Contents
1 / Diabetes, Clinical Dentistry and Changing ParadigmsBattling and Insidious Foe
A Challenge for Dentists
A Biology of Complexity
How Diabetes Occurs
IDDM
NIDDM
Promoting Health, Preventing The Disease
Conclusion
For Additional Information
2 / Oral Complications in Diabetes
Summary
Caries (Tooth Decay)
Periodontal Disease
Saliva
Other Pathological Features of the Oral Cavity
References
3 / Oral Opportunistic Infections: Links to Systemic Diseases
Diabetes Mellitus
Preterm Low Birth Weight Babies
Diseases Associated With Diabetes
4 / Detection and Prevention of Periodontal Disease in Diabetes
Overview
Gingivitis
Thrush
Pathophysiology
Progress of Periodontal Disease
Diabetic Control
Oral Factors
Natural Dentition
Oral Hygiene
Acute Infections
Oral Surgery
Diabetes Control
Risk of Infection
References
5 / Oral Complications of Diabetes: A Guide for Dental Hygienists
Oral Complications
Dental Management
Diabetic Emergencies
The Role of Diet
Planning Dental Treatment
Dental Tips for Patients With Diabetes
6 / Oral Complications of Diabetes: A Guide for Patients
What is the relationship between poor oral health and diabetes?
What is the link between diabetes and periodontal disease?
Controlled Diabetics Have New Reason to Smile
How does periodontal disease develop?
How is periodontal disease treated?
Since I have diabetes, do I need to do anything to prepare for oral surgery?
Are other oral problems linked to diabetes?
Keep your teeth
How can you protect your teeth and gums?
Things to keep in mind
1. Diabetes, Clinical Dentistry and Changing Paradigms
Go Top of Page
The infectious diseases that took the young lives of our ancestors in the early part of the 20th century have been replaced at the end of the century with chronic and degenerative diseases. This has awakened a new respect for and interest in cancer, heart disease, dementia, dwarfism, periodontal diseases, chronic pain, osteoporosis, arthritis and rheumatism—all known since time immemorial but, until recently, only as a faint background to the acute tragedies of assorted fevers and plagues.
Our changing demographics indicate that nearly 20 percent of all Americans will be 65 years of age or older by the year 2010. We are beginning to appreciate the changing patterns of disease—disease that is chronic, that affects older people, that debilitates but does not necessarily kill. These patterns are reflected in the goal of the health professions. Our challenge now is not to extend life, but to improve the quality of the human condition throughout the lengthened lifespan—a changing paradigm.
Battling an Insidious Foe
Slowly evolving and symptomless, chronic noninfectious diseases are mysterious and frightening. Because it is hard to imagine being sick when you feel fine, by the time signs and symptoms do appear, it usually means that the disease has progressed to a serious stage.
For many people, diabetes is just such a disease. Diabetes is a disease of metabolism, an alteration of what Claude Bernard, a 19th-century French physiologist, called the "milieu interieur," a malfunction of the mechanisms that regulate sugar utilization which results in hyperglycemia. Between 13 and 15 million Americans are believed to have the disease, and about half are unaware of their condition.
Early detection is important because diabetes can lead to life-threatening complications_heart disease, blindness, neuropathies (including chronic facial and oral pain), periodontal diseases, tooth loss, stroke, kidney failure and even gangrene. In 1993, about 400,000 deaths resulting from any cause are estimated to have occurred in people with diabetes.1 Only heart disease and cancer kill more Americans than diabetes and its complications.
A Challenge for Dentists
Diabetes poses a significant public health challenge for the United States. Some 800,000 new cases are diagnosed each year, or 2,200 per day. The changing demographic patterns in the Unites States are expected to increase the number of people who are at risk for diabetes and who eventually develop the disease. Diabetes is a chronic disease that usually manifests itself as one of two major types: Type 1, mainly occurring in children and adolescents 18 years and younger, in which the body does not produce insulin and thus insulin administration is required to sustain life; or Type 2 occurring usually in adults over 30 years of age in which the body's tissues become unable to use its own limited amount of insulin effectively. While all persons with diabetes require self-management training, treatment for Type 2 diabetes usually consists of a combination of physical activity, proper nutrition, oral tablets and insulin. Type 1 diabetes has been sometimes referred to as juvenile or insulin-dependent diabetes; and Type 2 diabetes has been referred to as adult-onset or noninsulin dependent diabetes.
