Monday, December 15, 2014

Importance of Oral Health during Pregancy

Oral Health During Pregnancy

   Oral health care in pregnancy is often avoided and misunderstood by physicians, dentists, and patients. Evidence-based practice guidelines are still being developed. Research suggests that some prenatal oral conditions may have adverse consequences for the child. Periodontitis is associated with preterm birth and low birth weight, and high levels of cariogenic bacteria in mothers can lead to increased dental caries in the infant. Other oral lesions, such as gingivitis and pregnancy tumors, are benign and require only reassurance and monitoring. Every pregnant woman should be screened for oral risks, counseled on proper oral hygiene, and referred for dental treatment when necessary. Dental procedures such as diagnostic radiography, periodontal treatment, restorations, and extractions are safe and are best performed during the second trimester. Xylitol and chlorhexidine may be used as adjuvant therapy for high-risk mothers in the early postpartum period to reduce transmission of cariogenic bacteria to their infants. Appropriate dental care and prevention during pregnancy may reduce poor prenatal outcomes and decrease infant caries.


During pregnancy, the oral cavity is exposed more often to gastric acid that can erode dental enamel. Morning sickness is a common cause early in pregnancy; later, a lax esophageal sphincter and upward pressure from the gravid uterus can cause or exacerbate acid reflux. Patients with hyperemesis gravidarum can have enamel erosions. Management strategies aim to reduce oral acid exposure through dietary and lifestyle changes, plus the use of antiemetics, antacids, or both. Rinsing the mouth with a teaspoon of baking soda in a cup of water after vomiting can neutralize acid. Pregnant women should be advised to avoid brushing their teeth immediately after vomiting and to use a toothbrush with soft bristles when they do brush to reduce the risk of enamel damage. Fluoride mouthwash can protect eroded or sensitive teeth.


One fourth of women of reproductive age have dental caries, a disease in which dietary carbohydrate is fermented by oral bacteria into acid that demineralizes enamel (Figure 1). Pregnant women are at higher risk of tooth decay for several reasons, including increased acidity in the oral cavity, sugary dietary cravings, and limited attention to oral health. Early caries appears as white, demineralized areas that later break down into brownish cavitations. Fillings or crowns are a sign of previous caries. Untreated dental caries can lead to oral abscess and facial cellulitis. Children of mothers who have high caries levels are more likely to get caries. Pregnant patients should decrease their risk of caries by brushing twice daily with a fluoride toothpaste and limiting sugary foods. Patients with untreated caries and associated complications should be referred to a dentist for definitive treatment.

Figure 1.
Severe adult dental caries.
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Figure 1.
Severe adult dental caries.


Pregnancy oral tumor (Figure 2) occurs in up to 5 percent of pregnancies and is indistinguishable from pyogenic granuloma. This vascular lesion is caused by increased progesterone in combination with local irritants and bacteria. Lesions are typically erythematous, smooth, and lobulated; they are located primarily on the gingiva. The tongue, palate, or buccal mucosa may also be involved. Pregnancy tumors are most common after the first trimester, grow rapidly, and typically recede after delivery. Management is usually observational unless the tumors bleed, interfere with mastication, or do not resolve after delivery. Lesions surgically removed during pregnancy are likely to recur.

Pregnancy oral tumor (pyogenic granuloma).

Figure 2.
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Pregnancy oral tumor (pyogenic granuloma).

Figure 2.


Teeth can loosen during pregnancy, even in the absence of gum disease, because of increased levels of progesterone and estrogen affecting the periodontium (i.e., the ligaments and bone that support the teeth). For uncomplicated loose teeth not associated with periodontal disease (see below), physicians should reassure patients that the condition is temporary, and alone it will not cause tooth loss.


Gingivitis (Figure 3) is the most common oral disease in pregnancy, with a prevalence of 60 to 75 percent. Approximately one half of women with preexisting gingivitis have significant exacerbation during pregnancy. Gingivitis is inflammation of the superficial gum tissue. During pregnancy, gingivitis is aggravated by fluctuations in estrogen and progesterone levels in combination with changes in oral flora and a decreased immune response. Thorough oral hygiene measures, including tooth brushing and flossing, are recommended. Patients with severe gingivitis may require professional cleaning and need to use mouth rinses such as chlorhexidine (Peridex).

Figure 3.
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Figure 3.


Periodontitis is a destructive inflammation of the periodontium (Figure 4) affecting approximately 30 percent of women of child-bearing age. The process involves bacterial infiltration of the periodontium. Toxins produced by the bacteria stimulate a chronic inflammatory response, and the periodontium is broken down and destroyed, creating pockets that become infected. Eventually, the teeth loosen. This process can induce recurrent bacteremia, which indirectly triggers the hepatic acute phase response, resulting in production of cytokines, prostaglandins (i.e., PGE2), and interleukins (i.e., IL-6, IL-8), all of which can affect pregnancy. Elevated levels of these inflammatory markers have been found in the amniotic fluid of women with periodontitis and preterm birth compared with healthy control patients. In one study, researchers found minimal oral bacteria in the amniotic fluid and placenta of women with preterm labor and periodontitis. It seems probable that this inflammatory cascade alone prematurely initiates labor. The mechanism is thought to be similar for low birth weight; the release of PGE2 restricts placental blood flow and causes placental necrosis and resultant intrauterine growth restriction.

Figure 4.
Moderately severe periodontitis.
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Figure 4.
Moderately severe periodontitis.

