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Promote oral health in patients with diabetes

Voda, Sandra C. MSN, RN-C, ONC

doi: 10.1097/01.NURSE.0000389024.03265.c1

Help your patients with diabetes avoid potentially serious periodontal disease with these guidelines.

Sandra C. Voda is a registered nurse at the Masonic Home of New Jersey in Burlington, N.J.



PEOPLE WITH DIABETES know that the disease can affect their heart, kidneys, eyes, blood vessels, and nervous system. But many are unaware that periodontal disease is also associated with diabetes. Periodontal disease can cause painful chewing, xerostomia (dry mouth, also a symptom of diabetes), severe mouth ulcers, tooth decay, and systemic infections that may be difficult to treat. Smoking can exacerbate these problems.1 Whether you work in inpatient or outpatient settings, be sure to educate your patients with diabetes about preventive oral healthcare.

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Nothing but the tooth

Most tooth loss results from dental caries and periodontal disease, such as gingivitis. Periodontal disease is two to three times more prevalent in people with diabetes.2 It also progresses faster and is more severe; about one third of people with diabetes have severe periodontal disease.3

Tooth loss can cause psychological, social, and physical impairment. Poor-fitting dentures may distort speech, interfere with mastication, and cause alterations in taste, resulting in malnutrition. Tooth loss can be prevented by early diagnosis of dental caries and periodontal disease, regular dental visits, and good oral hygiene.4,5



Gingivitis, or inflammation of the gums (gingiva), is characterized by edematous and possibly bleeding gums (see Marginal gingivitis). Typically caused by poor oral hygiene, it can progress to periodontal disease.4 Periodontal disease is a chronic inflammatory disease caused by a bacterial infection that destroys connective tissue and bone that support the teeth.2

Inflamed periodontal tissue, which is highly vascular, makes glycemic control more difficult. Inflammatory mediators, as well as bacterial lipopolysaccharides and other toxins, are introduced into the systemic circulation. Some inflammatory mediators stimulate the liver to produce acute-phase reactants such as C-reactive protein, serum amyloid A, and fibrinogen, which have harmful effects on other organs, including cardiovascular disease.2

This local and systemic inflammation leads to increased destruction of the periodontium, as well as increased insulin resistance and blood glucose levels in people with diabetes.6

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Heed the warning

The mouth is an early warning system for pathology in other parts of the body. In people with diabetes, oral signs and symptoms include a neurosensory disease called burning mouth syndrome, taste disorders, poor wound healing, and oral fungal infections.

Some patients may have fruity (acetone) breath, xerostomia, and changes in saliva thickness. Xerostomia, associated with excessive fluid losses such as polyuria, can lead to dental decay.

Many medications can cause xerostomia and increase salivary glucose concentration. The most common include anticholinergics, antiparkinsonians, antineoplastics, antihypertensives, anxiolytics, and antidepressants.7

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Teaching tips

Although patients and healthcare providers focus on preventing and managing diabetes complications, they may overlook good oral hygiene.5 Educate patients about signs and symptoms of poor oral health, such as gums that bleed easily.

In some patients, signs and symptoms of poor oral health may indicate undiagnosed diabetes. (See Diabetes speaks for signs and symptoms.) If you notice oral problems while assessing a patient, further evaluation is necessary by a dentist and healthcare provider.

During assessment, ask your patient the following questions:

  • Do you routinely visit a dentist? If so, how often? When was your last dental exam?
  • How often do you brush your teeth? Do you floss daily?
  • Do you wear dentures? Do they fit comfortably? How often are they cleaned?
  • Do you have mouth sores, bleeding gums, a bad taste in your mouth, or bad breath?
  • Have you ever attended a diabetes self-management program?
  • Do you have dental insurance?

You can help promote good oral health in your patients with diabetes by explaining that people with diabetes may not experience pain with periodontal disease. Stress the importance of regular dental checkups every 6 months and tell them that treating periodontal disease can significantly lower blood A1C levels.8 You can also advise patients to:

  • check the mouth daily for any problems and contact their dentist if the mouth is overly dry or sore, has cottage-cheese looking white patches (a sign of oral candidiasis), or if they have a persistent bad taste in the mouth.
  • brush with a fluoride-containing, tartar-control toothpaste at least twice a day and floss teeth once a day to help remove plaque.
  • remove and clean dentures daily.
  • postpone nonemergency dental procedures if blood glucose levels aren't adequately controlled.
  • control blood glucose levels, which help relieve dry mouth and other symptoms.

Encourage patients with diabetes and their families to attend diabetes education classes, where they'll learn about the importance of maintaining good oral health in addition to other areas of diabetes self-management. Provide patients with printed educational materials they can take home. (See On the Web for sites that offer information you can print out and give to your patients.)

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Keep them smiling

Poor oral health in patients with diabetes can cause complications, pain, and financial and social problems that diminish quality of life. Promote oral health education during your patients' hospitalization to ensure that they stay healthy.

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On the Web

American Dental Association Oral Health Topics: Diabetes

American Diabetes Association

National Diabetes Education Program

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Diabetes speaks

The following signs and symptoms may indicate that a patient has diabetes:

  • xerostomia
  • erythematous, edematous, or bleeding gingiva
  • gingival recession (gums pulling away from teeth)
  • purulent exudate between teeth
  • loose teeth or bite changes
  • changes in fit of removable partial dentures
  • oral candidiasis (thrush)
  • persistent halitosis (bad breath) or dysgeusia (altered taste).
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1. National Institute of Dental and Craniofacial Research. Diabetes and oral health .
2. National Diabetes Education Program. Oral health and diabetes .
3. National Diabetes Education Clearinghouse. Complications of diabetes in the United States .
4. United States Department of Health and Human Services. Healthy people 2010: understanding & improving health .
5. Centers for Disease Control and Prevention. Working Together to Manage Diabetes: A Guide for Pharmacists, Podiatrists, Optometrists, and Dental Professionals. Atlanta, GA: U.S. Department of Health and Human Services; 2007.
6. Chandna S, Bathla M, Madaan V, Kalra S. Diabetes mellitus: a risk factor for periodontal disease. Internet J Fam Pract. 2010; 9(1).
7. The Merck Manuals Online Medical Library. Ear, nose, throat, and dental disorders: xerostomia .
8. McKeever K. Gum care helps control type 2 diabetes and its complications. 2008 .
© 2010 Lippincott Williams & Wilkins, Inc.