Poor control of blood sugar can lead to severe gum disease, Dr Tan Wah Ching, Registrar, Periodontic Unit, Department of Restorative Dentistry at National Dental Centre, digs up some important advice to diabetes patients in her conversation with Charlotte Lim.

Q: How does a DM patient's diet affect her dental health?

A: The recommended diabetic diet that is low in sugar and carbohydrate content and high in fibre, is actually good for dental health. Reduced consumption of sticky and sugary food reduces the chances of developing dental caries (dental decay).

Q. Could you explain how periodontal disease develops?

A: Periodontal disease is a gum infection that destroys the structures which support the teeth in the mouth, like the alveolar bone, cementum, and periodontal ligaments.

The main cause of periodontal disease is dental plaque. This is a sticky film that constantly forms on our teeth. Proper oral home care will help prevent the built-up of dental plaque (brushing our teeth at least twice a day with a fluoridated toothpaste and flossing).

If plaque is not removed, it can turn into a hard substance called calculus or tartar. Calculus cannot be removed with normal home care and would require professional cleaning by dentists.

Accumulation of plaque and calculus on tooth surfaces over time, and to sites below the gums, can result in red and swollen gums. They may begin to bleed when brushed or flossed. This is called gingivitis and is the mildest form of periodontal disease.

The good news is that gingivitis is reversible with good oral home care. If left untreated, however, gingivitis may lead to more serious disease. This is the periodontal disease that we have been talking about.
 

Bacteria in plaque produce toxins which irritate the gums and cause infection. These toxins destroy the supporting tissues around the teeth, including the bone. When the bone is affected, the gums separate from the teeth, forming pockets which eventually fill with more plaque and infection. This infection leads to further loss of bone that holds the tooth in its socket, and subsequent tooth loss if left untreated.

Q: What are the common signs of periodontal disease?

A: The common signs of periodontal disease are not a pretty sight. They include bleeding gums, red, swollen and tender gums, gum abscesses, pus, loose or separating teeth, gum recession resulting in longer looking teeth, persistent bad breath, even mild discomfort like itchiness or a dull ache. Unfortunately, pain and severe discomfort are not often experienced by patients with periodontal disease until the disease is in the advanced stages. So, do take care!
 

Q: How is periodontal disease treated?

A: Periodontal disease cannot be treated by regular brushing and flossing. By this time, you will be sitting in the chair of a periodontist, a dentist who specialises in treating gum diseases.

The treatment you receive will depend on how severe the disease is. If the disease is still in the early stages, the periodontist can perform deep cleaning of the teeth and remove calculus as well as infected tissue under the gum. He or she will smoothen the infected root surfaces of the teeth to allow the gum to re-attach to the teeth. Antibiotics and mouthwash may also be prescribed to control the infection.

In advanced stages of gum disease, gum surgery may be necessary. When the flap is elevated, the tooth surfaces under the gum are carefully cleaned and infected soft tissue removed. The supporting bone may either be reshaped or regenerated.
 

Q: Do DM patients have more severe gum disease? Why?

A: There is a general agreement that the severity of gum disease can be affected by the patient's diabetic status DM patients with poor control of their blood sugar, tend to have more severe gum disease. They have reduced host response to bacteria infection. In the presence of dental plaque (soft deposits of bacteria and bacteria by-products found on tooth surface), and the hyperglycaemic state, they are less resistant to the bacteria challenge and therefore more prone to severe gum disease.
 

Q: Do DM patients respond well to gum treatment? Is there any difference in the mode of treatment for gum disease between a healthy individual and one with DM?

A: DM patients do respond to gum treatment. A DM patient with good control of his/her DM, shows clinical healing similar to a healthy individual. There are minimal differences in treating patients with DM. There is no evidence in the literature to support a more aggressive gum treatment for DM patients with good DM control.

Gum treatment, in most cases, involves deep cleaning with local anaesthesia. However, in cases where the patient's DM is poorly controlled and present with multiple gum abscesses, systemic antibiotics such as Doxycycline may be prescribed together with the routine gum treatment. Patients with poor DM control may have poorer healing following gum therapy, extractions and surgeries.

Q: Why is gum disease a danger to those with diabetes mellitus?

A: There are some initial studies which suggest that the toxins released by the bacteria causing gum disease, actually results in insulin resistance, thus poor blood sugar control in DM patients. Untreated gum disease in these poorly controlled DM patients can progress ultimately to more serious infections and even cause airway obstructions. 

Q: How does treatment of gum disease in DM patient help them keep their DM under control?

A: There is still no definite conclusion that treatment of gum disease in DM patients helps control their DM status. There are, however, some studies that have suggested that gum treatment may improve the control of blood sugar in DM patients. More studies are required before a definite conclusion can be established.

Q: Can DM patients receive dental implants? Are there any precautions to be taken prior to the procedure?

A: Most DM patients with well-controlled blood sugar levels can receive dental implants. However, DM patients with poor blood sugar control, and those with severe DM should not receive dental implants as their wound healing capacity may be impeded.

Precautions prior to the procedure would include having his medication/insulin injection and food prior to the implant surgery. He/she should also inform the attending dentist that he/she has DM, and the blood sugar level or HbA1c level from the latest blood test.

Q: What should a DM patient do if oral surgery (eg. removal of wisdom teeth) is needed?

A: He/she should seek an opinion from a dentist/oral surgeon. The attending dentist should be informed that the patient has DM and the level of his/her sugar control. Prior to the surgery, ensure that the level of blood sugar control is good, with good oral hygiene achieved. Medications and food should be taken prior to the procedure, and morning appointments would be ideal.

Well-controlled DM patients respond similarly to healthy individuals, in terms of healing response following gum treatment. Dental treatment is usually no different from treatment for healthy individuals. Poorly controlled DM patients appear to have poorer gum health, with more severe disease and poorer response to gum treatment. Thus, the control of DM plays a very big role in the management of the patient's periodontal (gum) health.