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Sugar isn’t always sweet: The connection between diabetes mellitus and periodontal disease.

The connection between diabetes mellitus and periodontal disease
While the connection between diabetes mellitus (commonly referred to as diabetes) and cardiovascular events is well established, emphasis is now being placed on dental clinicians to educate the public on the strong link between Diabetes and oral health. Diabetes is internationally considered to be one of the most prevalent and highest burdens on the modern health system of the developed world. The World Health Organisation estimates that up to 347 million people worldwide have diabetes while also projecting that by 2030, diabetic-related mortality will have doubled.[13] Therefore, it is imperative that dentists adhere to good practice principles by educating the community on the co-morbidities of diabetes, including (but not limited to) periodontal disease, xerostomia (dry mouth), hypogeusia (impaired or loss of taste) and others. For the purpose of this article, we will focus on the influence of periodontal disease.

Type 1 diabetes is a chronic disease involving an auto-immune attack on the pancreas, consequently resulting in a lack of insulin production. Type 2 diabetes develops when the body is unable to effectively use the insulin produced, usually due to lifestyle choices causing obesity which can inadvertently damage the pancreas and other organs associated with metabolism.[14] The body’s inability to produce or effectively use insulin leads to elevated blood glucose levels (hyperglycaemia) which can result in life-threatening consequences if not managed correctly. Diabetes can cause harm to a number of organs and systems within the body, but what is less commonly recognised is the risk that diabetes poses to oral health.[15] Periodontal disease is often referred to as the sixth complication of diabetes subsequent to heart disease, peripheral vascular disease, nephropathy (kidney pathologies), neuropathy (nerve pathologies) and ophthalmopathy (eye pathologies).[16]

Periodontal disease is the fifth most preventable health problem among Australians[17], affecting almost one quarter (24.2%) of adults aged 18 years and over.[18] It is the most common cause of tooth loss among the adult population[19] and studies illustrate that by age 65 and over 50% of the Australian population will experience periodontal disease to some degree.[20] Studies demonstrate that diabetics have a significantly higher rate of Periodontal disease than healthy individuals.[21],[22],[23] Susceptibility to periodontitis is increased by approximately threefold in people with diabetes and a clear relationship between severity of periodontitis and degree of hyperglycaemia has been identified.[24],[25] Furthermore, evidence supports the existence of a two-way relationship between periodontitis and diabetes; with inflammation of the periodontium having adverse effects on glycaemic control while diabetes causes a more uncontrolled immune response to bacteria in the periodontium.[26],[27],[28] Evidence illustrates that those patients with periodontitis show a significantly higher prevalence (two times) of diabetes than those without.[29]

Two decades ago, researchers at Columbia University’s Mailman School of Public Health studied a representative sample of 9,000 individuals with an absence of diabetes. By the conclusion of the study, 817 individuals had developed the disease. It was established that participants who presented with periodontitis were almost two times more likely to develop diabetes within 20 years, even after accounting for risk factors such as age, smoking, obesity and diet.[30] According to Dr. Dremmer, associate research scientist in the Department of Epidemiology at Columbia University’s School of Public Health, “These results support the view that periodontitis contributes to the development of diabetes.”[31]

Periodontal disease is the fifth most preventable health problem among Australians

The link between Diabetes and periodontal disease:

Among the numerous effects diabetes has on bodily functions and processes, dysregulation of the immune system renders individuals prone to infections. This has been linked to abnormal activities of immune cells known as interleukins and macrophages, crucial to our ability to fend off foreign invaders (e.g. bacteria, viruses, and fungal species).[32] Common variants of periodontal disease (plaque related gingivitis and periodontitis) are also affected by this break down in innate defences, resulting in more aggressive bodily responses to the same level of plaque healthy individuals may have. Where a healthy individual cleaning their teeth to a moderate degree may have mild forms of gingivitis, the same level of oral hygiene practice in a person with diabetes may produce a much more severe form of gingivitis or even periodontitis.[33] Diabetes may also cause dry mouth, which subsequently reduces the natural defences the saliva provides to our gums.[34] Although periodontitis is manageable, the damage it causes to the supporting structures of our teeth is irreversible. Common signs and symptoms of periodontitis include pronounced recession of the gums, loss of gums filling the spaces between teeth, pronounced bad breath, mobility and movement of teeth, more frequent pus involved infections of the gums and eventual loss of the teeth.[35]

