Diabetes and Periodontal Disease. Brianne Neelis & Katie Torres. Literature Review 1 11/4/08

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1 1 Diabetes and Periodontal Disease Brianne Neelis & Katie Torres Literature Review 1 11/4/08

2 2 Introduction Diabetes is a cardiovascular condition that effects an estimated 20 million people in the United States. 1 Diabetes is a metabolic disorder dealing with insulin secretion and can be controlled with diet and exercise, or insulin therapies. 1 Unfortunately, diabetes causes several problems with a patients general health, including their oral health. Cardiovascular disease, kidney disease, vision problems, and neurological problems are just a few of the complications associated with diabetes. 1 What is Diabetes? Diabetes is defined by a chronic state of hyperglycemia that results from dysfunction of the insulin production and secretion in the pancreas. 2 This chronic state of hyperglycemia has a negative affect on the rest of the tissues in the body. There are two types of diabetes mellitus, type one and type two. Type 1 diabetes is also known as insulin dependent diabetes because these patients rely on insulin medications to sustain life. 2 In this type of diabetes the mechanism that creates and secretes insulin does not work at all, making it important for these patients to monitor and control their blood sugar. 2 This type of diabetes has a strong genetic connection and is usually diagnosed in childhood or adolescence. Patients with type 1 diabetes are more susceptible to various other autoimmune disorders. Type 2 diabetes or non insulin dependent diabetes patients are insulin resistant and have problems producing and secreting insulin. 2 Though these patients retain the ability to produce insulin they often need insulin treatments later in the disease process. 2 At earlier stages of this disease many patients can control it with diet and exercise. 2 This type of diabetes

3 3 has a slower progression meaning the destruction of the producing and secreting insulin mechanism happens at a slower rate. 2 Type 2 diabetes also has a strong genetic component and is linked to a number of outside factors including increased age, obesity, and lack of physical activity. 2 What is Periodontal Disease? Periodontal disease is a chronic inflammatory disease that invades the supporting structures of the teeth. 9 This disease is caused by bacteria accumulation in the gingival pockets surrounding the teeth. 9 If this inflammation is not corrected then the disease will destroy the supporting structures of the teeth, often leading to tooth loss. 9 There are different classifications of periodontal disease based on severity. Gingivitis is the non-destructive form of periodontal inflammation and can be treated and cured, and periodontitis is the destructive form of periodontal inflammation that can be treated and controlled, but not cured. 9 This disease can be controlled in the early stages with little or no permanent damage to the supporting structures. If, however the bacteria is not removed and the disease is not controlled, bone loss, and tissue destruction will occur leading to mobile teeth, and often times tooth loss. 9 Periodontal disease can only be controlled, it cannot be cured. Removal of the bacteria from under the gingiva in a procedure called root planning and scaling will often times lead to reattachment of the gingival, and a healthier mouth and body. The patient must be aware that homecare is crucial in these cases, and that the hygienists will do their part but the patient must be an active participant in controlling periodontal disease.

4 4 Connections Between Periodontal Disease and Diabetes A systemic chronic inflammatory state can be induced by periodontal disease. As a result of this inflammation the body becomes more insulin resistant making it difficult for the patient to control their glycemic level. 2 It is shown that 64% of diabetic patients have some form of gingival inflammation compared to non diabetic patients who have a gingival inflammation rate of 50%. 1 This inflammation could lead to periodontal disease because it allows for more plaque to be trapped under the bulbous areas of gingival tissue. Research has revealed that there is little difference in the microbiota found subgingivally between subjects with diabetes and those without. Therefore, alterations in host immunoflammatory response to potential pathogens may play a predominant role. 2 Bacterial persistence in the periodontium may be facilitated by the impairment of neutrophil adherence, chemotaxis, and phagocytosis as a result of diabetes. 2 Diabetic patients have a hyper-responsive monocyte/macrophage phenotype, which increase the pro-inflammatory cytokines and mediators in the gingival crevicular fluid. 2 A heightened inflammatory response, irregularity in the metabolism of the bone structures, as well as decreased wound healing among diabetic patients, makes periodontal problems more severe. 1 Because the bone matrix is made up of 90% collagen the problems with collagen formation associated with diabetes affects the function of the osteoblast and osteoclasts. 1 This condition could be a factor in diabetes related to osteopenia, as well as severe periodontal breakdown. 1

