Reporting Template for Diabetes Prevention Pilot. December, 2002 We are having weekly diabetes prevention meetings that serve to collectively …
Clinical Update
Naval Postgraduate Dental School
National Naval Medical Center
8901 Wisconsin Ave
Bethesda, Maryland 20889-5600
|Vol 29, No 1 | 2007 |
Diabetes mellitus and periodontal disease: a two-way street through health
and disease
Lieutenant Commander John H Wilson, DC, USN and Commander Matthew J
Gramkee, DC, USN
Introduction
Diabetes Mellitus DM affects roughly 12 million people in the US; as many
as half of these people may be unaware of their condition Two forms of the
disease exist Type I DM formerly Insulin Dependent Diabetes Mellitus is
a result of destruction of the Islet of Langerhan cells in the pancreas,
resulting in a lack of endogenous insulin production Type II DM formerly
Non-Insulin Dependent Diabetes Mellitus comprises 85-90 of diabetes
cases, and is a result of impaired insulin receptors on the target cells1
Periodontal disease includes a spectrum of plaque-induced, inflammatory
conditions affecting
gingiva, cementum, and alveolar bone Estimates of the
prevalence of gingivitis in the US range from 39-60, while only 5-15 of
the population suffers from severe generalized periodontitis2 The
purpose of this clinical update is to present an evidence based review of
the effects of diabetes on the clinical course of periodontal disease, as
well as to argue the importance of achieving periodontal health in the
overall management plan for both type I and type II diabetics
Diagnosis and medical management of diabetes
The signs and symptoms of DM are the classic triad of polyuria, polydipsia,
and polyphagia, together with pruritis, weakness, and fatigue Physicians
rely on a battery of tests to diagnose DM, including fasting blood glucose,
oral glucose tolerance test, and casual plasma glucose fasting not
required One particularly useful test to determine the level of metabolic
control is the glycated hemoglobin A1c, or HbA1c This measures the
percentage of glycated hemoglobin moieties on red blood cells The HbA1c
gives a measure of the blood glucose status over the half-life of the RBC,
which is about 30-90 days1 Metabolic
control of DM involves special
attention to diet, exercise, weight loss, and multiple pharmacologic
agents Type I diabetics require exogenous insulin Type II diabetics are
usually managed with the use of sulfonylureas such as glipizide or
glyburide These drugs stimulate insulin release from the pancreas, as well
as promote insulin uptake in the tissues Other drugs, such as metformin
and troglitazone increase tissue sensitivity to insulin without increasing
pancreatic release of insulin, minimizing the risk of a hypoglycemic
crisis Complications of DM are a direct result of hyperglycemia, and
include retinopathy DM is the leading cause of blindness in the US,
nephropathy, neuropathy, macrovascular disease, and altered wound healing3
The sixth complication of diabetes
Numerous cross-sectional and longitudinal studies have identified DM as a
risk factor for periodontal diseases4-9 Ciancola et al4 looked at the
periodontal condition of Type I diabetics, and compared them to non-
diabetic controls While the prevalence of periodontitis among non-
diabetics aged 11-18 was only 17, the same age range of
diabetics had a
prevalence of periodontitis of 98 They also noted an almost linear
increase of periodontitis with age, with 39 of subjects over 19 years old
exhibiting mild to severe periodontitis The progression of clinical
attachment loss was found to be accelerated in Type I diabetics compared to
non-diabetics in a study by Firalti8 The significant difference was noted
despite similar levels of plaque control Metabolic control of Type I DM
has been shown to impact periodontal conditions Safkan-Seppälä and Ainamo6
demonstrated that poorly controlled Type I diabetics had significantly more