Diabetics will frequently incur periodontal disease to a greater severity than healthy individuals. The severity of a patient’s diabetes is directly correlated to the severity of the immune system dysregulation and consequently that of periodontal disease.[36] Diabetes may be one of few conditions known today in which its damage to the body will begin a cycle which continually worsens the illness, spiralling out of control. As teeth become more mobile, are lost, or the mouth becomes drier, our ability to eat more nutritious, unprocessed foods may deteriorate. Consumption of more refined foods will make diabetic control more difficult and decrease the body’s ability to fend off infections, resulting in more aggressive forms of periodontitis. Further deterioration in diabetic control will also affect numerous other bodily functions (e.g. eye sight, movement, control of bowel movements and urination) and may result in depression due to loss of quality of life.[37] Medication associated in managing this has also been associated with significantly decreased saliva production, further exacerbating the periodontal condition.[38]

The single major preventable risk factor for periodontal disease is smoking. Diabetics who smoke have increased blood-sugar levels and less control over these levels compared to a non-smoking diabetic. Smoking slows the body’s healing process as well as exponentially increasing the risk of an individual developing periodontal disease. Studies have established that diabetic smokers aged 45 and over will increase their chance of developing periodontal disease by twenty times more than a diabetic non-smoker.[39] Furthermore, exposure to second-hand smoke has been connected to a 50%-60% increased risk for developing periodontal disease.[40]

Treatment and prevention:

Studies illustrate that treating periodontal disease may lower the risk or prevent the development of diabetes. It is possible that intensive treatment of periodontal disease could improve blood flow, therefor markedly reducing inflammation throughout the body. [41] Furthermore, research suggests that individuals who maintain good diabetes control have a reduced risk of periodontal disease compared to individuals with poor diabetes management.[42]

Diabetes has the ability to negatively affect an individual’s health in numerous ways and increases the risk for many serious health problems. However, with the correct prevention such as recommended lifestyle changes and appropriate treatment methods, many people with diabetes are able to delay or prevent the onset of associated complications.[43] Oral and periodontal health should be encouraged as essential components of diabetes management.

The simplest way to decrease the risk of periodontal disease is by maintaining good oral hygiene. Regular brushing and flossing of teeth and gums using the correct techniques will help prevent plaque build-up, the number one cause of periodontitis. By identifying and treating in the early stages, progression into more severe stages of periodontitis and loss of teeth can be prevented. It is therefore imperative for individuals with diabetes to visit the dentist at least twice yearly. Early detection and management of periodontal disease is crucial to preventing tooth mobility and loss, as well as countless other failures in day to day function resulting from diabetes. Responsibilities of the dentist in this setting include education on diet and oral hygiene, managing periodontal and other oral conditions where present, scheduling regular review appointments, recommending relevant products to help reduce relapse of the disease, and referral to appropriate medical specialists to help in overall management of diabetes.

  • Schedule biannual dental check-ups (including a comprehensive periodontal examination) and inform your dentist that you have diabetes.
  • Morning appointments are most suitable for diabetics due to optimal insulin levels.
  • Work with your medical practitioner to monitor diabetic control and inform your dentist of any changes in your medical history or trouble controlling your blood sugar levels.
  • Opt to have dental x-rays done at least every 18 months.
  • Education on oral hygiene maintenance is extremely important – being well informed about the importance of oral hygiene increases the likelihood that individuals will focus more positively on their oral health.
  • Brushing teeth at least twice daily for two minutes using the technique recommended by your dentist will help remove bacteria and plaque.
  • Flossing teeth after brushing will help remove additional plaque and food particles from the teeth that a toothbrush cannot reach.
  • Use antibacterial mouth wash for added protection against plaque build-up.
  • Maintain a healthy diet and healthy eating patterns.


