Dentistry in Chesapeake, VA

Medical Dentistry

Diabetes Dentistry

National Diabetes Fact Sheet, 2007

Diabetes is the fifth-deadliest disease in the United States. It consumes 1 out of every 10 dollars spent on healthcare. Our goal is to educate the public on the devastating effects of diabetes and to work with our medical colleagues as a team to help treat this disease.

Our goal as dentists is to screen patients for diabetes and to refer these patients to an appropriate physician for diagnosis and treatment. Glycemic or blood sugar control is the gold standard of treatment for diabetics. With diabetes dentistry, we treat the oral and dental ramifications of diabetes.

Diabetes is a disease in which the body does not produce or properly use insulin. Insulin is a hormone that is needed to convert sugar, starches, and other food into energy needed for daily life. The cause of diabetes continues to be a mystery. Although both genetics and environmental factors such as obesity and lack of exercise appear to play roles.

In order to determine whether or not a patient has pre-diabetes or diabetes, healthcare providers conduct a fasting plasma glucose test (FPG) or an oral glucose tolerance test (OGTT). Either test can be used to diagnose pre-diabetes or diabetes. The American Diabetes Association recommends the FPG because it is easier, faster, and less expensive to perform.

With the FPG test, a fasting blood glucose level between 100 and 125mg/dl signals pre-diabetes. A person with a fasting blood glucose level of 126mg/dl or higher has diabetes.

In the OGTT test, a person's blood glucose level is measured after a fast and two hours after drinking a glucose-rich beverage. If the two-hour blood glucose level is between 140 and 199 mg/dl, the person tested has pre-diabetes. If the two-hour blood glucose level is at 200mg/dl or higher, the person has diabetes.

Diabetics should be taught to do home monitoring of blood glucose. This would involve the use of finger sticks and frequent determination of blood glucose over the course of the day. Therapy should be adjusted based on home monitoring.

Hemoglobin A1c (HbA1c) is an important gauge of adequacy of control. HbAlc will determine the level of control of blood glucose for the past two to three months. The goal is to get a HbA1c level less than 7% (usually achieved with pre-prandial blood glucose levels of 70-126mg/dl).

For every 1% decrease in HbAlc, there is:

21% decrease in mortality
21% decrease in diabetic complications
14% decrease in myocardial infarction
37% decrease in microvascular complications
Unfortunately only 31-37% of the diabetic population in this nation has an HbA1c of less than 7%.
36% have a blood pressure 130/80mm Hg or less
Just 48% have a standard cholesterol of 200mg/dl or less

The most distressing thing is that only 7.3% of diabetics achieve all three treatment goals.

As part of our diabetic dentistry service, our office routinely takes HbAlc as a means to screen and monitor how well a patient is maintaining their blood glucose levels.

Diabetes Statistics

Total: 23.6 million children and adults - 8% of the population have diabetes
Diagnosed: 17.9 million people
Undiagnosed: 5.7 million people
Pre-diabetes: 57 million people
Age 20 years or older: 23.5 million, or 10.7% of all people in this age group have diabetes.
Age 60 years or older: 12.2 million, or 23.1% of all people in this age group have diabetes.
There has been a 49% increase in the US in new cases diagnosed between 1990 and 2000 among adults.
The total prevalence of diabetes increased 13.5% from 2005-2007.
1.6 million new cases of diabetes were diagnosed in people ages 20 years or older in 2007.
The rate of increase is expected to rise exponentially.
If the present trends continue, one in three Americans and 1 in 2 minorities born in 2000 will develop diabetes in their lifetime.

Types of Diabetes

Please refer to the official fact sheet on this website under diabetes, provided by The Centers For Disease Control and Prevention, The National Institutes of Health, The American Diabetes Association, and other partners.

Complications of Diabetes in the United States

Heart disease and stroke:

Heart disease and stroke account for about 65% of deaths in people with diabetes
Adults with diabetes have heart disease 2 to 4 times higher than adults without diabetes
The risk of stroke is 2 to 4 times higher

High blood pressure:

About 73% of adults with diabetes have blood pressure greater than 130/80mm/Hg

Blindness

Diabetes retinopathy causes 12,000 to 24,000 new causes of blindness each year making diabetes the leading cause of new cases of blindness in adults 20-74 years of age.