clinical attachment loss and alveolar bone loss compared to those Type I
diabetics with good glycemic control The same association holds true for
Type II diabetics Emrich et al5 looked at the prevalence and severity of
periodontal disease in Native Americans Type II diabetics were found to
have an increased risk of destructive periodontitis with an odds ratio
ranging from 281 based on clinical attachment loss to 343 based on
alveolar bone loss Löe7 found that 8 of non-diabetic Pima Indians under
the age of 35 had advanced periodontal
disease, versus 48 of Type II
diabetics in the same age range He estimated the diabetics were about
three times more likely to exhibit periodontitis In a longitudinal study,
Taylor et al9 showed that Type II DM was associated with an increased rate
of alveolar bone loss progression Several mechanisms for worsened
periodontal status in diabetics have been studied Bissada et al10
demonstrated both decreased chemotaxis and phagocytosis of PMNs in
peripheral blood of diabetics Derangements of collagen metabolism occur in
diabetics Golub et al11 showed in vitro and in vivo that collagenase
activity is enhanced in diabetic rats Also, a dose-dependent decrease in
collagen production by fibroblasts was noted with increasing glucose
concentrations12 In a hyperglycemic environment, numerous proteins,
including collagen, undergo a non-enzymatic glycosylation process to form
advanced glycation endproducts AGEs AGEs result in a myriad of events,
including increased cross-linking and decreased solubility and turnover of
collagen AGEs induce macrophages and monocytes to increase secretion of
pro-inflammatory
cytokines such as interleukin-1 and tumor necrosis factor-
?3 Zambon et al13 suggested that both quantitative and qualitative
differences in periodontal pathogens could account for increased
susceptibility to periodontitis in diabetics Listgarten et al14 noted
increased thickness of the basement membrane of capillary endothelium in
diabetics compared to non-diabetics
Periodontitis as a risk factor for diabetes
While it is well established that diabetes mellitus is a significant risk
factor for periodontitis, researchers are beginning to look at the converse
- periodontal infections negatively impacting the glycemic control of both
Type I and Type II diabetics As early as 1960, Williams and Mahan15 noted
a significant reduction in insulin requirements in 7 of 9 patients after
periodontal therapy Taylor et al16 in a seven year longitudinal study of
Type II diabetics found that significantly more subjects demonstrated
worsening glycemic control who had severe periodontitis Grossi et al17 in
a randomized clinical trial of Type II diabetic Pima Indians showed that
scaling and curettage plus systemic doxycycline was able to reduce
HbA1c by
almost 10 More recently, Kuran et al18 noted an 11 decrease in HbA1c in
Type II diabetics after oral hygiene instructions and full mouth scaling
and root planing Slight increases were noted in the control group,
receiving only oral hygiene instructions Both in vitro and animal studies
have documented the role of the pro-inflammatory cytokine Tumor Necrosis
Factor - ? in insulin resistance Iwamoto et al19 have shown that non-
surgical periodontal therapy significantly reduced both HbA1c and serum TNF-
? in thirteen Type II DM patients They hypothesize that improved glycemic
control is achieved by reduction of TNF-? and improved insulin resistance
following control of periodontal inflammation Taken together, the evidence
suggests that control of periodontal disease should be an important part of
the overall management of patients with DM
Conclusion
The evidence overwhelmingly supports DM as a risk factor for periodontal
disease There is now a growing body of evidence that points to periodontal
infections as an independent risk factor for poor glycemic control in
