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Gum health in diabetic patients

Many research articles suggest that there is a bi-directional relationship between diabetes and periodontal disease as it can make it difficult for people who have diabetes to control their blood sugar. Read on to know more.

doctor and his diabetic patient

Diabetes and Periodontal diseases: The interlink

Periodontal disease is one of the major silent complications of diabetes especially in uncontrolled state.1

Severe periodontal disease can increase blood sugar, contributing to increased periods of time where there is high blood sugar content in the body. This puts people with diabetes at increased risk for diabetic complications.2

Diabetes and Periodontal diseases: The interlink

Prevalence

International Diabetes Federation stated that 425 million people worldwide (8.8% of adults 20–79 years old) have diabetes, and they have a 2 to 3-fold increase in the risk of periodontal diseases. Adults with an HbA1c level of >9% had a significantly higher prevalence of severe periodontitis than those without diabetes.

In India, the prevalence of the periodontal disease in diabetic patients was 86.8% (gingivitis 27.3% and Periodontitis 59.5%).

In a study conducted on n=1500 diabetic patients from India showed that the patients with periodontitis had ≥63% higher blood glucose level compared to patients without periodontal diseases:5

  • The mean fasting blood glucose level was 146.73±35.91
  • The mean postprandial blood glucose level was 247.66±56.16

It was also observed that the blood glucose levels increase with the severity of periodontal disease index score from 1 to 6.5

This shows that the glycaemic status is significantly (P<0.01) related to the prevalence and severity of periodontal disease.5

Figure 1: Mean blood glucose level (mg%) and periodontal status.

Figure 1:  Mean blood glucose level (mg%) and periodontal status.5

Diabetes and periodontal disease: The Bi-Directional correlation

Many research articles suggest that there is a bi-directional relationship between diabetes and periodontal disease as it can make it difficult for people who have diabetes to control their blood sugar.4,6

This is because diabetes patients are highly vulnerable to infection and inflammatory reactions.

I. Vulnerability to infections and risk of periodontal diseases.2

It is a known fact that different oral diseases and diabetes is interconnected such as salivary and taste dysfunction, oral bacterial and fungal infections (i.e., candidiasis), and oral mucosa lesions (i.e., stomatitis, geographic tongue, traumatic ulcer, lichen planus, etc.).7

Reduced saliva secretion also increases risk of gum diseases in diabetes. This is because saliva is known to prevent bacterial growth and avoids sticky foods to form plaque.6,7

When microorganisms interact with patient’s susceptibility along with environmental factor, this results in increased risk of periodontal diseases.7

During infection the periodontal tissues gets damaged in the presences of oral bacteria via. the action of matrix-degrading enzymes and various molecules impacting the host cells.7

The bacteria and the lipopolysaccharides released from it, when accumulates in the periodontal connective tissue this leads to progression from gingivitis to periodontitis.7

This triggers the immune system to produce interleukins and tumor necrosis factor (TNF) which further initiates inflammatory process.7

At the same time, the ability for the damaged tissue to repair is impaired due to the presence of cytokines which may cause further destruction to the tooth & bone.7

Figure 2: Etiology and pathogenesis of periodontal diseases.

Figure 2: Etiology and pathogenesis of periodontal diseases.

II. Vulnerability to inflammatory reaction and risk for periodontal diseases.

The pathogenic processes that link the two diseases are the upregulated inflammation as a by-product from each condition adversely affects the other. Diabetes increases the deposition of advanced glycation end-products (AGEs) in the periodontal tissues, and interactions between AGEs and their receptor (RAGE, the receptor for AGEs, found particularly on macrophages), which leads to activation of local immune and inflammatory responses.3,5,7

These upregulated responses lead to increased secretion of interleukin-1β (IL-1β), tumour necrosis factor-α (TNF-α), and IL-6, and increased oxidative stress.3,7

These factors result in local tissue damage, increased breakdown of the periodontal connective tissues and resorption of alveolar bone, thus worsening periodontitis. Adiposity and pro-inflammatory adipokines further contribute to the pro-inflammatory environment.3,7

In patients with both periodontitis and diabetes, there is elevated levels of circulating TNF-α, C-reactive protein (CRP) and markers of oxidative stress but there were marked reductions in the levels of these mediators following periodontal treatment.3,7

Figure 3: How diabetes mellitus could contribute to the development of periodontal disease

Figure 3: How diabetes mellitus could contribute to the development of periodontal disease.7

TNF: Tumor necrosis factor; IL-1β: Interleukins 1β; AGE: Advanced glycosylation product; RAGE: Receptors AGE.