Periodontitis and Poor Pregnancy Outcomes

Periodontitis has been associated with several poor pregnancy outcomes, although the mechanism by which this occurs remains unclear and controversy exists. Preterm birth is the leading cause of neonatal morbidity in the United States, costing approximately $26.2 billion per year. Studying the direct effect of any risk factor on the outcomes of preterm birth and low birth weight is extremely difficult because of the many confounding variables that may affect the same outcome.
In a recent systematic review of mainly cross-sectional, case-control, and cohort studies conducted between 1996 and 2006 in 12 countries and three states, investigators identified 24 studies demonstrating a positive relationship between periodontitis and preterm birth, low birth weight, or both. These studies involved approximately 15,000 mothers. Three of the studies were randomized controlled trials (RCTs). Conversely, 14 studies reported no relationship between periodontitis and poor pregnancy outcomes. A recent, large, U.S.-based RCT found no association between periodontitis and preterm birth and low birth weight.
Some of the study authors have postulated that racial differences in how periodontitis affects pregnancy outcomes may explain many of the varying results. Studies that involved more black patients had participants with more periodontal-related preterm labor. Another possible explanation is that treating periodontitis during pregnancy is too late to achieve a positive result. The focus should be on improving the condition before pregnancy.
The management of periodontitis in pregnancy is based on early diagnosis and deep root scaling. The authors of one RCT demonstrated that deep root scaling reduced the risk of birth before 37 weeks' gestation (preterm birth), with a risk reduction of 0.5 (confidence interval [CI], 0.2 to 1.3). For birth before 35 weeks' gestation (very preterm birth), the risk reduction was 0.2 (CI, 0.02 to 1.4) for women with periodontitis. In another RCT of deep root scaling combined with patient education, regular plaque removal, and routine chlorhexidine rinses, researchers also noted a reduction in the incidence of preterm low birth weight (risk reduction, 0.18; CI, 0.05 to 0.6). These studies, in addition to a recent U.S.-based RCT that found no benefit of treatment, reported no harm to the mother or fetus from treatment of maternal periodontal conditions.
Women with preexisting periodontal disease can reduce the risk of recurrence or worsening disease during pregnancy through proper oral hygiene. The American Academy of Periodontology recommends that all women who are pregnant or planning to become pregnant undergo a periodontal examination and any necessary treatment

Dental Care During Pregnancy


Every pregnant woman should be assessed for dental hygiene habits, access to fluoridated water, oral problems (e.g., caries, gingivitis), and access to dental care. Oral examination should include the teeth, gums, tongue, palate, and mucosa. Patients should be counseled to perform routine brushing and flossing, to avoid excessive amounts of sugary snacks and drinks, and to consult a dentist. Status of and plans for oral health should be documented. Many dentists are reported to be reluctant to treat pregnant women. Physicians and dentists can overcome this situation through education, clear communication, and the development of ongoing collaborative relationships. Physicians can share information on the safety of dental treatment in pregnancy with dental colleagues and provide clear referral recommendations.


Xylitol and chlorhexidine lower maternal oral bacterial load and reduce transmission of bacteria to infants when used late in pregnancy and/or in the postpartum period. Both topical agents are safe in pregnancy (U.S. Food and Drug Administration [FDA] pregnancy category B) and during breastfeeding. Studies have used different dosing levels, and the optimal dose for consistent prevention is unclear.


Dental radiography may be performed in pregnancy for acute diagnostic purposes. When possible, radiography should be delayed until after the first trimester. Screening radiography should be deferred until after delivery. Modern fast film, avoidance of retakes, and use of lead aprons and thyroid shields all limit risk. The teratogenic risk of radiation exposure from oral films is 1,000 times less than the natural risk of spontaneous abortion or malformation.


Ideally, dental procedures should be scheduled during the second trimester of pregnancy when organogenesis is complete. Urgent dental care can be performed at any gestational age. The third trimester presents the additional problems of positional discomfort and the risk of vena caval compression. Propping a woman on her left side, repositioning often, and keeping visits brief can reduce problems. Deferring dental care until after delivery can be problematic because new mothers are focused on the care of their newborn and may have dental insurance only during pregnancy.


Local anesthetics such as lidocaine (Xylocaine; FDA pregnancy category B) and prilocaine (Citanest; FDA pregnancy category B) mixed with epinephrine (FDA pregnancy category C) are safe for procedures when dosed appropriately.Sedatives such as benzodiazepines (e.g., midazolam [Versed; FDA pregnancy category D], lorazepam [Ativan; FDA pregnancy category D], triazolam [Halcion; FDA pregnancy category X]) should be avoided. Nitrous oxide is not rated and its use in pregnancy is controversial.


If mild cellulitis is present, penicillin, amoxicillin, and cephalexin (Keflex; all FDA pregnancy category B) are reasonable first-line antibiotics. Erythromycin base (not erythromycin estolate, which is associated with cholestatic hepatitis in pregnancy) or clindamycin (Cleocin; both FDA pregnancy category B) can be used in the type 1 hypersensitivity penicillin–allergic patient. For severe cellulitis, the patient should be hospitalized and treated with intravenous cephalosporins or clindamycin. To manage dental pain, acetaminophen (FDA pregnancy category B), ibuprofen (Motrin; FDA pregnancy category B in the first and second trimesters, category D in the third trimester), and limited use of oxycodone (Roxicodone; FDA pregnancy category B in the first and second trimesters, category D in the third trimester) are appropriate depending on the gestational stage.

Am Fam Physician. 2008 Apr 15;77(8):1139-1144.

Tuesday, December 2, 2014

Benefits of Chewing Gum

Saliva and Chewing Gum — The Benefits to Oral Health

As many of us know, saliva helps to keep the mouth moist. Saliva flow increases when we eat, allowing us to chew and swallow our food. It also has a protective effect by neutralizing acid when we eat a carbohydrate that lowers the pH of our mouth and clears away the food after a meal.
When we combine saliva flow with chewing sugarless gum it creates a new opportunity to stimulate more salivary flow to neutralize acids from foods eaten.
  What does this mean to you? It means that you can decrease the amount of tooth decay by limiting the acid you your teeth come into contact with.  After you eat, the pH of your dental plaque becomes acidic for a period of time, weakening teeth and making them susceptible to tooth decay.
A two-year sugarless chewing gum study was conducted on a population of children from third to fifth grade in Europe. Along with non-fluoridated water and regular fluoride toothpaste use, the results after just one year showed children that chewed sugarless sorbitol gum had a 41.7 percent reduction in dental caries compared to the control group of children who did not chew the sorbitol gum. (3) The study also showed that chewing three pieces of sugarless chewing gum per day was not difficult to maintain.
Prevention is simple. Talk to your dental professional about the smart choices you can make to help improve your oral health through the use of sugarless gum.

