Diabetes in Real Life

Diabetes education must include oral health

In this issue, Susan Weiner, MS, RDN, CDE, CDN, talks with dentist and certified diabetes educator Jerry Brown, DMD, CDE, about oral health for people with diabetes. Brown, who has type 1 diabetes, speaks to dental and diabetes care professionals about the overlap between their fields.

How does diabetes affect oral health?

Susan Weiner
Brown: Diabetes and periodontal disease — the most common oral disease — have a lot in common in that they are both inflammatory diseases that initiate an immune response. When somebody lives with constantly elevated blood glucose, as in poorly controlled diabetes, the blood becomes like syrup. This “syrupy” blood glycates (forms a coating on) the surface membranes of many of the body’s cells, including those that are involved with an immune response to inflammation. This glycation activates the immune system, but in a dysfunctional manner. When these glycated macrophages make their way through the systemic circulation and wind up beneath the highly vascular gum tissue, they wreak havoc. Cytokines are released that cause destruction of the connective tissue and alveolar bone responsible for supporting the teeth while simultaneously hampering the cells that are normally involved with hard and soft tissue repair. As this is taking place, the white blood cells that normally fight the bacterial invasion from dental plaque become less attracted to and less effective in destroying bacteria. So, conditions become favorable for the bacteria to multiply. This is also one of the reasons why, in general, people with poorly controlled diabetes have difficulty responding to infections.

Can a disease that begins in the mouth affect blood glucose?

Brown: Most definitely. Again, glycation of the cells lining the capillaries beneath the gum — the endothelium — make them extremely permeable for the passage of bacterial byproducts and chemical messengers into the systemic circulation. When these highly reactive substances reach the muscle, liver and adipose cells, they actually interfere with the signaling capabilities of the enzymes within the insulin receptors. This is classic insulin resistance and will lead to difficulties in controlling blood glucose even when the patient seems to be adhering to appropriate self-management behaviors. The patient’s poor oral health may be the missing piece of the puzzle when contemplating how to deal with the issue of poor glycemic control.

As diabetes educators, how can we recognize periodontal disease and other oral diseases?

Brown: It is unlikely that diabetes educators have had a course in oral pathology or in how to perform a basic oral health evaluation. However, there are some obvious signs to include in assessments when inspecting a patient’s mouth with a penlight, a tongue depressor and a cotton gauze. I review these during my slide presentations to diabetes educators. Obvious concerns include mucosal redness, missing teeth, brown or black spots on teeth, holes, root exposure and a burning sensation in the mouth, to name a few.

How can diabetes educators better collaborate with oral health care professionals?

Brown: A close look at the American Diabetes Association’s 2017 Standards of Medical Care in Diabetes reveals that referral to a “dentist for comprehensive dental and periodontal examination” is situated directly under referral to a registered dietitian for medical nutrition therapy and referral for diabetes self-management education and support as part of the components of the comprehensive diabetes evaluation. It would be necessary to perform a basic oral evaluation to adequately screen for complications and comorbidities. A basic oral evaluation would provide the health care team — including dentists as part of the health care team — with information necessary to optimally support a patient with diabetes.

What questions can we ask patients to gain insight into their oral health status?

Jerry Brown
Brown: The patient’s health history or interview should include the following questions:

  • When was the last time you visited a dental office for a cleaning and examination?
  • Was any treatment recommended, and if so, was it completed?
  • Do you notice any pain or swelling in your gums, teeth or anywhere else within your mouth?
  • Do your gums generally bleed when you brush?
  • Have you noticed any looseness or shifting of your teeth?
  • Does your mouth feel dry, and do you have any difficulty swallowing?

As we perform a basic oral evaluation, what findings would warrant a dental referral?

