Diabetes and tooth loss

Diabetic Retinopathy and Macular Edema: Treatment

Conditions

By Marilyn Haddrill

Each year, millions of Americans face vision loss related to diabetes.

In fact, according to recent data from the U.S. Centers for Disease Control and Prevention (CDC), nearly 26 million Americans — roughly 8.3% of the U.S. population — have diabetes, and more than 28% of diabetics age 40 or older in the U.S. have diabetic retinopathy (DR) and related diabetic eye disease.

To make matters worse, a significant number of cases of diabetes and diabetic eye disease go undetected or untreated because people fail to have routine eye exams as recommended by their optometrist or ophthalmologist.

If you have diabetes, you should see an eye doctor near you at least annually to prevent vision loss.

Most laser and non-laser treatments for diabetic eye disease depend on the severity of the eye changes and type of vision problems you have.

Diabetic retinopathy is diabetes-related damage to the light-sensitive retina in the back of the eye. As diabetes progresses, chronic high blood sugar levels cause changes that damage the tiny blood vessels in the retina. This causes these blood vessels to leak fluid or hemorrhage (bleed). Eventually, this leads to vision problems that cannot be corrected with eyeglasses or contact lenses.

If you have a diabetic vitreous hemorrhage, you may require a vitrectomy to remove the clear, gel-like substance in your eye’s interior.

Diabetic retinopathy is associated with a protein called vascular endothelial growth factor (VEGF) in the retina. VEGF stimulates the production of new blood vessels in the retina to bring more oxygen to the tissue because retinal blood circulation is inadequate due to diabetes.

Unfortunately, these tiny new blood vessels that form in the retina in response to VEGF are fragile and increase in number, leading to additional fluid leakage, bleeding and scarring in the retina that causes progressive vision loss.

Blood vessel leakage from diabetic retinopathy can cause fluid to accumulate in the macula, which is the most sensitive part of the retina that is responsible for central vision and color vision.

This condition — called diabetic macular edema — is the primary cause of vision loss associated with diabetic retinopathy. Diabetic macular edema (DME) is the leading cause of new cases of blindness in adults ages 20 to 74 in the United States, according to CDC.

Diabetic retinopathy treatment: Lasers

Laser treatment of diabetic eye disease generally targets leaking blood vessels or damaged tissue in the retina.

Some lasers treat leaking blood vessels directly by “spot welding” and sealing the area of leakage. This process is called

. Other lasers eliminate abnormal blood vessels that form from neovascularization.

Lasers also may be used to intentionally destroy tissue in the periphery of the retina that is not required for functional vision. This is done to improve blood supply to the more essential central portion of the retina to maintain eyesight.

Also, the peripheral retina is thought to be involved in formation of VEGF responsible for abnormal blood vessel formation. When cells in the peripheral retina are destroyed by photocoagulation (see below), the amount of VEGF is reduced, along with the potential to produce abnormal retinal blood vessels.

After laser treatment of the peripheral retina, some blood flow bypasses this region and instead provides extra nourishment to the central portion of the retina. The resulting boost of nutrients and oxygen to the central retina helps maintain the health of cells in the

that are essential for detailed vision and color perception. However, some peripheral vision could be lost due to this treatment.

The two types of laser treatments commonly used to treat significant diabetic eye disease are:

  • Focal or grid laser photocoagulation. This type of laser energy is aimed directly at the affected area or applied in a contained, grid-like pattern to destroy damaged eye tissue and clear away scars that contribute to blind spots and vision loss. This method of laser treatment generally targets specific, individual blood vessels.
  • Scatter (pan-retinal) laser photocoagulation. With this method, about 1,200 to 1,800 tiny spots of laser energy are applied to the periphery of the retina, leaving the central area untouched.

Treatment of clinically significant DME also entails using

to provide images of the eye’s interior. These images accurately guide application of laser energy, which helps “dry up” the localized swelling in the macula. A fluorescein angiogram also can identify the location of blood vessel leakage caused by proliferative diabetic retinopathy.

While laser treatment for diabetic retinopathy usually does not improve vision, the therapy is designed to prevent further vision loss. Even people with 20/20 vision who meet treatment guidelines should be considered for laser therapy to prevent eventual vision loss related to diabetes.

What to expect before, during and after laser treatment

Laser treatment for diabetic retinopathy typically requires no overnight hospital stay, so you will be treated on an outpatient basis in a clinic or in the an doctor’s office.

