11 minute read
Dealing with Diabetes
Understanding type 2 diabetes, how it affects teeth and the importance of lifestyle factors on its management
by Michaela von Geijer, Doctor of Dental Surgery
Diabetes is a dramatically growing disease, affecting hundreds of millions worldwide at enormous societal costs. Topical research proves a bi-directional link between periodontal disease and diabetes and that periodontal health benefits diabetes patients. As dental professionals, we can act from a holistic perspective and encourage positive lifestyle changes, influencing not just oral health but the overall well-being of our patients. There are two types of diabetes – Type 1 diabetes mellitus (meaning there is no insulin production) and Type 2 diabetes mellitus (T2DM). A patient with T2DM has a production of insulin, at least at an early stage of the disease. The function of insulin is to assist the body’s cells in absorbing glucose from the bloodstream. In patients with diabetes, the cells cannot make proper use of the insulin, resulting in insulin resistance. This article covers only T2DM and how lifestyle changes can improve T2DM or reduce the risk for patients with pre-diabetes.
A rapidly growing disease
T2DM affects hundreds of millions around the globe. Figures show the most pronounced increase in men compared to women and in low- and middle-income countries (Kolb & Martin, 2017; NCD-RisC., 2016). Many are not diagnosed, and one-in-two people remain undiagnosed (IDF diabetes atlas, 2021). Approximately 10% of adults have diabetes, and a more than 50% increase in diabetes incidence is predicted by 2040 (IDF Diabetes Atlas Tenth edition, 2021). The societal costs of treating diabetes and its complications have increased massively during the last decades. Diabetes complications are often established long before the actual diagnosis of the disease. Figures tell us that up to 30% of patients have micro- or macro-complication before diagnosis (Gilles et al. 2008; Cieslik et al., 2022). Also in Australia, medication and treatment complication costs have increased enormously within the last 15 years. Clearly, treating the complications due to diabetes costs much more than patients not developing diabetes (Dinh et al., 2022).
We must address this global epidemy and reverse diabetes at its early stages by creating and improving healthy habits. Even small changes will have an impact on overall health. Dental professionals are experts on this; we have the tools to inspire patients to individualised lifestyle changes.
Diabetes and periodontal disease
At the dental office, we meet patients daily at risk of developing T2DM or with confirmed disease. Because clinical signs of diabetes may be found in the mouth, we should refer the patient to a physician for a blood sugar check if we suspect pre-diabetes or diabetes. Early detection and treatment are of uppermost importance to reduce the risk of complications, and starting medication will also increase the quality of life for the individual.
The two-way relationship between diabetes and periodontal disease is well established, not the least among dental professionals. Keeping the periodontal tissue healthy and treating periodontal disease is key for patients with diabetes since periodontitis is associated with increased HbA1c and diabetes complications. We know that periodontal treatment will improve HbA1c levels (Sanz et al., 2018).
The importance of lifestyle factors
Taking good care of the mouth every day is a lifestyle factor we should encourage; However, dental professionals are also in a position to improve other lifestyle changes. We are trained in motivation and communication techniques and practice these skills at every session. Many of us have an in-depth knowledge of a healthy diet, which we often share with patients. Encouraging positive lifestyle changes in our patients will impact glycaemic levels for those with diabetes, thus decreasing the risk for complications and more medications. Even minor changes may result in a later onset or progression and hopefully fewer diabetes complications. Some lifestyle changes seem more critical than others, but every little step we can influence is beneficial – for the patient and society (Lau& Teoh, 2015).
We should refer the patient to a physician for a blood sugar check if we suspect prediabetes or diabetes
Lifestyle factors play a vital role in managing type 2 diabetes. Since they could be enough to reverse the disease early, we may prevent or delay type 2 diabetes in many patients through our influence. Lifestyle changes that impact diabetes are, for example, a healthy diet, daily exercise, a healthy weight, healthy gums, less stress, and 7-8 hours of sleep. The genetic component (family history) and ageing will, of course, also impact the development of T2DM (Wu et al. 2014, IDF Diabetes Atlas Tenth edition, 2021).
Normal body weight
Being overweight is one of the strongest risk factors for DMT2. The way we live today, with plenty of energy-dense, unhealthy Western foods and a sedentary lifestyle, causes an increase in body weight (Wu et al. 2014). The more excess weight, the more cell resistance to the insulin hormone is created. Especially visceral obesity, fat surrounding internal organs, seems to increase the risk, rather than high body mass index (BMI) (Kolb & Martin, 2017). Reducing weight is one of the primary targets to reduce the risk of diabetes (Hamman et al. 2006).
Healthy eating
For many people living in developed countries today, over-eating and unhealthy food are a problem, and an unhealthy Western diet will increase the risk for TD2 (Jannasch et al., 2017).
We all understand and know the importance of a healthy diet for all patients, but especially for patients with the risk of developing diabetes or with a diabetes diagnosis. Implementing changes towards a healthy diet is very hard; no one wants to be on a diet for the rest of their lives. We know that habit formation takes time to implement (Lally et al. 2009). Therefore, we must encourage small changes in eating habits that will become a natural preference for healthier food.
Healthy eating for T2DM patients with overweight includes a reduction of energy intake with smaller portions of food and a healthier choice of food, such as carbohydrates with a low glycaemic index rich in fibres (brown rice, buckwheat, whole oats, pulses) and healthier fats. In addition, an increased daily amount of vegetables and fruits adds minerals and vitamins to the body. Sugar, salt and red meat intake should be reduced, and alcohol consumption should be moderate. Remember that special diabetic food is not always healthier (Diabetes UK, The British Diabetic Association). Moreover, soft drinks should be avoided; water is the perfect thirst quencher. The Mediterranean and Paleolithic diets are examples of healthy eating, including a high intake of vegetables, fruit, olive oil, and fish, which are shown to reduce the risk for future diabetes (Martin-Pelaez S. 2020; Esposito et al., 2014).