Kidney disease

Diabetes is the leading cause of kidney failure

Nervous system disease

About 60 to 70% of people with diabetes have mild to severe forms of nervous system disease. The results of such damage include impaired sensation or pain in the feet or hands, slowed digestion of food in the stomach, carpal tunnel syndrome, and other nerve problems

Amputations

More than 60% of non-traumatic lower limb amputations occur in people with diabetes

Complications of pregnancy

Poorly controlled diabetes before conception and during the first trimester of pregnancy can cause major birth defects in 5% to 10% of pregnancies and spontaneous abortions in 15% to 20% of pregnancies

Sexual Dysfunction

Diabetes significantly increases the risk for sexual dysfunction in both men and women

Dental Disease

I saved this myriad of complications for last so that I can elaborate on them. Obviously this is where the dentist enters the picture with respect to treatment of diabetes. It is essential that the dental professional be part of the healthcare team in treating this disease.

Periodontal disease has been reported as the sixth complication of diabetes, along with retinopathy, nephropathy, neuropathy, macrovascular disease, and altered wound healing.

Citing The American Diabetes Association

Periodontal (gum) disease is more common in people with diabetes. Among young adults, those with diabetes have about twice the risk of those without diabetes
Almost one-third of people with diabetes have severe periodontal disease with loss of attachment of the gums to the teeth measuring 5 millimeters or more
Persons with poorly controlled diabetes (A1c >9%) were nearly 3 time more likely to have severe periodontitis then those without diabetes

One may pose the question is there a common denominator between the structural changes seen in the micorvascular complications of retinopathy, nephopathy and neuropathy and those seen in periodontitis or gum infection. The answer may be found in the formation of advanced glycation end products (AGE's).

In individuals with sustained hyperglycemia, proteins become irreversibly glycated to form advanced glycation end products (AGE's). These stable carbohydrate-containing proteins have multiple effects on cell-to-cell and cell-to-matrix interactions and are commonly thought to be a major link between the various diabetic complications. The formation of AGEs also occurs in the periodontium, and higher levels of periodontal AGE accumulation are found in those with diabetes than non diabetic subjects. (1)

Accumulation of advanced glycation end products (AGEs) as a result of the chronic hyperglycemic state of diabetes, coupled with the presence of infection and an exaggerated host response, may provide a viable explanation for the clinical outcomes observed in diabetic patients with periodontal disease. (2)

Both diseases are thought to share a common pathogenesis that involves an enhanced inflammatory response that can be observed at the local and systemic level. The inflammatory response is mainly caused by the chronic effects of hyperglycemia and specifically the formation of biologically active glycated proteins and lipids that promote inflammatory responses. (2)

An extensive body of evidence supports diabetes as a risk factor in periodontal disease. There is also mounting evidence that supports the concept that periodontal diseases can contribute to poorer glycemic control in people with diabetes. Chronic periodontitis, a predominantly gram-negative anaerobic infection, may serve as a focal source for sustained entry of bacterially derived lipopolysaccharides, or LPS, and host-produced inflammatory mediators into the systemic circulation. Some of the mediators released are interleukins, cytokines, and tumor necrosis factor-alpha. All of these mediators are reported to interfere with lipid metabolism and to cause insulin resistance. (3)

Despite the variation and limitations, evidence supports the concept that periodontal diseases can contribute to poorer glycemic control in people with diabetes and that treating periodontal infections could have a beneficial effect on glycemic control in either type 1 or type 2 diabetes. (3)

Obviously diabetes and periodontitis are inextricably woven. The treatment of diabetes ameliorates the destructive effects of periodontitis and the treatment of periodontitis ameliorates the destructive effects of diabetes.

For more information read an article about "PERIODONTITIS ASSOCIATED WITH DEVELOPMENT OF TYPE 2 DIABETES AND ITS COMPLICATIONS."

