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Watch Your Mouth!

David Spero

January 20, 2010

What health condition has killed the most adult humans since the beginning of recorded time? Most likely it was gum disease (also called “periodontitis”). Before modern food processing made food soft and mushy, people who lost their teeth couldn’t eat natural food. So they became weak and died. Unfortunately, gum disease may still be a killer for people with diabetes.

According to the American Academy of Periodontology (AAP), “Periodontal disease is often considered the sixth complication of diabetes. Those people who don’t have their diabetes under control are especially at risk.”

A 2005 study in Diabetes Care of Pima Indians with diabetes found that those with severe gum disease had three times the death rate from heart and kidney disease as those with healthier gums.

This is serious. According to major studies, a tripling of mortality rate would be approximately what you would expect from running an A1C of 12%. What could make gum disease so dangerous? And are we putting enough effort into our teeth?

The effect on heart and kidneys tells us that gum disease has something to do with blood vessels. Research shows that gum infection causes inflammation throughout the body, by releasing chemicals called “cytokines.” When the cytokines inflame blood vessels, the vessels block up with plaque. This blockage causes heart disease, kidney disease, and probably strokes as well.

Inflammation also causes insulin resistance, raising blood glucose. This connection is a vicious circle. Gum infections raise blood glucose levels. At the same time, high blood glucose makes it harder to fight infections. High glucose seems to weaken white blood cells called “neutrophils,” so they can’t kill germs as well.

So effective diabetes self-management needs a strong dose of dental care. According to Charles Martin, DDS, author of Don’t Sugarcoat it: The Story of Diabetes and Dentistry, doctors, dentists, and insurers are recognizing that dental care is an important part of diabetes care. “Insurers are incorporating dental services into medical plans because they see a connection between preventive oral care and improved overall health of diabetic patients.”

Treating Gums and Diabetes
It’s important to treat existing gum disease with antibiotics and cleanings. This alone might substantially improve glucose control. The AAP cites another study of Pima Indians with both diabetes and gum disease. This study found that, “when their periodontal infections were treated, the management of their diabetes markedly improved.”

How do you know if you have gum disease? The National Diabetes Information Clearinghouse lists seven possible symptoms. These are:

  • red, sore, swollen gums
  • bleeding gums
  • gums pulling away from your teeth so your teeth look long
  • loose or sensitive teeth
  • bad breath
  • a bite that feels different
  • dentures — false teeth — that do not fit well

If you have any of these symptoms, you should see a dentist or periodontist right away. And it’s probably a good idea for all of us to see dentists routinely for cleaning. According to The Gum Disease — Diabetes Project, gum disease causes “pockets” that are much deeper than the normal gap between tooth and gum. When this happens, you can no longer reach into the pocket with floss or a toothbrush, so it’s hard to get the germs out. “The gum disease then spreads into the underlying bone,” they say. “If the gum disease is not treated early enough, the patient will lose their teeth.”

Jenny at the Diabetes Update blog writes that “the usual care dentists recommend is not always enough” She cites Richard Bernstein, MD, author of Dr. Bernstein’s Diabetes Solution, as advocating long (several months) courses of antibiotics “to help people with diabetes regain excellent blood sugar control.”

But 90% of mouth care is self-care. I agree with Jenny that “the single most helpful thing you can do is to floss your teeth every day. Brushing does not prevent gum disease… If at first your gums bleed a lot or are painful, keep at it, over time they should toughen up and get healthier and bleeding will stop.” This Web page gives good flossing instructions.

Smoking aggravates gum disease, yet another reason for people with diabetes to quit. According to a Centers for Disease Control study, smokers are four times as likely as people who have never smoked to have gum disease. But if they quit, by 11 years after quitting, their risk is not significantly different from those who have never smoked.

Other tips:

  • Use soft-bristle toothbrushes — harder ones can damage gums.
  • Electric toothbrushes with rotating heads are more effective than manual brushes, but not by that much (reducing gum inflammation by 6% and plaque by 11% in one large study). Vibrating (nonrotating) electric brushes were no better than manual ones.

Fred Peterson, a spokesperson for the American Dental Association, says the association has no official recommendation regarding manual versus powered toothbrushes. “Both manual and powered toothbrushes can effectively clean your teeth. If you have arthritis or otherwise need assistance with movement, a powered brush may be easier to use.”

If you’re not doing much mouth care, this might seem like another “have-to” that you’d rather not face. But the payoff on time spent might be higher than with some other aspects of self-management. At least you’ll have better smelling breath and better tasting kisses!



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