eliminate harmful wastes from body tissues, including tissues of the mouth. Lowered blood flow causes the gum and bone tissue that support the teeth to become less healthy and less resistant to infection from the bacteria found in dental plaque.4
The most common reasons for a dry mouth in a diabetes patient are:
• Side effects of medication
• Neuropathy (autonomic)
• Lack of hydration
• Kidney dialysis
• Hyperglycemia
• Mouth breathing
• Smoking
Some clinical signs of dry mouth
• Loss of moisture, glistening of the oral mucosa
• Dryness of the oral membranes
• Irritated corners of the mouth (cheilitis)
• Gingivitis
• Difficulty wearing dentures
• Mucositis
• Mouth sores
• Yeast infection(Candidiasis), especially on the tongue and Palate.
• Dental cavities: increased prevalence and located in sites generally not susceptible to decay Dental Care for Dry Mouth Patients
The diabetes patient with dry mouth along with his or her oral health team will have to develop a routine for optimal oral health.
Here are some simple ways to accomplish that goal:
• Perform oral hygiene at least four times daily, after each meal and before bedtime.
• Rinse and wipe the mouth immediately after meals.
• Brush and rinse removable dental appliances after meals.
• Use only toothpaste with fluoride. Some toothpastes (such as Biotene) are formulated for dry mouth.
• Keep water handy to moisten the mouth at all times.
• Apply prescription-strength fluoride at bedtime as prescribed.
• Avoid liquids and foods with high sugar content.
• Avoid overly salty foods.
• Limit citrus juices (orange, grapefruit, tomato), as well as diet sodas.
• Avoid rinses containing alcohol. Several nonalcoholic mouthwashes are now available on the market.
• Use a lip balm or moisturizer regularly.
• Try salivary substitutes, gels or artificial saliva preparations. These may relieve discomfort by temporarily wetting the mouth and replacing some of the saliva constituents.
• In severe cases, use of pilocarpine might be used under a physician’s care.4,5
Diabetics also face increased susceptibility to getting other nasty dental health problems such as oral yeast infections, gingival abscesses, lichen planus, burning mouth syndrome and possible difficulties in wearing dental prosthetics.
Though diligent blood sugar control is the most important factor in maintaining. Diabetic’s oral health, rigorous dental hygiene is also imperative for those with this disease, for without it oral health problems can multiply exponentially. No one should smoke cigarettes, and this is especially true for diabetics.
Smoking is injurious to gums and mouth tissues and only adds to diabetic dental health problems.
If all of this sounds like bad news, there is an upside:
Diabetics who keep their blood sugar levels in check can usually receive any dental treatments that patients without diabetes can receive, which is especially important if you want to undergo cosmetic dental procedures to improve your smile.7,8
Management issues of operative dentistry among diabetics:
To minimize the risk of an intraoperative emergency, cliniciansneed to consider a number of management issues before initiatingdental treatment.
Medical history: It is important for clinicians to take a good medical historyand assess glycemic control at the initial appointment. Theyshould ask patients about recent blood glucose levels and frequencyof hypoglycemic episodes. Antidiabetic medications, dosagesand times of administration should be determined. A varietyof other concomitantly prescribed medications may alter glucosecontrol through interference with insulin or carbohydrate metabolism.The hypoglycemic action of sulfonylurea’s may be potentiatedby drugs that are highly protein- bound, such as salicylates,dicumerol, β-adrenergic blockers, monoamine oxidaseinhibitors, sulfonamides and angiotensin-converting enzyme inhibitors.
Epinephrine, corticosteroids, thiazides, oral contraceptives,phenytoin, thyroid products and calcium channel–blockingdrugs have hyperglycemic effects.
In general, morning appointments are advisable since endogenouscortisol levels are generally higher at this time.
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Patients undergoing major surgical procedures may require adjustmentof insulin dosages or oral antidiabetic drug regimens. Any complications of DM, such as cardiovascular or renal disease, will have their own effects on dental treatment planning. If necessary, thedentist should consult with the patient’s physician8. Scheduling of visits: In general, morning appointments are advisable since endogenous cortisol levels are generally higher at this time (cortisol increases blood sugar levels). For patients receiving insulintherapy, appointments should be scheduled so that they do notcoincide with peaks of insulin activity, since that is the periodof maximal risk of developing hypoglycemia.
Diet: It is important for clinicians to ensure that the patient haseaten normally and taken medications as usual. If the patientskips breakfast owing to the dental appointment but still takesthe normal dose of insulin, the risk of a hypoglycemic episodeis increased.
For certain procedures (for example, conscious sedation), the dentist may request that the patient alter hisor her normal diet before the procedure. In such cases, themedication dose may need to be modified in consultation withthe patient’s physician.
Blood glucose monitoring: Depending on the patient’s medical history, medicationregimen and procedure to be performed, dentists may need to measure the blood glucose level before beginning a procedure.This can be done using commercially available electronic bloodglucose monitors, which are relatively inexpensive and havea high degree of accuracy. Patients with low plasma glucoselevels (<
70 mg/dl for most people) should be given an oral carbohydrate before treatment to minimize the risk of a hypoglycemicevent. Clinicians should refer patients with significantly elevatedblood glucose levels for medical consultation before performingelective dental procedures.
During treatment: The most common complication of DM therapy that can occur inthe dental office is a hypoglycemic episode. If insulin or oral antidiabetic drug levels exceed physiological needs, the patientmay experience a severe decline in his or her blood sugar level.The maximal risk of developing hypoglycemia generally occursduring peak insulin activity. Initial signs and symptoms includemood changes, decreased spontaneity, hunger and weakness. Thesemay be followed by sweating, incoherence and tachycardia.
