|Year : 2017 | Volume
| Issue : 2 | Page : 46-49
Periodontitis and diabetes: A bidirectional, cyclical relationship - A brief review
Rakesh Agarwal1, Rashmi Baid2
1 Department of Cardiology, Institute of Cardiovascular Sciences, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
2 Department of Obstetrics and Gynecology, IPGMER and SSKM Hospital, Kolkata, West Bengal, India
|Date of Web Publication||7-Dec-2017|
Institute of Cardiovascular Sciences, IPGME and SSKM Hospital, Kolkata, West Bengal
Source of Support: None, Conflict of Interest: None
Diabetes mellitus and periodontitis have been said to have a bidirectional cyclical relationship, with diabetes leading to oral disease, and periodontitis, in turn, exacerbating hyperglycemia. Periodontitis is recognized as the sixth major complication of diabetes, having increased prevalence and severity in patients with diabetes. Early diagnosis of diabetes in patients with periodontitis can lead to the prevention of major morbidity and mortality associated with the disease. Therapy for diabetes may also lead to the improvement of periodontitis. In this review, we are presenting the current knowledge of the interplay and interaction between these two entities and the available data regarding treatment of the two entities together.
Keywords: Oral health in diabetes, Periodontitis and diabetes, periodontitis
|How to cite this article:|
Agarwal R, Baid R. Periodontitis and diabetes: A bidirectional, cyclical relationship - A brief review. Acta Med Int 2017;4:46-9
| Introduction|| |
The oral cavity is home to a vivid milieu of infectious agents, and its condition more often reflects the progression of systemic pathologies. There has been recently a shift in the paradigm from a traditional “oral cavity only” thought process to a systemic connection between the oral cavity and the internal milieu.
Periodontitis is a chronic inflammatory disease characterized by the destruction of supporting structures of the teeth (periodontal ligament and alveolar bone). Severe periodontitis has a prevalence of 10%–15% in the general population and has been shown to increase the risk of a first myocardial infarction as well as subclinical atherosclerotic heart disease.,, It has been associated with the future cognitive decline, with poor control of hypertension, and with chronic obstructive pulmonary disease.,, Periapical periodontitis has been shown to affect insulin sensitivity and exacerbate nonalcoholic steatohepatitis.,
Diabetes affects more than 415 million people worldwide and 69 million people in India., It has reached an epidemic status and is predicted to affect 592 million people by 2035. The prevalence of diabetes is likely to increase more in India compared to other countries. An upsurge in diabetes has also led to an increase in various complications due to longer disease duration; neuropathy being the most common, followed by cardiovascular, renal, ocular, and foot complications.,, Furthermore, Indians are more prone to the earlier development of diabetic complications (20–40 years) than Caucasians (>50 years) which means diabetes must be carefully screened in the Indian population.
Complications of diabetes pose a severe problem and cause the majority of morbidity and mortality in this population. Diabetes is associated with an increased susceptibility to infections, poor wound healing, and is hailed as a major risk factor for more severe and progressive periodontitis, leading to the destruction of tissues and supporting bone that forms the attachment around the tooth.
In this brief review, we are going to discuss the interrelationship between these two closely linked diseases based on available literature.
| Effect of Diabetes on Periodontium|| |
The influence that diabetes exerts on oral health has been extensively studied. Aggressive periodontitis was found as the sixth serious complication of diabetes as early as 1993.
Available data show a strong evidence in favor of considering diabetes as a risk factor for gingivitis and periodontitis. The risk of periodontitis is increased by threefold in patients with diabetes compared to nondiabetics., Studies on the Pima Indian population in the 1990s showed that the prevalence and incidence of periodontitis were higher in patients with type 2 diabetes mellitus (DM) compared to those who did not. Tooth loss in Pima Indians with type 2 diabetes was reported to be 15 times higher than in those without diabetes.,,
Furthermore, the level of glycemic control appears to be particularly significant and must be taken into account., Higher values of glycated hemoglobin (HbA1C) are reported in children and adolescents with periodontitis., Type 1 diabetic patients with poor glycemic control over preceding 2–5 years have a significantly greater prevalence of deep probing depths and advanced attachment loss compared to those with good metabolic control. Indian studies have also shown increased gingival inflammation, more dental plaque, increased PPDs, and attachment loss in patients with HbA1c >8, compared to those with HBA1c ≤7 and HBA1c = 7–8. Poor glycemic control leads to 11-fold increased risk for alveolar bone loss over 2 years period compared to controls.