Brown: A complaint of pain or swelling would warrant an immediate dental referral. Lumps or white or red patches on the tongue, cheeks, floor of the mouth or palate require a professional referral, as well. Teeth that have holes in them or have black or brown stains may require dental treatment. Of course, it would be difficult to recommend a behavior like healthy eating if a patient is missing teeth. Therefore, a discussion about the necessity for visiting a dentist to explore the options for restoring the patient’s ability to chew properly and eat foods high in fiber is extremely important. Remember that teeth are also necessary to support facial structure, as well as speaking, which could affect a patient’s self-image and contribute to depression.

How do we manage a dental referral for somebody who either does not have a dentist or cannot afford a dental visit?

Brown: If a patient requires a dental referral, the obvious first choice would be refer them to their family dentist. If they say they don’t have a dentist, then I suggest having a readily available list of local dental health care professionals who have the knowledge and willingness to care for patients with diabetes. A good resource for creating this list would be to contact your state and local dental associations. They should be able to provide a listing of dental clinics in a specific area that may provide lower-cost access to care, as well as identify clinics that are Medicaid providers. Dental schools and dental hygiene clinics are also places that can provide dental services for people with diabetes.

What are some examples of recommendations for patients with diabetes for maintaining their oral health?

Brown: First, educate patients that they are two to three times more likely to develop periodontal disease than somebody without diabetes. Emphasize that regular dental cleanings and evaluations can potentially help them save their teeth and that, because of their risk, these dental visits should take place three to four times per year. Detecting gingivitis before the pocketing and bone loss associated with periodontitis occurs is like detecting prediabetes before it progresses to type 2 diabetes. Using a soft-bristled toothbrush and an antimicrobial toothpaste at least twice per day along with daily flossing might be all that is necessary to reverse inflammation. Regular dental visits may also detect other problems frequently experienced by people with diabetes: tooth decay, dry mouth, Candida infections and missing teeth.

The bottom line is that glycemic control can improve oral health, and good oral health can improve glycemic control.

Disclosures: Brown reports he is a speaker for Colgate Oral Health. Weiner reports she is a clinical adviser to Livongo Health.

In this issue, Susan Weiner, MS, RDN, CDE, CDN, talks with dentist and certified diabetes educator Jerry Brown, DMD, CDE, about oral health for people with diabetes. Brown, who has type 1 diabetes, speaks to dental and diabetes care professionals about the overlap between their fields.

How does diabetes affect oral health?

Susan Weiner
Brown: Diabetes and periodontal disease — the most common oral disease — have a lot in common in that they are both inflammatory diseases that initiate an immune response. When somebody lives with constantly elevated blood glucose, as in poorly controlled diabetes, the blood becomes like syrup. This “syrupy” blood glycates (forms a coating on) the surface membranes of many of the body’s cells, including those that are involved with an immune response to inflammation. This glycation activates the immune system, but in a dysfunctional manner. When these glycated macrophages make their way through the systemic circulation and wind up beneath the highly vascular gum tissue, they wreak havoc. Cytokines are released that cause destruction of the connective tissue and alveolar bone responsible for supporting the teeth while simultaneously hampering the cells that are normally involved with hard and soft tissue repair. As this is taking place, the white blood cells that normally fight the bacterial invasion from dental plaque become less attracted to and less effective in destroying bacteria. So, conditions become favorable for the bacteria to multiply. This is also one of the reasons why, in general, people with poorly controlled diabetes have difficulty responding to infections.

Can a disease that begins in the mouth affect blood glucose?

Brown: Most definitely. Again, glycation of the cells lining the capillaries beneath the gum — the endothelium — make them extremely permeable for the passage of bacterial byproducts and chemical messengers into the systemic circulation. When these highly reactive substances reach the muscle, liver and adipose cells, they actually interfere with the signaling capabilities of the enzymes within the insulin receptors. This is classic insulin resistance and will lead to difficulties in controlling blood glucose even when the patient seems to be adhering to appropriate self-management behaviors. The patient’s poor oral health may be the missing piece of the puzzle when contemplating how to deal with the issue of poor glycemic control.

