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Diabetes and Periodontal Health Bi-directional

According to multiple studies, diabetics are at an increased risk of severe periodontitis. This association relationship appears to be bi-direction, meaning the presence of periodontal disease may hinder glycemic control in diabetes….

 
The two most common diabetes-related dental conditions include periodontal disease and dental caries. Other conditions may include; burning mouth syndrome, Candida infection, dry mouth, altered sensation of taste, altered tooth eruption and hypertrophy of the parotid glands. Non-dental health care providers often overlook diabetes-related complications that affect the oral cavity, which can have an enormous personal and financial impact on patients.

Periodontal diseases are a category of inflammatory diseases affecting the support system of the teeth. The support structures of the teeth include the gingiva, cementum (which covers the roots), the periodontal ligament and the alveolar bone – the bone onto which teeth are directly anchored. Periodontal disease manifests as an inflammatory lesion on the gingiva which extends into deeper supportive structures. As these structures become affected, loss of alveolar bone, tooth mobility, and abscess formation may occur, ultimately resulting in tooth loss.

According to multiple studies, diabetics are at an increased risk of severe periodontitis. This association relationship appears to be bi-direction, meaning the presence of periodontal disease may hinder glycemic control in diabetes. According to a meta-analysis, oral hygiene instruction combined with a thorough debridement of dental plaque and removal of calcified deposits resulted in a 0.40% decrease in HbA1c over after 3 months.

Periodontal disease may also be considered a risk indicator for long-term diabetes complications and outcomes. In a study done on a Native American Gila River community, Shultis et al., evaluated the progression of renal disease in participants with no initial evidence of renal disease. After classifying a total of 529 participants based on the severity of their periodontal disease, researchers evaluated the progression of renal disease. During a follow-up period of up to 22 years, 193 participants developed macroalbuminuria and 68 developed end-stage renal disease. Researchers determined that the risk of renal disease increased with an increase in the severity of periodontal disease. Using an adjusted model, individuals categorized as none/mild periodontitis, moderate periodontitis, severe periodontitis, their risk of developing macroalbuminuria was 2.0, 2.1 and 2.6, respectively (p=0.01). Further, in those classified as end-stage renal disease, the risk was 2.3, 3.5 and 4.9 (p=0.02).

Using data from the same community, researchers examined the effect of periodontal disease on mortality from cardiovascular or renal disease. Out of 628 participants, researchers determined that individuals with severe periodontitis experienced a increased risk of death 3.2 higher than participants in ‘none/mild’ and ‘moderate’ groups.

Using data from NHANES I study, Demmer et al., assessed baseline periodontal disease and diabetes onset after stratifying the baseline severity of periodontal disease into 6 categories. Assessing a total of 9,296 individuals without diabetes at baseline, researchers used logistic regression to determine the odds ratio of developing diabetes. Following a mean follow-up period of 17 years, individuals who did not display significant periodontal disease had no increased risk for diabetes – however, in group 3, 4, 5 and 6, the odds ratios for diabetes were 2.26, 1.71, 1.50, and 1.30, respectively.

In another study, researchers assessed the change in HbA1c in individuals with periodontitis but without diabetes. After categorizing participants based on the severity of periodontal disease at baseline and 5 years, researchers found up to a 5-fold increase in absolute HbA1c. Shockingly, the average increase in HbA1c in those having no periodontal disease, was only 0.005 %. Participants with advanced disease at baseline, and progressed over the study period, the mean increase in HbA1c was 0.143%.

Saliva production is known to be reduced in patients with diabetes. Acting as a buffer, saliva helps to neutralize the acid produced by certain bacteria found in the mouth. In diabetes, decreased saliva production from diabetic neuropathies, combined with hyperglycemia may further accelerate tooth decay.

There is some evidence that non-oral health care professionals lack general knowledge about the importance of oral health care in the spectrum of diabetes. In a survey, only half of the physicians referred their patients with diabetes for a dental evaluation, and as many as two-thirds may be unaware that periodontal disease could adversely affect metabolic management in patients with diabetes.

In order to promote oral health of diabetic patients, the International Diabetes Federation has published a Guideline for Oral Health for People with Diabetes. These guidelines consist of 5 recommendations for non-oral health care providers.

  • On an annual basis, ask if the person follows recommended guidelines for oral self-care, and has regular visits to a dental professional.
  • On an annual basis, ask if the person notices signs of periodontal (gum) disease, including bleeding with tooth brushing and gums that appear red and/or swollen.
  • Emphasize the importance of oral self-care and that seeing a dental professional on a regular basis is part of comprehensive care of diabetes.
  • If signs and symptoms of gum disease are reported, persons should be referred for professional dental care.
  • Provide an explanation of why it is important for persons with diabetes to maintain a healthy mouth, and treat gum disease when it is present.
Practice Pearls:
  • Diabetes is a systemic disease known to be a significant risk factor for periodontitis and other dental-related conditions.
  • Diabetic patients and non-dental health care providers may be unaware of the negative impact of diabetes on oral health
  • Individuals with severe periodontitis experienced a increased risk of death 3.2 higher than participants in ‘none/mild’ and ‘moderate’ groups.
  • Non-dental health care providers should emphasize the importance of dental visits with their diabetic patients as part of a comprehensive diabetes-management plan

Lamster, IB . Diabetes and Oral Health—Current Concepts Regarding Periodontal Disease and Dental Caries. US Endocrinology, 2012;8(2):93-97.