As healthcare providers, it’s important to discuss with our patients their eating habits, including the types and amounts of food they consume, in order to maintain a healthy weight and blood sugar level. Let’s share our expertise and advice on overall dietary patterns.
Physical activity
Physical inactivity is becoming a significant global health problem. Yet, performing any physical activity will enhance health, such as improving lipid profile, reducing blood pressure, and impacting overall well-being (Kanaley et al., 2022). The benefits of exercise can’t be overstated, especially for patients with pre-diabetes/diabetes. Daily exercise reduces glucose levels, improves insulin sensitivity, strengthens muscles and bones, and helps control body weight (Wu et al. 2014).
Among those who perform any physical activity during leisure time, the incidence of T2DM is lower (Smith et al. 2016). Physical activity might reduce the development of T2DM by 30-50% (Bassuk & Manson, 2005; Wu et al. 2014). There are physical guidelines for suitable activities, mainly applicable to patients with diabetes (Smith et al. 2016; CDC 2023).
Since we nowadays have a more sedentary lifestyle, we would all benefit from very short activity breaks during the day but also planning for regular physical activities several times a week. All kinds of activity are of value (Kanaley et al., 2022).
Avoid tobacco use
Tobacco usage, especially smoking cigarettes, is a lifestyle factor most of us bring up with patients suffering from periodontitis. It’s important to discuss this issue with all patients, as it can negatively affect their overall health and have a significant impact on diabetes. According to the World Health Organisation, smoking is a modifiable risk factor in preventing disease (WHO, 2016). Furthermore, smokers will find diabetes harder to manage since smoking impacts insulin sensitivity and insulin production in the pancreas (Durlach et al. 2022; Maddatu et al., 2017). Smoking will increase the prevalence of macro- and microvascular complications in these patients (Sliwinska-Mosson & Milnerowicz, 2017).
As dental professionals, we have the power to make a difference by sharing information and knowledge with our patients
It has been shown that smoking increases the risk of central obesity. In addition, the accumulation of visceral fat is a well-known risk factor for insulin resistance (Maddatu et al. 2017). Cigarette smoking is linked to a 30% or 40% increased risk of developing T2DM. (CDC, 2022). In light of this, smoking cessation is a fundamental task for diabetes prevention and for managing periodontitis.
Less stress
There seems to be some evidence that high stress and anxiety levels are related to T2DM. They increase cortisol levels which might hinder the insulin-producing cells from working properly and affect the insulin resistance or sensitivity in the cells (Wong et al., 2019; Hackett & Steptoe, 2017).
Enough sleep
Studies show that lack of sleep, insomnia, irregular sleep, waking up too early and other sleep-related disorders are associated with an enhanced risk for T2DM since it increases insulin resistance (Anothaisintawee et al., 2016; Engeda et al. 2013).
Too little sleep will raise cortisol levels, and cortisol will counteract the effect of insulin, causing insulin resistance. Sleeping five to six hours per night increases the risk for T2DM but there are also studies showing that sleeping more than the standard svene to eight hours per night might increase the risk of developing T2DM (Chaput et al. 2007; Engeda et al., 2013).
Thus, sleep-related disorders will make diabetes harder to manage, while a good night’s rest benefits patients with diabetes and all individuals alike.
Healthy gums
There is a two-way relationship between diabetes and periodontitis. Periodontitis increases the risk of diabetes by 20–30% and severe periodontitis is associated with a higher risk of diabetic complications (Graziani EFP, 2018). Patients with periodontitis and diabetes have poorer glycemic control, and patients with diabetes are more likely to develop periodontitis (Sanz et al. 2018).
Periodontal treatment reduces glucose levels and improves HbA1c in patients with diabetes; the effect is equivalent to adding a second antidiabetic drug (Chapple et al. 2013). After 12 months, periodontal treatment still had a good effect on HbA1c levels (Simpson et al. 2022). Periodontal treatment is safe to perform and should be carried out in patients with diabetes, just as in all patients with unhealthy gums. To maintain results, the patient must also perform thorough plaque control, cleaning all sides of the tooth with a toothbrush and interdental cleaning. Despite the clear connection between diabetes and periodontitis, information on oral health as a modifiable risk factor is rarely included in the information for patients with diabetes (AIHW, 2022; fip, 2021; Diabetes Australia, 2023)
Conclusion
It is essential to understand the complexity of diabetes and the numerous risk factors involved, some of which can be affected by a change of behaviour. When diagnosed early, patients only receive recommendations on lifestyle changes. Following the advice and making lifestyle improvements can make glucose values drop and insulin resistance disappear. A healthy lifestyle is associated with a lower risk of mortality in patients with T2DM (Han et al. 2022).
As dental professionals, we have the power to make a difference by sharing information and knowledge with our patients, medical staff, pharmacy, and other stakeholders. Every little lifestyle change benefits the patient.
About the author: Doctor of Dental Surgery, Dr Michaela von Geijer is working part-time at a private dental office in Sweden and at TePe HQ in Malmö, Sweden. She has long clinical experience, with a particular interest in prevention and oral health. She has always placed a high value on working with a preventative focus.
Dr von Geijer has held temporary preclinical positions as amanuensis at the University of Lund, including basic research and assistance with education/training at the medical and dental schools.
She also has experience lecturing to professionals when employed by pharmaceutical companies as well as companies within the dental industry.
She has been employed by TePe and a lecturer at universities around the world since 2015.
