Diabetes and periodontal health.

With the growing number of individuals having diabetes, it is likely that most dental practitioners will see patients with this disease more frequently. Therefore, it is not unlikely that in the near future, the daily schedule of patients may include at least one person with diabetes.

Course Objectives

Upon completion of this course the dental professional reader should be able to:

1. Define diabetes

2. Explain the difference between type 1 and type 2 diabetes

3.List the groups of people with a higher prevalence of diabetes

4. List the symptoms of diabetes

5. List the life threatening complications of diabetes

6. Explain what is important in evaluating patients with diabetes

7. Explain the impact of diabetes on periodontal disease

8. Explain the proper home management self-care plan for the patient with diabetes

Course Outline

I. Facts About Diabetes

II. Types of Diabetes

III. Symptoms of Diabetes

IV. Evaluating Patients with Diabetes

V. Impact on Periodontal Disease

VI. Home Irrigation

VII. Managing Periodontal Disease

VIII. Conclusion

IX. References

X. Test Questions

Facts About Diabetes

Diabetes afflicts 16.2 million people in the United States. That is about 6.3 percent of the population; 5.2 million of these individuals are presently undiagnosed and 1.3 million people will be diagnosed this year--or about 2,200 per day. Diabetes is the sixth leading cause of death. It is a chronic disease with no cure. (11) An additional 41 million individuals have prediabetes. Testing is recommended for everyone over the age of 45. Younger adults who are overweight, have a family history of diabetes, high cholesterol, high blood pressure, had gestational diabetes, gave birth to a baby over nine pounds, or are of a racial minority should also be tested; There are certain groups of people who have a higher prevalence of diabetes. These groups include: (1)

* Seniors (60 years          18.3%
of age and older)

* African Americans          25%
(65-74 years of age)

* Native Americans           14.5%

* Mexican Americans          24%
(45-74 years of age)

* Puerto Ricans              26%
(45-74 years of age)

* Cuban Americans            16%
(45-74 years of age)

Types of Diabetes

Type 1 diabetes is caused by destruction of the insulin producing Beta cells of the pancreas. This results in an insulin deficiency. Type 1 requires daily insulin intake and generally has an abrupt onset. This type accounts for 5%-10% of diabetes. (1)

Type 2 diabetes is caused by impaired insulin function resulting in insulin resistance and is sometimes combined with relative insulin deficiency. Onset of symptoms for type 2 is generally gradual and often related to obesity. This type accounts for 90%-95% of diabetes. (1)

Symptoms of Diabetes

Diabetics may exhibit the following symptoms: (1)

* Frequent urination

* Excessive thirst

* Extreme hunger

* Unusual weight loss

* Increased fatigue

* Irritability

* Blurry vision

However, many people with type 2 diabetes have no symptoms at all.

Life-Threatening Complications

Diabetes is a disease to take seriously. Each year, 12,000-24,000 people with diabetes lose their sight. It is the leading cause of end-stage renal (kidney) disease with 27,900 cases per year. Also, 56,000 per year face limb amputations making it the most frequent cause of nontraumatic lower limb amputations. People with diabetes are 24 times more likely to have heart disease or stroke--more than 77,000 deaths per year. (1)

Evaluating Patients with Diabetes

Initially, it is important to discern what type of diabetes the patient has as well as how long the disease has been present. This applies to both adults and children as younger individuals with a history of obesity are developing type 2 diabetes. (2) With some rare exceptions, such as gestational diabetes, which generally only lasts through pregnancy, (1) most patients should distinguish their disease as type 1 or 2. Age of onset and duration of the disease should be noted. (2)

The type of medication the patient takes should be recorded. Generally speaking, a patient who only takes oral medications is most likely type 2. However, those with type 2 may also need insulin injections. Therefore, confirmation by the physician may be necessary. In addition to type, ask patients about compliance, monitoring, most recent testing and results. (2)

Complications are a serious and life-threatening consequence of diabetes. (1,2) The incidence and severity of periodontal disease may present along with these complications, and has sometimes been considered an additional diabetic complication. (3)

