Link between Periodontal Disease and Diabetes

Link between Periodontal Disease and Diabetes

The human body is a single unit composed of a seemingly infinite number of biological processes that are so intertwined that a problem in any one system can have a profound effect on multiple other areas of the body.

As the entry point to the body, the mouth is no exception.

The two-way relationship between periodontitis and diabetes is the strongest among all systemic diseases.  Diabetes has been shown to increase the prevalence, severity (Stage), and rate of progression (Grade) of periodontitis.  And, periodontitis has been shown to influence blood sugar control in diabetic patients.

This link between gum disease and diabetes is not direct, but instead diabetes affects the pathogenesis of periodontal disease by altering the immune response and inflammation, increasing the risk of infection via high blood sugar, and by causing oral microbiome changes.

In the other direction, periodontal disease increases insulin resistance through persistent and chronic systemic inflammation.

Several studies have investigated the effect of a deep periodontal cleaning on diabetes.  They found that with the elimination of the bacterial infection, patients saw improved insulin sensitivity, improved glycemic control, and reduced HbA1c levels by 0.48% for at least 3 months following treatment.

This drastic reduction in glycosylated hemoglobin (Hba1c), which is a chronic measure of blood glucose, is similar to if you had added a second drug to a person’s usual diabetes medication regiment.

The link between gum disease and diabetes is so strong, that it has been suggested that periodontal disease be listed among the “classic complications” of diabetes, alongside stroke, kidney failure, and retinopathy.

Although the link is strong, 33% of people living with diabetes are unaware that it can affect their gum health.

Periodontal disease is a chronic bacterial infection resulting in inflammation.  Periodontal disease causes an immune response throughout the entire body, affecting many of the body’s systems.

Periodontal disease severity has been linked to many auto-immune, genetic, and acquired immune disorders.  These include:

  • Type I Diabetes
  • Rheumatoid Arthritis
  • Lupus
  • Crohn’s and Ulcerative Colitis
  • Irritable Bowel Syndrome
  • HIV
  • Vitamin D deficiency
  • Down’s Syndrome
Periodontal Disease 101

Periodontal Disease 101

Periodontal disease, also known as gum disease, begins with chronic bacterial growth in the mouth.  If left untreated, periodontal disease can eventually lead to tooth loss.

What are the Symptoms of Periodontal Disease?

Initially, bacteria build a home in the spaces between the tooth and the gum, called the periodontal pocket.  In the early stages, called gingivitis, the gums can become inflamed, red, sore, and can easily bleed when brushing or flossing.  Some people may even have persistent bad breath or a bad taste in their mouth.  If left untreated, inflamed and enlarged gums can even cause your teeth to shift and move.

Often this pain, inflammation and bleeding makes people want to brush and floss even less – exacerbating the problem.

Although the gums are inflamed and irritated, the tooth is still firmly rooted in the jaw bone.  However, as the bacterial infection grows, the bone tissue begins to be eaten away, like steel turning to rust.  When this happens, the teeth that were once anchored in the bone become loose and will eventually fall out.

Gum disease is the leading cause of tooth loss in adults, but unlike in children the tooth fairy can’t help you.

To stop the progression of this disease, it is important to see your periodontist for an accurate diagnosis and personalized treatment plan, which usually includes an initial deep cleaning followed by proper at home care and regular supportive periodontal therapy visits with your dental hygienist.

What causes Periodontal Disease?

Poor plaque control is the primary cause of periodontal disease.  Therefore, the first line of defence in reducing gum disease is at home care.

Other factors can make a person more susceptible to gum disease.  These factors include:

  • Family history of periodontal disease
  • Diabetic control
  • Heart disease
  • Medications – some medications have an effect on our oral health as they can increase or decrease saliva flow, which acts as a natural rinse in the mouth
  • Smoking status
  • Regular dental hygiene visits

How do I treat Periodontal Disease?

The first line of defence in reducing gum disease is at home care which includes;

  • brushing with a power toothbrush for 2 minutes twice daily
  • regular use of string floss to clean between the teeth
  • regular use of interdental brushes to clean between the teeth

To stop the progression of the disease, it is important to see your periodontist for an accurate diagnosis and personalized treatment plan, which usually includes an initial deep cleaning followed by proper at home care and regular supportive periodontal therapy visits with your dental hygienist.

What is my periodontist measuring?

What is my periodontist measuring?

Your periodontist and hygienist collect several values that give a good indication of your periodontal health and wellness at every appointment. 

