Watch Your Mouth!

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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  • Terrance

    I do not know if this normal but my gums stopped bleeding when I started taking insulin. Almost right away making it easier to take care of my mouth. Did anyone else notice this?

  • Fred

    “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 correlation, not causality. It could also be that bad gums is a marker for people who don’t follow good health practice, including managing their diabetes. While good gum care is a great idea, and the vicious circle you quote MIGHT be the case, it sounds like a lot of theorizing rather than proven fact. Is there any proof of this causality in any other study?

    If someone is trying to make changes to cope with diabetes, changing their dental habits may not be the best place to start and focusing on that might lead to not focusing on other more important changes that are clearly established.

  • David Spero RN

    Fred, there are many, many studies on periodontal disease and vascular disease. Most of them are in the general population, not just people with diabetes. The correlation is strongest for strokes, somewhat weaker for heart disease. I didn’t find many studies looking at kidney disease and gums.

    You are right that correlation doesn’t prove cause. It’s hard to prove cause, but the biological pathways for this link (inflammation and infection) are considered “highly plausible” by most of the people doing this research.

    I think I disagree that this is less important than other areas of self-care. You might be right that gums aren’t the place to “start,” but I think one should get to it fairly soon.

  • David Spero RN

    A study from India in September 2009 found that periodontal disease was the greatest risk factor for stroke. Hypertension was second and smoking was third.

    I would say the correlation between gum disease and diabetes is stronger than the association between obesity and diabetes, and we’ve go a whole industry pursuing that one.

    Terrance’s case might give support the “vicious circle” idea — perhaps starting insulin brought your blood glucose down so that your gum infections could heal. But keep flossing.

  • Tammy

    I commend your efforts to inform the community about the strong link between oral health care and diabetes and please know they are very much appreciated! You should join the online JPEC community by participating in free online CME/CDE/CE activities related to diabetes and oral health. I’ve participated in these events before and they are extremely informative and helpful. I hope you join to further spread the awareness. You can join through the website at:

  • Georgina

    I have type 2 diabetes, when I lived in NY I was receiving good dental treatment under my husbands plan. I moved to Florida and all hell broke loose. I couldn’t find a dentest that would take his plan at all, when I tried to get dental help and promised to pay whatever it was slowly I was refused. slowly all the work that had been started in NY began breaking apart, and I mean breaking to the point where now I have broken teeth 3 of them, two upper left mollers and one bottom right moller. I find it hard to crew my food and my gums are killing me. I know I have a gum desease but have not seen a dentist for 3 years. what I have realized is that here in Florida they don’t care about people, just money as I look around I see many people with rotten broken teeth including children but no one cares. Now my husband and I brush after meals, wash with listerine, floss regularly and try and keep our mouth as clean as we can until we find a dentist who cares and will help, we can pay but buildups and crowns cost lost of money and thats what I need. if you can find me a dentist who will trust us to pay him, and he is not just interested in money, let us know.

  • David Spero RN

    I can’t suggest a dentist in Florida. It sounds like you are doing well with the brushing and flossing. The one thing I would add is doing long rinses with an antiseptic mouthwash, to kill germs.

  • NormH

    A recent report suggests that treating gum disease in patients who have diabetes with procedures such as cleanings and periodontal scaling can reduce medical costs some 10 to 12 percent per month. This is encouraging.

  • Dr. Rochelle Riley

    As a dentist, one of the first things we do is an overall health exam. We proactively look for signs and symptoms of health complications directly related to oral health. We believe that often times we as dentists are the first line of defense in diagnosing and helping prevent chronic disease.

    We have more informative articles at to supplement the great information here.

  • Jacob

    Recently they discovered that apple polyphenols have the ability to inhibit and kill the bacteria that causes gum disease and gingivitis. I woud imagine that ginger root has effects on the same bacterias but I’m not sure if it has the ability to inhibit the bacteria the same way as apple polyphenols.

  • Teddy

    That is very encouraging to know that getting my treatments to my gum’s once a month will decrease my overall costs up to 10-12% over time.