However, this association appears to be similar to the association between glycemic control and other classic diabetes complications such as retinopathy and nephropathy. Thus, while poor control of diabetes clearly increases the risk of diabetes complications including periodontitis, not all patients with poor glycemic control develop major complications. Conversely, some well-controlled diabetics may as well suffer some major diabetic complications. Many well-controlled patients with diabetes have excellent periodontal health, others do not. However, this assumption should not deter one from aggressive treatment of either within the limits of the patient's clinical status. Most certified diabetes educators agree that there is a link between oral and systemic health and that collaboration with the dental profession would be a positive outcome for patients.
Some evidence has shown a varying response to the therapy of periodontal disease in patients with diabetes. In general, how diabetes adversely affects outcomes of periodontal disease has not been a much-researched topic. Most studies evaluating such are old, done in the 1990s. Well-controlled patients with diabetes have a similar response to the standard response protocol (SRP) like that of nondiabetics. However, those with poor control have a rapid recurrence of deep pockets and a poorer long-term prognosis. On the contrary, a recent study on 41 patients with diabetes and 21 nondiabetic individuals did not show statistically significant differences in treatment success of chronic periodontitis in the two arms. The study concluded that the researchers “did not absolutely support the assumption that the level of glycemic control significantly affected the periodontal therapy outcome in diabetics.”
Poorly controlled diabetes has in general been considered as a relative contraindication to dental implant treatment because of higher failure rates. However, whether this logic extends to periodontal treatment remains to be studied. Considering the role of poor glycemic control in severe periodontal disease, and the fact that periodontal disease tends to act like other complications of diabetes, it would only be logical to assume that poor glycemic control might portend poorer prognosis of the periodontal disease. However, well-conducted larger studies to substantiate this observation are currently lacking.
| Effect of Odontium on Diabetes|| |
A two-way interrelationship between diabetes and periodontitis is said to exist.,
Periodontitis is characterized by chronic inflammation, and inflammation can promote insulin resistance and dysregulate glycemia. In fact, the prevalence of periodontitis is higher in patients with albuminuria as well. A 2-year longitudinal trial showed that diabetic patients with severe periodontitis at baseline had 6 times higher risk of worsening glycemic control. Periodontitis has been shown to increase the mortality rate in individuals with chronic kidney disease from 32% to 41%. For patients also having diabetes, the 10-year all-cause mortality rate increases to 43%.
Back in 2009, a review of 25 studies suggested a small but significant 0.79% reduction in the HbA1c level after proper periodontal treatment. However, subsequent large systematic reviews and meta-analyses have failed to support this observation.
In 1999, a review showed inconclusive evidence that periodontal therapy could improve glycemic control. A Cochrane database systemic review done in 2010 showed some evidence in the improvement of metabolic control after treating periodontal disease although the authors concluded that the individual studies included, lacked the power to detect a significant effect. An absolute difference of 0.27% in HbA1c was recently reported with treatment. A recent Cochrane Database systemic review included 35 studies and 2565 participants to investigate the effect of periodontal therapy on glycemic control in people with DM. The review found low-quality evidence that the treatment of periodontal disease by SRP improves glycemic control with a mean HbA1C reduction of only 0.29% at 3–4 months. Furthermore, there was insufficient evidence that this is maintained beyond 4 months. Ongoing periodontal treatment may be required to maintain clinical improvement beyond 6 months.
