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Department: Red Flags

Dental health and diabetes

The link between oral hygiene and wellness

McDevitt, Diane MS, RN, ACNS-BC, ANP; Gattullo, Barbara APRN-BC, CDE

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doi: 10.1097/01.NME.0000668372.04867.9b
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Historically, the most common reasons for tooth loss are tooth decay and periodontal disease. Worldwide, the burden of oral disease impacts impoverished population groups and disadvantaged individuals. Severe periodontal disease, which often leads to tooth loss, is the 11th most prevalent disease globally. In the US, there's a decreasing trend in tooth loss; however, disparities exist and adults with lower incomes and education levels, as well as current smokers, experience a higher prevalence of tooth loss, according to the CDC.

Older adults are especially vulnerable to tooth loss and oral disease because of normal changes that occur with aging. These changes are believed to occur due to degenerating periodontal structure and root surface caries caused by a decline in mineralization of the root surface. One of the objectives of Healthy People 2020 is to decrease the number of adults ages 45 to 64 who've lost teeth due to dental caries or periodontitis. Currently, one in five adults age 65 or older has a dental cavity (untreated tooth decay). According to Harvard Health, two out of three US adults over age 65 have periodontal disease.

Impaired oral health may have a significant impact on an individual's general health, and several oral disorders are connected with chronic diseases such as diabetes. For patients with diabetes, commonly recognized complications, such as cardiovascular, renal, and eye problems, are stressed with integral management of care. This article takes a look at a lesser known problem—the risk of periodontitis.

Periodontitis

Periodontitis is defined as a chronic inflammatory gum disease (see Picturing periodontal disease). It's a primary oral infection triggered by Gram-negative anaerobes that evolve from a reaction to increased plaque on the teeth. Although the oral cavity is the location for periodontitis, it's a risk factor for systemic inflammatory diseases and associated with cardiac/renal mortality, atherosclerosis, and ischemic heart disease.

Periodontitis can be classified by stages, ranging from an initial presentation of gingivitis, progressing to mild peritonitis, and then to moderate and/or advanced disease (see Stages of periodontal disease). The defining symptoms include receding gums; continuing bad breath; swollen, red, and/or bleeding gums; ill-fitting dentures; loose teeth; and pus or discharge in between teeth and gums. Generally, diagnosis is made according to the disease stage and treatment options. Risk is assessed by glycemic control and further complications that occur.

Elevated blood glucose levels promote the development of bacterial and fungal infections, which may result in salivary gland dysfunction. In individuals with diabetes and periodontitis, the prevalence of oral Candida infection is approximately 52%. Individuals with type 2 diabetes that isn't well controlled have three times the risk of periodontitis compared with individuals without diabetes. Treatment of periodontitis may result in a 0.4% to 0.6% improvement in HbA1c.

Patient tips

Consider these general oral health tips for your patients living with diabetes:

  • Brush at the margin of teeth and gums with a soft-textured, multitufted nylon bristle toothbrush after every meal or at least twice a day. An interdental brush can be added to the routine to assist with removal of additional debris. Remember thoroughness, rather than vigor, is the key. An electric toothbrush may assist individuals with arthritis or mobility issues. Use of fluorinated toothpaste in any age group speeds up remineralization so tooth enamel will absorb calcium and phosphorus.
  • Floss teeth after every meal to help decrease plaque formation.
  • If wearing dentures, remove and rinse after every meal and thoroughly clean with a brush at least once daily. Thoroughly clean the oral cavity with dentures removed to cleanse all surfaces, especially those under dentures.
  • Take note of bleeding or gum sores.
  • If you can't eat your regular meals because of dental work or tooth problems, follow a sick-day plan or soft diet.
  • Have regular dental checkups (two to four checkups a year at minimum, depending on your oral health).
  • Be sure to tell the dentist that you have diabetes.
  • Remember that infected teeth can raise glucose levels, so extra blood glucose checks may be necessary.
  • Remember that keeping a water bottle handy every day isn't the only way to stay hydrated. Choose tomatoes, cucumbers, celery, and berries for their water content.
  • Fungal infections are more common in those who wear dentures, smoke, have elevated blood glucose levels, or take frequent antibiotics. Be on the outlook for white or red patches that may be sore and can lead to ulcers.
  • Observe for dry mouth conditions (see Dry mouth). Decreased amounts of saliva can cause dry mouth, which can lead to problems tasting food, inflamed and bleeding gums, and a greater risk of tooth loss from periodontal disease. A prescription toothpaste or fluoride mouth rinse may safeguard against cavities.
  • If experiencing the flu or a cold, choose sugar-free drinks to stay hydrated, sugar-free cough syrups and cough drops, and replace your toothbrush once feeling better.
  • Adhere to a healthy lifestyle, regular exercise, and avoid smoking.

Treatment recommendations should include a referral to a dentist where a proper exam can be conducted and the extent of disease determined. Treatment is multifaceted and includes a deep cleaning and scaling (removal of tartar and plaque beneath the gums) to help the gums reattach to the teeth. Antibacterial medication can be prescribed orally or placed topically in the periodontal pockets. If the disease has progressed and there's a possibility of bone involvement, surgery may be contemplated.

Education on the importance of regular checkups should be stressed. Over the past decade, only 44.5% of individuals older than age 2 had regularly scheduled dental visits during the previous 12 months, according to HealthyPeople.gov. A multidisciplinary approach works best, consisting of the patient, the dentist, and the healthcare team. Patients with diabetes should be educated about the increased risk of periodontal disease and encouraged to continue good oral health habits.

Optimal oral health

Maintaining good oral hygiene is important for everyone, with or without diabetes, and dental preservation must be a lifelong process. As nurses, we can support our patients living with chronic diseases such as diabetes and give positive recognition for the time and motivation involved in self-care. Oral disease prevention measures and health promotion efforts should be integrated to identify at-risk patients. Together, we must continue to educate patients with diabetes about the importance of preventive measures to ensure optimum oral health.

Stages of periodontal disease

Gingivitis: The mildest type of periodontal disease manifests with gums that bleed with toothbrushing; gums are red, swollen, and tender. At this stage, gingivitis can be assisted with dental treatment and effective dental hygiene.

Mild periodontitis: Gingivitis that's untreated can result in gums drawing away from the teeth; periodontal pockets grow in between the gum and teeth where tooth erosion starts, which may result in bacterial infection. Immediate attention is necessary to prevent the spread of tooth erosion and bone damage.

Moderate-to-advanced periodontitis: Substantial bone loss, expanding periodontal pockets, and tooth loss will result in this last stage of periodontal disease.

Picturing periodontal disease

Patients with diabetes are at higher risk for developing gum disease and mouth infections. These infections can make blood glucose levels rise, which in turn can make mouth infections worse. Good dental hygiene and regular dental appointments are the best prevention.

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Dry mouth

Individuals with diabetes frequently experience the sensation of dry mouth referred to as xerostomia, which is symptomatic of hyperglycemia and also reflects the diminished salivary flow rate stemming from autonomic nerve dysfunction or the microvascular changes that impede the salivary glands. Medications, such as diuretics, antihistamines, antidepressants, and some antihypertensives, can cause the adverse reaction of dry mouth. A few of the antiepileptic drugs can cause gingival overgrowth. A deficiency or decrease in oral saliva can ensue in mouth infections and accelerate mouth decay.

Patients with dry mouth should be instructed to take regular sips of water or sugar-free drinks, drink fluids with each meal, use sugar-free gum, consume alcohol in moderation and avoid tobacco, limit salty or spicy foods, and consider use of a humidifier at night.

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