If untreated, possible consequences include unconsciousness, hypotension,hypothermia, seizures, coma and death.
If the clinician suspects that the patient is experiencing ahypoglycemic episode, he or she should
terminate dental treatment and immediately administer 15 grams of a fast-acting oral carbohydrate such as glucose tablets or gel, sugar, candy, soft drinks orjuice. It is important to note that the α glycosidase inhibitorsprevent the hydrolysis of sucrose into fructose and glucose.Therefore, a hypoglycemic episode in a patient taking thesedrugs should be treated with a direct source of glucose. Afterimmediate treatment, dentists should measure blood glucose levelsto confirm the diagnosis and determine if repeated carbohydratedosing is needed. If the patient is unable to swallow or losesconsciousness, the dentist should seek medical assistance; 25to 30 ml of a 50 percent dextrose solution or 1 mg of glucagonshould be administered intravenously. Glucagon also can be injectedsubcutaneously or intramuscularly7.
It is important for dentists to educate patients about the oralimplications of diabetes mellitus. Among the mechanisms thought to produce the tissuedamage associated with chronic hyperglycemia are glycation oftissue proteins and excess production of polyol compounds fromglucose1. People with poorly controlledDM also may have impaired wound healing and increased susceptibilityto infections. Some people experience peripheral andautonomic neuropathies such as numbness and tingling of extremities,oral paresthesia and burning.
Severe hyperglycemia associated with type 1 ketoacidosis ortype 2 hyperosmolar nonketotic state usually has a prolongedonset. Therefore, the risk of a hyperglycemic crisis is muchlower than that of a hypoglycemic crisis in a dental practicesetting.
Ketoacidosis may develop, with nausea, vomiting, abdominalpain and an acetone odor. Definitive management of hyperglycemiarequires medical intervention and insulin administration. However,it may be difficult to differentiate between hypoglycemia andhyperglycemia based on symptoms alone.
Therefore, the dentist should administer a carbohydrate source to a patient in whom a presumptive diagnosis of hypoglycemia is made. Even if thepatient is undergoing a hyperglycemic episode, the small amountof additional sugar is unlikely to cause significant harm7.The clinician should measure blood glucose levels after immediatetreatment.
After treatment: Clinicians should keep in mind these postoperative considerations.Patients with poorly controlled DM are at greater risk of developing infections and may demonstrate delayed wound healing. Acuteinfection can adversely affect insulin resistance and glycemiccontrol, which, in turn, may further affect the body’scapacity for healing. Therefore, antibiotic coverage may benecessary for patients with overt oral infections or for thoseundergoing extensive surgical procedures.
If the dentist anticipates that normal dietary intake will beaffected after treatment, insulin or oral antidiabetic medicationdosages may need to be appropriately adjusted in consultationwith the patient’s physician. Salicylates increase insulin secretion and sensitivity and can potentiate the effects of sulfonylurea’s, resulting in hypoglycemia.
Therefore, aspirinand aspirin-containing compounds generally should be avoidedfor patients with DM8.
The following tips are from the National Institute of Dental Health:
• Controlling your blood glucose is the most important step you can take to prevent tooth and gum problems. People with diabetes, especially those whose blood glucose levels are poorly controlled, are more likely to get gum infections than non-diabetics. A severe gum infection can also make it more difficult to control your diabetes.
Once such an infection starts in a person with diabetes, it takes longer to heal. If the infection lasts for a long time, the diabetic person may lose teeth.
• Much of what you eat requires good teeth for chewing, so it is extremely important to try to preserve your teeth. Because the bone surrounding the teeth may sometimes be damaged by infection, dentures may not always fit properly and may not be perfect substitutes for your natural teeth.
• Taking good care of your gums and teeth is another important measure. Use a soft-bristle brush between the gums and the teeth in a vibrating motion. Place the rubber tip of the toothbrush between the teeth and move it in a circle.
• If you notice that your gingiva bleeds while you are eating or brushing your teeth, see a dentist to
determine if you have a beginning infection. You should also notify your dentist if you notice other abnormal changes in your mouth, such as patches of whitish-colored skin.
Have a dental checkup every six months. Be sure to tell your dentist that you have diabetes and ask him or her to demonstrate procedures that will help you maintain healthy teeth and gums.
REFERENCES:
1. Diabetes statistics. National Diabetes Information Clearinghouse, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health. Available at:
www.niddk.nih.gov/health/diabetes/pubs/
dmstats/dmstats.htm.Accessed Aug. 27, 2001.
2. Moore PA, Weyant RJ, Mongelluzzo MB, et al.
Type 1 diabetes mellitus and oral health:
assessment of periodontal disease. J Periodontol 1999;70:409 –417.
3. Lin BP, Taylor GW, Allen DJ, Ship JA. Dental caries in older adults with diabetes mellitus. Spec Care Dentist 1999;19:8–14.
4. Levin JA, Muzyka BC, Glick M. Dental management of patients with diabetes mellitus.
Compend Contin Educ Dent.1996;17:82–90.
5. Rees TD. The diabetic dental patient. Dent Clin North Am 1994; 38:447–463
6. Sreebny LM, Yu A, Green A, Valdini A.
Xerostomia in diabetes mellitus. Diabetes Care 1992;15:900–904.
7. Quirino MR, Birman EG, Paula CR. Oral manifestations of diabetes mellitus in controlled and uncontrolled patients. Braz Dent J 1995;6:131–136.
8. Haber J, Wattles J, Crowley M, Mandell R, Joshipura K, Kent RL. Evidence for cigarette smoking as a major risk factor for periodontitis. J Periodontol 1993;64:16–23.
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