©  2010 Colgate-Palmolive Company

Note: If you have TMJ symptoms, gum chewing is not recommended.

Friday, November 21, 2014

Diabetes and Oral Health


Diabetes and oral health                

Practice Implications. Dental practitioners will be treating more patients with diabetes in the future, and this article provides an overview of the systemic and oral aspects of the disease that impact dental treatment.
Diabetes mellitus is a syndrome of abnormal carbohydrate, fat and protein metabolism that results in acute and chronic complications due to the absolute or relative lack of insulin. There are three general categories of diabetes: type 1, which results from an absolute insulin deficiency; type 2, which is the result of insulin resistance and an insulin secretory defect; and gestational, a condition of abnormal glucose tolerance during pregnancy.
Diabetes develops in people of all ages, although in greater frequency in African-Americans and Hispanics, and prevalence's have increased dramatically over the past several decades. Diagnosis is made on the basis of a host of systemic and oral signs and symptoms, including gingivitis and periodontitis, recurrent oral fungal infections and impaired wound healing.
Safely managing the patient with diabetes requires effective communication among multiple health care providers.
Approximately one-third of adults with diabetes in the United States are undiagnosed, and preventive care among patients with diabetes falls below national health objective standards. Therefore, dental professionals can play an important role in diagnosing and managing patients with diabetes. Furthermore, because poorly controlled diabetes leads to significant morbidity and mortality, dentists can counsel their patients with diabetes about improving glucose regulation, maintaining oral and nutritional health, performing daily glucose monitoring tests and seeing medical professionals for routine care.
Owing to the increasing longevity of the American population and the growing prevalence of diabetes, as well as the increased effectiveness of diagnostic and therapeutic protocols, researchers have predicted that dental practitioners will be treating more patients with this disease.


In 1999, the National Centers for Health Statistics reported that more than 10 million Americans were living with diabetes (distributed among white, black, Hispanic and other racial/ethnic groups). In 1997, an estimated 124 million people worldwide were living with diabetes. By the year 2010, the number of people with diabetes worldwide is projected to reach 221 million, and in certain regions of the world (for example, Asia, Africa), diabetes rates could rise twofold or threefold.
People with diabetes have a substantially higher risk of mortality and shorter life expectancy than do those without diabetes. Diabetes was the sixth most common cause of death in 2001, accounting for more than 71,000 deaths in the United States. In 1996, nearly 3 percent of the adult population reported experiencing diabetes as a chronic condition, with rates increasing from less than 1 percent in people younger than 18 years of age to greater than 10 percent in adults aged 75 years and older. Diabetes has great racial discrepancies. A survey conducted in 1996 found that 8.7 percent of whites aged 65 years and older had diabetes compared with 19.9 percent of blacks, and the prevalence of diabetes among Hispanics in the United States is approximately twice the prevalence among non-Hispanic whites. Blacks aged 45 years and older report higher rates of chronic diabetes-related problems than do their white counterparts. Premature death is a significant problem due to diabetes, and the problem is getting worse with time. In 1999, a nationwide survey estimated that 180 years of potential life were lost per 100,000 Hispanics before the age of 75 years as a result of diabetes, an increase from 134 years of potential life lost per 100,000 Hispanics in 1980.
The burden of diabetes on the health care system is remarkable; in 2000, 23.6 million visits to physicians’ offices were for diabetes-related issues. During the past two decades, the prevalence of diabetes has increased 30 to 40 percent, and the burden of diabetes and its complications are likely to increase as the population grows older. Obesity is a major risk factor in the development of diabetes at any age, and the number of overweight children and adolescents in the United States has increased substantially in the past two decades. In summary, diabetes represents a growing medical disorder, with concomitant morbidity and mortality that can affect people of all ages.


Signs and symptoms.

The onset of symptoms is rapid in type 1 diabetes, and includes the classic triad of polyphagia, polydipsia and polyuria, as well as weight loss, irritability, drowsiness and fatigue. Symptoms of type 2 diabetes develop more slowly, and frequently without the classic triad; rather, these patients may be obese and may have pruritus, peripheral neuropathy and blurred vision. Opportunistic infections, including oral and vaginal candidiasis, can be present. Adults with long-standing diabetes, especially those with poorly controlled hyperglycemia, may develop micro vascular and macro vascular conditions that can produce irreversible damage to the eyes (retinopathy, cataracts), kidneys (nephropathy), nervous system (neuropathy and paresthesias), and heart (accelerated atherosclerosis), as well as recurrent infections and impaired wound healing.
It is less common to encounter a dental patient with acute signs and symptoms of hyperglycemia, although glucose control worsens in the presence of an uncontrolled infection. An insulin-deficient patient with acute hyperglycemia often may have a “fruity” breath. Alternatively, hypoglycemia is more commonly observed owing to an imbalance of glucose intake and use of hypoglycemic agents. Weakness, sweating, mental confusion, incoordination and trembling occur when a person’s serum glucose level falls below 50 to 70 milligrams per deciliter, and symptoms become severe (loss of consciousness and convulsions) when levels fall below 40 mg/dL.


