PERIODONTAL DISEASE AND DIABETES MELLITUS

 

Diabetes mellitus comprises a clinically and genetically heterogeneous group of metabolic disorders manifested by abnormally high levels of glucose in the blood (1). This abnormally high level of glucose in the blood is brought about by insulin deficiency caused by pancreatic b-cell dysfunction, insulin resistance in the liver or muscle tissue, or a combination of both. It is known that chronic hyperglycemia leads to long-term damage of various organs such as the heart, eyes, kidneys, nerves and vascular system.

 

Influence of diabetes on oral health

A large body of evidence demonstrates that diabetes is a risk factor for gingivitis and periodontitis. Periodontitis is implicated as the sixth complication of diabetes mellitus. The degree of glycemic control is an important variable in the relationship between diabetes and periodontal diseases, with a higher prevalence and severity of gingival inflammation and periodontal destruction being seen in those with poor control (2,3,4). Large epidemiological studies have shown that diabetes increases the risk of alveolar bone loss and attachment loss approximately three-fold when compared to nondiabetic individuals (5). These findings have been confirmed in meta-analyses of studies in various diabetic populations.

The mechanisms of diabetes’ effect on periodontium are similar to the pathophysiology of the classic microvascular and macrovascular diabetic complications. There are few differences in the subgingival microbiota between diabetic and non-diabetic patients with periodontitis (6). This suggests that alterations in the host immunoinflammatory response to potential pathogens may play a predominant role. Elevated pro-inflammatory cytokines in the periodontal environment may play a role in the increased periodontal destruction seen in many people with diabetes. Formation of advanced glycation end-products, a critical link in many diabetic complications, also occurs in the periodontium, and their deleterious effects on other organ systems may be reflected in periodontal tissues as well (7). Matrix metalloproteinases are critical components of tissue homeostasis and wound healing, and are produced by all of the major cell types in the periodontium. Production of matrix metalloproteinases such as collagenase increases in many diabetic patients, resulting in altered collagen homeostasis and wound healing within the periodontium.

Influence of periodontal infection on diabetes:

Periodontal diseases are inflammatory in nature; as such, they may alter glycemic control in a similar manner to obesity or other inflammatory conditions. Studies have shown that diabetic patients with periodontal infection have a greater risk of worsening glycemic control over time compared to diabetic subjects without periodontitis (8).

 

Periodontal intervention trials suggest a significant potential metabolic benefit of periodontal therapy in people with diabetes. Several studies of diabetic subjects with periodontitis have shown improvements in glycemic control following scaling and root planing combined with adjunctive systemic antibiotic. The magnitude of change is often about 0.9–1.0% in the hemoglobin A1c test. There are some studies in which periodontal treatment was associated with improved periodontal health, but minimal impact was seen on glycemic control (8,9).

Most of these studies used scaling and root planing alone, without adjunctive antibiotic therapy.

Several mechanisms may explain the impact of periodontal infection on glycemic control. As discussed above, systemic inflammation plays a major role in insulin sensitivity and glucose dynamics. Evidence suggests that periodontal diseases can induce or perpetuate an elevated systemic chronic inflammatory state, as reflected in increased serum C-reactive protein, interleukin-6, and fibrinogen levels seen in many people with periodontitis (10).

 

Dentists and other general health care providers should understand the diagnostic and therapeutic methodologies used in diabetes care. They must be comfortable with the parameters of glycemia that are used to establish a diagnosis and management of patient’s ongoing glycemic control.

A collaborative approach by physicians and dentists towards patient can ensure prevention of significant complications in patients with coexisting periodontal infections and diabetes. It is, thus, very important to communicate with patients about importance of oral health as it may play an important level in their glycemic control.

 

References:

  1. Mealey BL, Ocampo GL. Diabetes mellitus and periodontal disease. Periodontol 2000 2007: 44: 127–153.
  2. Ervasti T, Knuuttila M, Pohjamo L, Haukipuro K. Relation between control of diabetes and gingival bleeding. J Periodontol 1985: 56: 154–157.
  3. Gusberti FA, Syed SA, Bacon G, Grossman N, Loesche WJ. Puberty gingivitis in insulin-dependent diabetic children. J Periodontol 1983: 54: 714–720.
  4. Campus G, Salem A, Uzzau S, Baldoni E, Tonolo G. Diabetes and periodontal disease: a case–control study. J Periodontol 2005: 76: 418–425.
  5. Shlossman M, Knowler WC, Pettitt DJ, Genco RJ. Type 2 diabetes mellitus and periodontal disease. J Am Dent Assoc 1990: 121: 532–536.
  6. Sastrowijoto SH, Hillemans P, van Steenbergen TJ, Abraham- Inpijn L, de Graff J. Periodontal condition and microbiology of healthy and diseased periodontal pockets in type 1 diabetes mellitus patients. J Clin Periodontol 1989: 16: 316–322.
  7. Schmidt AM, Weidman E, Lalla E et al. Advanced glycation endproducts (AGEs) induce oxidant stress in the gingiva: a potential mechanism underlying accelerated periodontal disease associated with diabetes. J Periodontal Res 1996: 31: 508–515.
  8. Christgau M, Palitzsch KD, Schmalz G, Kreiner U, Frenzel S. Healing response to non-surgical periodontal therapy in patients with diabetes mellitus: clinical, microbiological, and immunological results. J Clin Periodontol 1998: 25: 112–124.
  9. Aldridge JP, Lester V, Watts TLP, Collins A, Viberti G, Wilson RF. Single-blind studies of the effects of improved periodontal health on metabolic control in Type 1 diabetes mellitus. J Clin Periodontol 1995: 22: 271–275.
  10. D’Aituo F, Parkar M, Andreou G et al. Periodontitis and systemic inflammation: control of the local infection is associated with a reduction in serum inflammatory markers. J Dent Res 2004: 83: 156–160.

 

This article is submitted by Dr. Pavan Bajaj.

Specialty: MDS Periodontology

Areas of interest: Periodontal regeneration and local drug delivery

Pertinent work experience/ achievements: Masters in Periodontology. Has authored several publications.