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. 

• 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.

• 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:

• 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]