Impact on Periodontal Disease

While the presence of diabetes has been shown to increase a person's risk for periodontal disease, (3,4) it is metabolic control that has been established as playing the most important role. (5,6)

In those whom diabetes is uncontrolled or poorly controlled, there is generally more attachment and alveolar bone loss resulting in more severe periodontal disease. (6,7)

Poor metabolic control has been shown to affect the patients' immune response making them more susceptible to periodontal disease. (5,6) Those with poor metabolic control often have prolonged hyperglycemia. (3,6) This state produces the formation of Advanced Glycation End Products, called AGEs. (3,8) This alters the response of the immune system by:

* Impairing polymorphonuclear leukocyte (PMN) functioning (3)

* Enhancing expression of inflammatory mediators such as cytokines (3,9)

* Increasing production of oxygen free radicals (3,8)

Home Irrigation Shown to Help in the Management of Individuals with Diabetes

A recent study has shown that individuals with diabetes who added twice daily water irrigation to their oral care routine improved both oral and systemic health parameters better than those who only brushed and flossed. (10)

The 12-week clinical trial consisted of 56 subjects with either type 1 or type 2 diabetes (for at least one year and on the same medication for at least six months) and moderate to advanced periodontal disease (pockets ranging from 5 mm-8 mm). Both groups received ultrasonic scaling and root planing. Each group was then assigned to a self-care routine consisting of either routine oral hygiene only or routine oral hygiene plus twice daily water irrigation with the Pik Pocket[R] subgingival irrigation tip. (10)

At 12 weeks, the following outcomes were observed from baseline: (10)

Periodontal Parameters:

* The irrigation group had significantly better reductions in plaque, gingivitis, and bleeding on probing in comparison to routine oral hygiene group

* Both groups had similar reductions in probing depth and gains in clinical attachment

Systemic Parameters:

* Both groups had numerical improvements in glycated hemoglobin measurement (HbA1C); there was no statistical difference between the groups

* The irrigation group had statistically significant improvement in reactive oxygen species (ROS) generation over the control group

* The irrigation group had significant improvements in the serum cytokine levels of IL-1[beta] and PG[E.sub.2]. The control group had an improvement for IL-1[beta] only.

The superior reduction in periodontal outcomes for the irrigation group was anticipated as numerous studies over the last 40 years have demonstrated the ability of home irrigation to improve oral health above and beyond that of routine oral hygiene. (11-17) What has been less firmly established is how improvements in oral health affect systemic health parameters. The design of this study examines that link. Individuals with diabetes may have prolonged hyperglycemia, which stimulates a process of inflammatory tissue destruction. Two components of this destructive process are the generation of ROS (also called oxygen free radicals) and pro-inflammatory cytokines. (3,8)

In this study, the greater reduction in clinical parameters correlated to a greater reduction in the expression of both oxygen free radicals and pro-inflammatory cytokines. (3,8) These findings lead the researchers to conclude that the inclusion of subgingival water irrigation as an adjunctive therapy may have a cumulative positive influence in regaining periodontal tissue health in diabetic individuals.

Managing Periodontal Disease in Diabetic Patients

Many individuals with diabetes are unaware of the oral health implications of their disease. (18) Regular professional oral care and self-care is critical for all patients with diabetes. It is up to the dental team to educate the patient about the link between diabetes and periodontitis. (19) Relating periodontal findings to diabetes provides the patient with a concrete example of the impact of diabetes on oral health. Depending on metabolic control and periodontal disease status, frequent periodontal maintenance visits may be required.(2)

Type 1 or 2 patients with good glucose control can be treated similarly to healthy individuals. For individuals who are uncontrolled or poorly controlled, medical clearance should be given before periodontal therapy, including scaling and root planing. (2,7) Research has shown that individuals with poor control may initially respond well to therapy, but the results are short term. A return to deep pockets leads to a less favorable long-term response to therapy. (7)

Ideally, a self-care plan should be tailored to the patient's individual needs. Patients with diabetes may experience more gingivitis and deeper probing depths due to an impaired immune response. (7) Because of this, people with diabetes need meticulous self-care.

