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. 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. 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. 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).
Periodontal disease is the fifth most preventable health problem among Australians, affecting almost one quarter (24.2%) of adults aged 18 years and over. It is the most common cause of tooth loss among the adult population and studies illustrate that by age 65 and over 50% of the Australian population will experience periodontal disease to some degree. Studies demonstrate that diabetics have a significantly higher rate of Periodontal disease than healthy individuals.,, 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., 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.,, Evidence illustrates that those patients with periodontitis show a significantly higher prevalence (two times) of diabetes than those without.
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. 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.”
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). 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. Diabetes may also cause dry mouth, which subsequently reduces the natural defences the saliva provides to our gums. 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.
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. 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. Medication associated in managing this has also been associated with significantly decreased saliva production, further exacerbating the periodontal condition.
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. Furthermore, exposure to second-hand smoke has been connected to a 50%-60% increased risk for developing periodontal disease.
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.  Furthermore, research suggests that individuals who maintain good diabetes control have a reduced risk of periodontal disease compared to individuals with poor diabetes management.
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. 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.
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