The Bidirectional Relationship between Periodontitis and Diabetes: How Should Patients Affected by Either or Both These Diseases be Managed?

This summary is based on a series of articles published in the Journal of Clinical Periodontology (2013, 40 Supplement 14)

• Anne Beaudin;  McGill University, Montréal, Québec
• Andrea Hsu;  Private office, Montreal, Quebec
• Christopher M. Nguyen; McGill University, Montréal, Québec
• JW Martin Kim; Private office, Richmond, British Columbia
• Simon D. Tran; McGill University, Montréal, Québec

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Context

Diabetes, a chronic inflammatory disease, is one of the major public health burdens of our contemporary society. There are two types of diabetes mellitus: Type I, when the pancreas makes little or no insulin, and Type II, which makes up most of diabetes cases and occurs through a decompensatory mechanism with cells gradually ceasing to respond to insulin.

In understanding the pathogenesis of this complex inflammatory disease, it is important to evaluate other potential risk factors affecting diabetes control and contributing to its complication, such as periodontitis. Periodontal diseases include a reversible form, gingivitis, and an irreversible form, periodontitis. As a whole, periodontal diseases can be found in over 90% of people.

The link between periodontitis and diabetes has been defined as a bidirectional relationship, though the synergistic impact of periodontitis and diabetes on each other is not fully understood. With an increasing subset of the population affected by either or both these conditions, practitioners must however be aware of the clinical implications in order to adapt their treatments based on their patients’ risks.

Purpose of the Review

Periodontitis and diabetes are multifactorial inflammatory diseases that appear intertwined in a bidirectional relationship. The fact that poor periodontal outcomes result from hyperglycemia in diabetes has been recognized for a long time (Fig 1).  This is achieved by impairing immune response, thickening of blood vessels, altering microvascular healing, and ultimately interfering with wound repair and remodelling, thus promoting periodontal disease progression. There are also emerging evidences that periodontitis has a negative impact on glycaemia in both diabetics and non-diabetics (Fig 2). Meanwhile, periodontitis increases systemic inflammation resulting in increased insulin resistance. The presence of a chronic subclinical inflammation leads to elevated haemoglobin A1c, rendering glycemic control more challenging for diabetic patients.

This review aims at providing clinicians with the latest evidences reported on the link between periodontitis and diabetes. While it may be premature to outline specific clinical recommendations to practitioners, a few basic clinical guidelines have been delineated and should be considered when treating patients with diabetes and/or periodontitis.

Key Messages

A few general clinical guidelines should be considered when treating patients with diabetes and/or periodontitis. Treatment considerations should include the following:

1. Diagnosis of patient’s periodontal condition;

Potential oral/periodontal exacerbation in diabetic patients: xerostomia, burning mouth syndrome, increase risk of infection, delayed healing, periodontal abscess, periodontitis, gingival inflammation, oral candidiasis

2. Medical consultation of patients suspected of undiagnosed diabetes or poorly controlled diabetes;

1. Diagnosis (Type 1 or Type 2), duration of diabetes and treatment history
2. Level of glycemic control (ideal HbA1c <7%)
3. Medications (consideration of drug interaction and medical emergencies)
4. Other risk factors for periodontitis contributing to diabetic complications

3. Education of patients regarding the bidirectional relationship of periodontal disease and diabetes, particularly of the impact of periodontal disease on glycemic control and of potential diabetes-related complications;

4. Periodontal therapy and patient motivation to develop and maintain optimal periodontal health; 

1. Be mindful of potential medical emergencies (insulin shock, diabetic keto-acidosis)
2. Stress-reduction treatment approach
3. Adjunctive use of antibiotics in patient with poor glycemic control to minimize risks of infection
4. Rapid treatment in case of acute oral or periodontal infections

5. Routine follow-up to monitor periodontal health as part of patient’s ongoing management of diabetes

Figure 1: Possible pathways linking diabetes to adverse periodontal outcomes

Figure 2: Possible pathways linking periodontitis to adverse glycemic outcomes and potentially to the development of diabetes Type 2

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