Thursday, April 05, 2007

Oral manifestations of diabetes

Hygienists, as well as all members of the dental team, should be familiar with oral manifestations of diabetic patients. This is because vigilance in changes in the oral cavity at recall appointments may be an indicator of the emergence or progression of the disease. If this is the case, the dentist should refer the patient to his or her physician for appropriate testing, assessment, and management.

• Gingivitis and periodontitis - Persistent poor glycemic control has been reported with the incidence and progression of diabetes-related oral complications, which include gingivitis, periodontitis, and alveolar bone loss. Periodontal disease is the most prevalent oral complication in both insulin-dependent (IDDM) and noninsulin-dependent (NIDDM) patients and has been named the “sixth complication of diabetes mellitus.”

Periodontal disease is more severe and occurs with higher frequency in both NIDDM and IDDM patients, especially if the diabetes is not well controlled and there are other complications, such as retinopathy. The reason for greater incidence of periodontal destruction in diabetic patients in unclear. However, studies of the periodontal flora find similar microorganisms in diabetic and nondiabetic patients, suggesting that alteration in host responses to periodontal pathogens account for these differences in periodontal destruction. Current research supports the conclusion that periodontal infections contribute to problems with blood sugar control, so treatment of chronic periodontal infections is imperative in managing diabetic patients.

• Dental caries - Because diabetic patients are susceptible to oral sensory, periodontal, and salivary disorders, any or all of these conditions could increase their risk of developing new or recurrent caries. Factors in caries development include traditional elements (Streptococcus mutans and previous caries), as well as poor metabolic control of the diabetes.

Caries in the crowns of teeth appear to be greater in adults with poor control of IDDM. However, the prevalence of root caries requires further studies. Oral infections aside from dental caries and periodontal disease are more severe. Life-threatening deep neck infections and palatal ulcers are examples of the severity of these conditions.

• Oral mucosal diseases - Diabetic patients experience higher prevalences of lichen planus, recurrent aphthous stomatitis, and oral fungal and bacterial infections. These most often may be caused by chronic immunosuppression and require continued followup.

• Salivary dysfunction - Diabetic patients, especially those with type 2, often complain of dry mouth or xerostomia and experience salivary gland dysfunction. The complaint of “thirst” is very common. The hygienist may recommend over-the-counter salivary substitutes to help diabetic patients feel more comfortable.

• Candidiasis - Is a common fungal infection of the oral mucosal surfaces and removable prostheses and often presents in adult diabetics. Candida pseudohyphae, a cardinal sign of oral candida infections, have been reported significantly higher in diabetics who smoke cigarettes, those who wear dentures, and who have poor blood sugar control. Salivary hypofunction may also increase candida infections.

• Burning mouth and taste disturbances - Diabetic patients have increased complaints about burning mouth. More than one-third of adult diabetics report hypogeusia (abnormal diminished taste perception). In some cases this may result in overeating, leading to obesity; in others, loss of weight due to lack of appetite. Many diabetic patients may also exhibit the characteristic “fruity breath.”

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