Powered devices such as toothbrushes, flossers and oral irrigators may need to be a first choice rather than optional consideration for many patients with diabetes. The use of all three devices by a patient can provide a multipronged approach in fighting periodontal disease. Power brushes and flossers are effective in removing plaque and reducing gingivitis and bleeding. (20) However, for maximum patient benefit, the addition of oral irrigation can further enhance gingivitis and bleeding on probing reductions (10-14,16,17) as well as control subgingival bacteria (12,15) and modify the host immune response (10,11) (see Figures 1 and 2). Importantly, these devices are readily available at variable prices making them affordable for most patients.

Conclusion

Treating patients with diabetes will be a continuing challenge for many oral health practitioners. Current knowledge about diabetes will be critical. The American Diabetes Association can provide both patients with diabetes and health care practitioners with the most current information. They can be found on the Internet at www.diabetes.org. The American Academy of Periodontology also has position statements and publications with information on treating patients with diabetes and on the relationship between diabetes and periodontal disease. They too can be found on the web at www.perio.org.

TEST QUESTIONS: Diabetes and Periodontal Health

1. --diabetes results in an insulin deficiency.

A. Type 1

B. Type 2

2. Which of the following is/are symptoms of diabetes?

1. Irritability

2. Decreased urination

3. Increased thirst

4. Hunger

A. 2, 3, and 4

B. 1, 2, and 4

C. 1, 3, and 4

D. All of the above

3. --diabetes is caused by impaired insulin function causing insulin resistance.

A. Type 1

B. Type 2

4. Which of the following is/are a life-threatening complication of diabetes?

1. Amputations

2. Kidney disease

3. Heart Disease

4. Stroke

A. 1 and 3

B. 2 and 4

C. 3 and 4

D. All of the above

5. In evaluating a patient it is important to determine what type of diabetes the patient has as well as how long the disease has been present.

A. True

B. False

6. Uncontrolled or poorly controlled diabetics generally have more periodontal attachment and alveolar bone resulting in less severe periodontal disease.

A. True

B. False

7. Poor metabolic control has been shown to affect patients' immune response making them more susceptible to periodontal disease.

A. True

B. False

8. Which of the following can benefit a diabetic patient by reducing gingivitis and bleeding on probing?

1. Power Flossers

2. Power Oral Irrigators

3. Power Toothbrushes

4. Oral Irrigation

A. 1 and 3

B. 2 and 4

C. 1, 2, and 4

D. All of the above

9. Diabetes is the second leading cause of death.

A. True

B. False

10. Which of the following group of people have the highest prevalence of diabetes?

A. Puerto Ricans

B. Seniors

C. African Americans

D. Native Americans

Please note: There is an administrative fee of $8 to cover a portion of grading and publication costs. This fee MUST accompany the test when it is submitted for grading. Use answer sheet opposite. APPROVED FOR ONE CONTINUING EDUCATION CREDIT-ADAA Members Only

Glossary

Cytokines--a class of immunoregulatory substances (as lymphokines) that are secreted by cells of the immune system.

Diabetes--a group of diseases characterized by high levels of blood glucose resulting from defects in insulin production, insulin action or both.

Glycation--the uncontrolled, nonenzymatic reaction of sugars with protein. Chemical glycation is also very important in the damage done to people with diabetes when their sugar levels rise above normal and in damage done to critical proteins of long-lived nerve cells in aging.

Hyperglycemia--abnormal increased content of sugar or glucose in the blood.

Periodontal Disease--various diseases that affect the periodontium, especially gingivitis and periodontitis.

Periodontitis--inflammation of the periodontium that involves alveolar bone loss and deepening of the gingival sulcus (pocket).

Polymorphonuclear Leukocyte (PMN)--small actively motile white blood cells containing many lysosomes and specializing in phagocytosis.