Controlling the blood glucose level is the most important step for the diabetic to prevent tooth and gum problems. However, maintenance of good oral hygiene cannot be overemphasized. The diabetic patient who is well managed medically and whose glucose levels are controlled can receive any indicated dental treatment. Because infection aggravates diabetes our ultimate goal should be to stress early care to help prevent complications of gum and periodontal disease. Important management for effective oral hygiene include antibiotics, calculus and plaque removal.
A number of major complications of diabetes present major challenges to oral health professionals: acidosis, hypoglycemic coma and hypoglycemia, neuropathy, kidney diseases, peripheral vascular diseases, heart disease, stroke, digestive diseases and opportunistic microbial infections such as those of the mouth associated with gingivitis, periodontal disease and candidiasis. Therefore, oral health professionals have major opportunities for health promotion, disease prevention, diagnosis and therapy related to diabetes.
Some studies have shown a possible improvement in diabetic control (as measured by glucose levels) after treatment for periodontal disease. A reduction in inflammation associated with oral infection is believed to reduce harmful effects that lead to poor metabolic control. The management of diabetic patients presents another critical reason for dentists to obtain comprehensive dental and medical information before initiating diagnostic and treatment procedures.
In addition, people with all types of diabetes who use tobacco products face a significant risk of severe periodontal disease. In one study, 30 percent of patients aged 19 years and older who had insulin-dependent diabetes mellitus, or IDDM, also had periodontal disease. In Pima Indians with non-insulin-dependent diabetes mellitus, or NIDDM, tooth loss is 15 percent higher than that among those without diabetes, and the incidence of periodontal disease is 2.6 percent higher. Prevalence of gingivitis, periodontal attachment loss, bone loss and tooth loss are characteristics of patients with IDDM.
A Biology of Complexity
Diabetes is an excellent example of a biology of complexity, which reminds us that health is really a profound and intricate balance of the components of the human body throughout life. Reduced blood circulation to the legs leading to sores and ulcers; kidney failure; and neurological, circulatory, reproductive and ocular problems are frequent and confounding complications in patients with diabetes that reflect the biological complexity associated with chronic and degenerative diseases.
Six hormones are important in regulating fuel metabolism in humans. In general terms, insulin is the primary anabolic hormone (linked with synthesis and storage of body fuels), while the other five hormones subserve catabolic functions (that is, breakdown and oxidation of stored fuels for the provision of energy in the absence of food intake). The primary hormones involved in diabetes are insulin and glucagon. The biological regulation that maintains a balance between anabolic and catabolic functions is at the heart of diabetes.
Types of diabetes.
Of the estimated 13 to 15 million people in the United States who have diabetes, between 90 and 95 percent have NIDDM, also called Type II diabetes. The second form of diabetes is IDDM, also called Type I. IDDM affects an estimated 800,000 people. The cost to the U.S. economy of both types is about $92 billion per year, with $45 billion in direct medical costs and $47 billion in indirect costs (such as disability, work loss and premature mortality).1
A third type of diabetes—gestational diabetes—has been found to develop in some pregnant women. The condition appears to be transient in that it disappears when the pregnancy is over, but women who have it appear to have an increased susceptibility to developing NIDDM in later years.
Identifying those at risk.
Diagnostically, people at high risk of developing diabetes can be identified through analysis of accumulated glucose in blood and saliva. Hyperglycemia can be associated with unusual changes in the microbial ecology of the oral cavity, resulting in gingivitis, periodontal disease and oral candidiasis. Studies in clinic, community and hospital populations indicate that people with diabetes have a higher risk of developing bacterial and yeast infections, including asymptomatic bacteriuria, infections in surgical wounds and group B streptococcal infections.
How Diabetes Occurs
Diabetes is a disorder of metabolism, which is the way the body uses digested food for growth and energy. Most digested food is broken down by digestive enzymes into glucose, which circulates in the blood stream and is taken up by the cells for growth and energy. For the glucose to get into the cells, the hormone insulin must be present.
