Introduction:
Diabetes is a progressive, chronic disease that not only dramatically increases the risk of vascular diseases in an individual but, when left uncontrolled, is a significant cause of mortality. Furthermore, as diabetes is a chronic systemic disease mainly featured by increased blood glucose levels and malfunctioning lipid metabolism, it weakens the individual for an immune breach (at an increased risk of infections) due to the absence or decreased insulin level. Hence the impact of type 1 or type 2 diabetes is on multiple organs, and their functions are affected directly or indirectly.
Dental surgeons and patients suffering from dental issues should possess a basic understanding of this disease's pathogenesis and its direct, indirect, or systemic manifestations. It is linked based on the theory that periodontal diseases are a subsequent extension of the gingival inflammation into the underlying supporting structures of the periodontium, including the alveolar bone or jawbone.
Periodontal diseases initiated by plaque, later on, turn orally invasive with the byproducts of anaerobic or aerobic pathogens on the tooth and the adjoining structures. The progression of periodontal disease depends fundamentally upon the causative microorganisms, host response and extent of immunity breached, systemic disorders or hormonal abnormalities, and immunosuppressive nature or, in fact, even the host's genetic predispositions.
How Are Periodontal Disease Pathogenesis and Diabetes Linked?
Periodontal disease is a chronic bacterial infection that affects the gingiva. The alveolar bone (supporting the teeth) loss is caused by an anaerobic gram-negative microorganism present in the bacterial plaque that adheres to the teeth. Anaerobic gram-negative bacteria and inflammatory cells or increased PMNs (polymorphonuclear leukocytes) can also be significant sources of alveolar bone loss or gingival recession due to periodontal pathologies.
Some microbial components, especially lipopolysaccharide, activated macrophages that synthesize and secrete proinflammatory molecules such as cytokines, IL-1 (interleukin-1), tumor necrosis factor-alpha (TNF-alpha), prostaglandins (significant amounts of PGE2), accessory enzymes, and also, AGEs are increased in diabetic patients causing an atypical inflammation and inhibition of reactive oxygen species (ROS).
Sustained hyperglycemic levels also cause elevated NET levels (neutrophil extracellular traps) composed of decondensed chromatin and cytotoxic proteins. These increases in NETs aggravate tissue damage and delays wound healing. The NETs are incapable of ingesting microorganisms and instead contain them.
Various herpes viruses, such as the human cytomegalovirus (HCMV) and Epstein-Barr virus, have recently emerged as pathogens in cases of destructive periodontal diseases. Many conditions can predispose and facilitate the occurrence of periodontal diseases, such as smoking, genetic influences, estrogen deficiency, estrogen excess, dyslipidemia, and obesity.
What Are the Clinical Symptoms of Periodontal Disease in Type 1 and Type 2 Diabetes?
One or more of these clinical features are predominant in diabetic patients. However, with proper oral hygiene, regular visits to the dental surgeon every six months to one year for follow-ups and treating clinical pathologies observed orally will aid in symptomatic relief of oral health issues.
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Mouth ulcers, canker sores, or gingival inflammation are seen nearly in most diabetics (who do not have frequent access to dental visits or are negligent of oral hygiene and scaling or prophylaxis).
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Bleeding on probing by the dental surgeon and bleeding gingiva while brushing or flossing.
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Persistent bad breath or halitosis.
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Ill-fitting dentures due to alveolar bone resorption or bone pathologies and infections.
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Increased gaps between the contact surfaces of teeth and misaligned teeth.
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Tooth mobility ranging from mild to severe (grades 1, 2, and 3).
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Leaking of pus (periapical pathologies, root infections, or gingival abscesses and swellings).
What Are the Oral Hygiene Instructions Recommended for Diabetic Patients?
As per the American Dental Association (ADA), correct tooth brushing and flossing are sufficient oral hygiene aids to maintain and prevent recurring dental issues. However, accessory interdental cleaning aids like interproximal brushes, chemical plaque control by the regular usage of mouthwashes (Chlorhexidine 0.12 % or Triclosan-containing mouthwashes), and oral prophylaxis at the in-clinic appointment with the dental surgeon every six months to one year are highly recommended as oral systemic complications can be prevented by the dental management in diabetes patients.
1. Toothbrushing:
A primary requisite of correct tooth brushing is brushing twice daily with a nylon or soft-bristled brush with round bristles and fluoridated toothpaste. Hard back and forth motions and sawing motions between the teeth' contact surfaces should be avoided. Instead, small circular, short back and forth, and vertical motions for the front teeth (both the labial and the lingual surfaces) will be beneficial. The modified Stillman technique, the simple Fones technique, and the Bass method or sulcular technique are some of the recommended tooth brushing techniques by the ADA. The toothbrush also needs to be replaced every three to four months as the bristles may be frayed within this duration.
2. Mouthwashes:
Rinsing with mouthwash should preferably be done after flossing.
3. Flossing:
The floss should be curved around each tooth and scraped several times in an up and down motion from the gingival portion to the crown portion of the tooth to dislodge food accumulation and for plaque control.
How Does the Dental Surgeon Manage a Diabetic Patient?
Diabetics, even without any dental issues, should be regularly recalled by the dentist to check for gingival, periodontal, and alveolar bone status by half-yearly scaling or oral prophylaxis.
Dietary diabetic measures, increased nutritional supplementation, and regular visits to the diabetologist and the dental surgeon hold the key to proper glycemic control (HbA1C levels) and oral health. Scaling and root planing, along with antibiotic therapy administration for targeting the periodontal pathogens most likely to be invasive in high-risk diabetics, is a suitable treatment modality every 6 to 12 months for these cases.
Dental treatment also comprises the first step of documenting the patient's medical history in detail. The dentist can give appropriate oral hygiene instructions suited to the patient's individual needs and antibiotic prophylaxis before undertaking any procedures.
Conclusion:
To conclude, substantial evidence of a bi-directional relationship exists between diabetes and periodontal disease. Therefore, timely dental checkups and diabetologists' recommended regimens and medications for controlling blood sugar levels are an interdisciplinary pathway to prevent the aggravation and boost the immunity breached by diabetes and periodontal disease in an individual.
