or tongue. also, patients may experience signs like dry mouth, which increases the incidence of decay. poorly controlled diabetes usually leads to gum recession, since plaque creates more harmful proteins in the gums. tooth decay and cavities are some of the first oral problems that individuals with diabetes are at risk for. increased blood sugar levels translate into greater sugars and acids that attack the teeth and lead to gum diseases. gingivitis can also occur as a result of increased blood sugar levels along with an inappropriate oral hygiene. periodontitis is an oral disease caused by untreated gingivitis and which destroys the soft tissue and bone that support the teeth. this disease may cause the gums to pull away from the teeth which may eventually loosen and fall out. diabetic people tend to experience more severe periodontitis because diabetes lowers the ability to resist infection and also slows healing. at the same time, an oral infection such as periodontitis can make diabetes more difficult to control because it causes the blood sugar levels to rise. to prevent further diabetic complications as well as serious oral problems, diabetic persons must keep their blood sugar levels under control and have a proper oral hygiene. a study in the journal of periodontology found that poorly controlled type 2 diabetic patients are more likely to develop periodontal disease than well-controlled diabetics are. at the same time, diabetic patients are recommended to have regular checkups with a dental care provider at least once in three to four months. diabetics who receive good dental care and have good insulin control typically have a better chance at avoiding gum disease to help prevent tooth loss. dental care is therefore even more important for diabetic patients than for healthy individuals. maintaining the teeth and gum healthy is done by taking some preventing measures such as regular appointments at a dentist and a very good oral hygiene. also, oral health problems can be avoided by closely monitoring the blood sugar levels. patients who keep better under control their blood sugar levels and diabetes are less likely to develop oral health problems when compared to diabetic patients who control their disease moderately or poorly. poor oral hygiene is a great factor to take under consideration when it comes to oral problems and even more in people with diabetes. diabetic people are advised to brush their teeth at least twice a day, and if possible, after all meals and snacks. however, brushing in the morning and at night is mandatory as well as flossing and using an anti-bacterial mouthwash. individuals with diabetes are recommended to use toothpaste that contains fluoride as this has proved to be the most efficient in fighting oral infections and tooth decay. flossing must be done at least once a day, as well because it is helpful in preventing oral problems by removing the plaque between the teeth, which is not removed when brushing. diabetic patients must get professional dental cleanings every six months. in cases when dental surgery is needed, it is necessary to take some special precautions such as adjusting diabetes medication or taking antibiotics to prevent infection. looking for early signs of gum disease (redness, swelling, bleeding gums) and informing the dentist about them is also helpful in preventing further complications. quitting smoking is recommended to avoid serious diabetes complications and oral diseases. diabetic persons are advised to make morning appointments to the dental care provider as during this time of the day the blood sugar levels tend to be better kept under control. not least, individuals with diabetes must make sure both their physician and dental care provider are informed and aware of their condition, medical history and periodontal status. medication nonadherence because many patients with diabetes have two or more comorbidities, they often require multiple medications. the prevalence of medication nonadherence is high among patients with chronic conditions, such as diabetes, and nonadherence is associated with public health issues and higher health care costs. one reason for nonadherence is the cost of medications. being able to detect cost-related nonadherence is important for health care professionals, because this can lead to strategies to assist patients with problems paying for their medications. some of these strategies are use of generic drugs or therapeutic alternatives, substituting a prescription drug with an over-the-counter medication, and pill-splitting. interventions to improve adherence can achieve reductions in diabetes morbidity and mortality, as well as significant cost savings to the health care system. smartphone apps have been found to improve self-management and health outcomes in people with diabetes through functions such as specific reminder alarms, while working with mental health professionals has also been found to help people with diabetes develop the skills to manage their medications and challenges of self-management effectively. psychological mechanisms and adherence as self-management of diabetes typically involves lifestyle modifications, adherence may pose a significant self-management burden on many individuals. for example, individuals with diabetes may find themselves faced with the need to self-monitor their blood glucose levels, adhere to healthier diets and maintain exercise regimens regularly in order to maintain metabolic control and reduce the risk of developing cardiovascular problems. barriers to adherence have been associated with key psychological mechanisms: knowledge of self-management, beliefs about the efficacy of treatment and self-efficacy/perceived control. such mechanisms are inter-related, as one's thoughts (e.g. one's perception of diabetes, or one's appraisal of how helpful self-management is) is likely to relate to one's emotions (e.g. motivation to change), which in turn, affects one's self-efficacy (one's confidence in their ability to engage in a behaviour to achieve a desired outcome). as diabetes management is affected by an individual's emotional and cognitive state, there has been evidence suggesting the self-management of diabetes is negatively affected by diabetes-related distress and depression. there is growing evidence that there is higher levels of clinical depression in patients with diabetes compared to the non-diabetic population. depression in individuals with diabetes has been found to be associated with poorer self-management of symptoms. this suggests that it may be important to target mood in treatment. in the case of children and young people, especially if they are socially disadvantaged, research suggests that it is important that healthcare providers listen to and discuss their feelings and life situation to help them engage with diabetes services and self-management. to this end, treatment programs such as the cognitive behavioural therapy - adherence and depression program (cbt-ad) have been developed to target the psychological mechanisms underpinning adherence. by working on increasing motivation and challenging maladaptive illness perceptions, programs such as cbt-ad aim to enhance self-efficacy and improve diabetes-related distress and one's overall quality of life. bariatric surgery while weight loss is clearly beneficial in improving glycemic control in patients with diabetes type 2, maintaining significant weight loss can be a very difficult thing to do. in diabetic people who have a body mass index of 35 or higher, and who have been unable to lose weight otherwise, bariatric surgery offers a viable option to help achieve that goal. in 2018 a patient-centered outcomes research institute funded study was published which analyzed the effects of three common types of bariatric surgery on sustained weight loss and long-lasting glycemic control in patients with diabetes type 2. the results of this study demonstrated that, five years after bariatric surgery, there was meaningfully significant weight loss in a large majority of patients. in addition, and more importantly, this study showed that, in type 2 diabetic patients with a body mass index of 35 or higher, bariatric surgery has the potential to lead to complete remission of diabetes in as many as 40% of those people who have the procedure. like any operation, bariatric surgery is not without risks and complications, and those risks need to weighed against the potential benefits in anyone considering going through with such a procedure. research