Improving Diabetes Control with Good Oral Health

by Erin Page, DDS

As a practicing dentist with type 1 diabetes, I have noticed a concerning deficiency in the care of diabetic patients as it relates to their oral health:  Rarely are patients educated on the relationship between oral health and diabetes by their doctors or dentists, nor does regular communication between a patient’s dentist and his or her primary care physician or endocrinologist occur.  This is particularly significant since one in ten Americans has diabetes, and multiple studies have shown diabetes control impacts oral health and viseversa.^1,2,3,4

Diabetic patients are told of the many debilitating and life-threatening complications resulting from poor management of the disease, including loss of vision, nephropathy, neuropathy, and poor wound healing leading to amputation.  However, patients are generally not told that periodontal disease can also result from uncontrolled diabetes, or that periodontal disease can actually make management of diabetes more difficult.

Periodontitis, an inflammatory disease which causes loss of the supporting structures of the teeth, including the gum and bone, can lead to teeth loosening and, if untreated, tooth loss.  Studies in the Journal of American Dental Association have reported a more frequent occurrence of Periodontitis in the diabetic population.¹  One recent analysis of the National Health and Nutrition Examination Survey showed edentulism (complete loss of teeth) occurs more frequently in diabetics, and dentate (having teeth) diabetic patients have a greater number of missing teeth than non-diabetic patients.³  The higher frequency of periodontitis is of particular concern for diabetics, since numerous studies have also shown that periodontitis worsens glucose control.^1,2  Undergoing treatment for periodontitis can help to restore good glucose control.  In clinical studies, diabetic patients with periodontal disease who received scaling, root planing, and adjunctive antibiotic therapy had a reduction in mean HbA1c values of nearly 1 percent (e.g., HbA1c of 8 to 7).¹ 

Since periodontitis is an inflammatory disease and poor diabetes control causes reduced wound healing and a pro-inflammatory response, the two conditions compound each other.¹  This is imperative to note since inflammatory mediators act antagonistically to insulin, thus increasing insulin resistance among type 2 diabetics.

Periodontitis also leads to the inability to maintain a healthy diet, an important component of good glucose control.  With decreased dentition, chewing food becomes increasingly difficult and has been associated with lower consumption of dietary fibers, fruits, vegetables and a higher intake of cholesterol and saturated fatty foods.³  Furthermore, edentulism and tooth loss have been associated with chronic heart disease, hypertension, stroke, cancer and other systemic diseases³, which is of particular importance since cardiovascular heath can become compromised in diabetics.

Knowing there is a bidirectional relationship between periodontitis and diabetes, it is appropriate that dentists be part of the prophylactic care team to manage diabetes.  Yet, general dentists and periodontists often fail to educate diabetic patients on this relationship and are unsure of their role in helping to manage diabetic patients’ care.  An interesting article by Ira Lamster, professor and dean of the College of Dental Medicine at Columbia University, written in the Journal of the American Dental Association, stated “that most GPDs [General Practice Dentists] reported a lack of confidence in their ability to screen patients for diabetes mellitus, viewed active management of care of patients with diabetes mellitus as peripheral to their role as healthcare professionals and thought that their colleagues and patients did not expect them to perform such activities.”²  The article further stated that “proactive management of the care of [diabetic] patients was not performed routinely” by general dentists or periodontists.²

Given the two-way relationship between periodontitis and diabetes, diabetics should encourage their dentists to join their team of healthcare providers that help them manage their diabetes.  Diabetic patients should ask their dentist to talk to them about the relationship between oral health and diabetes and encourage communication between their dentist and their primary care physician or endocrinologist.  As a diabetic patient and a dentist, I would like to see patients and providers work together to address this often missing component in diabetic care to achieve a greater level of health for those with diabetes.

Sources:

1. Mealey BL.  Periodontal disease and diabetes: A two-way street.  J. American Dental Assoc. 2006; 137: 26S-23S.
2. Lamster IB, Lalla E, Borgnakke WS, et al.  The relationship between oral health and diabetes mellitus.  J. American Dental Assoc. 2008; 139: 19S-24S.  
3. Patel MH, Kumar JV, Moss ME.  Diabetes and tooth loss:  An analysis of data from the national health and nutrition examination survey, 2003-2004.  J. American Dental Assoc. 2014; 144(5): 478-485.  jada.ada.org. 
4. Mosen DM, Pihlstrom DJ, Snyder JJ, et al.  Assessing the association between receipt of dental care, diabetes control measures and health care utilization.  J. American Dental Assoc. 2012; 143(1): 20-30.  jada.ada.org.