Consequences of untreated periodontitis

Periodontitis when left untreated, there is a cumulative reaction between the bacteria/bacterial markers and pro-inflammatory mediators that enters the circulation to upregulated systemic inflammatory state.3

This gives rise to impaired insulin signalling and increased insulin resistance which results in elevated HbA1c levels and increased risk of complication in the diabetic patients.3

Hence, threating periodontal condition not only reduces the inflammation but also reduces the bacterial load thereby, reducing complications.3

Figure 4: Potential mechanisms linking periodontitis and diabetes, and the impact of periodontal therapy on diabetes control.3 Key: CRP, C-reactive protein; HbA1c, glycated haemoglobin; IL-6, interleukin-6; TNF-α, tumour necrosis factor-α

Figure 4:  Potential mechanisms linking periodontitis and diabetes, and the impact of periodontal therapy on diabetes control.3

Key: CRP, C-reactive protein; HbA1c, glycated haemoglobin; IL-6, interleukin-6; TNF-α, tumour necrosis factor-α

Management of Periodontitis in diabetes

Keeping blood glucose levels under good control will help to prevent gum disease developing or spreading. Using an antiseptic mouthwash can help reduce bacteria and plaque build-up, but it cannot be considered as a replacement for tooth cleaning as it can mask more serious damage. In some cases, scaling may be required to remove tartar.8

Antimicrobial therapy showed a ~11% improvement in HbA1c level. There is also a significant reduction in the number of microorganisms in periodontal pockets (P <0.01), and there was also a significant reduction in the number of circulating TNF-alpha level (P <0.015).8

Summary

Patients with diabetes have a higher risk of developing periodontal diseases. Care should be taken to keep the blood glucose level in check and to maintain a good oral hygiene. Controlling diabetes is the only way to reduce the intensity of periodontal diseases among diabetes patients.

Tips for counselling diabetic patients with periodontal diseases

It is important for a diabetic patient with periodontal diseases to keep a close eye on their glycaemic levels.9

Things to follow9

  • Avoid acidic drinks like soda, energy drinks and water with lemon. These can erode the enamel of your teeth, which can lead to decay
  • Good oral hygiene, including brushing the teeth twice daily (morning and last thing at night),
  • Flossing three times a week or using interdental brushes regularly
  • Stopping smoking if necessary.
  • Use of a zinc-based toothpaste to control gingivitis symptoms

Tell your dentist that you have diabetes.9

  • Tell your dentist about any changes in your health or medicines.
  • Share the results of some of your diabetes blood tests, such as the HBA1C or the fasting blood glucose test.
  • Ask if you need antibiotics before and after dental treatment if your diabetes is uncontrolled.

 

Reference

  1. Deshpande K, et al. Diabetes and periodontitis J. Indian Soc Periodontol. 2010 Oct-Dec; 14(4): 207–212.
  2. Diabetes and Periodontal Disease | Perio.org [Internet]. Perio.org. [cited 8 June 2020]. Available from: https://www.perio.org/consumer/gum-disease-and-diabetes.htm
  3. Preshaw PM et al,. Periodontitis and diabetes. BDJ Team. 2020 May; 7:27–35. 
  4. Preshaw PM, et al. Periodontitis and diabetes: A two-way relationship. Diabetologia. 2012 Jan;55(1):21-31.
  5. Rajhans NS, et al. A clinical study of the relationship between diabetes mellitus and periodontal disease. J Indian Soc Periodontol 2011;15:388-92.
  6. Negrato CA et al. Buccal alterations in diabetes mellitus. Diabetol Metab Syndr. 2010; 2: 3.
  7. Llambés F et al.  Relationship between diabetes and periodontal infection. World J Diabetes. 2015 Jul 10; 6(7): 927–935.
  8. Iwamoto Y, et al. The Effect of Antimicrobial Periodontal Treatment on Circulating Tumor Necrosis Factor-Alpha and Glycated Hemoglobin Level in Patients With Type 2 Diabetes. Journal of Periodontology. 2001;72(6):774-778.
  9. Diabetes, Gum Disease, & Other Dental Problems | NIDDK [Internet]. National Institute of Diabetes and Digestive and Kidney Diseases. 2020 [cited 12 February 2020]. Available from: https://www.niddk.nih.gov/health-information/diabetes/overview/preventing-problems/gum-disease-dental-problems

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