5 5 Literature shows that the extent of glycemic control has a great effect on the relationship between diabetes and periodontal disease. 2 Those with poorly controlled diabetes had a three-fold increased risk of having periodontitis. Subjects with poorly controlled type II diabetes had an eleven-fold increased risk of having periodontitis. Those with controlled diabetes of any type had no significant increase in the risk of periodontitis when compared to the non-diabetic subjects. 2 Although periodontal disease is a result of poor diabetic control, this relationship is not bidirectional. 3 Control of periodontal disease does not equal improvement of the diabetic condition. 3 However, in diabetic patients without periodontal disease the diabetes is usually well controlled. 8 Medications prescribed by physicians for diabetic patients commonly cause xerostomia. Xerostomia is the condition of dry mouth. 4 When the mouth is dry, plaque and bacteria accumulate more readily making the periodontal disease causing bacteria more prevelant. 4 This plaque accumulation could be a risk factor for presence and severity of periodontal disease and should be discussed with the patient. Diabetes also can cause general vascular degeneration in the organs. 1 A study shows that this also can take place in the gingiva. 1 The decreased blood flow to the bone and gingiva surrounding the teeth creates a nutrient starved environment. 6 The lack of blood flow can also create problems with tissue healing and regeneration creating problems with healing after any type of periodontal therapy. 1 Dental Hygienists Role Physicians frequently fail to inform their diabetic patients of the effects of this disease on the oral cavity. 8 The dental hygienist will most likely be the first healthcare professional to

6 6 recognize the oral indications of diabetes. Due to this, the hygienist will play a key role in aiding the patient to understand how their diabetes affects their oral cavity. The hygienist will also need to stress the importance of maintaining a close connection with their dentist and physician. Education and frequent prophylaxis to maintain periodontal disease will be a key role of the hygienist to keep the patient healthy. Patient s Role The patient needs to have a good understanding of their diabetes. Physicians and dentists should be contacted regularly and seen frequently. The patient will need to have good oral hygiene care at home to maintain periodontal disease. They will also need to take insulin or glucose as prescribed by their family physician to sustain their diabetes. Also the patient should be provided with some scientific literature that shows how diabetes affects the oral cavity and how to prevent those complications. Conclusion It is clear that periodontal disease and diabetes are related in many ways. Periodontal disease is listed as an outcome of diabetes mellitus. 1 It is important to understand the metabolic, inflammatory, and mechanical issues surrounding patients who suffer from diabetes. Ensuring that hygienists provide their patients with the proper information, and skills to keep their oral cavity healthy, and in turn keep their body healthy is vital to the dental hygiene profession.

7 7 References 1. Ryan M, Carnu O, Kamer A. The influence of diabetes on the periodontal tissues. J Am Dent Assoc October;134. p Mealey BL, Ocampo GL. Diabetes mellitus and periodontal disease. Periodontal ;44: Bouchard P, Kinane D. Periodontal disease and health: consensus report of the sixth European workshop on periodontoglogy. J Clin Periodontol. 2008; 35. p Lamster I, Lalla E, Bordnakke W, Taylor G. The relationship between oral health and diabetes mellitus. J Am Dent Assoc October; 139. p Demmer RT. Jacobs DR. Desvarieux M. Periodontal disease and incident type 2 diabetes. J diabetes. 2008;31: Kidambi S, Patel S. Diabetes mellitus considerations for dentistry. J Am Dent Assoc October; 139. p Nelson RG. Periodontal disease and diabetes. Oral Diseases. 2008; 14(3): Herring MD. Shah SK. Periodontal disease and control of diabetes mellitus. J Am Osteopath Assoc July; 106(7):

8 8 9. Mobley CC, Cappelli DP. Prevention in Clinical Oral Health Care. 1 st ed. St Louis (Missouri): Elsevier; c2008. Chapter 2, Epidemiology/biology of periodontal diseases; p

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