1. The Global Diabetes Community, Causes of diabetes, (accessed October 6, 2015).

2. World Health Organization [WHO], About diabetes, (accessed 25 September, 2015).

3. Ibid

4. National Diabetes Services Scheme, Gestational diabetes, (accessed October 6, 2015).

5. WHO, About Diabetes, 2015.

6. Harald Loe, “Periodontal disease: the sixth complication of diabetes mellitus,” Diabetes Care 16, no. 1 (1993): 329.

7. Sandra Senzon, Reversing gum disease naturally: a holistic home care program (New Jersey: John Wiley & Sons, Inc, 2003), 9.

8. Marc Lazare, Dr. Lazare’s the patients guide to dentistry (USA: Trafford Publishing, 2011), 48.

9. Jill Shiffer Nield-Gehrig and Donald E. Villmann, Foundations of periodontics for the dental hygienist, 2nd ed. (Baltimore: Lippincott Williams & Wilkins, 2008), 41.

10. Nkem Obiechina, Understanding periodontitis: a comprehensive guide to periodontal disease for dentists, dental hygienists and dental patients (Bloomington: Author House, 2011), 8.

11. Sudeep Kothai et al., “Periodontal chip: an adjunct to conventional surgical treatment”, International Journal of Drug Research and Technology 2, no.6. (2012): 411.

12. Ellershaw and Spencer, Dental attendance patterns, 36

13. World Health Organization, World Diabetes Day 2014,, (accessed September 2, 2015).

14. Debora C. Matthews, “The relationship between diabetes and periodontal disease,” Journal of the Canadian Dental Association 68, No. 3 (2002): 161.

15. National Institute of Dental and Craniofacial Research, Diabetes: dental tips, (accessed August 06, 2015).

16. Andrew Kaga, M.D., Type 2 diabetes: Social and scientific origins, medical complications and implications for parents and others (North Carolina: McFarland & Company, Inc, 2010), p. 200.

17. Sergio Chrisopoulos., & Jane Harford., Australian Institute of Health and Welfare, Australian Research Centre for Population Oral Health, Oral health and dental care in Australia: key facts and figures 2012, Cat. No. DEN 224. Canberra: AIHW.

18. Australian Institute of Health and Welfare 2010, Socioeconomic variation in periodontitis among Australian adults 2004-06, Research report series no. 50. Cat. No. DEN 207. Canberra: AIHW.

19. National Institute of Dental and Craniofacial Research, Periodontal (gum) disease, (accessed September 2, 2015).

20. Sergio Chrisopoulos., Kate Beckwith., & Jane Harford, Australian Institute of Health and Welfare, Australian Research Centre for Population Oral Health, Oral health and dental care in Australia: key facts and figures 2011, Cat. No. DEN 214. Canberra: AIHW.

21. T. C. Simpson et al., “Treatment of periodontal disease for glycaemic control in people with diabetes,” Australian Dental Journal 55, (2010): 473.

22. Nkem Obiechina, Understanding periodontitis: a comprehensive guide to periodontal disease for dentists, dental hygienists and dental patients (Bloomington: Author House, 2011), 37.

23. Lazare, Dr. Lazare’s guide, 51-52.

24. P.M. Preshaw, “Periodontitis and diabetes; a two- way relationship,” Diabetologia 55, No.1. (2012): 25.

25. Tammy Davenport, Diabetes and gum disease – what’s the connection?,, (accessed September 2, 2015).

26. P.M. Preshaw, Periodontitis and diabetes, 25.

27. David P. Cappelli & Connie Chenevert Mobley, “Biological and chemical indicators of disease risk,” in Prevention in clinical oral health care, ed. David P. Cappelli & Connie Chenevert Mobley (Missouri: Mosby Inc, 2008).

28. Tara Parker-Pope, “Gum disease signals diabetes risk”, The New York Times Company, August 7, 2015,, (accessed September 2, 2015).

29. Robert Hirsch, “Diabetes and periodontitis,” Australian Prescriber 27, No. 2. (2004): 36.

30. Tara Parker-Pope, Gum disease signals diabetes risk, 2015.

31. NKC Dental, Your oral health affects your overall health,, (accessed September 2, 2015).

32. Dana T. Graves & Tayyan A. Kayal, “Diabetic complications and dysregulated innate immunity,” Frontiers in Bioscience 1, No.13 (2008): 1227-1239.

