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Diabetes and Periodontal Disease: an Update for Health Care Providers

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Diabetes and Periodontal Disease: an Update for Health Care Providers In Brief Periodontitis has been identified as the sixth complication of diabetes. FROM RESEARCH TO PRACTICE / ORAL HEALTH AND DIABETES Advanced glycation end-products, altered lipid mechanisms, oxidative stress, and systemically elevated cytokine levels in patients with diabetes and peri- odontitis suggest that dental and medical care providers should coordinate therapies. Diabetes and Periodontal Disease: An Update for Health Care Providers Inflammation of the Periodontium dence of loss of tooth support that is Periodontitis is a chronic inflamma- often seen as spreading of teeth result- G. Rutger Persson, DDS, PhD tory disease of the mouth that involves ing in open spaces between the teeth (Odont Dr) the gingiva (gum tissues), teeth, and (diastemas). Despite similar plaque supporting bone. Periodontitis is clini- scores (bacterial deposits), patients cally defined as the loss of connective with poorly controlled type 2 diabetes tissue attachment to the teeth and display more severe gingival bleeding alveolar bone loss. If periodontitis is compared to those with diabetes in left untreated, the involved teeth will good or moderate control.2 Patents exfoliate. with poorly controlled type 2 diabe- In many cases, periodontitis is the tes are at greater risk for periodontal second stage of an inflammatory pro- disease progression than patients with cess that begins with gingivitis. From well-controlled type 2 diabetes.3 a clinical perspective, gingivitis pres- Treatment of chronic periodon- ents with swollen tissues and increased titis usually includes oral hygiene redness but with no loss of connective instructions, information on the role tissue attachment between root sur- of diet, and professional cleaning of faces and bone. The inflammatory cell the teeth and gum tissues using hand infiltrate in gingivitis is dominated by instruments or ultrasonic devices. In a polymorphonuclear neutrophil infil- trate (acute inflammation), whereas addition, antibacterial mouth rinses, the histopathology of periodontitis is local or systemic antibiotics, and sur- dominated by a plasma cell infiltrate (chronic inflammation).1 The clinical signs of periodontitis include swelling, redness and bleeding from the gums, spacing between teeth, loose teeth, and exposure of root sur- faces through loss of bone around the teeth. The disease can present locally, involving a few teeth, or be more gen- eralized. Figure 1 shows the severity of gingival inflammation in a patient Figure 1. Example of severe peri- who had received initial periodon- odontitis in an African-American tal non-surgical treatment 3 months patient with uncontrolled dia- before the photo was taken. betes (A1C > 9.0%) who has not In patients with a systemic disease responded to initial periodontal such as diabetes, the disease is often therapy. Notice the extent of spacing more generalized. Patients with poor between teeth and the severe inflam- glycemic control often present with mation (redness of gum tissues) and severely inflamed gum tissues and evi- dental plaque (bacterial deposits). Diabetes Spectrum Volume 24, Number 4, 2011 195 gical intervention may be included in periodontal therapy. Prevalence of Gingivitis and Periodontitis in Relation to Diabetes The prevalence of periodontitis in the United States is subject to controversy. Current data suggest that the preva- lence of periodontitis has decreased across ethnicity, sex, and age-groups to < 10%.4 Different interpretations of the same data suggest, however, that up to 50% of U.S. adults may suffer from various degrees of periodontitis.5 The prevalence of periodonti- tis is significantly higher among middle-aged people with diabetes than in similar-aged people without diabetes.6 Analysis of data from the third National Health and Nutrition Examination Survey has revealed that a self-reported family history of dia- betes, hypertension, high cholesterol, and clinical evidence of periodontal disease bears a probability of 27–53% that the patient has undiagnosed dia- betes.7 Analysis of periodontal status in people with type 1 or type 2 diabe- Figure 2. Levels of select bacteria associated with periodontitis in periodon- tes from a population-based German tal pockets of subjects without a diagnosis of diabetes and in subjects with study has demonstrated an association type 2 diabetes. A similar severity of periodontitis, but with lower bacterial between both types of diabetes and counts, was identified in subjects with diabetes for A. actinomycetemcomi- tooth loss.8 tans serotype Y4 (A.a (b) Y4), P. gingivalis, T. forsythia, and T. denticola, all Attention to oral disease in addi- associated with periodontitis. tion