Diabetes and periodontitis.

Diabetes mellitus is a major health problem that affects approximately 18 million people in the United States. (1) Periodontal disease and other oral cavity problems commonly are associated with diabetes. Also, blood glucose levels are persistently elevated above recommended levels. Multiple studies have conclusively demonstrated a link between diabetes mellitus and periodontal disease in humans. (2,3)

Poorly controlled diabetic patients are much more likely to suffer from periodontitis, gingivitis and other problems of the oral cavity than are well-controlled diabetic or nondiabetic patients. Irregular dental visits, poor oral hygiene and smoking tended to be more common among study subjects with poor glucose level control.

Severe periodontitis may be an important risk factor in the progression of diabetes, and control of periodontal infection may be essential to achieve long-term diabetic control. Since diabetes is a risk factor for periodontal disease, the possibility that periodontal disease either predisposes or exacerbates the diabetic condition has received more attention.

Recently, a model has been presented that postulates that periodontal disease increases the severity of diabetes and complicates metabolic control. (4) This model proposes that the combination of infection and advanced glycogen end-product (AGE)-mediated cytokine up-regulation may explain the increase in tissue destruction seen in diabetic periodontitis and also may explain how periodontal infection may complicate the severity of diabetes and the degree of metabolic control.

Diabetics are more likely to develop periodontal disease than nondiabetics, (5) and the severity of the periodontal disease is usually related to the duration of the diabetes (6,7) as measured by the glycosylated hemoglobin. The concentration of glycosylated hemoglobin in serum is a direct function of the time that hemoglobin is exposed to elevated glucose levels. (8)

A longitudinal study of diabetes and periodontal disease has been carried out in members of the Pima tribe, an American Indian population that has an approximately 50% prevalence of non-insulin-dependent. (9) This is the highest reported prevalence of non-insulin-dependent diabetes in the world. Poor glycemic control was defined as the occurrence of glycosylated hemoglobin of 9%-or-more at follow-up. Poorly controlled diabetes resulted in significant increases in the depth of periodontal pockets, attachment loss and gingival inflammation in patients without prior periodontitis. Thus, periodontally healthy patients with poor oral hygiene and poorly controlled diabetes may be at greater risk for the initiation and/or progression of periodontitis. (10) The results indicated that severe periodontitis may be an important risk factor in the progression of diabetes, and that the control of periodontal infection is essential to achieve long-term control of diabetes mellitus.

References

(1.) Centers for Disease Control and Prevention. National Diabetes Fact Sheet: General Information and National Estimates on Diabetes in the United States, 2002. Atlanta, Georgia: US Dept of Health and Human Services, Centers for Disease Control and Prevention; 2003.

(2.) Cianciola LJ, Park BH, Bruck E, Mosovich L, Genco RJ. Prevalence pf periodontal disease in insulin-dependent diabetes mellitus (juvenile diabetes). J Am Dent Assoc 1982;104:653-660.

(3.) Schlossman M, Knowler WC, Pettitt DJ, Genco RJ. Type 2 diabetes mellitus and periodontal disease. J Am Dent Assoc 1990;121:532-536.

(4.) Grossi SG, Genco RJ. Periodontal disease and diabetes mellitus: a two-way relationship. Ann Periodontol 1998;3:51-61.

(5.) Papapanou PN. Periodontal disease: epidemiology. Ann Periodontol. 1996;1:1-36.

(6.) Hugoson A, Thorstensson H, Falk H, Kuylenstierna J. Periodontal conditions in insulin-dependent diabetics. J Clin Periodontol 1989;16:215-223.

(7.) Thorstensson H, Hugoson A. Periodontal disease experience in adult long-duration insulin-dependent diabetics. J Clin Periodontol 1993;20:352-358.

(8.) Scannapieco FA. Position paper of the American Academy of Periodontology: periodontal disease as a potential risk factor for systemic diseases. J Periodontol. 1998;69:841-850.

(9.) Knowler WC, Pettit DJ, Saad MF, Bennett PH. Diabetes mellitus in the Pima Indians: risk factors and pathogenesis. Diabetes Metab Rev. 1990:6:1-27.

(10.) Cutler CW, Machen RL, Jotwani R, Iacopino AM. Heightened gingival inflammation and attachment loss in type 2 diabetics with hyperlipidemia. J Periodontol. 1999;70:1313-1321.

For more information on this topic, visit www.diabetes.org and click on the tab for health professionals and scientists. This will connect you for further information on Professional Meetings and Education, Resources for Professionals, Clinical Practice Recommendations, Professional Membership, Journals, Books of Professionals, Diabetes Research, Recognition Programs, Latino Health Care and other topics.

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By Joe Knight, PA-C 

Joe Knight is a family practice Physician Assistant and a medical and science writer in Fresno, California. His medical interests include academic dentistry and sport medicine.