The American Diabetes Association’s diagnostic criteria for diabetes require a fasting blood glucose level of 126 mg/dL or greater. The measurement of glycosylated hemoglobin, or HbA1c, is a good measure of long-term (six to 12 weeks) glucose regulation. For people with diabetes, the goal is to maintain HbA1c levels below 7 percent (normal levels fall between 4 and 6 percent). HbA1c levels above 9 percent reflect poorly controlled diabetes, and indicate the need for aggressive diabetic control.


Diabetes is not a curable disease, and therapy has four goals:

  • – to normalize blood glucose levels;
  • – to prevent acute complications and eliminate symptoms;
  • – to maintain ideal body weight;
  • – to prevent or minimize chronic complications.

Oral hypoglycemic medications depend on functioning pancreatic beta cells to stimulate insulin secretion and, therefore, are used to treat many patients with type 2 diabetes. Insulin is required for patients with type 1 diabetes, as well as for patients with type 2 diabetes who do not respond to dietary therapy alone or in combination with oral hypoglycemic therapy. Diet and physical exercise are a necessary component of therapy for patients with both type 1 and type 2 diabetes.
Dentists should be familiar with the medications used for diabetes; updated lists of common therapies are available. Oral hypoglycemic agents include sulfonylureas (which enhance insulin secretion), biguanides (which reduce hepatic glucose production), alpha-glucosidase inhibitors (which delay glucose adsorption) and thiazolidinediones (which enhance insulin sensitivity). Insulin is available in short-acting (one to 1½ hours), regular-acting (four to six hours), intermediate-acting (eight to 12 hours) and long-acting (24–36 hours) formulations. Insulin pumps provide a continuous burst of insulin to help control serum glucose levels.
Home glucose monitoring is recommended several times daily to help regulate rapid fluxes in blood sugar levels due to diet, medications and physical and psychological stresses. Many tools are available to help people with diabetes, including home-based urine and blood tests and glucometers. Patients must undergo regular examinations by physicians to monitor triglyceride, fasting glucose and HbA1c levels. Dentists should document their patients’ most recent home-based glucose and laboratory test results, and monitor blood pressure levels in the dental office to assist in oral health supervision.
Nutritional supervision is a critical component of diabetes management, and dentists can assist in this endeavor. Risk factors for impaired nutritional intake include gingivitis and periodontitis, oral microbial infections, poorly fitting or lack of removable prostheses, dysphagia and salivary dysfunction. A realistic nutritional plan that includes regular oral hygiene and requisite dental treatment can help patients maintain good blood glucose control and nutritional status.




Gingivitis and periodontitis.

Persistent poor glycemic control has been associated with the incidence and progression of diabetes-related complications, including gingivitis, periodontitis and alveolar bone loss. Nationwide surveys have demonstrated that people with diabetes, especially poorly controlled diabetes, have a significantly higher prevalence of severe periodontitis. Several mechanisms have been proposed to explain the increased susceptibility to periodontal diseases, including alterations in host response, subgingival microflora, collagen metabolism, vascularity, gingival crevicular fluid and heredity patterns. Multiple pathophysiological mechanisms (compromised neutrophil function, decreased phagocytosis and leukotaxis) also have been implicated in the increased alveolar bone loss found in patients with diabetes. Furthermore, poorly controlled diabetes, particularly in connection with tobacco use, is a risk factor for periodontal disease.
Figure 1.
Figure 1.
Periodontal abscess in a mandibular right first molar in a patient with type 1 diabetes.
Figure 2.
Figure 2.
Radiograph of the patient in Figure 1 demonstrating rapid and aggressive periodontitis-associated alveolar bone loss.
In addition, evidence supports the observation that periodontal infections contribute to problems with glycemic control. For example, adults with diabetes who received ultrasonic scaling and curettage in combination with systemically administered doxycycline therapy demonstrated, at three months, significant reductions in mean HbA1c, reaching nearly 10 percent from the pretreatment values. The mechanisms for this relationship are undergoing investigation and require validation. However, evidence suggests that periodontitis-induced bacteremia will cause elevations in serum proinflammatory cytokines, leading to hyperlipidemia, and ultimately causing an insulin-resistance syndrome and contributing to destruction of pancreatic beta cells. Treating chronic periodontal infections is essential for managing diabetes.

Dental caries.

The relationship between diabetes and dental caries has been investigated, but no clear association has been clarified. It is important to note that patients with diabetes are susceptible to oral sensory, periodontal and salivary disorders, which could increase their risk of developing new and recurrent dental caries. For example, several studies have reported a greater history of dental caries in people with diabetes. Factors for caries development include the traditional elements (for example, Streptococcus mutans levels, previous caries experience), as well as poor metabolic control of diabetes, underscoring the need for dental professionals to follow up all patients with diabetes on a regular basis for new and recurrent dental decay.

Salivary dysfunction.

People with diabetes have been reported to complain of dry mouth, or xerostomia, and experience salivary gland dysfunction (Figure 3). A recent study detected impaired salivary uptake and excretion by salivary scintigraphy in adults with type 2 diabetes.The cause is unknown, but may be related to polyuria or to alterations in the basement membranes of salivary glands.Xerostomic complaints may be due to thirst, a common manifestation of diabetes. Saliva may be useful to diagnose and/or monitor systemic diseases, and it may be possible in the future to evaluate glucose levels or diabetes-specific autoimmune markers from oral fluids, thus eliminating the need for serum blood evaluation for diagnosis and monitoring.
Figure 3.

Figure 3.
Salivary hypofunction, xerostomia and dental caries in a patient with long-standing type 1 diabetes.

Oral mucosal diseases.

Diabetes is associated with a greater likelihood of developing certain oral mucosal disorders. There are reports of greater prevalences of lichen planus (Figure 4) and recurrent aphthous stomatitis, as well as oral fungal infections. While these associations have not been found consistently in all populations of subjects with diabetes, they may be due to chronic immunosuppression and require continued follow-up by health care practitioners. In patients with type 1 diabetes, chronic immunosuppression most likely is a sequelae of the disease, whereas in patients with type 2 diabetes, acute hyperglycemia causes alterations in immune responsiveness. Oral mucosal disorders represent an opportunity to coordinate diabetes care between physicians and dentists, which can improve the referral of patients to oral health practitioners.
Figure 4.