Other oral complications as a result of diabetes are:

Xerostomia and Dental Caries

Diabetes can lead to marked dysfunction of the secretory capacity of the saliva glands
This can lead to markedly increased dental cavities, inflammation, fissuring of the lips, inflammation or ulcers of the tongue and buccal mucosa
This can lead to Candidiasis or fungul infection
Difficulty eating, speaking, swallowing, and wearing dentures
Candidiasis - a fungal infection of the mouth
Lichan Planus- a chronic inflammatory disease
Burning mouth syndrome
The pathophysiology is mainly idiopathic but can be associated with uncontrolled diabetes, hormone therapy, psychological disorders, neuropathy, terestomia, and candidiasis

1- Advanced glycation end products (AGEs) induce oxidant stress in the gingiva. J Periodontal Res 1996:31:508-515

2- Janet H. Southerland, DDS, MDH, PhD, George W. Taylor, DMD, Dr. PH and Steven Offenbacher, DDS, PhD, MMSc, Diabetes and Periodontal Infection: Making the Connection Clinical Diabetes 23:171-178, 2005 American Diabetes Association

3- George W. Taylor, DMD, DrPH- The effects of periodontal treatment in diabetes. JADA, Vol 134, October 2003

I would encourage a visit to the American Diabetes Association at www.diabetes.org. This website has a wealth of information. Much of my data was gleaned from this site.

If you use the search engine on this website you will get 757 results by typing in "dental disease," you will get 381 results by typing in "dental complications," and 282 results by typing in "periodontitis."

Below are two levels of periodontitis and the clinical results of treatment. The first case is moderate periodontitis. Treatment consisted of conservative scaling and root planning. Notice the marked improvement in tissue health.

The second case involves generalized advanced periodontitis with generalized advanced bone loss. The treatment was full mouth extractions with complete upper and lower dentures. Yes we got rid of the periodontal infection but to the regrettable loss of the patient's teeth. This was an unfortunate situation considering the fact that it could have been prevented with earlier intervention of treatment.

Picture - Case #1
Before with moderate periodontitis	After treatment health gums

Picture - Case #2
Before with advanced periodontal disease	Untreated periodontal disease results in dentures

Call today to reserve your diabetes dentistry consultation with Dr. Robert A. Simmons. Our dental office is conveniently located in the Great Bridge Hickory area in Chesapeake, Virginia just north of the North Carolina border. We serve patients from Virginia Beach, Norfolk, Hampton Roads, Moyock, Elizabeth City, Currituck, Outer Banks and beyond with personalized dental care.

In addition to the above acknowledgements I would like to acknowledge all of the following:

American Diabetes Association
Centers for Disease Control
Dr. Leslie Fang, MD PhD - A leading teacher at Harvard Medical School, At the Massachusetts General Hospital, served as Chief of the Walter Bauer Fium and as the Clinical Director of The Governing Board of the Medical Services Association. He has served and chaired the Medical Internship Selection Committee of the Massachusetts General Hospital for two decades. One of my favorite mentors: Thanks Dr. Fang
Melpomeni Peppa, MD Jaime Uribarri, MD and Helan Vlassara, MD - Glucose, Advanced Glycetion End Products, and Diabetes Complications: What Is New and What Works Clinical Diabetes 21:186-187, 2003
Carolyn Robertson, A.D.R.N, M.S.N., CDE. , B.C, Andrew Joy Drexlar, MD.; Anthony T Vernillo, DDS., PhD Update on diabetes diagnosis and management, JADA, Vol. 134,October 2003
Brian Mealey DDS, MS, Periodontal disease and diabetes- A two way street, JADA. Vol 137, 2006
Marian Emmanuel Ryan, DDS. PhD.; Oana Carny DMD; Augola Kauzer, DMD., PhD., The Influence of diabetes on the periodontal tissues. JADA, Vol. 134, October 2003
Januce Hamilton - Mouth and Body, Connecting Dental Health and Overall well-being, AGD Impect, April 2008 pg 49
Jorge Idela Toure, MD, FACS, Wound Healing, Chronic Wounds eMedicine
James W. Little, DMD, MS, Nelson L. Rhodus, DMD,MS - Pharmacologic management of type 2 diabetes: A review for dentistry. General Dentistry, Nov/Dec 2007 pg 564-571
J.L. Wautier, PJ. Guillaugseau, Advanced Glycetion end products, Their Receptors and Diabetic Angiopathy Diabetes Metab (Paris) 2001, 27, 535-542

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