Another very recent overview of systematic reviews on the effectiveness of periodontal treatment in improving glycemic control have identified 11 systematic reviews with meta-analyses and did not support the theory that periodontal treatment improves glycemic control. An average reduction of 0.46% in HbA1c with median 0.40% was identified in patients with diabetes who received periodontal treatment.
Chronic inflammation has been proposed as the underlying mechanism linking poor odontal health to glycemic control., Chronic periodontal infections with Gram-negative organisms may exacerbate insulin resistance. Organisms such as Porphyromonas gingivalis, Tannerella forsythensis, and Prevotella intermedia lead to higher C-reactive protein (CRP), interleukin-6 (IL), and fibrinogen levels. Furthermore, systemic bacteremia or toxemia might play an independent part in exacerbating the inflammatory process. It is already known that obesity, atherosclerosis, diabetes and insulin resistance all are linked with chronic inflammation. For example, blocking tumor necrosis factor alpha (TNF-α) improves insulin sensitivity and production of IL-6, TNF-α, and CRP are interlinked.
A ligature model of alveolar bone loss in Zucker fatty rats showed that periodontitis was associated with deterioration in glucose metabolism.
A shift in the monocyte/macrophage phenotype may result in the overproduction of pro-inflammatory cytokines in response to periodontal infection, in patients with diabetes.
TNF-alpha has been proposed as the culprit to interlink periodontal disease and diabetes. Elevated TNF-a levels stimulate fibroblasts leading to the synthesis of matrix-degrading enzymes and stimulate osteoclasts leading to active bone resorption.,
| Conclusion|| |
The association between diabetes and inflammatory periodontal disease has been studied extensively. The relationship between these two conditions appears not only bidirectional but cyclical. Not only does diabetes predisposes the individual to oral disease but also periodontitis once established exacerbates diabetes and worsens the metabolic control.
It has been shown that the undiagnosed diabetics and prediabetics can be diagnosed in the dental office by chair-side HbA1c readings. Over 30% of patients with periodontitis could be harboring a yet unknown prediabetes or diabetes. Longer the time they stay undiagnosed, easier they develop the complications. Furthermore, untreated diabetes may be associated with greater complications related to the management of periodontitis itself, including infections which might account for studies showing better benefit with antibiotics along with SRP for periodontitis management.
Some of the patients could have benefitted from a routine periodontal examination early in the course of their diabetes, and this could perhaps have prevented grave complications. Furthermore, it might be the time that diabetologists, internists, and endocrinologists refer their patients more often to periodontists before finalizing the treatment plans.
Proper management of the blood sugar levels may improve the oral health of DM patients. Routine evaluation for diabetic status in patients with undiagnosed diabetes may identify such patients at early stages of the disease, preventing the future complications.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Rydén L, Buhlin K, Ekstrand E, de Faire U, Gustafsson A, Holmer J, et al.
Periodontitis increases the risk of a first myocardial infarction: A Report from the PAROKRANK study. Circulation 2016;133:576-83.
Preshaw PM, Alba AL, Herrera D, Jepsen S, Konstantinidis A, Makrilakis K, et al.
Periodontitis and diabetes: A two-way relationship. Diabetologia 2012;55:21-31.
Li P, He L, Sha YQ, Luan QX. Periodontal status of patients with post-acute myocardial infarction. Beijing Da Xue Xue Bao 2013;45:22-6.
Southerland JH, Moss K, Taylor GW, Beck JD, Pankow J, Gangula PR, et al.
Periodontitis and diabetes associations with measures of atherosclerosis and CHD. Atherosclerosis 2012;222:196-201.
Iwasaki M, Yoshihara A, Kimura Y, Sato M, Wada T, Sakamoto R, et al.
Longitudinal relationship of severe periodontitis with cognitive decline in older Japanese. J Periodontal Res 2016;51:681-8.
Southerland JH. Periodontitis may contribute to poor control of hypertension in older adults. J Evid Based Dent Pract 2013;13:125-7.
Chung JH, Hwang HJ, Kim SH, Kim TH. Associations between periodontitis and chronic obstructive pulmonary disease: The 2010 to 2012 Korean National Health and Nutrition Examination Survey. J Periodontol 2016;87:864-71.