Figure 4.
Oral reticular lichen planus in a patient with type 2 diabetes.

Oral infections (candidiasis).

Another manifestation of diabetes and an oral sign of systemic immunosuppression is the presence of opportunistic infections, such as oral candidiasis. Fungal infections of oral mucosal surfaces and removable prostheses are more commonly found in adults with diabetes (Figure 5). Candida pseudohyphae, a cardinal sign of oral Candida infection, have been associated significantly with cigarette smoking, use of dentures and poor glycemic control in adults with diabetes. Salivary hypofunction also may increase the oral candidal carriage state in adults with diabetes. The oral health care professional can readily make the diagnosis of oral candidiasis and provide therapy, but most importantly, he or she should pursue the infection’s etiology, which could include a diagnosis of diabetes mellitus.
Figure 5.

Figure 5.
Oral pseudomembraneous candidiasis in a patient with poorly controlled type 1 diabetes.

Taste disturbances.

Taste is a critical component of oral health that is affected adversely in patients with diabetes. One study reported that more than one-third of adults with diabetes had hypogeusia or diminished taste perception, which could result in hyperphagia and obesity. This sensory dysfunction can inhibit the ability to maintain a proper diet and can lead to poor glycemic regulation.

Neurosensory and visual disorders.

Patients with diabetes have reported increased complaints of glossodynia and/or stomatopyrosis. A common, yet poorly understood, orofacial neurosensory disorder, burning mouth syndrome, has been associated with diabetes mellitus. Patients may experience long-lasting oral dysesthesias, which could adversely affect oral hygiene maintenance. Peripheral neuropathies can impair the use of oral hygiene devices, and diabetic retinopathy can produce visual disturbances, ultimately leading to blindness, which, in turn, also could impair daily oral and prosthesis hygiene. Dysphagia, another sequelae of diabetes, is caused by altered strength, speed and/or coordination of the cranial nerve musculature.

Dental treatment considerations for the patient with diabetes.

Antibiotic coverage.

Patients with poorly controlled diabetes are at risk of developing oral complications because of their susceptibility to infection and sequelae, and likely will require supplemental antibiotic therapy. Anticipation of dentoalveolar surgery (involving mucosa and bone) with antibiotic coverage may help prevent impaired and delayed wound healing. Orofacial infections require close monitoring. Cultures should be performed for acute oral infections, antibiotic therapy initiated and surgical therapies contemplated if appropriate (for example, incision and drainage, extraction, pulpectomy). In cases of poor response to the first antibiotic administered, dentists can select a more effective antibiotic based on the patient’s sensitivity test results.

Adjustment of insulin or hypoglycemics.

Most forms of dental therapy should not interfere with the medical control of diabetes. However, dentoalveolar surgery, orofacial infections and the stress of dental procedures can increase serum glucose levels and metabolic insulin requirements. Therefore, dentists must consider modifying medical therapy in consultation with the patient’s physicians. For example, patients whose condition is controlled with insulin usually will require increased insulin dosages in the presence of an acute oral infection.
Medications used by dental professionals may require adjustment of diabetes-associated therapies. For example, large amounts of epinephrine can antagonize the effects of insulin and result in hyperglycemia. Small amounts of systemic corticosteroids can severely worsen glycemic control; patients taking oral hypoglycemic agents who are placed on steroid therapy may require short-term insulin therapy to maintain glycemic control. Alternatively, hypoglycemia can be promoted by aspirin, sulfa antibiotics and antidepressants.

Monitoring glycemic control.

Two critical steps are involved in treating patients with diabetes: establishing the diagnosis (type 1 or type 2 diabetes, and the form of therapy) and the level of disease control (well-controlled or poorly controlled). Most commonly, blood glucose or HbA1c levels will be available from the physician’s office. Medical updates must be recorded in the dental record at each visit to guide the clinician’s treatment decisions. The dentist should be able to use a glucometer to measure blood glucose levels rapidly from a patient’s fingertip. Finally, the dental office should be equipped with immediate sources of glucose in case a diabetic-induced hypoglycemic event occurs.
One study determined that the risk of infections was directly related to fasting blood glucose levels. Patients with levels below 206 mg/dL had no increased risk, whereas patients with fasting blood glucose levels above 230 mg/dL had an 80 percent increased risk of developing infection. Therefore, dentists must be familiar with the diabetic status of their patients, and make appropriate accommodations to prevent and treat effectively diabetes-associated oral and systemic disorders.

Communication with physicians.

Regular communication with physicians is a critical component of safely treating patients with diabetes. Communication must be bidirectional: physicians must be apprised of oral manifestations of the disease to help them regulate blood glucose levels, and dentists must be updated on glycemic control to help them maintain a patient’s oral health. Treating patients with diabetes also represents an opportunity to expand a dentist’s referral base. Physicians who treat children and adults with diabetes could be a good referral source of patients whose oral health care needs may not be satisfied adequately.

Treatment of oral complications of diabetes.

Dentists must be cognizant of the various methods of treating effectively the oral complications of diabetes mellitus. Many treatments are no different from those recommended for patients without diabetes. However, managing patients with diabetes does require more rigorous follow-up, more aggressive interventional therapy rather than observation, regular communication with physicians and greater attention to prevention. Patients with diabetes, particularly those with a history of poor glycemic control and oral infections, require more frequent recall visits and fastidious attention to acute oral infections.


