By Dr Anand Induchoodan
Many patients seeking dental care have significant medical and other local conditions that may alter both the course of their oral disease and the therapy provided; it is therefore the duty of the clinician to identify these problems and to formulate a proper treatment plan.
Advances in science and technology over the last decades have expanded our knowledge of pathogenesis of periodontal disease. In addition to the interrelationships between periodontal interaction and host immune response, a number of environmental, physical and psychosocial factors affects periodontal tissues and modify tissue expression.
Periodontitis has been defined as an inflammatory disease of supporting structures of teeth, of specific bacterial origin which progress with episodic attachment loss. The destructive process of periodontitis is thought to begin with the accumulation of bio films which contain significant bacterial masses on the tooth surface at or below the gingival margin.
Diabetes mellitus is a metabolic disregulation, which develops from either a deficiency in insulin production (IDDM) or impaired insulin utilisation (NIDDM). It is characterised by the classic triad of symptoms like polyuria, polydipsia and polyphagia.
The prevalence of diabetes mellitus is more than twice as high in patients with periodontitis compared to healthy subjects.
Classic complications of diabetes include retinopathy, nephropathy, neuropathy, cardiovascular disease and impaired wound healing. Periodontal disease is considered as the sixth greatest complication of diabetes.
Oral manifestations of diabetes mellitus
The common oral manifestations of diabetes include the following: gingivitis; periodontal disease; multiple periodontal abscesses, xerostomia and salivary gland dysfunction; recurring bacterial, viral and fungal (Candida) infections; dental caries; periapical abscesses; loss of teeth; delayed wound healing; burning mouth syndrome; taste impairment; and oral lichen planus.
Gingivitis and periodontitis: Persistent poor glycemic control has been associated with the incidence and progression of gingivitis, periodontitis and alveolar bone loss. A clinician can easily observe these diseases in the oral cavity. Common signs being bleeding gums, mobility of teeth, bad taste, receding gingiva exposing roots of the teeth, migration of teeth from their original position and development of spacing between teeth.
Xerostomia and Salivary gland dysfunction: People with diabetes have been reported to complain of dry mouth, or xerostomia, and experience salivary gland dysfunction. The cause is unknown, but may be related to polyuria or to alterations in the basement membranes of salivary glands. Xerostomia can lead to further complications like increased caries and oral candidiasis.
Oral infections: Another manifestation of diabetes and an oral sign of systemic immune suppression is the presence of opportunistic infections, such as oral candidiasis. Candida pseudohyphae, a cardinal sign of oral Candida infection, can be easily identified in patient mouth. It usually appears as which curd like deposit on the oral mucosal surface which can be easily removed from the underlying surface.
Dental caries and periapical pathologies: The relationship between diabetes and dental caries has been investigated, but no clear association has been clarified. It is important to note that patients with diabetes are susceptible to oral sensory, periodontal and salivary disorders, which could increase their risk of developing new and recurrent dental caries. These caries can in turn lead to periapical pathologies like periapical abscess, which is an acute condition presenting as a round to oval pus filled swelling in the alveolar mucosa. It is an extremely painful condition and should be treated immediately, otherwise leading to complications like space infections and cellulitis.
Neurosensory disorders: Patients with diabetes have reported increased complaints of glossodynia and stomatopyrosis. A poorly understood orofacial neurosensory disorder called burning mouth syndrome has been allied with diabetes mellitus. Long-lasting oral dysesthesias experienced by patient could adversely affect oral hygiene maintenance.
Oral mucosal diseases: There are reports of greater prevalences of lichen planus and recurrent aphthous stomatitis in diabetic patients. They may be due to chronic immune suppression and require continued follow-up by healthcare practitioners. Oral mucosal disorders represent an opportunity to co-ordinate diabetes care between physicians and dentists, which can improve the referral of patients to oral health practitioners.
Lichen planus presents itself as white radiating lines called Wickhams stria on the oral mucous sometimes with similar lesions on the extremities.
Halitosis/bad breath: Diabetic patient may also present with halitosis because of the xerostomia in controlled diabetics and acetonic breath in the uncontrolled diabetics. Halitosis in such patients can be controlled and treated with proper guidelines given by oral health practioner.