Astolphi RD, Curbete MM, Colombo NH, Shirakashi DJ, Chiba FY, Prieto AK, et al.
Periapical lesions decrease insulin signal and cause insulin resistance. J Endod 2013;39:648-52.
Sasaki H, Hirai K, Martins CM, Furusho H, Battaglino R, Hashimoto K, et al.
Interrelationship between periapical lesion and systemic metabolic disorders. Curr Pharm Des 2016;22:2204-15.
Madras Diabetes Research Foundation (India) 2014. Available from: http://www.mdrf.in/
. [Last assessed on 2017 Oct 8].
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53.
Mohan V, Shah S, Saboo B. Current glycemic status and diabetes related complications among type 2 diabetes patients in India: Data from the A1chieve study. J Assoc Physicians India 2013;61:12-5.
Unnikrishnan RI, Rema M, Pradeepa R, Deepa M, Shanthirani CS, Deepa R, et al.
Prevalence and risk factors of diabetic nephropathy in an urban South Indian population: The Chennai Urban Rural Epidemiology Study (CURES 45). Diabetes Care 2007;30:2019-24.
Rema M, Premkumar S, Anitha B, Deepa R, Pradeepa R, Mohan V, et al.
Prevalence of diabetic retinopathy in urban India: The Chennai urban rural epidemiology study (CURES) eye study, I. Invest Ophthalmol Vis Sci 2005;46:2328-33.
Joshi SR. Metabolic syndrome – Emerging clusters of the Indian phenotype. J Assoc Physicians India 2003;51:445-6.
Löe H. Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care 1993;16:329-34.
Mealey BL. Periodontal disease and diabetes. A two-way street. J Am Dent Assoc 2006;137 Suppl:26S-31S.
Emrich LJ, Shlossman M, Genco RJ. Periodontal disease in non-insulin-dependent diabetes mellitus. J Periodontol 1991;62:123-31.
Nelson RG, Shlossman M, Budding LM, Pettitt DJ, Saad MF, Genco RJ, et al.
Periodontal disease and NIDDM in pima Indians. Diabetes Care 1990;13:836-40.
Shlossman M, Knowler WC, Pettitt DJ, Genco RJ. Type 2 diabetes mellitus and periodontal disease. J Am Dent Assoc 1990;121:532-6.
Papapanou PN. Periodontal diseases: Epidemiology. Ann Periodontol 1996;1:1-36.
Mealey BL, Moritz AJ. Hormonal influences: Effects of diabetes mellitus and endogenous female sex steroid hormones on the periodontium. Periodontol 2000 2003;32:59-81.
Gusberti FA, Syed SA, Bacon G, Grossman N, Loesche WJ. Puberty gingivitis in insulin-dependent diabetic children. I. Cross-sectional observations. J Periodontol 1983;54:714-20.
Deshpande K, Jain A, Sharma R, Prashar S, Jain R. Diabetes and periodontitis. J Indian Soc Periodontol 2010;14:207-12.
] [Full text]
Tervonen T, Oliver RC. Long-term control of diabetes mellitus and periodontitis. J Clin Periodontol 1993;20:431-5.
Jindal A, Parihar AS, Sood M, Singh P, Singh N. Relationship between severity of periodontal disease and control of diabetes (Glycated hemoglobin) in patients with type 1 diabetes mellitus. J Int Oral Health 2015;7:17-20.
Taylor GW, Burt BA, Becker MP, Genco RJ, Shlossman M. Glycemic control and alveolar bone loss progression in type 2 diabetes. Ann Periodontol 1998;3:30-9.
Mealey BL, Oates TW, American Academy of Periodontology. Diabetes mellitus and periodontal diseases. J Periodontol 2006;77:1289-303.
Lopes MH, Southerland JH, Buse JB, Malone RM, Wilder RS. Diabetes educators' knowledge, opinions and behaviors regarding periodontal disease and diabetes. J Dent Hyg 2012;86:82-90.