Make sure you have someone drive you to and from the office or clinic on the day you have the procedure. Also, you’ll need to wear sunglasses afterward because your eyes will be temporarily dilated and light sensitive.

Before the procedure, you will receive a topical anesthetic or possibly an injection adjacent to the eye to numb it and prevent it from moving during the laser treatment.

Your eye doctor will make these types of adjustments to the laser beam before it is aimed into the eye:

  • The amount of energy used
  • The size of the “spot” or end of the beam that is directed into the eye
  • The pattern applied by the laser beam onto the targeted area

A laser treatment typically lasts at least several minutes, but more time may be required depending on the extent of your eye condition.

During laser treatment, you might experience some discomfort, but you should feel no pain. Right after a treatment, you should be able to resume normal activities. You might have some discomfort and blurry vision for a day or two after each laser treatment.

The number of treatments you need will depend on your eye condition and extent of damage. People with clinically significant diabetic macular edema may require three to four different laser sessions at two- to four-month intervals to stop the macular swelling.

Though the specific mechanism by which laser photocoagulation reduces diabetic macular edema is not fully understood, a landmark study called the Early Treatment Diabetic Retinopathy Study (ETDRS) showed that focal (direct/grid) photocoagulation reduces moderate vision loss caused by DME by 50 percent or more.

If you have proliferative diabetic retinopathy (PDR) — meaning that leakage of fluid has begun in the retina — the laser treatment should take from 30 to 45 minutes per session, and you may require up to three or four sessions.

Your chance of preserving your remaining vision when you have PDR improves if you receive scatter laser photocoagulation as soon as possible following diagnosis.

Early treatment of PDR particularly is effective when macular edema also is present.

Macular Edema Treament, Non-laser

Injection of corticosteroids or other medications into the eye — either directly or in the form of an injectable implant — often is recommended over laser procedures for the treatment of diabetic macular edema. In some cases, a combination of drug injections and laser treatment may be recommended.

In this video, an eye doctor explains diabetic eye disease. (Video: National Eye Institute)

In this video, Rep. James Clyburn asks African-American diabetics to get annual eye exams.

As diabetic retinopathy worsens, in addition to VEGF, other small “signal” proteins (cytokines) are released by cells, causing additional inflammation in the retina that can cause or worsen DME.

Corticosteroids have been shown to have a beneficial effect by decreasing the amount of VEGF and other inflammatory cytokines produced by cells (a process called “down-regulation”), which can lead to a reduction of diabetes-related macular edema.

Though the following medications reduce levels of several proteins associated with inflammation, they are generally classified as “anti-VEGF” medicines.

Anti-VEGF drugs or drug-releasing implants that are FDA-approved for injection into the eye for treatment of DME in the United States include:

  • Iluvien (Alimera Sciences)
  • Ozurdex (Allergan)
  • Lucentis (Genentech)
  • Eylea (Regeneron)

Iluvien is a tiny implant that delivers a sustained, slow release of a corticosteroid (fluocinolone acetonide) to treat diabetic macular edema. It is prescribed for patients who previously have been treated with corticosteroids and did not have a clinically significant rise in intraocular pressure (a potential side effect of corticosteroid use).

In clinical trials required for FDA approval, patients receiving the Iluvien implant demonstrated a statistically significant improvement in visual acuity within three weeks of the procedure, compared with a control group; and at 24 months after the procedure, 28.7 percent of patients showed an improvement in visual acuity of 15 letters or more on a standardized eye compared to baseline (prior to undergoing the procedure).

According to Alimera Sciences, a significant advantage of Iluvien over other treatments for DME is the longevity of its effect. Iluvien is designed to provide a sustained release of corticosteroid medication for 36 months (three years), compared with other treatments that last only a month or two.

Ozurdex, another FDA-approved implant for DME treatment, releases a sustained dose of dexamethasone (a corticosteroid) to the retina. The Ozurdex implant also is FDA-approved for treatment of posterior uveitis and for macular edema following branch retinal vein occlusion (BRVO) or central retinal vein occlusion (CRVO) — two types of eye strokes.

Lucentis (ranibizumab), marketed by Genentech, is FDA-approved for both the treatment of diabetic macular edema and treatment of diabetic retinopathy with or without DME).

Clinical trials of Lucentis have shown that up to 42.5% of patients who were given monthly eye injections of the drug gained at least 15 letters in best corrected visual acuity (BCVA) on a standard eye chart two years after initiation of the treatment, compared with 15.2% of patients in a control group.