Diabetes mellitus affects people of all ages, and its prevalence has been increasing. Providing safe and effective oral medical care for patients with diabetes requires an understanding of the disease and familiarity with its oral manifestations. The goal of therapy is to promote oral health in patients with diabetes, to help prevent and diagnose diabetes in dental patients receiving routine stomatological care and to enhance the quality of life for patients with this incurable disease.

The Journal of the American Dental Association (October 2003) 134, 4S-10S
doi: 10.14219/jada.archive.2003.0367

Monday, November 3, 2014

Xerostomia/ Dry Mouth

Dry Mouth - Xerostomia

What is Dry Mouth Xerostomia

Dry Mouth Syndrome or Xerostomia is a condition where the mouth becomes very dry, because of not having enough saliva to keep it wet. Xerostomia is a result of reduced saliva flow due to decreased secretion from salivary glands.
A dry mouth is a symptom of an underlying problem, rather than a disease in itself. About 10 per cent of the general population and 25 per cent of older people have dry mouth syndrome.

Waking Up with Dry Mouth • When it is a problem?

Waking up with dry mouth is usual, especially among the elderly. But if you have a dry mouth all or most of the time, it is not only uncomfortable due to difficulty in speaking and eating, but it can also lead to more serious health problems due to loss of the protective effects of saliva.
Temporary mouth dryness is not worrying. Most people have experienced the temporary sensation of xerostomia from time to time especially when they are nervous or anxious. Dry mouth becomes a problem when it becomes a chronic condition affecting the patient's normal mouth function.

Health risks caused by Xerostomia

  • Saliva helps chewing, swallowing and digesting food.
  • Saliva also protects teeth from tooth decay by diluting and washing away the food residuals, sugars and the acids produced by bacteria.
  • Reduced saliva flow results in lower (acidic) pH levels in the mouth, increasing the risk of tooth decay, gum disease and oral infections.
  • It can lead to dryness, a burning or sore feeling in the mouth or throat, bad or metallic or reduced taste, dentures becoming loose and causing sore areas, difficulty in chewing, swallowing and speaking.

Dry Mouth symptoms

The first symptoms of dry mouth usually appear when waking up at night or in the morning. Some common symptoms associated with cases of xerostomia are :
  • A sticky, dry feeling in your mouth and tongue
  • Cracked lips
  • Difficulty in chewing, swallowing, tasting, or talking.
  • Mouth sores
  • Frequent bad breath
  • Dentures that do not fit comfortably.
  • Sore throat.

Causes of Dry Mouth - Xerostomia

There are several reasons that might cause a consistent dry mouth problem.
  • Smoking is one of the top causes of dry mouth. Many heavy smokers experience dry mouth symptoms.
  • Dry mouth can be a side effect of prescription drugs and medicines, that reduces the flow of saliva. Studies show that up to 400 prescription and over-the-counter medications can contribute to symptoms of dry mouth. Drugs used to control high blood pressure, parkinson disease, anti-anxiety agents, anti-depressants, antihistamines, decongestants and pain killers are some of the drugs causing xerostomia.
  • Conditions that lead to dehydration, such as fever, excessive sweating, vomiting, diarrhea can cause temporary dry mouth.
  • Some systemic diseases and conditions that affect the salivary glands cause dry mouth syndrome. (diabetes, Hodgkin's, Parkinson's disease, HIV/AIDS and Sjogren's syndrome are usual causes of xerostomia symptoms)
  • Cancer treatment (Radiation therapy and chemotherapy) can damage the salivary glands reducing or even stopping the saliva flow.

Dry Mouth Remedies and Treatments

Depending on the causes of dry mouth, your health care provider can recommend the appropriate dry mouth treatment. Xerostomia could be caused as a symptom of a number of systemic diseases that you might not be aware of. If you are experiencing any dry mouth symptoms, visit your physician or dentist to determine what is causing the condition and recommend the proper xerostomia remedy.

Natural Dry Mouth Remedies

If there is no permanent organic problem that causes the dry mouth, you could try first the following dry mouth home remedies that can provide a natural cure to the problem:
  • Drinking plenty of fluids to avoid dehydration, is the simplest dry mouth remedy that helps to ease xerostomia problems.
  • Avoid drinks with caffeine, such as coffee, tea and some sodas, which can cause the mouth to dry out.
  • Don't use tobacco or alcohol, which dry out the mouth
  • Some people find that chewing sugarless chewing gum stimulates saliva flow.
  • Use of a humidifier in the bedroom reduces nighttime oral dryness and helps in not waking up with dry mouth.
  • Some herbs and herbal preparations are recommended as a dry mouth remedy. Chinese green tea, chamomile and ginger are known to be particularly effective. Herbal blends are available from alternative medicine suppliers.
  • If your dry mouth is the result of medication, your doctor might change your prescription or dosage. Talk to your doctor, if you have dry mouth symptoms, about possibly changing the drugs causing xerostomia with others with less side-effects.

Over the Counter Dry Mouth Treatments

If the natural dry mouth remedies do not ease the xerostomia symptoms, you could try other treatments including some over the counter products :
  • Moisturizing gels and toothpastes are widely used as a dry mouth remedy to provide a temporary relief.
  • Rinsing with mouthwashes specially formulated to help dry mouth may also help. Avoid mouth rinses or mouthwashes that contain alcohol or peroxide, as these ingredients will further dry out your mouth.

Medical Dry Mouth Treatments

If there is a permanent damage of the salivary glands and the causes of dry mouth cannot be eliminated, the above treatments may not help enough. In this case :
  • If your salivary glands are not working properly but still produce some saliva, your doctor might give you a prescription medicine that helps the glands work better.
  • Doctors can prescribe mouth moisturizers, such as artificial saliva substitute which comes as a spray to help moisten the mouth and relieve dry mouth symptoms. There are many saliva substitutes on the market, generally available through pharmacy outlets, which are highly effective in reducing the unpleasant side effects of reduced flow of saliva.

