After five years of writing about diabetes, I still think gum care is among the most important and least appreciated aspects of self-management. Studies keep showing how gum (periodontal) disease and diabetes make each other worse. So are you flossing yet?
Severe gum disease (periodontitis) can cause diabetes. According to researchers at Marquette University, “Periodontitis may [raise levels of inflammatory cytokines and serum lipids]… These cytokines can produce an insulin resistance syndrome similar to that observed in diabetes and initiate destruction of pancreatic beta cells leading to development of diabetes.”
Just as gum disease contributes to diabetes, having diabetes worsens gum conditions. 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.”
The link between diabetes and gum disease is that both cause inflammation, not just locally, but through the whole body. Inflammatory cytokines like interleukin 1 (IL-1) and tumor necrosis factor (TNF) inflame blood vessels, creating small scars. Soon the vessels block up with plaque. These blockage are linked with heart disease, kidney disease, and strokes, all major complications of diabetes.
A study from Bangalore, India looked at 200 people, half of whom had recent strokes or heart attacks. Researchers controlled for family history of stroke, diet, smoking and alcohol consumption, diabetes, hypertension, total serum cholesterol level, and education level. Those with worse gums (pocket depths greater than 4.5 millimeters) had far higher risk of strokes.
Along with inflammation, infection of the gums creates a vicious diabetes circle. Gum infections can 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.
And one more thing. The latest research indicates that gum disease is a major risk factor for erectile dysfunction (ED), very common in men with diabetes. Improving the gum disease may cause erections to return.
Diagnosing Gum Disease
The National Diabetes Information Clearinghouse lists seven possible symptoms of gum disease. 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 keep in mind that diabetes means you are more likely to have gum disease, even without symptoms.
What Can You Do?
Ninety percent of dental care is self-care. The most important thing is to brush, floss, and rinse with antiseptic mouth rinse at least once a day, preferably more. Jenny Ruhl at Diabetes Update says, “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.
But professional dental care is also super-important. 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, although using a toothpick sometimes helps. That’s where professional help comes in.
Researchers at University of Buffalo (UB) found that “Elimination of periodontal infection and reduction of periodontal inflammation in diabetic patients resulted in a significant short-term reduction in the concentration of glycosylated hemoglobin (HbA1c).” (Apparently there was no long-term follow-up.)
Another UB report found that simple tooth cleaning is not enough for many people with diabetes. Antibiotics can also be important. “Studies incorporating systemic antibiotics along with mechanical debridement [cleaning] result in a reduction …in [A1C]… The treatment of chronic periodontal infection is essential in the diabetic patient.”
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.”
So you want to have your teeth cleaned by a professional at least twice a year, probably more if you have diabetes. Richard Bernstein, MD, author of Dr. Bernstein’s Diabetes Solution, advocates long (several months) courses of antibiotics “to help people with diabetes regain excellent blood sugar control.”
Of course, all this dental care can be expensive. Medical insurance should cover dental care for people with diabetes, because it’s a vital part of care, but sometimes it doesn’t. If there’s a dental school near you, that might be an option for affordable care.
When I started taking gum care seriously, my gums bled like crazy while flossing, and they hurt. Now they don’t bleed or hurt, and Aisha says I taste better, too. So let’s get flossing, and see a good dentist if you possibly can. You might see a dramatic payoff in your A1C levels!