Research also has shown that Lucentis injections and Lucentis injections combined with laser photocoagulation both were significantly more effective than laser treatment alone for the treatment of DME.

Eylea (aflibercept) is another anti-VEGF drug that is FDA-approved for the treatment of DME. It is also approved for treatment of advanced age-related macular degeneration (AMD) and macular edema following retinal vein occlusion.

Data from two studies of 862 patients revealed that eye injections of Eylea administered monthly or every two months (after five initial monthly injections) were more significantly more effective for treatment of diabetic macular edema than laser treatment. Also, patients who received Eylea treatments gained, on average, the ability to read approximately two additional lines on an eye chart, compared with almost no change in visual acuity among patients in a control group.

Retisert (Bausch + Lomb) is another intraocular implant that delivers long-term, sustained release of a corticosteroid (fluocinolone acetonide) and is used for the treatment of DME.

Retisert is designed to deliver corticosteroid therapy inside the eye for up to 2.5 years, according to Bausch + Lomb. The device is implanted into the eye through a surgical incision in the sclera.

Risks associated with intraocular steroid treatment for DME include steroid-induced cataracts and glaucoma. Vision loss from cataracts usually can be restored with cataract surgery. To reduce the risk of glaucoma, your eye doctor might recommend preventive use of glaucoma eye drops or even glaucoma surgery.

Diabetic Retinopathy, Other Treatments

In some people who have proliferative diabetic retinopathy, bleeding into the

(vitreous hemorrhage) makes laser photocoagulation treatment impossible because the blood obscures the surgeon’s view of the retina.

If the vitreous hemorrhage fails to clear within a few weeks or months, a vitrectomy surgery may be performed to mechanically remove the hemorrhage — after which, laser photocoagulation can be applied. The laser procedure is performed either at the time of the vitrectomy or shortly thereafter.

Retinal bleeding and vitreous hemorrhage also can cause bands of scar tissue to form. These bands of scar tissue can shrink and — if attached to the retina — can cause the retina to pull away from its base to create traction. This traction may lead to retinal tears or possible retinal detachments.

If you experience a tractional detached retina as part of PDR and shrinking scar tissue that tugs at the retina, you usually will be scheduled promptly for a procedure to reattach the retina.

Eye Drops for Diabetic Retinopathy Treatment

Some individuals with diabetic macular edema may experience reduced symptoms and improved vision after treatment with corticosteroid medication delivered to the eye via eye drops rather than an intraocular implant.

Research has shown that patients with diffuse DME who used Durezol corticosteroid eye drops (Alcon) four times a day for one month had reduced retinal swelling and a significant improvement in visual acuity, compared with similar DME patients who did not use the eye drops.

Visit An Eye Doctor

Remember: If you have diabetes (or are at risk of diabetes), see an eye doctor near you for an annual comprehensive eye exam, and follow your doctor’s recommendations for follow-up care. Your vision depends on it!

Page updated July 2019

Schedule an exam.

Find an eye doctor near you. Notes and References

FDA approves Genentech’s Lucentis (ranibizumab injection) for diabetic retinopathy, the leading cause of blindness among working age adults in the United States. Press release issued by Genentech in April 2017. Alimera Sciences provides details on FDA approval of Iluvien as the first long-term treatment for diabetic macular edema. Press release issued by Alimera Sciences in September 2014. Allergan announces FDA approves revised indication for Ozurdex (dexamethasone intravitreal implant) 0.7 mg for the treatment of diabetic macular edema. Press release issued by Allergan in September 2014. Allergan receives FDA approval for Ozurdex (dexamethasone intravitreal implant) 0.7 mg as treatment option for use in certain patients with diabetic macular edema. Press release issued by Allergan in June 2014. Treatment of diffuse diabetic macular oedema using steroid eye drops. Acta Ophthalmologica. November 2012. FDA approves Lucentis to treat diabetic macular edema. FDA press release issued in August 2012. Dexamethasone drug delivery system (Ozurdex) for the treatment of refractory diabetic macular oedema: retrospective case series analysis. Acta Ophthalmologica. Published online ahead of print in August 2012. Ranibizumab for diabetic macular edema: results from 2 phase III randomized trials: RISE and RIDE. Ophthalmology. April 2012. Long-term safety, high-resolution imaging, and tissue temperature modeling of subvisible diode micropulse photocoagulation for retinovascular macular edema. Retina. Published online ahead of print, November 2011. The RESTORE study: ranibizumab monotherapy or combined with laser versus laser monotherapy for diabetic macular edema. Ophthalmology. April 2011. National Diabetes Fact Sheet: National estimates and general information on diabetes and prediabetes in the United States, 2011. U.S. Department of Health and Human Services, Centers for Disease Control and Prevention. 2011. Effects of intensive glucose lowering in type 2 diabetes. New England Journal of Medicine. July 2010. Diabetic retinopathy. Cleveland Clinic: Current Clinical Medicine, 2nd ed. 2010. Serous detachment of the neural retina. Ophthalmology, 3rd ed. 2008. Comparison of the Modified Early Treatment Diabetic Retinopathy Study and mild macular grid laser photocoagulation strategies for diabetic macular edema. Archives of Ophthalmology. April 2007.

