When counseling diabetic patients about the complications associated with diabetes, it is imperative that pharmacists remind them about the importance of maintaining proper oral hygiene in order to reduce or prevent the incidence of periodontal disease. This disease, also commonly referred to as the "sixth complication of diabetes," is the most prevalent oral complication of diabetes.1 Individuals with poorly controlled diabetes are at the greatest risk of developing periodontal disease.1
There are 2 general categories of periodontal disease: gingivitis and periodontitis. Gingivitis, which is an inflammation of the gingival tissue, affects, to some degree, ~80% of individuals in the United States. It is the milder form of periodontal disease, and it is reversible with proper treatment.2 If left untreated, however, gingivitis may progress to the more severe, irreversible form of periodontal disease, periodontitis, which can result in alveolar bone loss.3
Periodontal disease is the primary cause of tooth loss in people 45 years and older. It is estimated that ~20% of individuals in the United States have periodontitis.4 Patients with diabetes are 2 to 3 times more likely to develop periodontal disease, compared with persons without diabetes.1 Diabetic patients who smoke have up to 20 times greater risk for developing periodontal disease than nonsmokers. Smoking seems to impair blood flow to the gums?which may affect wound healing in this tissue area.5
It is estimated that ~33% of individuals diagnosed with diabetes have severe periodontal disease, resulting in the loss of attachment of the gums to the teeth measuring =5 mm.6
Results from another study showed that patients with poorly controlled diabetes respond differently to bacterial plaque at the gum line than individuals with well-controlled diabetes and nondiabetic individuals. Persons with poorly controlled diabetes have more harmful cytokines in the gingival tissue, which cause inflammation of the gum tissue.4
In addition, studies have shown that diseased gums release significantly higher levels of bacterial proinflammatory components such as endotoxins into the bloodstream of individuals with severe periodontal disease, compared with people with healthy gums.7 Consequently, these harmful bacterial components in the blood could in turn travel to the heart and cause complications. The findings of still another study suggest that periodontal disease also may cause oral bacterial components to enter the bloodstream and cause the liver to make C-reactive proteins, which are a predictor of an increased risk for cardiovascular disease.7
Research has shown that the development and the severity of periodontal disease among diabetics are affected by poor glycemic control, as well as by alteration of the microflora in the oral cavity, an impaired or compromised immune system, and vascular changes.8,9 Severe periodontal disease can increase blood glucose, thus increasing the likelihood of further diabetic complications.8 Treatment for periodontal disease is dependent on its severity and may involve plaque removal, pharmacologic therapy, surgery, or dental implants.10
The Role of the Pharmacist
When counseling patients with diabetes, pharmacists will encounter many opportunities to address any issues they may have regarding diabetes, as well as to reinforce the importance of adhering to the treatment plan to prevent or minimize the complications associated with diabetes. The first line of defense in reducing or preventing the incidence of periodontal disease is the practice of good oral hygiene.
Patients should be educated about other oral health care problems?such as xerostomia, candidiasis, and dental caries?which may be manifested as the result of poorly controlled diabetes as well as improper oral hygiene. Patients always should be reminded that the risk of the development of periodontal disease, as with other complications of diabetes, is linked to glycemic control. Through proper oral hygiene, the incidence of many other health complications may indeed be deterrable.
Ms. Terrie is a clinical pharmacy writer based in Haymarket,Va.
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