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Diabetes and gum disease

Johnson & Johnson is delighted to bring you this article, with the aim of supporting the ongoing CPD needs of dental healthcare professionals in improving and maintaining the oral health of their patients.

This article is equivalent to one hour of Enhanced CPD. To provide feedback on this article, please contact dentalcpd@its.jnj.com

Aims and objectives

The aim of this article is to provide evidence-based information on the two-way potential effect of diabetes and gum disease, and offer guidance on preventive recommendations based on high-quality study results to support dentists trying to help such afflicted patients.

On completing this CPD session, the reader will:

• Understand that systemic diseases – including diabetes – have an effect on oral health

• Understand the mechanism linking diabetes and periodontal disease

• Understand the current guidelines for patient care

• Understand the role of improved oral health as part of efforts to improve general health

• Understand how to communicate the oral health need to patients effectively.

Diabetes and gum disease

This article provides evidence-based information on the two-way potential effect of diabetes and gum disease, and offer guidance on preventive recommendations based on high-quality study results to support dentists trying to help such afflicted patients.

According to the World Health Organization, diabetes is increasing.1 In 2014, 422 million adults were living with diabetes compared to 108 million in 1980.1

It has also been established that systemic diseases – including diabetes – have an effect on oral health.2 As Cullinan and colleagues (2009) wrote: ‘A large number of epidemiological studies have now linked poor oral health with cardiovascular diseases, poor glycaemic control in diabetics, low birthweight preterm babies and a variety of other conditions. The majority have shown an association, although not always strong. As a result, a number of meta analyses have been conducted and have confirmed the associations and at the same time cautioned that further studies are required, particularly with regard to the effect of periodontal treatment in reducing risk.’2

The two-way mechanism

Such is the weight of evidence linking diabetes and periodontal disease that the latter is considered the sixth complication of diabetes, alongside retinopathy, nephropathy, neuropathy, macrovascular disease and poor wound healing.2 Indeed, patients with diabetes are between two and three times more likely to develop chronic periodontitis that those who are not diabetic.3

What then, is the mechanism to which this link may be attributed? Taylor and colleagues (2013) offer a starting point, stating: ‘Diabetes is the pathological consequence of a number of physiological changes and the resulting metabolic dysregulation, hyperglycaemia and chronic inflammation potentially impact on tissue integrity and repair.’4

Looking at the two-way relationship between gum disease and diabetes, Preshaw and colleagues (2012) explained: ‘Diabetes increases inflammation in the periodontal tissues. For example, gingival crevicular fluid (GCF; a fluid exudate that flows from the gingival margins) levels of PGE2 [a prostaglandin] and IL-1β [interleukin 1] are higher in type 1 diabetic patients with either gingivitis or periodontitis compared with those in non-diabetic individuals with the same level of periodontal disease. In a study of type 2 diabetic patients, those with HbA1c* >8% had a significantly higher GCF IL-1β level compared with patients with HbA1c <8%, and both HbA1c and random glucose were independent predictors of an elevated GCF IL-1β level.’5

Overall, as suggested by Engebretson and Kocher (2013): ‘On the basis of this and previous systematic reviews and meta-analysis, that compare the effects of periodontal therapy on diabetes outcomes, it may be concluded that a consistent albeit moderate treatment effect size on HbA1c has been observed across studies as a result of periodontal therapy in subjects with type 2 diabetes. This analysis of newly available data has demonstrated a statistically significant effect of periodontal therapy on HbA1c similar to that observed in past systematic reviews.’3

Patient care

That same year, Chapple and Genco (2013) reported back from a working group that had met to evaluate the available evidence base for, ‘[…] the periodontal disease–diabetes paradigm […]’, with the aim of providing guidelines for patient care.6

They created the following guidance for dental professionals:

•‘Patients with diabetes should be told that they are at increased risk for periodontitis. They should also be told that if they suffer from periodontal disease, their glycaemic control may be more difficult, and they are at higher risk for other complications such as cardiovascular and kidney disease.

•‘Patients presenting with a diagnosis of type 1, type 2 or gestational diabetes should receive a thorough oral examination, which includes a comprehensive periodontal evaluation.

•‘If periodontitis is diagnosed, it should be properly managed. If no periodontitis is diagnosed initially, patients with diabetes should be placed on a preventive care regime and monitored regularly for periodontal changes.

• ‘Patients with diabetes presenting with any acute oral/periodontal infections require prompt oral/ periodontal care.