The gingival and periodontal signs which may alert the clinician that the patient has previously undiagnosed diabetes or that the patient’s diabetes is poorly controlled include:
Persistence of gingival inflammation after standard periodontal treatment (thorough supra-and subgingival scaling and cleaning, oral hygiene instruction)
Severe gingival inflammatory response to plaque and proliferation of gingival tissues at the gingival margin continuing alveolar bone loss despite periodontal treatment
Severe, aggressive periodontitis in people 20-45 years of age (deep periodontal pocketing, increased tooth mobility and tooth migration, causing teeth to over-erupt or spaces to open between teeth, and radiographic evidence of advanced bone loss) simultaneous formation of multiple periodontal abscesses.
Diabetes and periodontal disease
The mechanism by which diabetes mellitus contributes to development of periodontitis remains unclear although several mechanisms have been proposed. Prolonged exposure to hyperglycemic condition results in decreased fibroblast proliferation, decreased collagen synthesis, enhanced collagen glycosylation and cross linkage resulting in defective collagen metabolism and normal collagen is replaced with highly polymerised and cross linked collagen.
Increased blood glucose results in increased levels of gingival crevicular fluid (GCF) glucose. Increase in thickening of gingival capillary endothelial cell basement membrane and wall of small blood vessels takes place. This impairs oxygen diffusion and nutrition provision across basement membrane which alters normal tissue homeostasis leading to increased severity and progression of periodontal disease.
The initial dental therapy for patients with diabetes mellitus as with all patients should be directed towards control of all acute oral infections, at the same time, communication may be established with the patients physician so that a plan can be developed to obtain control of blood glucose levels. It is important to advise the physician of the periodontal status, since the presence of infections, including advanced periodontitis may increase insulin resistance, and contribute to worsening of diabetic state.
Management
The following behavioural recommendations should be included in regular instructions for diabetic patients:
l No smoking
l Strict glycemic control
l Professional counselling on the importance of oral health
l Qualified instruction in home oral care and the importance of soft tooth brushes
l Thorough oral cleaning at least twice a day – for more than 3 minutes
l Daily interdental cleaning (floss, tooth picks, interdental - brushes)
l Tongue-brushing
l Proper tooth brush handling - daily disinfection of the tooth brush.
l Antibacterial and anti-inflammatory ingredients in toothpaste and mouth rinses
Role of the periodontist/dentist
There are large numbers of undiagnosed individuals with diabetes. The dental professional is, therefore, in a prime position to recognise those patients at risk and to inform and provide them with the best possible course of therapy. The oral signs and symptoms of the diabetic patient can be important indicators of the risk of both periodontal disease and future diabetic complications.
Symptoms related to dental structures may furnish clues about the presence of diabetes. Dry mouth and thirst are classic symptoms of diabetes mellitus, and an increased incidence of thrush is considered a complication of diabetes. Rapid alveolar bone loss and acute or multiple periodontal abscesses suggest the presence of uncontrolled diabetes.
The relationship between diabetes and periodontal disease has led to important treatment planning considerations for the diabetic patient. A current theoretical concept is that periodontal treatment can have a positive effect on glycemic control of the diabetic patient and is based on the relationship between the mechanisms of periodontitis and diabetes.
Patients should be informed that periodontal infection may make it more difficult to control diabetes and conversely, poor diabetic control may increase susceptibility to periodontal infection.
Role of the diabetologist
Regular communication of dentist with diabetologist is a critical component of safely treating patients with diabetes. Communication must be bidirectional, diabetologist must be apprised of oral manifestations of the disease and dentists must be updated on glycemic control to help them maintain a patient’s oral health. Diabetologist should be well aware of the signs and symptoms of periodontitis, making a prompt diagnosis of the condition, as periodontitis can also lead to poor control of diabetes.
Treating patients with diabetes also represents an opportunity to expand a dentist’s referral base. Physicians who treat children and adults with diabetes could be a good referral source of patients whose oral health care needs may not be satisfied adequately.
Most forms of dental therapy should not interfere with the medical control of diabetes. However, dentoalveolar surgery, orofacial infections and the stress of dental procedures can increase serum glucose levels and metabolic insulin requirements. Therefore, dentists must consider modifying medical therapy in consultation with the patient’s diabetologist. Medical and dental practitioners need to be aware of the interrelationship between poorly controlled or undiagnosed diabetes mellitus and chronic gingivitis and periodontitis
l (Dr Anand Induchoodan is a periodontist at Aster Clinic in Al Khor.)