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Diabetes Qualified

Oral health – Practical recommendations

Oral health – Practical recommendations

Poorly managed diabetes leads to poor oral health, including tooth loss, which in turn negatively affects diabetes and its complications. PhD scholar Prakash Poudel, A/Prof Wenche S. Borgnakke and A/Prof Ajesh George discuss what care providers need to know about the importance of good oral health.

Poorly managed diabetes (hyperglycaemia) is an established risk factor for potentially serious oral complications, including periodontitis (destructive gum disease) that ultimately leads to loosened teeth and tooth loss if untreated.

In the opposite direction, oral infections, including the chronic infection that characterises periodontitis – together with its resulting loose or missing teeth — negatively impacts glycaemic management and diabetes complications, and contributes to incident type 2 diabetes (T2D) and gestational diabetes.

Oral manifestations of hyperglycemia

Diabetes and oral diseases share common modifiable risk factors, such as tobacco smoking, alcohol consumption, and an unhealthy lifestyle, including diets high in carbohydrates, and hence often occur in the same individuals.

Hyperglycaemia adversely affects oral health most commonly periodontal disease. The risk of periodontitis is reported to be 3-fold greater in people with poorly managed diabetes compared to those without diabetes. Despite periodontal disease being declared the 6th diabetes complication almost 30 years ago, periodontal/oral health is still an overlooked part in diabetes management.

Periodontal treatment

Periodontitis requires professional treatment involving scaling and root planing (“deep cleaning”) to remove soft (dental plaque) and hard (calculus, “tartar”) deposits on the teeth. Such non-surgical periodontal treatment can lead to a decrease in HbA1c levels of 0.3 – 0.7 percentage points 3 months post intervention, whose magnitude resembles the effect of adding a second oral anti-diabetic medication to metformin.

Importance of good oral health care in diabetes management

Education about the oral cavity and its links to all inflammation based chronic diseases, such as diabetes, has largely been absent from the lay press as well as the curricula for students of all health professions, except for dentistry and dental hygiene.

Oral health awareness among people with diabetes

Compared to persons without diabetes, people with diabetes are less likely to: be aware of their greater risk of oral health problems; brush teeth twice daily, floss regularly, and attend annual dental visits.

Diabetes care providers — Awareness and their roles

Acknowledging the bi-directional links between diabetes and oral health, guidelines by the International Diabetes Federation (IDF) and Royal Australian College of General Practitioners (RACGP) recommend that diabetes care providers incorporate in their diabetes care oral health inspection and referral of clients for dental examination and any needed oral care.

Practical guidelines for diabetes care providers

Diabetes care providers like GPs and CDEs are well positioned to check for signs of oral health problems as part of regular health check-up visits. They can recognise inflamed tissue and pus, as well as any halitosis by performing a simple visual inspection of the oral cavity (Table 1).

Table 1. Signs of oral health problems in diabetes
  • inflamed gingiva (red, swollen, bleeding mucosa surrounding the teeth)
  • spontaneous bleeding or bleeding during tooth brushing or eating hard food items
  • receded gingiva (gingiva “pulled away“ from the crown of the teeth so teeth are looking longer due to exposed root surfaces)
  • pus from the pockets around the teeth, or from abscess at root apex (tip) penetrating the jaw bone
  • sensitive or sore teeth (hot/cold, acidic/sweet)loose teeth
  • moved teeth (spreading or spacing)candidiasis (white patches on the tongue, cheeks or roof of mouth; redness in mucosa under [unclean] removable denture)
  • mouth dryness (xerostomia, hyposalivation)
  • halitosis (foul smelling breath, malodour)
  • dysgeusia (taste disturbances)
  • trouble speaking, smiling

Importantly, modest interventions by the medical care provider can significantly improve clients’ oral health, diabetes status, and quality of life (Table 2), and simple professional periodontal treatment can lead to a clinically relevant decrease in haemoglobin A1c (HbA1c) levels. Consequently, ensuring good oral health is an integral part of diabetes prevention, treatment, and management.

Table 2. Practical recommendations for diabetes care providers during office visit
  • incorporate oral health inspection/screening in diabetes routine care
  • provide referral to dental assessment
  • inquire regarding dry mouth; change medication (type, dosage, frequency, or timing)
  • advise that smoking tobacco and poorly managed diabetes can increase their risks of oral health problems
  • inform that gum disease and other oral diseases make it harder to manage blood glucose level
  • encourage to visit the dentist at least once a year
  • advise that periodontal treatment can be helpful to manage their blood glucose level
  • encourage to brush their teeth 2 times a day – and use floss or interdental brush if they are able to do so correctly

Diabetes care providers should inspect the oral cavity (Table 1), and educate clients about oral health risks to ensure they are motivated to engage in optimal oral hygiene behaviours and regular dental visits as part of their routine diabetes care (Table 2). Initial or annual dental examinations are currently recommended as standard practice in diabetes management.

Adequate oral health knowledge and literacy are positively associated with greater frequency of tooth brushing and dental visits that are known to be effective in attaining and maintaining good periodontal health.

To support diabetes care providers promote oral health, various resources have been developed.

Some states have evidence-based client resources which include a referral pathway for clients:





This 4-minute video provides a demonstration on how a Diabetes Educator could use an oral health screening tool to assess risk of poor oral health among clients with diabetes.

Hyperglycaemia increases the risk for potentially severe oral health problems which in turn impairs glycaemic management and exacerbates diabetes complications. Simple periodontal treatment can improve glycaemic management.

Therefore, as a routine part of client diabetes management, diabetes care providers should ask about oral health issues, visually inspect the oral cavity (Table 1), and educate clients regarding oral health risks to encourage them to maintain good oral health via optimal oral hygiene behaviours and regular dental visits (Table 2), – and thereby improve general health.