Diabetes is a metabolic disease characterized by hyperglycemia due to lack of insulin secretion and insulin resistance or both. The metabolic abnormalities involve carbohydrate, protein and fat metabolism. It affects all age groups equally but is more frequent in adults. This condition directly influences the oral health of individuals. Individuals with diabetes are twice more likely to suffer from oral diseases.
Approximately 220 million people or 2.8% of the worldwide population are diabetic. According to the American Diabetes Association, people with diabetes are 2-5 times more likely to develop gum diseases than someone without diabetes.
They are numerous risk factors that predispose the diabetic individual to oral diseases. Some of these include
Poor oral hygiene
Poor metabolic control
Duration of diabetes
Saliva plays a significant role in maintaining the health of the oral cavity (mouth). Salivary dysfunction occurs in individuals with diabetes. This causes a reduction in the saliva leading to dry mouth. The constant dryness of the mouth irritates the oral soft tissues leading to gum inflammation (gingivitis). Gum diseases are more severe in diabetic individuals because of delayed healing and lowered infection-fighting ability.
A lack of saliva in the mouth causes bacterial accumulation increasing the risk of bad breath and tooth decay. Fungal infections (oral candidiasis) has found to be associated with poor glycemic control and immune dysregulation.
Oral diseases and conditions associated with diabetes mellitus include:
Gingival (gums) enlargement
Periodontitis (infection of the gums and jawbone)
Dental (tooth) decay
Glossodynia (pain in tongue)
Xerostomia (dry mouth)
Oral lesions (lichen planus, apthous stomatitis)
Untreated diabetes can progress more rapidly towards tooth loss. Thrush (fungal infection) is another common oral complication among diabetics that causes mouth sores and ulcers. 1 in 5 cases of tooth loss are associated with diabetes
1. Glycated hemoglobin (HbA1c)
This test determines the average blood sugar level over the past 2 to 3 months. Glycated hemoglobin levels (A1C ≥6.5%) confirm the diagnosis of diabetes.
2. Fasting plasma glucose level (FPG)
Fasting is defined by the criteria of no calorie intake for a minimum of 8 hrs. FPG ≥126 mg/dl is the threshold level for the diagnosis of diabetes.
3. Oral glucose tolerance test (OGTT)
2-hr plasma glucose level ≥200 mg/dl during oral glucose tolerance test is the standard therapy for a diagnosis of type 2 diabetes. This test is performed after the administration of 75 g anhydrous glucose dissolved in water.
4. Random plasma glucose
Random plasma glucose ≥200 mg/dl in a patient with symptoms of high blood sugar indicates that the individual has diabetes.
As oral diseases occur more frequently in diabetes, the individual should always be clinically examined for any associated problems including decay, gum disease, dry mouth or oral lesions. Regular dental checkups will help identify any potentially occurring oral complications related to diabetes.
Management of oral diseases in diabetic individuals
A controlled diabetic has a lesser risk of developing oral diseases than an uncontrolled individual. Therefore first-line therapy for these individuals includes control of blood sugar using anti-diabetics (drugs and insulin preparations).
The list of the commonly observed oral conditions and their associated treatment measures are mentioned below
1. Gingival enlargement:
Is managed by professional oral prophylaxis (mechanical cleaning of the teeth by the dental practitioner). This should be followed by proper oral hygiene (brushing, flossing, and use of mouthwashes)
2. Dental decay:
Decay involving the teeth is treated using restorations followed by topical fluoride application. Flouride has shown to have an inhibitory effect on oral bacteria.
3. Dry mouth:
To relieve dry mouth, sip water throughout the day, chew sugarless gum or mints or use an over the counter available mouth moisturizers
Topical antifungal agents (Clotrimazole, Nystatin, amphotericin B) or systemic agents (Itraconazole, fluconazole, posaconazole) have shown efficiency in treating fungal infections of the oral cavity.
The essential health measure for the prevention of oral diseases in diabetic individuals is optimum glycemic control and good oral hygiene
1. Good oral hygiene measures include
Brushing with fluoride toothpaste twice a day, and flossing at least once daily
Brush twice daily for 2 min with a soft toothbrush using fluoridated toothpaste
Clean or scrape the tongue daily
Avoid mouth rinses with alcohol, as they tend to worsen the dry mouth
2. Smoking is a major preventable risk factor for gum disease and tooth loss in patients with diabetes. If you are a smoker get help from your health team on how to quit.
3. Low carbohydrate and high fiber diets reduce the prevalence of caries in diabetic individuals.
1. Leite RS, Marlow NM, Fernandes JK, Hermayer K. Oral health and type 2 diabetes. The American journal of the medical sciences. 2013 Apr 1;345(4):271-3.
2. Ship JA. Diabetes and oral health: an overview. The Journal of the American Dental Association. 2003 Oct 1;134:4S-10S.