks to all of you who joined us by asking great questions or by just tuning in. If you wish to continue any of today's discussions please feel free to visit the ADA Message Boards.

Keep up to date with all the ADA Live events and reference the archives here. We hope you found this interesting and informative and that you'll join us again next time here at ADA Live.

Dr__Ryan: Thank you. It's been great.

DONATE! Give hope for a better future!

Take the ride of your life

Ask the Dietitian Your Questions

New law protects against discrimination

Winning at Work