To collect these values, a periodontal probe is used.  A probe is a very thin, small ruler.  The probe is gently inserted in the small space that exists between your tooth and your gum.  Some of the values that we are able to collect from this measurement are described below:

a. Bleeding on Probing – What percentage of sites bleed after gentle probing?  Bleeding indicates inflammation of the gums due to a bacterial infection.

b. Probing Depth – How deep is the pocket between the tooth and gum?  A healthy periodontal pocket is between 3 and 4mm.  A periodontal pocket deeper than 5mm requires deep cleaning.

c. Gingival Thickness – How thick or thin is the gum tissue surrounding the tooth rooth?  Just like Goldilocks, your periodontist and hygienist are measuring that your gums are not to thick and not to thin, but juuuust right.

d. Mobility – How loose are teeth?  The periodontal ligament around each tooth allows for some movement and mobility (think of the need for a skyscraper to have some room for movement in the wind), but the tooth should be snug in the bone and soft tissue.

e. Furcation Involvement – Has bone resorbed away from the tooth so much that the probe can fit between the roots of the teeth?

f. Plaque Score – How much visible plaque is on the tooth surface?

Like a report card, your periodontist and hygienist review these values at every appointment and look for areas of improvement as well as areas that require some more attention and focus.

Classifications of Periodontal Disease

Classifications of Periodontal Disease

Everyone lives with a small amount of inflammation and bacteria in their mouths, but it is when this bacterial infection in the gums proceeds to chew away at the bone that supports the tooth that we are diagnosed with periodontal disease.  Periodontal disease often goes undetected by the patient because there is no pain associated with the disease.  That is until teeth become loose, gums become red and inflammed and they begin to bleed when they are flossed or brushed.

In 2017, more than 170 clinicians and researchers came together to redefine the way that we classify periodontal disease.  Now, using language similar to that used in oncology (i.e., Stage 1 through 4) we are able to communicate the severity and rate of disease progression to patients and other clinicians better than ever before.

Your periodontist is a specialist in the gums and bone that support the teeth.  They collect information such as the depth of the pockets around your teeth, the amount of bone that’s been lost around the teeth (as seen on an x-ray), and the amount of bleeding and inflammation, and other factors like diabetes and smoking status to give an accurate diagnosis.  The diagnosis is made up of two factors, stage and grade.

First, a patients stage of disease is like the GPS of a car.  Stage describes the severity and complexity of the disease.  How straight of a path are we on from health to severe disease.  Staging of periodontal disease can rank from Stage 1, incipient periodontitis through to Stage 4, advanced periodontitis with extensive tooth loss.

Secondly, a patients grade of disease is like the speedometer of a care.  Grade describes how quickly the disease is progressing.  How fast are we moving from health to disease.  Grading of periodontal disease can rank from Grade A, slow rate through to Grade B, rapid rate.

Both smoking and diabetes status are known factors that can influence our Grade, how fast we are progressing from health to disease.  Being a non-smoker and having normal, controlled blood glucose levels slows the rate of progression.  Smoking more than 10 cigarettes per day and/or having an HbA1c greater than 7% rapidly increase the rate of disease progression.

Your periodontal diagnosis and classification should be updated every 5 years with a full mouth series of x-rays conducted at your periodontal office or general dentist.

The best way to prevent and to treat periodontal disease is by regular visits to your dental office as well as putting a high priority on oral hygiene at home.

Intra/Extra-oral Examination

Intra/Extra-oral Examination

The intra-oral and extra-oral soft tissue examination is an essential part of all dental exams.  This examination is performed in a thorough and systematic nature to ensure that no parts of the head and neck region are missed or overlooked.

This examination can be broken down into sequential steps to review all tissues and to determine if they are within normal limits (WNL) or if there is an abnormality noted.

If an abnormality is noted in an intra/extra-oral examination, further detailed notes about the abnormality such as size, colour, location, surface texture, and consistency are made.  Information about the onset, location, duration, characteristics, aggravating and alleviating factors, related symptoms, and treatment are all considered by your dental hygienist and periodontist.

As part of a full intra/extra-oral examination for abnormalities in our oral pathology, a detailed medical history, family history, drug/medication history, and social history are taken.

As a patient, we can prepare for our intra/extra-oral examination by being aware of any abnormal colouration, bumps, textures, or sensations in our head and neck region. 

A full video of what to expect during a full intra/extra-oral examination by your dental hygienist or periodontist can be viewed below.

Cannabis Use and our Oral Health

Cannabis Use and our Oral Health

We know of the negative effects of smoking cigarettes and other nicotine products on our oral health, but does cannabis cause the same outcomes?

Yes.  Marijuana impacts our oral health and has been directly linked to a higher prevalence and earlier onset of periodontal disease than those who do not use marijuana regularly.

