Complete Nurse's Guide to Diabetes Care, 3rd Edition

Chapter 14:

Dental Issues in Patients with Diabetes

Geralyn Spollett, MSN, C-ANP, CDE,1 and Charles A. Crape, DMD2

1Spollett is an adult nurse practitioner at Yale Diabetes Center, New Haven, CT. 2Crape has a private practice in Milford, CT.

Individuals with diabetes are two to three times more likely than those without the disease to develop dental problems, such as caries, periodontal and oral mucosal diseases, and tooth loss. Dental problems can affect glycemic control and may lead to the vascular complications associated with diabetes. Those with periodontal disease and diabetes may have worse diabetes control and be at greater risk for developing cardiorenal complications.1,2Epidemiological studies have found a high degree of association between periodontal disease and diabetes, with this relationship being bidirectional.3 Poorly controlled diabetes can complicate routine dental visits, as well as oral surgery and dental implant procedures. Maintaining recommended blood glucose levels and following guidelines for good oral hygiene, including regular checkups, are key factors in reducing the incidence of dental problems.

PROMOTING DENTAL CARE

Nursing care of patients with diabetes should promote oral hygiene and prevention of dental disease as standard components of continuing diabetes management. Nurses need to emphasize routine dental care not only as a deterrent to tooth loss but also as an important measure in maintaining glycemic control. Patients must understand the integral relationship between dental care and glycemic control, in which a deterioration of one leads to the deterioration of the other.

The Centers for Disease Control and Prevention recommend that patients with diabetes see a dentist every 6 months and more frequently if periodontal disease is present.4 The American Diabetes Association (the Association) Standards of Medical Care in Diabetes includes an examination of the oral cavity in the initial visit but offers no guidelines for periodic dental examinations.5

People with diabetes are less likely than those without diabetes to have had a recent dental examination. In a study by Tomar and Lester,6 subjects who had not seen a dentist in the preceding 12 months cited a lack of perceived need for dental care and an underappreciation of the relationship between oral health and general health. In fact, when compared with other preventive care services (a dilated eye examination and a podiatric examination), dental care visits were the least likely to have occurred. Using data from the National Health and Nutrition Examination Survey 1999–2004, a study was done to calculate the prevalence of untreated dental diseases, self-reported poor oral health, and the number of missing teeth for adults in the U.S. who had certain chronic diseases. Those with rheumatoid arthritis, diabetes, or a liver condition were twice as likely to have an urgent need for dental treatment as the other participants.7

Inadequate dental care has a strong socioeconomic basis. Patients pay a much larger portion of dental costs out of pocket than they do for most other health-care services. Medicare has no provision for dental care, and Medicaid provides only limited coverage in some states. Tomar and Lester found that the disparity in frequency of dental visits among racial, ethnic, and socioeconomic groups was greater than that for any other type of health-care visit for subjects with diabetes.6 Among subjects whose annual household income was more than $50,000, 81.6% had seen a dentist in the preceding 12 months, compared with only 41.2% of those who earned less than $10,000 a year. Similar disparities did not exist for physician visits or foot examinations.6

Recent research studies have examined the feasibility of screening for diabetes in dental practices. Because uncontrolled diabetes is associated with the progression of periodontal disease, many people treated for dental problems may not realize that they have, or are at high risk for, developing diabetes. Of the 1,022 patients in community and private dental practices screened by fingerstick A1C tests, values of ≥5.7% were found in 416 people. Those ≥45 years of age had the highest proportion of positive screening tests (40.7%). Coordination between primary care providers and dental offices assisted in referring these patients for further assessment of diabetes.8

Practical Point

Smoking increases the risk of periodontal disease. Nurses need to support smoking cessation as a centerpiece in the promotion of oral health.

COMMON DENTAL PROBLEMS OF INDIVIDUALS WITH DIABETES

Nurses caring for people with diabetes need to promote daily oral hygiene to preserve gum health and prevent tooth decay. Having an understanding of the various dental diseases and conditions commonly found in these patients will lead to earlier recognition and referral for treatment of the problem.