Type 1--a form of Diabetes Mellitus that usually develops before age 20 and is characterized by a severe deficiency in insulin secretion resulting from atrophy of Islets of Langerhans.

Type 2--common form of Diabetes Mellitus that generally develops in adults but may occur in children and adolescents. Most often seen in obese individuals. It is characterized by Hyperglycemia resulting from impaired insulin utilization coupled with the body's inability to compensate with increased insulin production.

References

(1.) National Diabetes Fact Sheet. The American Diabetes Association. Available at www.diabetes.org. Accessed June 1, 2004.

(2.) Rees T. Periodontal management of the patient with diabetes mellitus. Periodontology 2000; 23(1):63-72.

(3.) Nishimura F et al. Periodontal disease as a complication of diabetes mellitus. Ann Periodontol 1998; 3(1):20-29.

(4.) Grossi Set al. Assessment of risk for periodontal disease. I. Risk indicators for attachment loss. J Periodontol 1994; 65(3):260-67.

(5.) Soskolne WA. Epidemiological and clinical aspects of periodontal disease in diabetics. Ann Periodontol 1998; 3(1): 312.

(6.) Taylor GW. Glycemic control and alveolar bone loss progression in Type 2 diabetes. Ann Periodontol 1998:3(1): 30-39.

(7.) Mealy B et al. Position paper: Diabetes and periodontal disease. J Periodontol 2000; 71(4):664-78.

(8.) Lalla E et al. Enhanced interaction of advanced glycation end products with their cellular receptor RAGE: Implications for the pathogenesis of accelerated periodontal disease in diabetes. Ann Periodontol 1998 3:13-19

(9.) Salvi GE et al. PGE2, IL-1beta and TNF-alpha responses in diabetics as modifiers of periodontal disease expression. Ann Periodontol 1998; 3(1):40-50.

(10.) Al-Mubarak Set al. Comparative evaluation of adjunctive oral irrigation in diabetics. J Clin Periodontol 2002; 29:295-300.

(11.) Cutler CW et al. Clinical benefits of oral irrigation for periodontitis are related to reduction of pro-inflammatory cytokine levels and plaque. J Clin Periodontol 2000; 27:134-43.

(12.) Chaves ES et al. Mechanism of irrigation effects on gingivitis. J Periodontol 1994; 65: 1016-21.

(13.) Newman MG et al. Effectiveness of adjunctive irrigation in early periodontitis: Multicenter evaluation. J Periodontol 1994; 65:224-29

(14.) Flemmig TF et al. Adjunctive supragingival irrigation with acetylsalicylic acid in periodontal supportive therapy. J CIin Periodontol 1995; 22:427-33.

(15.) Flemmig TF et al. Supragingival irrigation with 0.06% chlorhexidine in naturally occurring gingivitis I: six-month clinical observations. J Periodontol 1990; 61:112-17.

(16.) Lobene RR. The effect of a pulsed water pressure cleansing device on oral health. J Periodontol 1969; 40:51-54.

(17.) Burch et al. A two-month study of the effects of oral irrigation and automatic toothbrush use in an adult orthodontic population with fixed appliances. Am J Orthod Dentofac Orthop 1994;106: 121-26.

(18.) Moore PA et al. Diabetes and oral health promotion: A survey of disease prevention behaviors. JADA 2000; 131(9):1333-41.

(19.) Lyle DM. Diabetes: A Risk Factor for Periodontal Disease. J Practical Hyg 2001; 10:11-16.

(20.) Jahn CA. Automated oral hygiene self-care devices: Making evidence-based choices to improve client outcomes. J Dent Hyg 2001; 75(2):171-89.

Carol Jahn has a BS in dental hygiene from the University of Iowa and an MS in Continuing Education and Training Management from the University of St. Francis. As the Educational Programs Manager for Waterpik Technologies Carol designs multimedia educational programs for dental professionals. She is a nationally recognized speaker having provided more than 100 continuing education courses. Additionally, she has published 20 papers and contributed to three textbooks.