What to know about diabetic retinopathy

Treating DR depends on several factors, including the severity and type of DR, and how the person with DR has responded to previous treatments.

With NPDR, a doctor may decide to monitor the person’s eyes closely without intervening. This is known as watchful waiting.

Individuals will need to work with their doctor to control diabetes. Good blood sugar control can significantly slow the development of DR.

In most cases of PDR, the patient will require immediate surgical treatment. The following options are available:

Focal laser treatment, or photocoagulation

The procedure is carried out in a doctor’s office or an eye clinic. Targeted laser burns seal the leaks from abnormal blood vessels. Photocoagulation can either stop or slow down the leakage of blood and buildup of fluid in the eye.

People will usually experience blurry vision for 24 hours following focal laser treatment. Small spots may appear in the visual field for a few weeks after the procedure.

Scatter laser treatment, or pan-retinal photocoagulation

Scattered laser burns are applied to the areas of the retina away from the macula, normally over the course of two or three sessions. The macula is the area at the center of the retina in which vision is strongest.

The laser burns cause abnormal new blood vessels to shrink and scar. Most patients require two or three sessions for the best results.

Individuals may have blurry vision for 24 hours following the procedure, and there may be some loss of night vision or peripheral vision.

Vitrectomy

This involves the removal some of the vitreous from within the eyeball. The surgeon replaces the clouded gel with a clear liquid or gas. The body will eventually absorb the gas or liquid. This will create new vitreous to replace the clouded gel that has been removed.

Any blood in the vitreous and scar tissue that may be pulling on the retina is removed. This procedure is performed in a hospital under general or local anesthetic.

The retina may also be strengthened and held in position with tiny clamps.

After surgery, the patient may have to wear an eye patch to gradually regain use of their eye, which can tire after a vitrectomy.

If gas was used to replace the removed gel, the patient should not travel by plane until all gas has been absorbed into the body. The surgeon will tell the patient how long this should take. Most patients will have blurry vision for a few weeks after surgery. It can take several months for normal vision to return.

Surgery is not a cure for diabetic retinopathy. However, it may stop or slow the progression of symptoms. Diabetes is a long-term condition, and subsequent retinal damage and vision loss may still occur despite treatment.

Prevention

For the majority of people with diabetes, DR is an inevitable consequence.

However, patients with diabetes who successfully manage their blood sugar levels will help to prevent the onset of a severe form of DR.

High blood pressure, or hypertension, is another contributing factor. Patients with diabetes need to control their blood pressure by:

  • eating a healthy and balanced diet
  • regularly exercising
  • maintaining a healthy body weight
  • smoking cessation
  • strictly controlling alcohol intake
  • taking any antihypertensive measures according to their doctor’s instructions
  • attending regular screenings

Early detection of symptoms increases the effectiveness of the treatment.

Written by Christian Nordqvist

Diabetic retinopathy

Diabetic retinopathy is a condition that may occur in people who have diabetes. It causes progressive damage to the retina, the light-sensitive lining at the back of the eye. Diabetic retinopathy is a serious sight-threatening complication of diabetes.
Diabetes interferes with the body’s ability to use and store sugar (glucose). The disease is characterized by too much sugar in the blood, which can cause damage throughout the body, including the eyes.
Over time, diabetes damages small blood vessels throughout the body, including the retina. Diabetic retinopathy occurs when these tiny blood vessels leak blood and other fluids. This causes the retinal tissue to swell, resulting in cloudy or blurred vision. The condition usually affects both eyes. The longer a person has diabetes, the more likely they will develop diabetic retinopathy. If left untreated, diabetic retinopathy can cause blindness.