Dental Caries and Gingivitis

Maintaining oral hygiene and preventing dental caries is a necessary component in the overall health of people with diabetes. Tooth decay and loss can compromise the ability to chew nutritious foods, such as fruits, vegetables, whole-grain or fibrous starches, and meat-based protein. The ingestion of foods that are soft and easy to masticate often causes a sharp rise in glucose levels, affecting diabetes control. Dental treatments such as root canal and bridgework not only are uncomfortable but also require adjustments in food and insulin to maintain glucose control while the dental work is being done. Therefore, emphasis should be placed on the maintenance of excellent oral health and the preservation of tooth integrity.

Topical treatments, such as fluoride applications, fluoride mouth rinses, and salivary substitutes, can help prevent caries and also reduce dry mouth symptoms associated with diabetes. Products on the market containing xylitol, such as gums and hard candies, have been shown to decrease plaque buildup on teeth and lower the risk of cavities. In addition, xylitol increases collagen formation and may have the ability to strengthen the fibers that hold teeth into place. Xylitol should be listed either as the only sweetener or appear in the first three ingredients on label for gum or candy. Gums must be chewed for 5 min to get the protective dose.9

Some essential oils help to lower the bacteria in the mouth or increase moisture. Two lozenges on the market from the Nuvora company contain both xylitol and essential oils that dissolve slowly and help the mouth feel slippery.

Chewing gums containing recaldent, a milk-derived protein, reduce acidity in the mouth and supply the teeth with calcium and phosphate. Recaldent protects tooth enamel and decreases tooth sensitivity. Gums containing recaldent will list “calcium casein peptone calcium phosphate” in the ingredients.

Gingivitis, or inflammation of the gum tissue, is more prevalent in children and adults with diabetes, despite levels of plaque control similar to those of the general population.10 Patients with diabetes have more decayed and filled tooth surfaces, as well as a higher incidence of root caries, which may be associated with more gingival recession. Often, gingivitis progresses to periodontal disease and subsequent tooth loss. Patients who have partial or total tooth loss (edentulism) tend to be older and to have longer duration of disease. They also have higher glycated hemoglobin A1c (A1C) levels and higher rates of microvascular complications (i.e., retinopathy, nephropathy, neuropathy, peripheral arterial disease).

Patient Education Topics to Promote Oral Health

• Influences of diabetes on oral health

• Achievement of glycemic control goals

• Tobacco cessation counseling

• Healthy eating habits

• Oral hygiene measures, such as routine and between-meal brushing, flossing, using a water pick device or ultrasonic plaque removing brushes

• Topical fluoride applications and dental sealants

• Adjustments in daily diabetes regimen for dental appointments or procedures (e.g., fasting, changes in insulin or diet before oral surgery, soft or liquid diet after a procedure)

Salivary Dysfunction and Xerostomia

Patients with type 2 diabetes (T2D) show reduced salivary uptake and excretion,11 and they also lack the protective components of saliva that help reduce oral bacteria. During episodes of hyperglycemia, glucose levels in the saliva can increase, providing a medium for bacterial growth. The resulting infection further increases glucose levels, and a vicious cycle of infection and hyperglycemia may ensue.

Xerostomia, or dry mouth, may be related to salivary dysfunction, polydipsia, changes in the salivary basement membranes, or dehydration associated with hyperglycemia. Diuretics; antihypertensives; anti-inflammatory medications; and asthma-relieving medications, such as inhalers, antihistamines, and antidepressants taken alone or in combination, also can affect salivation and aggravate xerostomia.

Patients with xerostomia may experience difficulties in lubricating, masticating, tasting, and swallowing, which can alter nutritional intake and further affect glycemic control. Complications resulting from xerostomia include mucositis, ulcers, and desquamation, as well as opportunistic bacterial, viral, or fungal infections.12 Improvement in glycemic control may alleviate dry mouth and prevent further oral health problems. Over-the-counter products such as Biotene mouthwash or lozenges containing xylitol can increase moisture in the mouth.

Oral Mucosal Diseases

Oral mucosal diseases occur more frequently in patients with diabetes, linked to chronic immunosuppression or acute hyperglycemia. Optimizing glycemic control is the key to prevention and treatment for each of these diseases.

Candidiasis

Fungal infections such as candidiasis are common in individuals with diabetes, particularly smokers with inadequately controlled glucose levels or patients who have dentures or other mouth appliances. Because candidiasis thrives in a warm, moist environment, denture wearers who have diabetes need to remove and clean their dentures daily to maintain healthy gums and oral membranes. Persistent hyperglycemia can predispose patients to the development of oral candidiasis, which presents as white plaque on the oral mucosa and gums. The area of infection is usually tender and bleeds easily. Medications used to treat this condition are fluconazole and nystatin oral rinse.