Marijuana has been implicated in several adverse effects in dentistry, including:

  • Xerostomia – A major side effect of cannabis use is dry mouth.  Having enough saliva is important to wash away bacteria and to keep the mouth hydrated.
  • Stomatitis – Sores and spots of inflammation can develop through excessive cannabis use.
  • Dysgeusia – Marijuana use can distort your sense of taste and smell.
  • Leukoplakia – Similar to what is seen in cigarette smokers, cannabis users can develop thick, white/grayish patches in the mouth.
  • Gingival hyperplasia – The gingiva (gums) can become inflammed, red, and enlarged when exposed to marijuana smoke.
  • Periodontal disease – Cannabis use creates an environment for bacteria to thrive.  Marijuana also induces bone resorption in the jaw.
  • Dental caries – Tooth decay is a major side effect of cannabis use of all types
  • Increased snacking
  • Decreased focus on oral hygiene care

With the recent legalization of cannabis in Canada, many consumers think it is less harmful than cigarettes.  For this reason, we have seen a steady increase in marijuana use in almost all age groups in Canada.  However, the safety of marijuana is not proven, in fact, it may be more damaging to our oral tissues than cigarettes.

Smoking one joint causes equivalent damage to smoking 5 nicotine cigarettes.  Joints have been shown to have 3x higher levels of tar and a higher rate of combustion.  This higher, less controlled rate or combustion results in a higher rate of injury to the delicate oral tissues.

To fight these adverse effects of smoking (either cannabis or tobacco), it’s important to have good at home dental hygiene practices.  This includes brushing with an electric toothbrush for 2 minutes twice daily.  As well as flossing and using interdental brushes to clean the crevices between the teeth, bacteria’s favourite hiding places.

It is also important to keep regularly scheduled visits with your dentist and periodontist.  When visiting the dentist, be truthful with them about your smoking history.

If you have consumed cannabis in any form (smoked, ingested, or topical) 24 hours before a visit to your dentist, it is important to reveal this.  Cannabis can have residual motor and cognitive for as long as 24 hours, depending on its route of administration.

Marijuana and its active components can cause tachycardia (fast heart beat), can reduce blood pressure, and can increase respiratory complications.  These side effects can all adversely effect a patient, laid back in a dental chair.  Cannabis can also interact with the local anesthetics or the sedation medications used in many dental procedures.

The risks related to marijuana use rise with its concentration.  Having all of the facts is important in your choice to consume cannabis, whatever the form.

Impact of our Diet on our Oral Health

Impact of our Diet on our Oral Health

They say you are what you eat and this is especially true when we consider how our diet impacts our oral health and wellness.

Some aspects of our diet that have been shown to have a positive effect on our oral health include:

Anti-inflammatory foods – tomatoes, fatty fish, green leafy vegetables

Chronic inflammation is the link between overall and our oral health. Periodontal disease is primarily a disruption in our inflammatory state.  Eating foods known to have anti-inflammatory properties can help to combat this at the site of infection.

Anti-oxidant foods – tomatoes (lycopene), dark berries, artichokes, pecans

Anti-oxidant rich foods have properties that help to balance the highly oxidized environment that the bacterial infection causing periodontal disease create.

Immune support – citrus fruits, garlic, ginger, broccoli

Our bodies natural defence against bacterial infection is our immune system.  Eating a diet high in immuno-supportive foods can have a beneficial effect on our oral and systemic health.

Microbiome support – fibre, probiotics, prebiotics

Our oral microbiome is the second largest microbial community in humans (second only to the gut).  Our oral microbiome has many roles including; initiating digestion, regulating our immune response, controlling our metabolic processes, detoxification, providing a barrier, and preventing unhealthy bacterial, viral and fungal growth, among many others.

Eliminate trans-fat and lower saturated fat, omega-6 and cholesterol-rich foods – eat instead omega-3 fat rich foods (fatty fish, legumes, soy, flax, avocado), plant sources of protein

Trans and highly saturated fatty acids found in processed carbohydrates as well as in animal meats contribute to a pro-inflammatory status in the body, promoting bacterial growth and ultimately, periodontal disease.

Bone support – calcium, vitamin D

A key characteristic of periodontal disease is a loss of the bone tissue that supports our teeth.  To support the alveolar bone it is important to incorporate foods rich in calcium and vitamin D into our diets including milk, cheese, yogurts, and even a daily vitamin D supplement.

Low glycemic index foods – sweet potato, whole oats, whole grains

The bacteria in our mouths eat what we eat, and their favourite fuel source are simple carbohydrates.  To support a healthy body and healthy oral cavity, eat complex carbohydrates with a low glycemic index.

Several studies support the message to:

  • Eliminate processed sugars/carbohydrates
  • Eliminate trans fats
  • Eat a colourful diet
  • Include Vitamin D supplementation
  • Eat fibre-rich foods
  • Drink water
  • Make small, sustainable changes
Ultrasonic vs. Hand Instruments – which is more effective?

Ultrasonic vs. Hand Instruments – which is more effective?