Insulin reacts with the insulin receptor at the cell membrane, allowing glucose to enter the cell. Insulin is synthesized in the pancreas, a gland 5 to 6 inches in length tucked behind the stomach. The pancreas is a compound organ containing several types of cells that function independently. It is mainly composed of acinar cells, which synthesize and secrete various digestive enzymes through the pancreatic duct into the duodenum. The pancreas also contains quite different cells in areas called the islets of Langerhans. The islets produce internal secretions, including the hormone insulin in the beta cells, the hormone glucagon in the alpha cells and somatostatin in the delta cells, which may regulate the synthesis of both insulin and glucagon.
Insulin functions to reduce the concentration of glucose in the blood in at least four processes:
· to stimulate (probably by altering membrane permeability) the muscles to remove more glucose from the blood;
· to stimulate both the muscles and the liver to convert more glucose into glycogen for storage;
· to inhibit the liver from producing glucose from glycogen or other stored materials;
· to stimulate the muscles and liver to oxidize carbohydrates at a more accelerated rate.
Scientists did not begin to understand the causes of diabetes until the latter part of the 19th century. By 1889, two German physicians, Johann von Mering and Oskar Minkowski, observed that removal of the pancreas resulted in the excretion of sugar into the urine and the development of several symptoms associated with diabetes—excessive thirst, frequent urination, glucose in blood and urine, coma, visual disorders involving retinopathy, neuropathy and kidney disease.
IDDM
The precise cause of diabetes is not known. Scientists assume that IDDM may be more than one disease and may have a number of different causes. For example, a number of scientific groups have provided evidence that IDDM is influenced by multiple genes that confer susceptibility—genes that are prevalent as risk factors in some families but not in other families. IDDM usually occurs in children and adults younger than 30 years of age and thus is known as juvenile diabetes. IDDM occurs equally among males and females, is more common among whites and is very rare in most Asian-, African- and Native American populations. Some Northern European countries, including Finland and Sweden, have high rates of IDDM.
IDDM exhibits 30 to 50 percent concordance in identical or monozygotic twins, suggesting that the disorder depends on environmental factors as well as genes. Additional evidence suggests that IDDM susceptibility genes are not linked to, but interact with, the human leukocyte antigen system.
Type I diabetes mellitus, or IDDM, is thought to result from the destruction of pancreatic beta cells. Genetic susceptibility to IDDM is encoded by several genes near the insulin gene on chromosome 11. Presumably, IDDM is primarily an autoimmune disease associated with a loss of tolerance for several pancreatic islet cell protein molecules, including insulin; glutamic acid decarboxylase, or GAD; and tyrosine kinase, or IA-2, proteins. When these molecules in the beta cells are exposed to the immune system as foreign (by becoming altered in some manner), they are no longer given tolerance or protection from immunological attack. The immune system produces antibodies against these normal cell components (autoantibodies), attacks these molecules and in the process destroys the beta cell.
With reduced or eliminated beta cells, the pancreas produces little or no insulin. The body is then unable to use glucose for energy and glucose accumulates in the blood, giving rise to the abnormally high glucose levels that are the hallmark of hyperglycemia and diabetes. The kidneys overwork to filter the excess glucose into the urine, and the body becomes dehydrated as a result. The body breaks down its stores of fat and protein to provide more glucose to the cells "starving in the midst of plenty." If the breakdown of fat continues unchecked, acidic by products called ketones accumulate. These ketones, combined with dehydration, induce coma and eventually death. However, subclinical abnormal processes precede the apparent rapid onset of IDDM.
A number of research laboratories, including some supported by the NIDR, have identified antibodies to autoantigens associated with the pancreatic beta cells before there is any apparent diabetes. It is hoped that early detection of this autoimmune attack on the beta cells could allow for a counterattack to halt the antibody production and prevent the disease.
Another very recent discovery has been that IDDM shows familial patterns, suggesting an inherited disease process. Scientific investigations have discovered that selective mouse and human characteristics are produced by imprinting—that is, a developmental, often tissue-specific, form of gene regulation by which only one of the two parental alleles or genes is expressed, while the other imprinted allele is repressed. Imprinting has been found for a number of genes that are physically located in the chromosome 11p15 region (for example, insulinlike growth factor, insulin like growth factor receptor, insulin). Imprinting may explain the observed parental effects on IDDM-associated susceptibility.
Treating IDDM.
Treatment of diabetes requires therapeutic insulin coupled with a dietary plan, a daily exercise program and tests for blood glucose levels taken several times a day.