Lichen Planus

Lichen planus, a chronic mucocutaneous disease, appears to be an immunologically mediated process involving a hypersensitivity reaction at a microscopic level. The lesions associated with lichen planus can contain increased numbers of CD4, CD8, macrophages, dendritic cells, and other immune-regulating cells. Because the corticosteroids and immunomodulating drugs used to treat this condition can lead to hyperglycemia, diabetes therapy must be regulated carefully to reduce glucose levels that can inhibit the healing process.

Angular Cheilitis

Angular cheilitis, a lesion that occurs at the outer corners of the mouth, commonly is associated with fungal infections. It is treated with an antifungal cream or an antifungal-steroid preparation applied to the area two to three times a day for 2 weeks. Again, improved glucose levels can help promote healing.

Burning Mouth Syndrome

Patients with burning mouth syndrome may complain of tongue or mucosal sensations when no lesion is present. Suboptimal glucose control, salivary dysfunction, candidiasis, and neurological abnormalities all may contribute to the syndrome. Treatment may include prescribing salivary substitutes or using benzodiazepine or tricyclic antidepressant therapy to reduce the burning sensation. Patients who decrease their alcohol and caffeine intake also may find relief. Interestingly, burning mouth syndrome has been found in patients with undiagnosed diabetes. When diabetes is diagnosed and glucose control achieved, the symptoms of burning mouth syndrome often resolve.

Oral Ulcers

Oral ulcers, whether the benign aphthous ulcers or the potentially fatal palatal ulcers, occur more frequently in the diabetic population and must be treated with care. Because individuals with diabetes tend to develop more severe infections, oral ulcers require aggressive management and evaluation by a dental professional.

Periodontal Disease

The prevalence of periodontitis in patients with diabetes is 17%, compared with 9% in patients without diabetes.13 The rate increases dramatically among smokers with diabetes, who are 20 times more likely to develop periodontitis with loss of supporting bone than individuals without diabetes.14 The incidence and severity of periodontal disease increase with inadequate glucose control, age, and duration of disease. Patients with poorly controlled diabetes are three times more likely to develop chronic periodontal diseases compared with normoglycemic individuals despite similar composition in subgingival biofilms.15

Patients with inadequate glycemic control in either T1D or T2D have more interproximal loss of connective tissue attachment and alveolar bone loss than patients with well-controlled diabetes. The extent of the periodontal disease is more severe and can progress rapidly to loss of attachment around teeth resulting in endentulism.15 Many factors contribute to the difficulty in preventing and treating periodontal disease in individuals with diabetes (see Table 14.1).

Table 14.1—Physiological Problems in the Patient with Diabetes That Make Treating Periodontal Disease Difficult

• Increased susceptibility to infection

• Impaired wound-healing ability

• Magnified inflammatory response

• Vascular changes

• Inhibition of vasodilation

—Vasoconstriction

—Accelerated atherosclerosis

—Focal thrombosis

• Neuropathies from accelerated connective tissue damage

• Gingival changes compromising periodontal integrity

Source: Modified from Hein.13

Immune Response

Although severe periodontal disease is related to increased plaque or calculus, other mechanisms also may play a role in the development of the disease.16 The presence of diabetes can activate a protective humoral immune response. Smoking or the presence of diabetes can alter neutrophil function, lowering the protective response and placing the patient at greater risk for infection. Impairment of the polymorphonuclear leukocyte also leaves the patient with a reduced defense against gram-negative microbial infection. Any defect in the function of the polymorphonuclear leukocyte may mean a shift in the balance between destruction and repair in the initiation or progression of periodontal disease.16

Collagen Formation

Hyperglycemia reduces the growth of the fibroblast, an essential element in the building of collagen for the peridontium. A fine balance between destruction and repair of the periodontal tissue already exists; therefore, any element that decreases collagen formation will result in a loss of tissue turnover and ultimately will affect periodontal integrity. Patients with diabetes have an alteration in collagen metabolism and suppressed white blood cell function. Together, these factors increase susceptibility to periodontal infection and reduce healing.