Symptoms of diabetic retinopathy include:

  • Seeing spots or floaters
  • Blurred vision
  • Having a dark or empty spot in the center of your vision
  • Difficulty seeing well at night

When people with diabetes experience long periods of high blood sugar, fluid can accumulate in the lens inside the eye that controls focusing. This changes the curvature of the lens, leading to changes in vision. However, once blood sugar levels are controlled, usually the lens will return to its original shape and vision improves. Patients with diabetes who can better control their blood sugar levels will slow the onset and progression of diabetic retinopathy.

According to a 2018 American Eye-Q® Survey conducted by the AOA, nearly half of Americans didn’t know whether diabetic eye diseases have visible symptoms (often which the early stages of diabetic retinopathy does not). The same survey found that more than one-third of Americans didn’t know a comprehensive eye exam is the only way to determine if a person’s diabetes will cause blindness, which is why the AOA recommends that everyone with diabetes have a comprehensive dilated eye examination at least once a year. Early detection and treatment can limit the potential for significant vision loss from diabetic retinopathy.

Treatment of diabetic retinopathy varies depending on the extent of the disease. People with diabetic retinopathy may need laser surgery to seal leaking blood vessels or to discourage other blood vessels from leaking. Your doctor of optometry might need to inject medications into the eye to decrease inflammation or stop the formation of new blood vessels. People with advanced cases of diabetic retinopathy might need a surgical procedure to remove and replace the gel-like fluid in the back of the eye, called the vitreous. Surgery may also be needed to repair a retinal detachment. This is a separation of the light-receiving lining in the back of the eye.
If you are diabetic, you can help prevent or slow the development of diabetic retinopathy by:

  • Taking your prescribed medication
  • Sticking to your diet
  • Exercising regularly
  • Controlling high blood pressure
  • Avoiding alcohol and smoking

What causes diabetic retinopathy?

Diabetic retinopathy results from the damage diabetes causes to the small blood vessels located in the retina. These damaged blood vessels can cause vision loss:

  • Fluid can leak into the macula, the area of the retina responsible for clear central vision. Although small, the macula is the part of the retina that allows us to see colors and fine detail. The fluid causes the macula to swell, resulting in blurred vision.
  • In an attempt to improve blood circulation in the retina, new blood vessels may form on its surface. These fragile, abnormal blood vessels can leak blood into the back of the eye and block vision.

Diabetic retinopathy is classified into two types:

  1. Non-proliferative diabetic retinopathy (NPDR) is the early stage of the disease in which symptoms will be mild or nonexistent. In NPDR, the blood vessels in the retina are weakened. Tiny bulges in the blood vessels, called microaneurysms, may leak fluid into the retina. This leakage may lead to swelling of the macula.
  2. Proliferative diabetic retinopathy (PDR) is the more advanced form of the disease. At this stage, circulation problems deprive the retina of oxygen. As a result, new, fragile blood vessels can begin to grow in the retina and into the vitreous, the gel-like fluid that fills the back of the eye. The new blood vessels may leak blood into the vitreous, clouding vision.

Other complications of PDR include detachment of the retina due to scar tissue formation and the development of glaucoma. Glaucoma is an eye disease in which there is progressive damage to the optic nerve. In PDR, new blood vessels grow into the area of the eye that drains fluid from the eye. This greatly raises the eye pressure, which damages the optic nerve. If left untreated, PDR can cause severe vision loss and even blindness.
Risk factors for diabetic retinopathy include:

  • Diabetes. People with type 1 or type 2 diabetes are at risk for developing diabetic retinopathy. The longer a person has diabetes, the more likely he or she is to develop diabetic retinopathy, particularly if the diabetes is poorly controlled.
  • Race. Hispanics and African Americans are at greater risk for developing diabetic retinopathy.
  • Medical conditions. People with other medical conditions, such as high blood pressure and high cholesterol, are at greater risk.
  • Pregnancy. Pregnant women face a higher risk for developing diabetes and diabetic retinopathy. If a woman develops gestational diabetes, she has a higher risk of developing diabetes as she ages.

How is diabetic retinopathy diagnosed?

