I have diabetes. How does it affect my gums, and what should I ask my dental team and my physician?

How diabetes and gum disease affect each other

Gum disease begins when plaque bacteria along the gum line trigger inflammation. In its early, reversible form (gingivitis) the gums redden, swell and bleed. If the inflammation persists, it can advance to periodontitis, in which the gum pulls away from the tooth, pockets form, and the bone that holds the tooth is gradually lost. The difference between the two stages is explained in Gingivitis versus periodontitis: why the difference changes your care.

Diabetes changes this picture in two directions:

• Diabetes raises the risk of gum disease. High blood sugar can reduce the body's ability to fight the bacteria that cause gum infection, so people with diabetes are more likely to develop gum disease and, when blood sugar is poorly controlled, more likely to have severe disease.
• Gum disease can make diabetes harder to manage. Periodontitis is a long-standing infection, and a persistent infection like this can push blood sugar up. People with gum disease may find their blood sugar harder to control, which is why your physician should know about your gum status.

Neither direction is a guarantee. Many people with diabetes keep healthy gums, and other factors, especially smoking, also raise the risk of gum disease. The point is that the two conditions are usually managed together, not separately.

What your dental team needs to know

A dental medical history is not paperwork for its own sake; it changes what is looked for and how care is timed. For a patient with diabetes, the useful details are:

• Which type of diabetes you have and roughly how long you have had it.
• How it is managed, meaning diet alone, pills, injections or a combination. Bring a current medication list; the office does not need you to recite doses from memory, and this guide gives none.
• How well controlled it has been recently, as your physician reported it at your last visit. If you track blood sugar at home, say so.
• All other medications and conditions, including blood pressure, heart or kidney conditions and anything for cholesterol or mood. Many medications reduce saliva, and dry mouth matters for your gums and teeth. Why your dentist asks about medications before looking at your teeth explains why the list is so useful.
• Whether you have episodes of low blood sugar, how you usually notice them and what you do about them. The team can plan around this, and you can keep your usual glucose source with you.
• Your physician's name and contact details, so the office can share findings or ask a question with your permission.

Update the history at every visit, because diabetes management changes over time.

What the exam looks for when you have diabetes

The gum exam itself is the same careful exam everyone should receive, but the dental team pays particular attention to the problems that diabetes makes more likely:

• Bleeding and swelling of the gums, the earliest signs of inflammation. Gum disease usually does not hurt, so bleeding you notice when you clean between your teeth is worth mentioning rather than waiting out; see Can gum disease develop without pain?.
• Pocket depths, measured with a small probe around each tooth. Deeper pockets mean the gum has detached from the tooth. What the gum pocket numbers mean at your dental exam explains the numbers you may hear.
• Bone levels on X-rays, which show whether periodontitis has reached the supporting bone and whether it is changing between visits.
• Dry mouth, whether from diabetes itself or from medications. Less saliva means less natural rinsing and buffering, which raises the risk of decay and gum problems and can make the mouth sore.
• Fungal infection (thrush), white or red patches that are more common when blood sugar is high, when the mouth is dry or when dentures are worn.
• Slow healing or recurring sores, including around extraction sites or under a denture.
• Abscesses or loose teeth, which can signal advanced disease.

How diabetes figures into the diagnosis

Dentists and periodontists classify periodontitis by stage (how much damage has occurred) and grade (how quickly it appears to be progressing and how likely it is to progress). In the classification agreed at the 2017 World Workshop and published in 2018, diabetes and its level of control are treated, like smoking, as factors that can raise the grade. In plain terms, the same amount of bone loss may be judged as a higher-risk situation in a patient with diabetes, which can lead to closer monitoring. Ask your dentist what stage and grade were recorded and what each means for you.

What may change in your care plan

Maintenance intervals

There is no single correct interval between cleanings. Your dental team usually sets it from your risk: the depth of your pockets, how much bone has been lost, how well you can clean at home, whether you smoke, and how stable your diabetes is. Patients with diabetes and a history of periodontitis may be advised to come in more often than twice a year, and the interval can be lengthened again if the gums stay stable.

Appointment timing

Longer appointments, such as a deep cleaning, can affect when you eat and how your medication fits around the visit. Rather than following a general rule, ask the office what it advises patients with diabetes before an appointment, and ask your physician whether any adjustment is needed on treatment days. Keep your glucose source with you and tell the team at once if you feel the way you usually feel when your blood sugar drops.

Healing after treatment

Scaling and root planing, the deep cleaning that removes bacteria and hardened deposits from below the gum line, is the usual first treatment for periodontitis, and gum surgery may be discussed when deep pockets persist. Because high blood sugar is associated with slower healing and more infections, your dentist may want to know that your control is stable before elective surgery, may space treatment differently, and will usually schedule a re-evaluation to check how the tissues have responded.

Gum treatment and blood sugar: what the evidence does and does not say

The sources cited for this guide describe an association: when periodontitis is treated, measures of long-term blood-sugar control tend to improve modestly in the months afterward. This is a reason to take gum treatment seriously, and a reason for your physician to know about it. It is not a treatment for diabetes, and it does not replace medication, diet, exercise or your physician's plan. Any change to your diabetes management belongs with your physician.

Signs that deserve a sooner visit

Call the dental office sooner than your scheduled visit if you notice gums that bleed easily or have changed color, persistent bad taste or breath, a tooth that feels loose or has shifted, gums that are pulling away from teeth, a sore that has not healed within about two weeks, white patches in the mouth, or pain or swelling of the gum around a tooth.

Some situations are medical emergencies, not dental appointments. If facial or neck swelling is spreading quickly, if there is swelling with fever, if you have any difficulty breathing or swallowing, or if there is uncontrolled bleeding or severe injury, call 911 or go to the nearest emergency department rather than using an appointment request form. Tell the emergency staff that you have diabetes and which medications you take.

Questions for your physician

• Does my gum status or planned dental treatment change anything in my diabetes plan?
• Is my control stable enough right now for elective dental surgery, or should it wait?
• Should I change anything about meals or medication on the day of a longer dental appointment?
• May the dental office contact you, and will you share my recent control with them?
• Do any of my medications cause dry mouth, and are there alternatives worth discussing?

Questions for your dental team

• Do I have gingivitis or periodontitis, and what stage and grade were recorded?
• Which of my findings, if any, could be related to my diabetes?
• How often should I come in, and what would allow the interval to be lengthened?
• What do you advise patients with diabetes before an appointment?
• How should I clean between my teeth given my gum pockets, and would a different brush or an interdental tool help?
• Do I have signs of dry mouth or thrush, and what do you recommend?
• What should prompt me to call before my next scheduled visit?
• Will you send your findings to my physician, and what do you need from me to do that?

If implants are part of your future planning, Dental implants and diabetes: which health details affect planning? covers the extra questions that apply.

The next step

Fill in the worksheet below before your next medical and dental appointments, and bring the same sheet to both. If you have diabetes and have not had a gum assessment recently, you can request an appointment online (a request is not a confirmed appointment; the team follows up) or call the office during hours. Mention your diabetes when you book so the medical history can be reviewed at the visit.