Dry Mouth and Tooth Decay

Saliva is important for the protection of your teeth against tooth decay, regulating the mouth's pH value and diluting the acids produced by the dental plaque bacteria. Patients suffering from xerostomia are in greater risk of tooth decay.
In some severe cases of xerostomia, when the patient's teeth are very susceptible to decay, dentists suggest the use of dental sealants in order to prevent tooth decay, along with using dry mouth remedies. Dry mouth can cause extensive tooth decay (even in a person with a healthy mouth for years), and it contributes to many other oral health problems.
If you keep waking up with dry mouth or experience xerostomia symptoms too often during the day, take extra care with your daily oral hygiene to reduce the risk of cavities and periodontal disease. Seek the advice of a dentist on dry mouth remedies as soon as persistent dry mouth symptoms appear.

Saturday, October 11, 2014

Natural Remedies to Freshen Breath (Halitosis)

Freshen Up Your Breath with Simple Natural Remedies   

Bad breath often known as Halitosis can put people off causing social embarrassment. To add on to their woes, most advertisements promoting toothpastes, mouthwash and breath fresheners, project these sufferers in an unpleasant light. Why does this arise making millions of people across the globe going red in the face? Let us find out …

Causes for Bad Breath
The medical term for bad breath is known as Halitosis.  Although there are many causes, some types of bad breath are considered quite normal, while a few others denote an underlying medical condition.
Dental Hygiene
Dental Hygiene
Dental Hygiene (Image source:
Persistent bad breath may be due to poor dental hygiene.  The nearly invisible film of colourless bacteria that is constantly forming in your mouth, known as plaque build-up is often responsible.  With improper brushing, plaque can irritate your gums (gingivitis) and eventually form plaque-filled pockets between your teeth and gums causing periodontitis.  Regular flossing and brushing of teeth can prevent food particles from accumulating in your mouth, thus protecting against bad breath.  The uneven surface of the tongue also can trap germs that produce odours.  Moreover, unclean dentures or those that do not fit properly can embrace odour-causing bacteria and food particles.
Dry Mouth
Dry mouth known as xerostomia is onе оf thе mаin саuѕеѕ of bad breath.  Saliva is responsible for cleansing the mouth and eliminating particles that may cause odour.  Nevertheless, with a drop in saliva production, a condition occurs naturally during sleep called dry mouth.  This leads to oxygen inactivity making the mouth and tongue a haven for bacteria.
SmokingSmoking and oral tobacco may contribute to bad breath due to accumulation of nicotine, tar and other substances in the mouth that increases the risk of developing gum disease. (Read more bad effects of smoking)
Certain medications ѕuсh аѕ antihistamines, asthma / bronchitis inhalers may cause dry mouth resulting in bad breath.
Mouth Infections
Oral surgery such as tooth removal may cause surgical wounds leading to foul odour in the mouth.  Tooth decay, gum disease, or mouth sores are some of the other factors.
Odorous Foods
Odorous foods
The breakdown of certain foods with strong odours such as onions, and garlic, are carried through the bloodstream and exhaled by the lungs causing foul odour.
Skipping Meals
Fasting and not eating breakfast causes bad breath.
Other conditions
Chronic inflammation in the nose, throat or sinuses contribute to postnasal drip, produced bу thе sinuses due to excessive mucus, as a common allergic reaction. Nevertheless, mucus iѕ thе perfect breeding ground fоr bacterial growth, which feeds off thiѕ condition resulting in bad breath and a bad taste in уоur mouth.
Tiny stones covered with bacteria formed in the tonsils produce odorous chemicals producing bad breath
Diseases, such as some cancers, tuberculosis, or syphillis and conditions such as metabolic disorders, can cause a distinctive breath odour because of the chemicals they produce
Other diseases that can cause halitosis are respiratory tract infections, diabetes, liver disease, gastrointestinal and renal dysfunction
Prevention and Cure
However, one can defeat the smelly bacteria in your mouth by following a few simple and amazing home remedies that can be implemented in the comfort of your home straight from the cupboards…here are some of the best and effective time tested remedies for you.
Natural Home Remedies
Brush Your Tongue
Tongue ScraperAll of us ensure regular brushing of teeth while completely ignoring the tongue.  Tiny hair like projections covering the tongue, give the impression of a mushroom forest, under a microscope. The caps under the mushrooms are safe places for forming plaque as the food we eat are accumulated there causing a foul odour.  Hence, gently sweeping the top of your tongue, while brushing, helps food and bacteria from accumulating beneath the caps.