Patients with diabetes also may have an increased level of collagenase, an enzyme that, when activated, can lead to the loss of connective tissue attachment. The decreased formation of collagen and the increased production of collagenase alter the homeostasis within the periodontal tissues.17 This commonly is manifested by loose teeth, which limit the patient’s ability to properly chew food. Once this connective tissue attachment is lost, it cannot be regenerated and usually leads to multiple tooth extractions.

Wound Healing and Recovery Time

Advanced glycosylation end products (AGEs), the result of prolonged hyperglycemia, may alter wound healing and contribute to the severity of periodontal disease. AGEs can change the solubility of collagen and alter its turnover rate. AGEs not only bind to phagocytes, initiating an inflammatory response to the bacteria present in the mouth, but also can activate collagenase. AGEs may cause a thickening of the basement membrane of blood vessels, which further compromises the wound healing process by inhibiting the activation or exchange of nutrition, oxygen, and various antibodies.17 Vascular endothelium growth factor may play a major role in tissue ischemia impeding wound healing.18

Glucose control affects recovery time after treatment of periodontal disease. In one study, patients with well-controlled diabetes had an uneventful recovery, whereas those with inadequately controlled diabetes did well initially but had a more rapid reoccurrence of pockets and a less favorable prognosis.19 Sustaining long-term metabolic control in patients with diabetes is necessary to ensure periodontal health.20 A collaborative effort between dental health providers and the diabetes care team is essential in achieving positive outcomes in periodontal care.

Systemic Effects

Periodontal disease has been associated with atherosclerosis and coronary heart disease, particularly in those with diabetes and smokers.21,22 This also was demonstrated in other studies that found that those with severe periodontal disease had 3.2 times greater risk for cardiorenal mortality1 and for macroalbuminuria and end-stage renal disease.2 Although more research needs to be done to explore for a causal link, treating the inflammatory nature of periodontal disease may positively influence the severity of diabetes and its complications.

Treatment

In some patients, undiagnosed periodontal disease may disrupt glucose control and increase A1C values. Periodontitis-induced bacteremia may elevate serum proinflammatory cytokines, leading to hyperlipidemia and furthering insulin resistance. In the past, treatment of this severe dental problem was deemed important to improve glycemic control.23 This belief has been challenged by the recent publication of the Diabetes and Periodontal Therapy Trial (DPTT).24

The response to periodontal treatment in persons with T2D was studied in the DPTT, a large, multicenter randomized control trial designed to study the effects of nonsurgical periodontal therapy among the participants with periodontitis.24 The intervention consisted of two or more sessions with scaling and root planing and follow-up supportive care. The trial lasted 6 months and data were collected on 473 participants. The results showed that the nonsurgical periodontal therapy did not improve glycemic control in the T2D with periodontitis. The study participants had A1C levels of 7% to <9%, and 72% were obese. Because the sample of patients studied was representative of persons with T2D in the U.S., the results of the study are generalizable to this population.24

Practical Point

Advanced periodontitis can present with diffuse gingival inflammation and generalized bleeding of the gum tissue on examination. Patients may complain of “tender gums” that bleed whenever they brush their teeth. This discomfort may lead to increased reluctance to pursue oral hygiene. During treatment for periodontitis, patients must follow specific hygienic measures: use of an automatic toothbrush, interdental cleaning, irrigation with a water pick, and mild abrasive dentifrices.13 Patients with periodontitis also need more frequent checkups.

Patients with periodontal disease need a thorough medical assessment, a dental history, and clinical and radiographic examinations. A periodontal probe, with calibrated measurements in millimeters, is inserted into the spaces between the teeth and the gingiva to measure the distance from the margin of the gingiva to the depth of the sulcus. A probing depth >3 mm is suspicious for peridontitis. Bone loss seen on the X-rays is further evidence of periodontitis.25

Antibiotics, particularly tetracycline and doxycycline, have been prescribed for periodontitis. These drugs seem to reduce the formation of collagenase or inhibit the degradation of collagen. They are used with mechanical therapy and may help reduce glucose levels by controlling the infection. Mechanical therapy alone does not completely eliminate periodontal disease when the organisms have invaded connective tissue.13 Chronic gram-negative periodontal infection triggers and sustains systemic inflammation.26

DENTAL VISITS

To prevent hypoglycemic episodes during the dental examination, the patient must have proper food intake before the appointment. However, some procedures, such as conscious sedation, may require the patient to withhold food for a period of time before or after the procedure.27 In these cases, a reduction in the amount of medication or insulin may be necessary. To avoid hypoglycemia, patients should not schedule the dental appointment during the hours of peak insulin activity or at a usual mealtime. If a hypoglycemic event occurs, the dental procedure should be stopped and 15 g carbohydrate should be administered. Glucose tabs or gel are often the quickest and easiest form of treatment, and patients should be advised to carry these easy-to-administer forms of glucose to every dental visit.