Periodontitis is a chronic oral infection that results in the breakdown of the tissues and bone that support the teeth.  Deep cleaning is the primary treatment option for patients with generalized chronic periodontitis. 

Dental hygienisits and periodontitis have a gamut of instrumentation and techniques to chose from when combating periodontal disease and removing the bacterial infection.

Many of us have experienced hand-held instrumentation to scrape the hard deposits from the root surface.  Manual instruments come in a variety of shapes and angles, made specifically to fit the anatomy of each of our unique teeth.  Manual instruments need to be used with care and a delicate touch so as not to remove any of the root surface or cementum.  Also, just as a knife dulls, hand-held instruments dull and require continuous sharpening for their optimal performance.  This introduces tremendous variability in the use as a tool for hygienists.

Ultrasonic instrumentation is another, more advanced option for dental hygienists to use in the removal of hard and soft deposits on the teeth.  Ultrasonic instruments incorporate a powerful stream of water and vibration of the instrument tip.  This combination removes plaque without the need for continuous sharpening.  To use each tip optimally, clinicians need advanced training and experience.

There is much debate over which is the better of the two techniques.  Our office has undertaken a study to determine if similar improvements in periodontal outcomes can be achieved using ultrasonic instruments alone versus their combination with hand-held instruments.

Results of this study will be published in a peer-reviewed dental journal in 2020.

Guided Biofilm Therapy (GBT)

Guided Biofilm Therapy (GBT)

The major culprit in gingivitis and periodontal disease is bacteria and the sticky biofilm that it creates as a byproduct of living, breathing and growing.  This sticky biofilm coats our teeth and makes for an even more appealing environment for bacteria to reside.

To remove this biofilm, our periodontists and hygienists have several tricks up their sleeve, but none better than Guided Biofilm Therapy (GBT).  GBT is not just a single trick, but in fact is an 8-step process.

1. Assess – all teeth and implants are assessed and screened

2. Disclose – bacterial biofilm is stained and made easily visible to the clinician and to the patient

3. Motivate – the mirror is turned so that the patient can see just which areas in the mouth have more or less biofilm accumulation than others

4. AirFlow (above the gum line) – water and anti-microbial powder combine to polish away all of the visible biofilm

5. PerioFlow (below the gum line) – in deep periodontal pockets, a special nozzle is used to combine water and anti-microbial powder to polish away all biofilm and bacteria below the gum line

6. Instrumentation – classical dental instruments are used to remove any remaining hard deposits on the teeth

7. Check – a quick double check of all of the areas is done by the hygienist

8. Recall – based on the amount of bacteria, biofilm, and hard deposit was removed, you will decide with your periodontist and hygienist how often you should receive professional care in addition to your normal home care routine

GBT is new to North America, and in April 2019, Donna Lavoie, one of our dental hygienists was invited to attend the North American launch of GBT as a Key Opinion Leader in her field.  Donna joined leaders in Dental Hygiene to share opinions and thoughts on this significant advancement in the field.

As early adopters, we closed our doors to patients for a full day to give our Dental Hygiene team one-on-one training with a global leader in EMS technologies, Tim Ives.  Tim challenged our team to understand the theory and concepts behind the technology.  After their morning in the classroom, our hygienists turned to practice on each other.  Not only did they perfect their skill, but they now also have had the experience!  This gives them a major advantage when sharing dialogue with patients throughout all 8 steps of the GBT protocol.

Non-Surgical Supportive Periodontal Therapy (SPT)

Non-Surgical Supportive Periodontal Therapy (SPT)

A bacterial infection causes inflammation, sore gums, bleeding gums, and eventually eats away at the bone that supports our teeth, causing them to become loose and eventually fall out.

While at home oral hygiene is very important, regular visits to your dentist and periodontist are necessary to clean the pockets of space between the teeth and gums.  This non-surgical periodontal therapy cleans away the bacterial infection, giving your body a head start in eliminating the infection and returning to a healthy state.

Supportive periodontal therapy (SPT) is provided by your dental hygienist who has been equipped with all of the most up-to-date technologies.

1. Lights – it is important that your hygienists field of view is well-lit and illuminated

2. Loupes – these personalized glasses magnify the field that the hygienist sees, so that they leave nothing behind

3. Disclosing Solution – this blue solution stains the plaque and biofilm, changing its colour making it that much easier for your hygienist to see and to remove

4. Air Polishing – in a process known as Guided Biofilm Therapy (GBT), your hygienist uses a powerful blast of water and anti-microbial powder to scrub away the plaque and bacterial biofilm that has accumulated

5. Ultrasonic Instrumentation – a powerful stream of water combined with an oscillating sharp edge removes the plaque from the edge of the tooth

6. Hand Instrumentation – your hygienist uses an array of different size and shaped bladed instruments to remove any remaining bacteria