Download the connection between periodontal disease and diabetes

THE CONNECTION BETWEEN
PERIODONTAL DISEASE AND DIABETES
Jeffrey A. Sibner, DMD
In America, more than 9% of the adult population is diabetic, representing more that
21 million people. Alarmingly, the incidence of diabetes is increasing, with more than
half a million more cases diagnosed in 2002 than in 1998[1]. Periodontal disease is even
more widespread, with more that 80% of Americans 65 years or older suffering from
some form of the disease[2]. It is not surprising that problems that affect such large
numbers often overlap, and there is a growing body of evidence that the two diseases are
more harmful in combination.
DIABETES
Diabetes is classified into two types – insulin dependant and insulin resistant. Insulin
dependant diabetes is referred to as Type 1, and usually first appears in adolescents and
young adults. In this form of the disease, the body destroys β-cells that are stored in the
pancreas. Type 2 diabetes accounts for roughly 85-90% of all diabetics. This form is
more insidious than Type 1, and affects a much older population. Type 2 diabetes can
often come on slowly over a period of years so that many people are unaware that they
are diabetic.
Diabetes affects much more than the way our bodies use and process sugar. It effects
our ability to heal properly and can result in long-term problems with chronic infection.
The disease effects the way blood vessels function, in both the large vessels near the heart
and in the very small vessels in our muscles and organs. The American Diabetes
Association (ADA) lists eye, kidney, nerve and gum problems as known complications of
diabetes.
There is a large body of evidence that suggests patients with diabetes have an
increased chance of having more advanced forms of periodontal disease. Various studies
have shown that diabetics develop periodontal disease earlier (even as teenagers), more
often and to a greater degree than non-diabetics[3]. One study showed a 300% increase in
the likelihood of developing periodontal disease in subjects with diabetes.[4]
How does Diabetes affect gum disease??? Altered glucose metabolism affects many
of the cells responsible for wound healing.
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Gum tissues are stimulated to over-react to the bacteria that cause periodontitis.
This results in an exaggeration in the amount of bleeding and swelling.
The equilibrium between cells that create and remove bone is altered in favor of
the cells that destroy bone.
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Small blood vessels in the gum tissue exhibit the same problems that are seen in
diabetics that have retinopathy (eyes) or nephritis (kidneys).
PERIODONTAL DISEASE
Periodontal disease is one of the most prevalent diseases that affects adults
worldwide. The earlier stages of periodontitis are characterized by inflamation of the
gums, while moderate to advanced periodontal disease is marked by loss of the bone that
holds teeth in place. Between 7 and 15% of adults have signs of severe periodontitis.2
Periodontal disease is caused by bacteria and the body’s reaction to these bacteria.
Because this reaction is responsible for many of the problems associated with the disease,
some people are more prone to developing periodontal disease than others. This is why
once someone has been diagnosed with gum disease, they are much more likely to
develop an acute form of the disease again.
Our understanding of gum disease has changed markedly over the last 10 years. In
the 1980's and 90's, periodontitis was considered a local disease where the body mounted
a response to bacteria lying in the “pocket” between the gum tissue and the tooth. Our
current understanding is that periodontal disease has far reaching consequences and can
increase the likelihood of diabetes, heart disease, stroke, high blood pressure and adverse
pregnancy outcomes.
Because periodontal disease causes inflamation of the surrounding gum tissues,
chemical messengers such as C-Reactive Protein (CRP), Interluken-6 (IL-6) and
fibrinogen are produced. These circulate throughout the body and “arm” the body to
defend against bacteria and other sources of inflamation. Newspapers and magazines
have recently had many articles written about the link between periodontal disease, CRP
and heart attacks.
How does periodontal disease affect diabetes? Chronic inflamation caused by
periodontal bacteria can lead to an increase in insulin resistance because of endotoxins
released by the bacteria. White blood cells respond to bacteria and produce cytokines,
factors known to increase insulin resistance. In fact, changes to white blood cells that
occur with diabetes can cause an even higher production of these cytokines than normal.
