Periodontitis is the chronic inflammation of the oral cavity involving the gum, teeth and the supporting bone. Since it appears to have a similar pathophysiology as other microvascular complications of diabetes it can be considered to be the fourth chronic microvascular complication of diabetes mellitus. There is a three-fold increase in risk of periodontal disease among patients with diabetes mellitus. Periodontitis in diabetes is associated with increased myocardial infarctions, strokes and renal related complications, poor glycaemic control and an increase in the risk of dying of cardiorenal causes. However, treatment of periodontal disease has been demonstrated to improve glucose control and reduce inflammatory markers.
Improvements in periodontal health among patients with diabetes mellitus can be achieved with better oral health education, oral examination in diabetic clinics during regular visits and annual dental examinations by qualified dentists. Dental treatments for periodontal infections include mechanical disruption of the pathogenic biofilm using scaling and planing, use of systemic antibiotics to treat refractory pathogens and specialized dental surgery in advanced disease.
Keywords: Periodontitis, gingivitis, periodontal disease, diabetes mellitus, type 2 diabetes mellitus, type 1 diabetes mellitus, orocrinology, oral health, oral examination
Periodontal disease can be considered as a fourth chronic microvascular complication related to altered lipid metabolism, advanced glycated end products and oxidative stress that accompany chronic hyperglycaemia in patients with diabetes mellitus. Periodontitis is defined as a chronic inflammation of the oral cavity that involves the gum (gingiva), tooth and the supporting bone. In early stages when the inflammation is limited to the gums it is called gingivitis (Figure 1A & B).1
Examination of the oral cavity (“orocrinology”) is an important part of the clinical assessment of patients with diabetes mellitus and was recently summarized by us as an easy to understand seven step process.2 Clinically gingivitis presents with redness, swelling and tendency to bleed from the gums. With periodontitis there is an increase in the spaces between teeth with loosening of the teeth from the socket (Figure 1C). In more advanced disease the roots of the teeth are exposed due to loss of bone (Figure 1D).1
Bidirectional relationship between diabetes and periodontitis
Diabetes mellitus and chronic periodontal disease are both highly prevalent chronic conditions. A large number of epidemiological studies have established that periodontitis is more prevalent, is more severe and more progressive among patients with type 1 and type 2 diabetes mellitus.3 The increase risk of periodontitis is further increased with an increased duration of diabetes mellitus and with poor glycaemic control.4 In United States the increased risk of prevalence of periodontitis in patients with diabetes has been suggested to be 2.9-fold.5
Among patients with diabetes and concurrent periodontitis there is an increased risk of diabetes related complications including coronary heart disease, strokes, progression of diabetic renal disease and death.6 Patients with advanced periodontitis have difficulty in achieving blood glucose targets. Patients with type 1 diabetes and concurrent periodontitis have poorer glycaemic control and an increased risk of diabetic ketoacidosis and development of microvascular complications.7
Impact of treatment of periodontitis on diabetes mellitus
A metanalysis which included nine controlled studies suggested that treatment of periodontitis can potentially improve HbA1c levels by 0.7%.8 This is similar to what is noted in placebo-controlled trials of most oral diabetic agents. However, a subsequent Cochrane review concluded that despite current evidence suggesting improvement in metabolic control with treatment of periodontitis this evidence was weak because of the lack of statistical power from available studies.9 Though there are studies suggesting improvement in highly sensitive C-reactive protein and other inflammatory markers after treatment of periodontal disease there are no studies suggesting improvement in hard cardiovascular outcomes after periodontal treatment.10
Treatment of Periodontal disease in patients with Diabetes
1. Oral health education
Similar to foot care education, oral health education should be an integral part of diabetes care. Regular brushing, interdental cleaning and dental consultation should be encouraged as part of a standard of care in management of diabetes mellitus. The link between periodontitis and chronic vascular complications should be explained. The role of the oral cavity as a gateway to, and as a mirror of, overall health, must be emphasized. Home-based oral care, such as antiseptic mouthwashes, subgingival irrigation and dentifrices, should be used only under the supervision of a qualified dental care professional.
2. Dental Evaluation
All persons with diabetes should get a regular, annual dental checkup as we do currently with annual ophthalmology examination. Occult infections, including gingivitis and periodontitis, can be a cause of uncontrolled hyperglycaemia. Hence, patients with refractory diabetes should be strongly encouraged to visit the dentist. Additionally, persons with oral ulcers, bleeding gums and painful teeth must be referred for dental evaluation.
3. Mechanical Therapy
Traditionally dentists use non-surgical scaling and root planing (SRP) in dental clinics to interrupt the biofilm in periodontitis. The interruption of the biofilm reduces the virulence of the micro-organisms present and helps the patients to establish better periodontal health. Studies have suggested these simple therapies improve glycaemic control in patients with concurrent diabetes and periodontitis.1
4. Antibiotic therapy
Patients not responding to SRP, presence of periodontal abscess, presence of necrotizing periodontitis or those with advanced periodontitis require antibiotic therapy. Commonly used antibiotics include tetracycline, doxycycline, metronidazole, penicillin, cephalosporins, macrolides and ciprofloxacin.
5. Surgical treatment
Patients with advanced periodontitis need dental surgery including pocket reduction surgery, soft tissue grafting, bone grafting etc. Details on those are beyond the scope of this review.
6. Improving glycaemic control
There is no evidence that strict metabolic control in itself improves established periodontal disease without specific periodontal treatment. However, there is plenty of evidence that periodontal treatment is more effective when combined with improvements in glucose control.12
Oral examination and annual dental examination should be part of standard of care among patients with diabetes mellitus. There is an increase in the risk of periodontal disease among patients with diabetes mellitus. Untreated periodontal disease can impact glucose control and also the chronic inflammatory state than accompanies chronic periodontitis increases the risk of cardiovascular disease, renal disease and death. Treatment of periodontal disease which includes mechanical scaling and planing, use of systemic antibiotics and periodontal surgery leads to improvements in glucose control and inflammatory milieu.
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