Diabetic retinopathy can be diagnosed through a comprehensive eye examination. Testing, with emphasis on evaluating the retina and macula, may include:

  • Patient history to determine vision difficulties, presence of diabetes, and other general health concerns that may be affecting vision
  • Visual acuity measurements to determine how much central vision has been affected
  • Refraction to determine if a new eyeglass prescription is needed
  • Evaluation of the ocular structures, including the evaluation of the retina through a dilated pupil
  • Measurement of the pressure within the eye

Supplemental testing may include:

  • Retinal photography or tomography to document the current status of the retina
  • Fluorescein angiography to evaluate abnormal blood vessel growth

How is diabetic retinopathy treated?

Laser treatment (photocoagulation) is used to stop the leakage of blood and fluid into the retina. A laser beam of light can be used to create small burns in areas of the retina with abnormal blood vessels to try to seal the leaks.

Treatment for diabetic retinopathy depends on the stage of the disease. The goal of any treatment is to slow or stop the progression of the disease.
In the early stages of non-proliferative diabetic retinopathy, regular monitoring may be the only treatment. Following your doctor’s advice for diet and exercise and controlling blood sugar levels can help control the progression of the disease.

Injections of medication in the eye are aimed at discouraging the formation of abnormal blood vessels and may help slowdown the damaging effects of diabetic retinopathy.
If the disease advances, the abnormal blood vessels can leak blood and fluid into the retina, leading to macular edema. Laser treatment (photocoagulation) can stop this leakage. A laser beam of light creates small burns in areas of the retina with abnormal blood vessels to try to seal the leaks.
Widespread blood vessel growth in the retina, which occurs in proliferative diabetic retinopathy, can be treated by creating a pattern of scattered laser burns across the retina. This causes abnormal blood vessels to shrink and disappear. With this procedure, some side vision may be lost in order to safeguard central vision.

Eye Bleeding With Diabetes

Q2. Can diabetes affect your teeth? My friend is having trouble. She lost one tooth and broke another one within the past two months.

Dental health is a real concern for many people with diabetes, but it does not get the attention it deserves. I am glad that you are bringing it up. Diabetes is linked to tooth loss primarily because people with diabetes are more susceptible to periodontal disease. Periodontal diseases are infections, inflammations, and loss of tissue in the gums and other tooth-supporting structures such as bone.

Individuals with diabetes, especially those who have poor glucose control, have a blunted defense mechanism against infections. Minor infections in the mouth, therefore, can linger on or worsen, causing chronic inflammation and erosions. Along with poor glucose control, smoking and alcohol use also cause and aggravate periodontal disease. And this isn’t just a problem in adults with diabetes. Diabetic children, too, often have extensive periodontal disease by the time they reach adolescence.

Keep in mind that periodontal diseases are preventable and can be treated. It is very important to do so not only to prevent tooth loss but also because periodontal disease is linked to heart attacks and strokes. In the past few years, we have come to understand that individuals who experience heart attacks and strokes also tend to have periodontal disease. People with diabetes should maintain normal glucose levels, get regular dental care, floss at least daily, refrain from smoking, and drink in moderation.

Q3. My husband is 58 and has type 2 diabetes. Two days ago his breath started to smell very strongly, and he was suddenly very tired and slightly nauseated. He recovered from this, and the smell went away. I’ve read about acetone breath in diabetics. Do you think that is what he had? What’s the cause?

— Alice, Connecticut

Acetone breath in diabetics is caused by an excess production of acetone. Acetone, hydroxybutyrate, and acetoacetate are ketones, byproducts of fat metabolism. When the body does not have enough insulin (as is the case in people with diabetes), a hormone that is key in glucose metabolism, it instead uses fatty acids as an alternative source of energy, and ketones are the result of this process. Ketones are also produced during a fasting state or when consuming a ketogenic (high-fat, low-carbohydrate) diet.

Ketones can cause nausea, vomiting, and fatigue. But I am concerned that your husband might be experiencing diabetic ketoacidosis, which is a serious and life-threatening condition. I suggest that you check your husband’s sugar level at the time you notice his acetone breath and contact his doctor for further advice. It is also quite likely that his acetone breath might be a result of missing meals.

Q4. I’m 47 years old and was recently diagnosed with diabetes. I’m about 25 pounds overweight and lead a sedentary lifestyle, but I’m starting a diet and an exercise program. Will my diabetes go away if I lose weight, watch my diet, and exercise regularly?