Baking Soda
Baking soda makes an excellent remedy for bad breath as it cleans the teeth by changing the pH balance in your mouth.  This discourages growth of bacteria that cause bad breath.  For fresh breath, sprinkle some baking soda into your palm, dip a damp toothbrush into the baking soda, and brush.
Another option is to use a toothpaste containing baking soda.
Gargling your mouth with baking soda dissolved in warm water, apart from cleaning your teeth will also help keep your tongue clean sans bacteria.
Another great way to fight the germs causing bad breath is by way of gargling your mouth with 1 tablespoon of baking soda mixed with a cup of hydrogen peroxide in a ratio of 2%-3%.
Make a paste using three parts baking soda to one part salt, and just a few drops of warm water blend and apply to tongue with tongue brush and brush to scrape away debris; also apply paste to toothbrush and brush gums and teeth; then add warm water to the remaining paste and swirl around mouth rinsing.  However, make sure to floss teeth earlier.
Hydrogen Peroxide
Rinsing your mouth with hydrogen peroxide before brushing is a good cure for bad breath.
Tea-Tree Oil
Using toothpaste containing tea-tree oil, a natural disinfectant or adding the oil to the toothpaste can be an effective cure
You can also prepare a mouthwash with tea tree oil by adding 3 drops to a cup of warm water.  Gargle this solution for two to three times daily, if possible after each meal.
Apple Cider Vinegar
Rinsing your mouth with a glass of water mixed with half tablespoon of Apple cider vinegar works magic and eliminates bad breath.
Eating yogurt rich in acidophilus for 6 weeks will help balance theе good аnd bad bacteria in thе intestines thuѕ eradicating halitosis completely.  Including yoghurt in your daily diet is very essential as it not only helps the intestines but also promotes overall health.
Vitamins/ Zinc
Taking vitamin E, vitamin C and zinc hеlр kеер oral germs at bay.
Olive oil
Consumption of unheated extra virgin olive oil helps against bad breath
Eating lеѕѕ meat аnd lots оf fresh fruits аnd vegetables laden with fibre, hеlр fight halitosis effectively. If уоu wаnt tо cure уоur disgusting breath condition, snack оn fresh raw vegetables аnd fruits ѕuсh аѕ celery, carrot, apple аnd pear.
Fruit and vegetable juices too are helpful in treating Halitosis or bad breath and hence, should be consumed generously.  Juices extracted from green vegetables are particularly valuable.
Citrus Fruits
Dry mouth often causes bad breath.  Therefore eating citrus fruits abundant in Citric acid, stimulates the saliva, restraining mouth bacteria, that is responsible for causing bad breath.
Rinse with a glass of water and the juice of half a lemon after each meal in order to prevent recurrence of bad breath.
Yоu саn mix оnе teaspoon оf lemon аnd ginger juice intо a glass оf water аnd simply gargle.
Drinking lemon will refresh your breath.
Pomegranate саn treat bad breath.  For this dry pomegranate peel in the sun and mixed with boiling water may be used as a rinse when cold.
To use pomegranate as a drink, dry pomegranate peel in the shade (not sun).  Tаkе thе dried peel mix it in a food processor to powder.  Then, add аbоut thrее grams intо a glass оf hot оr cold water along with Lemon аnd ginger for consumption. (Also read pomegranate health benefits)
Avocados work by removing intestinal decomposition, which is a known factor for bad breath.  Therefore, they make excellent mouth freshener.
Unripe guava, abundant in tannic, malic, oxalic, and phosphoric acids as well as calcium, oxalate, and manganese is useful.  Chewing the unripe fruit, makes a great tonic for the teeth and gums as it aids bleeding gums and impedes bad breath.  Chewing tender leaves of guava tree also end bleeding gums and bad odour emanating from your breath.
Herbs can be used as breath freshener. Chewing on a small stem of fresh spearmint, rosemary and tarragon for up to a minute can help alleviate bad breath.
Loaded with Chlorophylls, containing mild antiseptic properties, Parsley helps counteract bad breath.  Chewing or swallowing few sprigs of parsley, apart from improving digestion will help reduce intestinal gas.  Making a decoction of coarsely chopped parsley with two cups of boiling water, along with two or three whole cloves or a quarter teaspoon of ground cloves, strained and consumed when cool makes an amazing mouthwash.
mint leaves
Mint leaves (Image credit: beresah /
Chewing on mint leaves or gum can stop bad breath avoiding any kind of embarrassment.  Mixing a few sprigs of mint added to half a litre of boiling water and left for an hour to cool if gargled works well.
Basil Leaves
Every morning chew five leaves of Basil and drink water for a cure.
Gargle your mouth with a spoonful of ginger juice mixed in a glass of hot water.
A mixture made with Lemon ginger аnd warm water for rinsing your mouth twice a day also helps.
Sunflower Seeds
Chew some sunflower seeds and drink a glass of water after meals to get rid of Halitosis.
Fenugreek Seeds
Fenugreek seedsA tea prepared from Fenugreek seeds helps combat bad odour. This is prepared by adding one teaspoon of fenugreek seeds to half a litre of coldwater and cooking for fifteen minutes on low heat. This tea strained and consumed as a beverage is a natural cure for bad breath.
Cardamom Seeds
The aromatic flavour of cardamom seeds act as a natural breath freshener and is sure a great remedy for bad breath.
ClovesCloves are rich in potent antibacterial substance, eugenol.  Therefore  propelling one into your mouth and biting it will filter the essence through your mouth. Spit it out after a few minutes. However, using powdered cloves or clove oil may burn though.
Cinnamon Stick
Like cloves, cinnamon too contains antiseptic properties.  Hence sucking a cinnamon stick can prove beneficial.
Certain beverages as wine whiskey beer and coffee leave a residue that can attach to the plaque in your mouth and permeate your digestive system. Therefore, each breath you take reeks of bad odour.
Drink Black/Green Tea
Since black and green teas contain powerful polyphenols antioxidants that attack bacterial growth in your mouth, substitute coffee with black or green tea for your morning cuppa for refreshment.
Water has a cleansing effect therefore drinking plenty of water can prevent bad breath and help flush out germs from your mouth.  Keep a glass of water by your bedside at night and drink plenty before you go and wake up from bed for better results.
Sugarless Gum
Chewing on sugarless gum keeps the mouth moist and enables easy flow of saliva. This prevents dry mouth and subsequently the bad odour associated with it.
Skipping meals can become a haven for breeding bacteria as the mouth starts drying without food.
Stress can contribute to innumerable problems with dry mouth being no exception. Dry mouth brings about bad odour and stress aggravates the production of volatile sulphur compounds in the mouth smelling bad.
  • Cigarettes
  • alcohol,
  • onions, garlic
  • strong cheeses like Camembert, Roquefort, and blue cheese
  • Refined carbohydrates like white sugar, white bread and products prepared with them
  • Meat and eggs
  • Some fishes like anchovies and seaweed are high in ‘fishy’ amine odours
  • Never wear dentures, to sleep.  Clean them and leave until morning
  • certain medications that cause bad breath
  • skipping meals
  • dry mouth
  • Alcohol based mouthwashes
  • Article from read and digest  written by Reeta