A growing body of research has demonstrated a strong, bi-directional relationship between diabetes and periodontitis. With the prevalence of diabetes expected to rise in the United States, dental students and professionals have an increasingly important role to play in supporting the early diagnosis of diabetes.
Diabetes
Diabetes is a metabolic disease characterized by an impairment in the body’s ability to create or use insulin, the key hormone responsible for blood glucose regulation. There are two main types:
Type 1 diabetes is an autoimmune disease affecting cells in the pancreas, causing little or no insulin production.
Type 2 diabetes is a chronic disease in which the body does not adequately use the insulin it produces (“insulin resistance”).
Diabetes is estimated to affect 34.2 million people in the U.S., or 10.5% of the population, with 7.3 million of those believed to be undiagnosed. Type 2 diabetes represents 90-95% of all cases. A further 88 million people are believed to have pre-diabetes, a term used to describe elevated blood glucose levels that do not meet the clinical threshold for type 2 diabetes.
Diabetes is associated with serious complications like cardiovascular disease, stroke, renal disease, neuropathy, vision loss, and amputation. In recent years, research has also established a connection between diabetes and periodontitis.
The connection between diabetes and periodontal disease
Those with diabetes have been found to suffer from periodontitis at considerably higher rates, and with greater severity, than the general population, to such an extent that it is often referred to as “the sixth complication of diabetes”. A 2018 meta-analysis demonstrated that diabetes can increase the risk or progression of periodontitis by as much as 86%. Poorer glycemic control was associated with higher risk.
The relationship between diabetes and periodontitis is bi-directional. Periodontal disease can impair glycemic control, making diabetes more difficult to manage and increasing the risk of serious complications. With one disease reinforcing the other, patients can find themselves trapped in a vicious cycle of deteriorating health — both oral and systemic.
The value of early detection
The pathophysiological changes associated with diabetes begin a considerable time before diagnosis, by which point early complications are often already present. These include oral health complications, with a 2020 study finding periodontal pocket formation and alveolar bone loss in those with elevated blood glucose levels that were below the threshold of even pre-diabetes.
Early detection of type 2 diabetes is shown to reduce complications like cardiovascular morbidity and mortality, with earlier interventions associated with higher efficacy. If detected even earlier, at the pre-diabetic stage, research shows that intervention can delay or even prevent its progression to type 2 diabetes.
Given the high number of people living with undiagnosed diabetes and pre-diabetes — and the potential oral and systemic health risks this presents to our patients — dental professionals must actively support the early detection of diabetes. So what part can you play as a dental student?
Detecting early signs of diabetes
There are immense oral and systemic health benefits to be gained by proactively screening for and managing periodontal disease. With periodontal destruction already present at diagnosis, we can view periodontal disease as a possible early indicator of diabetes or pre-diabetes — and an ideal opportunity to provide beneficial interventions.
A recent study found that periodontal treatment reduced overall systemic inflammation in patients with type 2 diabetes. Another study found evidence that periodontal therapy improved aspects of cardiovascular function in patients with type 2 diabetes. Inflammation plays a key role in all three diseases — periodontitis, diabetes, and cardiovascular disease — but periodontal therapy appears to reduce the overall systemic inflammatory burden that contributes to all three.
In addition, other oral health manifestations include oral lesions, with the most commonly identified being xerostomia, candidiasis, lichen planus, lingual varices, and prosthetic stomatitis. If your patient presents with these signs, encourage a visit to a physician to screen for diabetes or pre-diabetes.
Further resources
The earlier diabetes (and periodontal disease) are detected, the better chance you have to improve your patient’s oral and systemic health outcomes. You can learn more about oral care for patients with diabetes via the following resources:
Oral Health for People with Diabetes (International Diabetes Federation)
The Case for Including Oral Health Indicators (Platform for Better Oral Health in Europe)
- Management of Periodontal Disease in Patients with Diabetes: Good Clinical Practice Guidelines (International Journal of Diabetes in Developing Countries)
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