to medical conditions by both medical and dental care providers will than any other organ. Teeth provide a with periodontitis have a lipopolysac- improve the ability to identify individ- nonshedding surface with a complex charide (LPS) capsule with endotoxins uals unaware of their diabetic status. biofilm containing bacteria that are and heat-shock proteins. Pretreatment Dentists should establish referral pat- in balance with the host, but bacterial profiles of serum antibody titers to terns, communicate with physicians, species with high virulence can also different heat shock proteins and LPS and use dental screening as a tool for be identified. levels from Porphyromonas gingiva- referral of patients with severe gin- Periodontitis has a complex infec- lis, an anaerobe commonly found in gival or periodontal inflammation.9 tious etiology, and the establishment periodontitis lesions, can predict the It would be advantageous if blood of infection is usually slow. A bacterial outcome of periodontal therapy in glucose assessments were performed biofilm of both aerobic and anaero- patients with diabetes such that those in dental offices for patients at risk bic bacteria, including > 500 species, with elevated titers have a more favor- for type 2 diabetes. Likewise, physi- may be found in periodontal pockets able treatment outcome.14 cians should refer patients with type around teeth.11 Bacteremia is rarely Unpublished data based on 282 2 diabetes to dentists for treatment of identified in periodontitis. However, subjects, among whom 9.3% had gingival or periodontal inflammation. endotoxins from bacteria identified type 2 diabetes with similar severity This is especially important because in periodontal pockets and associ- of periodontitis, suggest that patients the pathophysiology of periodontal ated with periodontitis can be found with type 2 diabetes may have fewer inflammation is not limited to the oral in serum in > 30% of nondiabetic bacteria in periodontal pockets but cavity and can have important effects patients who present with early signs the same severity of disease. These on glycemic control. Indeed, periodon- of periodontitis.12 data suggest that the inflammatory titis has been identified as the sixth In general, the bacterial infec- response to infection in people with complication of diabetes.10 tion in periodontitis does not differ type 2 diabetes is more severe than in between nondiabetic patients and nondiabetic subjects (G.R.P, unpub- Pathophysiology of Periodontitis as a those with type 2 diabetes. However, lished observations). This may be Complication of Diabetes the immune response to periodon- explained by a lack of ability to pro- The oral cavity, as part of the gas- tal bacterial infection does differ in duce functional antibodies against trointestinal tract, is populated by that patients with type 2 diabetes do bacteria in periodontal infection. a diverse and large microbiota and not develop antibodies to pathogens This is illustrated in the diagram in has been identified as a location with associated with periodontitis.13 Many Figure 2, which includes four bacterial a more dense bacterial colonization of the anaerobic bacteria associated species associated with periodontitis. 196 Diabetes Spectrum Volume 24, Number 4, 2011 This observation is consistent with the oxidative stress.22 Clinical data have about the need for good oral health. general perception of an increased sus- suggested that the presence of AGEs Referral of patients with uncontrolled FROM RESEARCH TO PRACTICE / ORAL HEALTH AND DIABETES ceptibility to infection among patients in patients with diabetes is associated diabetes for dental evaluation and with type 2 diabetes. with the biofilm on teeth, indicat- periodontal treatment may result in Periodontal infections trigger the ing an increased risk for periodontal better control of blood glucose levels. release of pro-inflammatory cytokines damage.23 Although a survey of the oral cav- both at the site of the periodontal ity should be included in a thorough infection and throughout the endothe- Impact of Periodontal Therapies on medical examination, health care lial cell system.15 Studies of gingivitis Glycemic Control providers other than those within the in humans with or without type 1 From a Cochrane-based review, 24 dental team usually are not aware of diabetes have shown that both dia- the authors concluded that there what clinical signs of periodontitis betic and nondiabetic subjects react is some evidence of improvement to consider. An increased redness of to experimental plaque accumulation in metabolic control in people with the gum tissues along the teeth is a with gingival inflammation. However, diabetes after treatment of periodon- classic sign of gingivitis, a condition subjects with type 1 diabetes develop tal disease but also recognized that that indicates
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