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Diabetes Mellitus and Oral Health: An Update

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.Medical Complications.
.Oral Complications.
.Dentists' Role In Addressing Diabetes Mellitus.
.Smoking Cessation Intervention.
.References .
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Good oral health can result in better outcomes for diabetics. As you know, treating periodontal infections can help a patient improve their glycemic control. A dentist can literally be the catalyst in the prevention, early detection and treatment of diabetes and other potentially debilitating conditions.

There are three general categories of diabetes: a) Type 1, which is the result of an absolute insulin deficiency in the body; b) Type 2, which is caused by an insulin secretory defect and insulin resistance; and c) gestational diabetes, which occurs during pregnancy and is due to abnormal glucose tolerance.1 There are approximately 18.2 million people in the United States who have diabetes; 13 million have been diagnosed, while 5.2 million are unaware that they have this disease. Each year an additional 1 million adults in the United States are diagnosed with diabetes.2

Medical Complications
Some of the more serious medical conditions associated with untreated or inadequately managed diabetes include nephropathy, retinopathy, neuropathy, peripheral vascular disease, and coronary heart disease.3,4

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Oral Complications
The oral health complications of uncontrolled diabetes mellitus can include caries, periapical abscesses, loss of teeth, impaired ability to wear dental prostheses (due to salivary gland dysfunction), lichen planus, as well as the following conditions5:

Gingivitis and periodontal disease: Evidence suggests that people with diabetes are at a higher risk of developing gingivitis, which when there is poor glycemic control, may progress to advanced periodontal disease. In addition, data also suggests that periodontal infection can adversely affect glycemic control in people with diabetes.6 Therefore, it is important that people with periodontal disease and who have diabetes receive regular dental treatment. Periodontal disease is the most common oral complication of diabetes.7

Xerostomia and salivary gland dysfunction: It is not completely known why people with diabetes tend to have xerostomia and salivary gland dysfunction. A decrease in salivary flow can lead to an increased susceptibility to dental caries, dry and cracking oral mucosa, mucositis, ulcers and potentially an inflamed, depapillated tongue. Difficulty chewing, tasting and swallowing food are also complications associated with xerostomia, which may lead to a reduction in the amount of food consumed and further complications for the person with diabetes.8 To minimize discomfort and to help prevent caries, salivary substitutes and fluoride topical treatments can be offered to the patient with diabetes.

Oral candidiasis: Oral candidiasis is a fungal infection commonly associated with diabetes. Oral lesions associated with candidiasis include median rhomboid glossitis, atrophic glossitis, denture stomatitis, pseudomembraneous candidiasis (thrush), and angular cheilitis.8 Topical and/or systemic medications can be used to treat this condition.

Burning mouth syndrome: Diabetes has been associated with burning mouth syndrome, but the cause of this condition is not fully understood. There are usually no clinical signs of oral problems, but symptoms of intense pain and a burning sensation are experienced.

It is important to note that burning mouth symptoms have been experienced by people who have had undiagnosed Type 2 diabetes. This suggests that patients who indicate that they are experiencing a burning sensation in their mouth or tongue should be advised to see a physician to be screened for diabetes.9

While the above conditions should be treated in the same way for people with or without diabetes, it is important to note that people with diabetes do require more follow-up care. Intraoral infections in patients with diabetes should be aggressively treated and managed, and there should be a concomitantly higher emphasis on preventive therapies and the need for good oral hygiene.

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Dentists' Role In Addressing Diabetes Mellitus
Identification: Patients who present for a dental visit and who manifest symptoms that are associated with diabetes should be referred to a physician for evaluation.

Management: Those who have been diagnosed should receive: a) aggressive treatment of any oral infections, b) regular dental examinations and prophylaxis, and c) oral hygiene instruction, with emphasis placed on the need to be meticulous about personal oral hygiene. In general, patients who have controlled diabetes and are receiving good medical care can receive dental treatment with only very minimal restrictions.

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Smoking Cessation Intervention
People with diabetes who smoke are at increased risk for periodontal disease, oral cancer, and are more likely to experience delayed wound healing.10 It is, therefore, important to discuss the oral implications of cigarette smoking, the impact it can have on general health, and the need for the patient to quit.

In summary, for diabetic patients the dentist should record glycemic control, refer potentially undiagnosed diabetics to their physicians for examination, consult with the patients’ physicians if systemic complications are present, and schedule patients for recall to monitor and treat oral problems and to maintain good oral hygiene.8 Additional information on diabetes and oral health can be found in the recent special edition of the Journal of the American Dental Association on Diabetes and Oral Health: Treating the Patient with Diabetes Mellitus, October 2003.

Article written by: David A. Albert, DDS, MPH, Columbia University School of Dental and Oral Surgery.

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References
1. Ship, J.A. (2003). Diabetes and oral health: An overview. The Journal of the American Dental Association, 134, 4s-10s.

2. Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2002. Atlanta, GA: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2003.

3. Moore, P.A., Zgibor J.C., & Dasanayake, A.P. (2003). Diabetes: A growing epidemic of all ages. The Journal of the American Dental Association, 134, 11s-15s.

4. Harris, M.I. Summary. In: National Diabetes Data Group; National Institute of Diabetes and Digestive and Kidney Diseases. Diabetes in America. 2nd ed. Bethesda, Md.: National Institutes of Health, National Institute of Diabetes and Digestive and Kidney Diseases; 1995: 1-13. NIH publication 95-1468

5. Vernillo, A.T. Diabetes mellitus: relevance to dental treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 91: 263-70.

6. Taylor, G.W. (2003). The effects of periodontal treatment on diabetes. The Journal of the American Dental Association, 134, 41s-48s.

7. Löe, H. Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care 1993; 16: 329-34.

8. Vernillo, A.T. (2003). Dental considerations for the treatment of patients with diabetes mellitus. The Journal of the American Dental Association, 134, 24s-33s.

9. Gibson, J., Lamey, P.J., Lewis, M., & Frier, B. Oral manifestations of previously undiagnosed non-insulin dependent diabetes mellitus. J Oral Pathol Med 1990; 19: 284-7.

10. Selwitz R.H., Philstrom B.L. How to lower risk of developing diabetes and its complications: recommendations for the patient. The Journal of the American Dental Association, 134, 54s-58s.

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