The Whole Tooth – Diabetes and Oral Health

Something that is a big deal for us D-folk is oral health. It’s also something that our docs and DSNs don’t talk about too often – and dentists often don’t have time to explain everything during a consultation (and if you’re like me, you don’t take it all in anyway!). So the lovely @MaxFoxJo, a tame dental student, agreed to write a guest post giving us the basics and some good ways to avoid fillings and extractions!

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You’re probably wondering what relevance teeth have with diabetes, but just hear me out and all will become clear. There are three main things that need talking about: decay, gum disease and prevention.

Decay

Let’s start with tooth decay – since most of us have had cavities and fillings. Decay happens when bacteria in the plaque on our teeth eat the sugars we eat in our diet; from a nibble of chocolate, a glug of reviving lucozade or even just plain old starchy potatoes. The bacteria produce an acid after they’ve eaten your sugar and bathe your teeth in their sweet juices (yum); the acids make tiny holes in your teeth which end up joining up until there’s barely anything left of the tooth and it collapses in to a cavity. Ta dah! They usually start out pretty small, but unless you change your habits, they will just get bigger as the bacteria continue their 24/7 party in your mouth. There’s an end point to these cavities; if you’re lucky it’s a simple filling, but anything more than that gets pretty invasive to your tooth, or even your body if you require extractions. So let’s get to the ‘betes and a bit more science. As we’ve already discovered, decay is a bacterial disease; once the bacteria have got access into the tooth they have pretty free access to the pulp which is full of blood vessels and nerves. This is when it starts to hurt if you have cold, hot or sweet things. Now, diabetes and infections don’t mix all that well so things can turn out pretty dire. Sometimes bacteria can swim their way down the roots of the teeth and make a big pressure cooker soup of joy – an abscess underneath the tooth. This is where a trapped infection can start messing with your BG levels, you might have experienced this with things like a throat infection – the same principles apply. As dentists, we want to get rid of this infection asap – we can do it very very quickly by extracting the tooth, or we can save the tooth and try to chemically bust the bacteria to smitherines with the help of antibiotics and root canal treatment. It’s always your choice, but it’s thoroughly depressing to extract the teeth of young adults because of decay. Nevertheless, acute infections in people with the D need treating right away. ANYWAY – your best bet here is to avoid getting these infections in the first place by preventing decay. I’ve chatted on Twitter with a lot of T1DM folk about how frequently they have to resolve night time hypos with things like lucozade or a mini mars bar or something equally as delicious. Except it’s 2am and they can’t be arsed getting out of bed to brush their teeth after. So we need some kind of compromise; if you go back to sleep with a mouth full of sugar then your oral bacteria (and low saliva flow) will run rampage over your teeth. My advice is to swish with a fluoride mouthwash and spit out, then get back in to bed; or have a drink of water and swish&swallow if you really can’t bring yourself to exit the womb of your duvet. Mouthwash is most ideal, water is next. What you don’t want to do is leave it bathing, or, weirdly, brush your teeth straight after – or else you end up brushing acid around your teeth. I kid you not. Saliva, fluoride and water are your friends.

Periodontal (gum) disease

Ah, gum disease; it can be pretty invisible to the person with it, but to the trained eye it is devastating. I’m not just talking a bit of bleeding when you brush your teeth, though that is often the first sign, i’m talking about loss of bone and gum and eventually the loss of teeth – ‘periodontitis’ as we call it. There is a direct relationship between glycemic control and destruction of the bone and gums in patients with diabetes. It’s not even an old people’s disease, if you have diabetes you can have a pretty aggressive form of this in your teenage and young adult years. But, as with many other complications, it’s all about how well your diabetes is controlled. Like tooth decay, periodontitis, is all down to bacteria in plaque covering your teeth. If plaque accumulates by the gums it will set off an immune response to fight infection within 1 day, it’s why we recommend you visit your gums with a toothbrush twice daily. Plaque also has the annoying ability to turn in tartar by using minerals in your saliva to harden like concrete and stick on your teeth. Tartar is a creamy white colour and it wont brush off with a toothbrush, it needs a dentist or hygienist to use some tiny instruments to scrape it off. If the plaque doesn’t have the chance to settle then it wont have the chance to cause disease – that is Dentistry101 (here, have a degree). Hyperglycaemia often causes white blood cells to give up on their meagre duties as infection fighters; if this happens then there’s not much that will fend off the nastiness in the plaque, and the bacteria can make your gums their kingdom. They grow down the side of the tooth and erode away at the gum, bone and ligament that holds the tooth in place. The further down the plaque gets, the more wobbly your teeth become until, eventually, it’s gone too far and it’s time for the adult tooth fairies. Treatment for this involves cleaning the roots of the teeth with very fine instruments under the gum line (there’s anaesthetic, don’t worry). It’s a pain in the arse and very unpredictable in patients with the D. Whilst we’re talking all things gummy, thrush is something that can affect your mouth if you’re running high sugars a lot. It’s been touched on in the sexy blog posts, same principles apply on needing treatment for it – just don’t use the same cream used for ‘down there’.

Prevention

The vast majority of dental diseases are preventable. Prevention is usually down to controlling plaque levels by brushing your teeth regularly to physically remove it and spit it down the sink to plaque heaven. Brushing twice daily in a SYSTEMATIC manner – start in one corner of the mouth and work your way around upper and lower teeth. Poor habits allow plaque to build up, especially if you miss the same area every time, and inflame the gums (gingivitis) – the first stage of periodontal disease. To prevent decay in the long run you can ask your dentist to paint a very high concentration paste on your teeth twice a year – it’s like a boost of shielding to your teeth to harden the outermost layer. You might also want to ask your dentist if they can prescribe you a higher fluoride containing toothpaste – this will almost certainly be of benefit if you have a few cavities already or have had a fair amount of dental work done in the past.

Other top tips: 



• Book appointments when you know your BG is most stable and you’re able to lie in a chair for a while without going hypo. If that means going just after lunch then tell the receptionist that.
• If you have periodontal disease and struggle to keep the D in check, go and see your dentist as current evidence suggests that getting your gums under control will help get the D under control too.
• Ask your dentist for some disclosing tablets – you an chew them after brushing your teeth to show any areas you’ve missed. It makes your tongue look like a Picasso painting too. You can also get them from Boots in the dental section.
• Drink through a straw as much as you can – it’ll bypass the teeth and give them a break from the fizzy stuff that erodes them.