— Mary, Alaska

It is wonderful that you are changing your lifestyle to become healthier! This will benefit you greatly, not only in controlling your blood sugar but also in improving your cholesterol levels, strengthening your bones, and improving your heart function. These changes come with a long list of health benefits, but whether they will allow you to stop taking medicines completely depends on several factors:

  • The primary cause of your diabetes
  • The length of time that you had undiscovered, or “hidden,” diabetes
  • The length of time you’ve had diagnosed diabetes
  • How well your pancreas is functioning, including how much insulin it is producing, and the extent of insulin resistance associated with excess weight

As you probably know, the cause of diabetes among most adults is twofold. It’s caused by insulin resistance resulting from excess weight, and inadequate insulin production in the pancreas. These two causes are also interrelated. Many people whose diabetes is primarily the result of excess weight and insulin resistance can potentially reduce their glucose levels by losing a significant amount of weight and controlling their sugar levels through diet and exercise alone. This assumes that their pancreas is still producing an adequate amount of insulin.

A good number of diabetics, however, have the illness but don’t know it for at least five years before diagnosis. This is crucial because over time, the insulin-producing cells in the pancreas decline in function. Often, by the time a patient is diagnosed, a critical number of cells have stopped producing insulin entirely. There is no way to reverse this. If your diabetes is diagnosed early in the disease process, however, aggressive management may help you prevent further loss of function in those cells. This means maintaining your fasting glucose levels below 100 mg/dl and your after-meal (two hours after) levels below 140 mg/dl. This is the same for morning and evening glucose levels.

It is also entirely possible for some people to control their blood glucose with diet alone. I have a few patients who have been able to do so. All are producing adequate insulin, have lost weight or are within their ideal body-weight range, and watch their diets.

Q5. It’s been years since I started taking metformin for diabetes, and lots of new medicines have come out since then. Should I talk to my doctor about switching to a newer drug? Are the newer ones better?

— Anonymous

The short answer is no. If your sugar level is controlled and you have a hemoglobin A1C level below 7 percent, there is no need to add or switch medications. If your sugar level is not controlled, however, and you are taking the maximum amount of metformin, another medicine is required to control it better. This usually means adding a medication rather than switching drugs completely. A class of drugs called insulin secretagogues (drugs that stimulate insulin secretion in the pancreas) — such as glyburide, glipizide, and glimepiride — can be used as additional medicines. There has been some controversy over the use of newer diabetes medicines, especially after a recent study indicated that rosiglitazone (Avandia, a relatively new medicine) could have some heart-related side effects.

Here are some issues your doctor might consider in prescribing medication:

  1. The ultimate goal of treating diabetes is to prevent premature death from its complications. However, no study has ever demonstrated that any of the medicines currently on the market reduce the chance of early death.
  2. Having said this, we know that by maintaining normal glucose levels we can reduce diabetes complications such as eye disease (including blindness) and kidney failure. This in turn improves the quality of life of those who suffer from diabetes. Also, our hope is that better control of glucose will prevent cardiac complications and strokes. In fact, a study is currently underway to determine whether achieving a normal glucose level prevents heart attacks, strokes, and premature death.
  3. Because diabetes is a progressive illness, almost all diabetics will eventually require more than one medicine to control their glucose. About 75 percent of diabetics will require more than one medicine to control their glucose nine years after diagnosis. A large number of people require at least three medicines, a combination of insulin and oral medicines, or insulin alone.
  4. Diabetes is a complex disease. Treatment with a combination of short- and long-acting medicines, secretagogues, and insulin sensitizers such as metformin, rosiglitazone, and pioglitazone is usually necessary. We gauge the adequacy of the medicines’ control of sugar by measuring the variations in glucose values and hemoglobin A1C.
  5. Diabetes is usually a progressive disease in which about 10 percent of the pancreatic cells that produce insulin stop functioning every year. This is a rough estimate. In a large study in England, the average person with type 2 diabetes required insulin administration six years after diagnosis. However, we can delay the progression by achieving good glucose control and protecting the ability of the pancreatic cells that produce insulin. Some medicines are better at preserving the function of these beta cells than others.
  6. To achieve good control, physicians use all the available medicines as needed.
  7. There is a sequential use of medicines that makes sense for patients based on what we know about their particular cases. For most diabetics, the first medicine used is metformin or a secretagogue such as glyburide or glipizide. The newest addition in this class is glimepiride, which is similarly effective but more expensive.
  8. For diabetics who are also obese, starting with metformin makes sense because this drug addresses insulin resistance — the central problem for many obese diabetics — and is associated with weight loss, or at least less weight gain than other drugs.
  9. If glucose levels are not controlled with the above medicines, or combinations thereof, thiazolinediones such as pioglitazone (Actos) and rosiglitazone (Avandia) can be considered. If sugar levels after your meals are high, then short-acting secretagogues such as repaglinide and nateglinide, or other newer medicines such as sitagliptin (Januvia) and exenatide (Byetta), can also be considered.
  10. In current practice, insulin is prescribed if blood sugar control remains poor despite the use of a combination of various oral medicines. It is increasingly common, however, to prescribe insulin early in the disease process to achieve better control of sugar and prevent the decline of the insulin-producing cells. Stay tuned for more developments in this area.