Periodontal disease can directly effect the diabetic condition. In one study,
participants with severe periodontal disease had 6 times the risk of losing control of their
blood sugar than subjects with healthy gums.[5] In another study, participants were 4
times more likely to suffer from one of the known complications of diabetes, such as
kidney or eye disease, than diabetics without gum disease.[6]
Treating Diabetics with Periodontal Disease
It is apparent that diabetes and gum disease are linked – what helps one disease may
influence the other. Many studies have shown that when periodontal disease is treated,
HbA1c levels and blood sugar control may improve. Levels of the inflammatory markers
like CRP, and cytokines like TNF-α, and IL-6 often improve as well. Studies have also
shown that improved control of blood sugar can influence the extent of bone loss and
inflamation associated with gum disease. In one large study, poorly controlled diabetics
had nearly 3 times the risk of bone loss than their well-controlled counterparts.[vii]
Because diabetics have poor wound healing, characterized by altered white blood cell
response to bacteria, dysfunctional small blood vessels and increased bone destruction,
they require a different level of dental care:
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More aggressive treatment of active gum disease, including pocket and bleeding
reduction
Use of local and systemic antibiotics
Nutritional supplements to strengthen the immune system and replace vitamins
Frequent maintenance appointments to prevent re-emergence of infection
Increased time spent on oral hygiene instruction and site specific problem solving
Active monitoring of casual glucose, HbA1c and CRP levels
Better Communication between dental and medical professionals
A Word About Nutritional Supplements
One of the hallmarks of inflammatory disease is oxidative stress. In diabetes, this is
the result of glucose intolerance and the many cellular changes that result. In periodontal
disease, oxidative stress is caused by toxins released by bacteria, as well as by chemicals,
such as hydrogen peroxide, released by white blood cells reacting to the bacterial
invasion. Infection and oxidative stress also deplete our reserves of many important
vitamins. It is essential to replace these vitamins and provide a source of antioxidants to
allow the immune system to function better. This is not just conjecture! Many studies
have shown antioxidants - particularly grape seed extracts, vitamins and minerals have
positive effects on both diabetes[8][9] and periodontal disease.[10]
[1]. Mealey, BL & Oates, TW. Diabetes Mellitus and Periodontal Diseases, J
Periodontol, 2006; 77:1289-1303
[2]. Wayne DB, Trajtenberg CP, Hymen DJ. Tooth and Periodontal Disease - A
Review for the Primary Care Physician, Southern Medical J 2001;94(9):925-932
[3]. Kirwan JP, Varastehpour A, Jing M, et al. Reversal of insulin resistance
postpartum is linked to enhanced skeletal muscle insulin signaling. J Clin Endocrinol
Metab 2004; 89:4678-4684
[4]. Cutler CW, Machen RL, et al. Heightened gingival inflammation and attachment
loss in type 2 diabetics with hyperlipidemia. J Periodontol 1999;70:1313-1321
[5]. Taylor, GW, Buret BA, Becker MP, et al. Severe periodontitis and resk for poor
glycemic control in patients with non-insulin-dependant diabetes mellitus. J
Periodontol 1996;67:1085-1093
[6]. Thorstensson H, Kuylensteirna J, Hugoson A. Medical status and complications
in relation to periodontal disease experience in insulin-dependent diabetics. J Clin
Periodontol 1996;23:194-202
[7]. Tsai C, Hayes C, Taylor GW. Glycemic control of type 2 diabetes and severe
periodontal disease in the U.S. adult population. Community Dent Oral Epidemiol
2002;30:182-192
[8]. Kar P, Laight D, Shaw KM, Cummings MH. Flavonoid-Rich Grapeseed Extracts: A
New approach in high cardiovascular risk patients? Int J Clin Pract. 2006;
60(11):1484-1492
[9]. Zhang FL, Gao HQ, et al. Selective inhibition by grape seed proanthocyanidin
extracts of cell adhesion molecule expression induced by advanced glycation end
products in endothelial cells. J Cardiovasc Pharmacol. 2006;48(2):47-53
[10]. Houde, V, Grenier D, Chandad F. Protective effects of grape seed
proanthocyanidins against oxidative stress induced by lipopolysaccharides of
periodontopathogens, J Periodontol 2006; 77(8):1371-9
For more information, please see our web pages on Periodontal Management of the
Diabetic Patient and the Periodontal Disease Resource Center.