Tervonen T, Knuuttila M, Pohjamo L, Nurkkala H. Immediate response to nonsurgical periodontal treatment in subjects with diabetes mellitus. J Clin Periodontol 1991;18:65-8.
Mirnić J, Djurić M, Predin T, Gusić I, Petrović D, Andjelković A, et al.
Impact of the level of metabolic control on the non-surgical periodontal therapy outcomes in diabetes mellitus type 2 patients – Clinical effects. Srp Arh Celok Lek 2013;141:738-43.
Marchand F, Raskin A, Dionnes-Hornes A, Barry T, Dubois N, Valéro R, et al.
Dental implants and diabetes: Conditions for success. Diabetes Metab 2012;38:14-9.
Han K, Nam GE, Kim DH, Park JB, Ko Y, Roh YK, et al.
Association of periodontitis with urinary albumin excretion in Korean adults with diabetes: The 2012 Korea national health and nutrition examination survey. Medicine (Baltimore) 2015;94:e1839.
Sharma P, Dietrich T, Ferro CJ, Cockwell P, Chapple IL. Association between periodontitis and mortality in stages 3-5 chronic kidney disease: NHANES III and linked mortality study. J Clin Periodontol 2016;43:104-13.
Garcia R. Periodontal treatment could improve glycaemic control in diabetic patients. Evid Based Dent 2009;10:20-1.
Taylor GW. Periodontal treatment and its effects on glycemic control: A review of the evidence. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1999;87:311-6.
Simpson TC, Needleman I, Wild SH, Moles DR, Mills EJ. Treatment of periodontal disease for glycaemic control in people with diabetes. Cochrane Database Syst Rev. 2010;(5):CD004714. doi: 10.1002/14651858.CD004714.pub2.
Li Q, Hao S, Fang J, Xie J, Kong XH, Yang JX, et al.
Effect of non-surgical periodontal treatment on glycemic control of patients with diabetes: A meta-analysis of randomized controlled trials. Trials 2015;16:291.
Simpson TC, Weldon JC, Worthington HV, Needleman I, Wild SH, Moles DR, et al
. Treatment of periodontal disease for glycaemic control in people with diabetes mellitus. Cochrane Database Syst Rev. 2015;(11):CD004714. doi: 10.1002/14651858.CD004714.pub3.
Faggion CM Jr., Cullinan MP, Atieh M. An overview of systematic reviews on the effectiveness of periodontal treatment to improve glycaemic control. J Periodontal Res 2016;51:716-25.
Yang NY, Zhang Q, Li JL, Yang SH, Shi Q. Progression of periodontal inflammation in adolescents is associated with increased number of Porphyromonas gingivalis
, Prevotella intermedia
, Tannerella forsythensis
, and Fusobacterium nucleatum
. Int J Paediatr Dent 2014;24:226-33.
Nishimura F, Iwamoto Y, Mineshiba J, Shimizu A, Soga Y, Murayama Y, et al.
Periodontal disease and diabetes mellitus: The role of tumor necrosis factor-alpha in a 2-way relationship. J Periodontol 2003;74:97-102.
Pontes Andersen CC, Flyvbjerg A, Buschard K, Holmstrup P. Periodontitis is associated with aggravation of prediabetes in zucker fatty rats. J Periodontol 2007;78:559-65.
Nagpal R, Yamashiro Y, Izumi Y. The two-way association of periodontal infection with systemic disorders: An overview. Mediators Inflamm 2015;2015:793898.
Grover HS, Luthra S. Molecular mechanisms involved in the bidirectional relationship between diabetes mellitus and periodontal disease. J Indian Soc Periodontol 2013;17:292-301.
] [Full text]
Holm NC, Belstrøm D, Østergaard JA, Schou S, Holmstrup P, Grauballe MB, et al.
Identification of individuals with undiagnosed diabetes and pre-diabetes in a Danish cohort attending dental treatment. J Periodontol 2016;87:395-402.