33. Academy of General Dentistry, How does diabetes affect oral health?, (accessed October 7, 2015).

34. Riva Touger-Decker and David A. Sirois, “Dental care of the person with diabetes,” in Handbook of diabetes medical nutrition therapy, ed. Margaret A. Powers (Maryland: Aspen Publishers, Inc, 1996), p.640.

35. Ellershaw and Spencer, Dental attendance patterns, 36

36. P.M. Preshaw, Periodontitis and diabetes, 25.

37. The global diabetes community, How does diabetes affect the body?, (accessed October 6, 2015).

38. Riva Touger-Decker “Dental care of the person with diabetes,” 1996.

39. Healingwell, Diabetes and periodontal disease: a guide for patients, (accessed October 6, 2015).

40. American Accreditation HealthCare Commission, “Periodontitis,” The New York Times, November 3, 2013, (accessed October 6, 2015).

41. Nicholas Bakalar, “Dental health: treating gum disease may ease other ailments,” The New York Times, March 27, 2007,, (accessed September 2, 2015).

42. Diabetes Research and Wellness Foundation, Periodontal disease and diabetes,, (accessed September 2, 2015).

43. American Diabetes Association, Living with diabetes: Complications, (accessed August 10, 2015).

Article Definitions

Type 1 diabetes (T1D):
Most commonly develops in childhood and adolescence and is typically triggered by an underlying genetic disposition, viral or bacterial infection, chemical toxins within food or an unidentified component which causes an autoimmune reaction.[1] The body’s immune system destroys the cells that produce insulin in the pancreas, resulting in patients requiring lifelong use of insulin injections. Without these injections patients would not survive.[2]

Type 2 diabetes (T2D):
Typically develops in adulthood as a result of a poor diet, obesity, lack of physical activity or a genetic disposition. This form of diabetes is the most common and consists of 90% of diabetes cases worldwide. Treatment can vary but usually involves lifestyle changes e.g. eating and exercise, weight loss, oral medication and in some extreme cases insulin injections.[3]

Gestational diabetes:
Occurs when the body is unable to cope with the extra demand for insulin production during pregnancy, ultimately resulting in high blood glucose levels. This condition develops among 5-8% of pregnant women, resembles type 2 diabetes in a number of ways and is easily managed. There are a number of risk factors that increase the likelihood of developing this condition such as family history of gestational diabetes, sufferers of polycystic ovary syndrome, obesity and previously giving birth to a large baby weighing over 9lb. Furthermore, research illustrates that 5-10% of women develop diabetes (most commonly type 2) after experiencing gestational diabetes.[4] Additional forms of diabetes: Includes congenital, cystic fibrosis-related and several forms of monogenic diabetes may also develop as a result of long term corticosteroid use.[5]

Periodontal disease: (gum disease)
An umbrella term ascribed to pathological conditions which involves the supporting structures of teeth (i.e. gums and/or bone) which are together referred to as the Periodontium.[6],[7] This process occurs when the immune system responds to excess bacterial build-up within the mouth, usually from lack of oral hygiene.[8] Periodontal diseases are categorized into two principal stages – gingivitis and periodontitis.[9]

Involves inflammation of the gums (scientifically referred to as gingiva) but does not involve the underlying bone support. Common signs of gingivitis include bleeding of gums, deep red/blue colour, and bad breath. The term gingivitis is derived from Latin; gingiva – gums, itis – inflammation.

Involves the inflammation, damage and finally loss of the alveolar bone and gums supporting teeth due to an immune reaction to bacterial invasion of the periodontal ligament.[10] As it progresses the alveolar bone is destroyed, forming space between the teeth and gum known as periodontal pockets.[11] The most common signs that an individual is suffering from periodontitis are gum bleeding (upon contact or spontaneous), recession or the appearance of teeth becoming longer, periodontal pockets, loose teeth and in the most severe cases loss of attachment.[12] Although periodontitis is manageable, the damage it causes to the supporting structures of our teeth is irreversible. The term periodontitis is also derived from Latin; periodontium – supporting structures of the tooth, itis – inflammation.

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