• ‘Patients with diabetes who have extensive tooth loss should be encouraged to pursue dental rehabilitation to restore adequate mastication for proper nutrition.

• ‘Oral health education should be provided to all patients with diabetes.

• ‘Patients with diabetes should also be evaluated for other potential oral complications, including dry mouth, burning mouth and candida infections.

• ‘For children and adolescents diagnosed with diabetes, an annual oral screening for early signs of periodontal involvement is recommended starting at the age of 6 years.

• ‘Patients who present without a diabetes diagnosis, but with obvious risk factors for type 2 diabetes and signs of periodontitis should be informed about their risk for having diabetes, assessed using a chair-side HbA1C test, and/or referred to a physician for appropriate diagnostic testing and follow-up care.’6

Communicating all of this information in a way that patients can understand may seem daunting to the dental healthcare professional, however the European Federation of Periodontology offers helpful guidance in this matter. Easy-to-understand messages may include:

‘At a recent meeting of top experts in dental and diabetes research from around the world, scientists looked closely at all the latest research into diabetes and gum disease to reach an agreement on, and to find a new understanding of how these two diseases might affect one another. They found that:

• ‘In people with diabetes, those who have severe gum disease have higher blood sugar levels (measured by a test called HbA1c), compared with those with healthier gums

• ‘Even [if] you don’t have diabetes, your body’s control of blood sugar levels is not as good as it should be when you have severe gum disease

• ‘The worse the gum disease, the more likely a person is to go on to suffer damage to other organs in their body because of their diabetes – for example, heart or kidney disease

• ‘Having severe gum disease might actually increase your chance of getting type 2 diabetes.’7

A holistic view

Offering an overview of the situation, Cullinan and colleagues (2009) stated: ‘[…] a recent consensus review by physicians and dentists recommended that education to encourage improved oral health should be part of efforts to improve general health, as this is likely to reduce the burden of cardiovascular disease and diabetes. If oral health is considered as part of general health, it follows that dental and medical care should be more closely integrated and that health education to encourage improved oral health should be included with the current healthy lifestyle messages, alongside smoking cessation, diet and exercise. The current evidence is such that prevention and treatment of periodontal disease may reduce chronic systemic disease risk at both the individual and community level. The dental profession, therefore, has an important role in ensuring that oral disease does not contribute to systemic disease in any individual.’2

Specifically in relation to diabetes, Yuen and colleagues (2009) offered the following advice: ‘Health professionals have the opportunity to educate patients with diabetes about oral […] complications (e.g., periodontitis and oral candidiasis) of diabetes and to promote proper oral health behaviors. They should provide appropriate special oral care information and advise concerns related to dental hygiene. In addition to the routine education of patients with diabetes about the importance of proper oral hygiene and receiving regular professional dental care, health professionals should educate patients about oral complications related to diabetes and measures that can be taken to prevent these oral complications […].’8

What we do know is that regular hygiene appointments combined with an effective home care regimen is of paramount importance for healthy teeth and gums over the long term, and that good oral health may help with good overall health.9

* HbA1c refers to glycated haemoglobin (A1c), which identifies average plasma glucose concentration.10

QUESTIONS: 

References

  1. Global report on diabetes. World Health Organization 2016

  2. Cullinan MP et al. Periodontal disease and systemic health: current status. Australian Dental Journal 2009; 54:(1 Suppl): S62-S69

  3. Engebretson S, Kocher T. Evidence that periodontal treatment improves diabetes outcomes: a systematic review and meta-analysis. Clin Periodontol 2013; 40 (Suppl. 14): S153-S163

  4. Taylor JJ et al. A review of the evidence for pathogenic mechanisms that may link periodontitis and diabetes. J Clin Periodontol 2013; 40 (Suppl. 14): S113–S134

  5. Preshaw PM et al. Periodontitis and diabetes: a two-way relationship. Diabetologia 2012; 55: 21–31

  6. Chapple ILC, Genco R. Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Clin Periodontol 2013; 40 (Suppl. 14): S106–S11

  7. Diabetes and gum disease. European Federation of Periodontology 2013; https://www.bsperio.org.uk/userfiles/DIABETES_GUM_DISEASE.pdf

  8. Yuen HK et al. Oral health knowledge and behavior among adults with diabetes. Diabetes Research and Clinical Practice 2009; 86: 239-246

  9. Simpson W. Oral Infections and the link to overall health. Microreviews in Cell and Molecular Biology 2012; 1(1): 1-3

  10. http://www.diabetes.co.uk/what-is-hba1c.html. Accessed 27 July 2017