As diabetes educators, how can we recognize periodontal disease and other oral diseases?

Brown: It is unlikely that diabetes educators have had a course in oral pathology or in how to perform a basic oral health evaluation. However, there are some obvious signs to include in assessments when inspecting a patient’s mouth with a penlight, a tongue depressor and a cotton gauze. I review these during my slide presentations to diabetes educators. Obvious concerns include mucosal redness, missing teeth, brown or black spots on teeth, holes, root exposure and a burning sensation in the mouth, to name a few.

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How can diabetes educators better collaborate with oral health care professionals?

Brown: A close look at the American Diabetes Association’s 2017 Standards of Medical Care in Diabetes reveals that referral to a “dentist for comprehensive dental and periodontal examination” is situated directly under referral to a registered dietitian for medical nutrition therapy and referral for diabetes self-management education and support as part of the components of the comprehensive diabetes evaluation. It would be necessary to perform a basic oral evaluation to adequately screen for complications and comorbidities. A basic oral evaluation would provide the health care team — including dentists as part of the health care team — with information necessary to optimally support a patient with diabetes.

What questions can we ask patients to gain insight into their oral health status?

Jerry Brown
Brown: The patient’s health history or interview should include the following questions:

  • When was the last time you visited a dental office for a cleaning and examination?
  • Was any treatment recommended, and if so, was it completed?
  • Do you notice any pain or swelling in your gums, teeth or anywhere else within your mouth?
  • Do your gums generally bleed when you brush?
  • Have you noticed any looseness or shifting of your teeth?
  • Does your mouth feel dry, and do you have any difficulty swallowing?

As we perform a basic oral evaluation, what findings would warrant a dental referral?

Brown: A complaint of pain or swelling would warrant an immediate dental referral. Lumps or white or red patches on the tongue, cheeks, floor of the mouth or palate require a professional referral, as well. Teeth that have holes in them or have black or brown stains may require dental treatment. Of course, it would be difficult to recommend a behavior like healthy eating if a patient is missing teeth. Therefore, a discussion about the necessity for visiting a dentist to explore the options for restoring the patient’s ability to chew properly and eat foods high in fiber is extremely important. Remember that teeth are also necessary to support facial structure, as well as speaking, which could affect a patient’s self-image and contribute to depression.

How do we manage a dental referral for somebody who either does not have a dentist or cannot afford a dental visit?

Brown: If a patient requires a dental referral, the obvious first choice would be refer them to their family dentist. If they say they don’t have a dentist, then I suggest having a readily available list of local dental health care professionals who have the knowledge and willingness to care for patients with diabetes. A good resource for creating this list would be to contact your state and local dental associations. They should be able to provide a listing of dental clinics in a specific area that may provide lower-cost access to care, as well as identify clinics that are Medicaid providers. Dental schools and dental hygiene clinics are also places that can provide dental services for people with diabetes.

PAGE BREAK

What are some examples of recommendations for patients with diabetes for maintaining their oral health?

Brown: First, educate patients that they are two to three times more likely to develop periodontal disease than somebody without diabetes. Emphasize that regular dental cleanings and evaluations can potentially help them save their teeth and that, because of their risk, these dental visits should take place three to four times per year. Detecting gingivitis before the pocketing and bone loss associated with periodontitis occurs is like detecting prediabetes before it progresses to type 2 diabetes. Using a soft-bristled toothbrush and an antimicrobial toothpaste at least twice per day along with daily flossing might be all that is necessary to reverse inflammation. Regular dental visits may also detect other problems frequently experienced by people with diabetes: tooth decay, dry mouth, Candida infections and missing teeth.

The bottom line is that glycemic control can improve oral health, and good oral health can improve glycemic control.

Disclosures: Brown reports he is a speaker for Colgate Oral Health. Weiner reports she is a clinical adviser to Livongo Health.