Learn more in the Everyday Health Type 2 Diabetes Center.

Diabetes is a condition that impacts your body’s ability to control blood glucose levels. If you have Type I diabetes, your body doesn’t produce enough insulin, which transports sugar from your blood to the body’s cells. If you have Type II diabetes, your body doesn’t respond to insulin as it should. In both cases, you’re more likely to have problems with your oral health.

How Does Diabetes Impact Your Oral Health?

Diabetes impacts your dental health in many ways. Patients with diabetes often experience dry mouth, where there’s less saliva than usual. Saliva serves an important function, helping to wash away food particles and acids. If you don’t have enough saliva, these particles may settle in the mouth, leading to tooth decay. This is why patients with diabetes have a higher risk of developing cavities. Dry mouth is also linked to ulcers, infections, and soreness in the mouth.

Diabetes can slow the healing process from wounds, so those who have dental surgery may struggle with a slower recovery time. These patients are also more susceptible to infections. Proper care and treatment will help you avoid or minimize these risks.

Is There a Connection Between Gum Disease and Diabetes?

Patients with diabetes have a higher risk of developing gum disease. Both early gum disease, known as gingivitis, and serious gum disease known as periodontitis are more likely in diabetes patients. In fact, almost 22 per cent of those with diabetes also suffer from periodontal disease. If you have diabetes, you’re as much as four times more likely to develop periodontal disease than someone without diabetes.

If you struggle to control your blood sugar levels, your risk for gum disease will increase. The association between gum disease and diabetes may also go both ways. Some research has suggested that gum disease may impact one’s ability to maintain stable blood glucose levels. Gum disease is caused by bacteria infecting the gum line. These bacteria will inflame the gums and may damage both the gum tissue and bone in your mouth.

Left untreated, gum disease can cause bad breath, pain, bleeding of the gums, difficulty chewing, and tooth loss. As mentioned previously, diabetes can also slow healing, which might make it more difficult to treat gum disease properly. However, it’s important to work closely with your dentist if you have signs of gum disease. The sooner you address the problem, the better your chances of avoiding serious complications like tooth loss and bone loss.

Does Diabetes Prevent You From Getting Dental Implants or Bridges?

Dental implants and bridges are a common solution for patients who have lost teeth. Due to the link between diabetes and gum disease, you may have a higher chance of needing a dental implant or bridge if you suffer from diabetes. Unfortunately, the same issues that tend to cause gum disease in diabetic patients can also make it more difficult for these individuals to get implants and bridges. This does not mean you cannot get this treatment if you have diabetes, only that you will need to work more closely with your dentist to explore and understand your options.

Before you can get a dental implant or bridge, you must have healthy gums. If advanced gum disease led to the tooth loss, you must get the gum disease under control before you can explore options for tooth replacement. If your gums are sufficiently healthy, the next step is getting your blood sugar under control. Your dentist will look for stable blood glucose levels when determining whether you’re a candidate for this type of dental surgery.

If you do get a dental implant or bridge, you will likely have a higher risk for complications such as infection. Those with diabetes also tend to experience a longer healing time. Stay in close communication with your dentist post-surgery to make sure you’re recovering properly, and be vigilant about your blood sugar levels to help prevent these types of complications.

How Can Patients With Diabetes Protect Their Dental Health?

If you have diabetes, let your dentist know. If you’re dealing with gum disease or other dental problems, you should also inform your physician. This will enable your key health care providers to work together to help you manage your condition and maintain good dental health. Controlling your blood sugar levels is one of the most important things you can do to support your dental health with diabetes.

Patients with diabetes should also be particularly vigilant about seeing the dentist often. Schedule an appointment for a routine cleaning at least once every six months. This will alert you to early signs of gum disease, cavities, and other problems, so you can get prompt treatment.

Though you may experience more complications with your oral health when you have diabetes, you shouldn’t get discouraged. With proper care and blood sugar control, you can actively work to protect your teeth.

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