Certain dental surgeries should not be done during episodes of severe hyperglycemia because of the higher risk for infection and poor wound healing. One study showed that the risk of infection was linked to higher fasting glucose level.28 Patients with levels <206 mg/dL had no increased risk, whereas patients with glucose levels >230 mg/dL had an 80% risk of developing infection.

MANAGING DENTAL IMPLANTS

Inadequate glycemic control can hinder the success of dental implant procedures. Diabetes-related inhibition of collagen matrix formation and alterations in protein synthesis can affect bone production and repair. Insulin helps modulate normal skeletal growth by stimulating bone matrix synthesis. Through direct and indirect processes, insulin can alter bone turnover rates, decrease the number of osteoblasts and osteoclasts, and reduce osteocalcin. Changes in bone metabolism, association of AGEs with extracellular matrix components, and level of glucose control may influence osseointegration and reduce the percentage of bone-to-implant contact.29

The impact of uncontrolled diabetes may not be as detrimental to the success of dental implants as previously thought. In the past, dental implant therapy was not offered as a viable therapeutic option for patients with poor glycemic control as the success of the procedure was doubtful. A recent study indicates that diabetes was not associated with altered implant survival one year after implementation of the procedure.30 Hyperglycemia, however, was associated with alterations in implant stabilization and early bone healing. Of the 117 study participants, 19 had A1C levels of <12%. The study group demonstrated no signs of significant postsurgical infection or compromised healing requiring antibiotic extension or incision and drainage. Differences in bone metabolism and healing did not last much more than 6 months after the initiation of the implant. Even with the initial slower healing rates in some persons with diabetes, the final outcome was similar in all groups at 12 months postprocedure.30

Practical Point

The timing of a patient’s dental visit may affect the daily diabetes treatment program. Nurses may need to counsel patients about changes in food or medication schedules as determined by the procedure to be done and the length of recovery. Blood glucose checks should be done before the dental visit and after the procedure, and action should be taken to correct levels outside of the acceptable range for control.

The 1998 National Institutes of Health Consensus Development Conference Statement on Dental Implants underlines the importance of glucose control in patients seeking dental implants.31 Patients with inadequately controlled diabetes should not be considered candidates for these procedures. A careful preoperative assessment must determine that a patient has no contraindications; at present, however, no guidelines have been established to select patients with diabetes as candidates for dental implants. A risk factor analysis for implant loss looks at a variety of issues, including type of diabetes, duration of disease, diabetes treatment program, current and previous glycemic control, history of periodontitis, amount of tooth loss, smoking history, and poor wound-healing history.

In the initial evaluation, some dental centers perform a complete blood cell count, fasting glucose, A1C, prothrombin, and partial thromboplastin times. If metabolic control is clinically inadequate, the implant procedure is delayed until glucose levels are within the set parameters. To reduce the risk of infection, a 10-day regimen of a broad-spectrum antibiotic may be prescribed and initiated the day before the procedure.32

Postoperatively, high circulating levels of glucose reduce wound healing and increase rates of infection, compromising the success of the implant procedure. Strict glucose control and meticulous oral hygiene are vital components of postprocedure care. During this time, patients are encouraged to stop smoking to reduce the risk of implant failure.

SUMMARY

Dental care needs to figure more prominently in the standards for periodic examinations and continuing care of people with diabetes. Just as nurses guide and encourage patients to have routine foot and eye examinations, they also must promote dental checkups as an important component of diabetes management. To help patients make this goal a reality, financial support for dental care must be more readily available to both the general population and individuals with chronic illness. As patient advocates, nurses must help payers to see the importance of dental health in preserving health and function in individuals with diabetes.

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