patients with DM With this knowledge, it is incumbent upon
dentists and
physicians alike to work together to achieve the desired goal of
improvements in patients overall health
References
1 Report of the Expert Committee on the Diagnosis and Classification of
Diabetes Mellitus Diabetes Care 1997 Jul;207: 1183-97
2 Burt B, Research, Science and Therapy Committee of the American Academy
of Periodontology Position paper: epidemiology of periodontal diseases J
Periodontol 2005 Aug;768: 1406-19
3 Mealey B Diabetes and periodontal diseases J Periodontol 1999
Aug;708:935-49
4 Cianciola LJ, Park BH, Bruck E, Mosovich L, Genco RJ Prevalence of
periodontal disease in insulin-dependent diabetes mellitus juvenile
diabetes J Am Dent Assoc 1982 May;1045: 653-60
5 Emrich LJ, Shlossman M, Genco RJ Periodontal disease in non-insulin-
dependent diabetes mellitus J Periodontol 1991 Feb; 622:123-31
6 Safkan-Seppälä B, Ainamo J Periodontal conditions in insulin-dependent
diabetes mellitus J Clin Periodontol 1992 Jan; 191:24-9
7 Löe H Periodontal disease The sixth complication of diabetes mellitus
Diabetes Care 1993 Jan;161:329-34
8 Firatli E The relationship between clinical periodontal status
and
insulin-dependent diabetes mellitus Results after 5 years J Periodontol
1997 Feb;682:136-40
9 Taylor GW, Burt BA, Becker MP, Genco RJ, Shlossman M Non-insulin
dependent diabetes mellitus and alveolar bone loss progression over 2
years J Periodontol 1998 Jan;691:76-83
10 Bissada NF, Manouchehr-Pour M, et al Neutrophil Functional Activity in
Juvenile and Adult Onset Diabetic Patients with Mild and Severe
Periodontitis J Periodontal Res 1982 Sep;175:500-2
11 Golub LM, Schneir M, Ramamurthy NS Enhanced collagenase activity in
diabetic rat gingiva: in vitro and in vivo evidence J Dent Res 1978
Mar;573:520-5
12 Willershausen-Zönnchen B, Lemmen C, Hamm G Influence of high glucose
concentrations on glycosaminoglycan and collagen synthesis in cultured
human gingival fibroblasts J Clin Periodontol 1991 Mar;183:190-5
13 Zambon JJ, Reynolds H, Fisher JG, Shlossman M, Dunford R, Genco RJ
Microbiological and immunological studies of adult periodontitis in
patients with noninsulin-dependent diabetes mellitus J Periodontol 1988
Jan;591:23-31
14 Listgarten MA, Ricker FH Jr, Laster L, Shapiro J, Cohen DW Vascular
basement
lamina thickness in the normal and inflamed gingiva of diabetics
and non-diabetics J Periodontol 1974 Sep;459:676-84
15 Williams RC, Mahan CJ Periodontal disease and diabetes in young
adults JAMA 1960 Feb 20;172:776-8
16 Taylor GW, Burt BA, Becker MP, Genco RJ, Shlossman M, Knowler WC,
Pettitt DJ Severe periodontitis and risk for poor glycemic control in
patients with non-insulin-dependent diabetes mellitus J Periodontol 1996
Oct;6710 Suppl:1085-93
17 Grossi SG, Skrepcinski FB, DeCaro T, Robertson DC, Ho AW, Dunford RG,
Genco RJ Treatment of periodontal disease in diabetics reduces glycated
hemoglobin J Periodontol 1997 Aug;688:713-9
18 Kiran M, Arpak N, Unsal E, Erdogan MF The effect of improved
periodontal health on metabolic control in type 2 diabetes mellitus J Clin
Periodontol 2005 Mar;323:266-72
19 Iwamoto Y, Nishimura F, Nakagawa M, Sugimoto H, Shikata K, Makino H,
Fukuda T, Tsuji T, Iwamoto M, Murayama Y The effect of antimicrobial
periodontal treatment on circulating tumor necrosis factor-alpha and
glycated hemoglobin level in patients with type 2 diabetes J Periodontol
2001 Jun;726:774-8
Lieutenant
Commander Wilson is a third year Periodontics resident at the
Naval Postgraduate Dental School Commander Gramkee is an associate
professor at the Naval Postgraduate Dental School, Department of
Periodontics
The views expressed in this article are those of the author and do not
necessarily reflect the official policy or position of the Department of
the Navy, Department of Defense, nor the US Government
Source:trms.ga.net
