The relationship between diabetes and periodontal disease is bi-directional, since both diseases affect each other. 

Good periodontal health can prevent the onset of diabetes and bring benefits to glycaemic control in those who already have the disease. At the same time, better controlled diabetes can minimise the risk of the development or exacerbation of gum disease. 

Diabetes and periodontal diseases are destined to coexist and endocrinologists and dentists are therefore destined to work together. Both type 1 and type 2 diabetes increase the risk for periodontitis and even advance the age of onset of this disease. According to scientific studies, a person with poorly controlled diabetes is approximately three times more likely to develop periodontitis than a non-diabetic. 

GREATER PREVALENCE OF PERIODONTITIS IN DIABETICS 

According to Dr. Cristina Serrano, a member of the SEPA-SED Diabetes and Periodontal Disease working group made up of experts from the Spanish Society of Periodontology and Osseointegration (SEPA) and the Spanish Diabetes Society (SED), “periodontitis is more common amongst diabetics because diabetes causes increased inflammatory response to pathogenic bacteria in the gums.” 

Furthermore, “it alters the body’s capacity to respond favourably to the inflammation and for subsequent repair of the tissues to take place,” she points out. This means that people with diabetes will experience much quicker destruction of the teeth’s supporting tissues than non-diabetic periodontal patients. For this reason, diabetics are more likely to show deep pockets and greater bone loss, especially if glycaemia is poorly controlled. However, this does not mean that these patients will not respond well to periodontal treatment. 

As Dr. Héctor J. Rodríguez-Casanovas, the scientific director of the magazine Cuida tus encías (Care for Your Gums) and a member of the SEPA-SED group stresses, “diabetics respond to periodontal treatment just as well as those who do not have the disease.” 

IMPACT OF PERIODONTAL HEALTH ON DIABETES 

Likewise, poor periodontal health will impact negatively on diabetes; many experts even point to periodontal disease as one of the complications of diabetes. 

Scientific studies show that “Type 2 diabetes is more common in individuals with periodontal disease. Additionally, uncontrolled periodontitis in diabetics is associated with poorer glycaemic control,” says Dr. Cristina Serrano. 

On the other hand, patients with diabetes who also have periodontitis have been shown to benefit significantly from periodontal treatment. In these cases, “if periodontitis is treated correctly, patients with impaired glucose tolerance may reduce their glycosylated haemoglobin (HbA1C) by an average of 0.4%, which would be equivalent to the reduction obtained by using a second hypoglycaemic drug”, reports Dr. Rodríguez-Casanova. Undoubtedly, “the treatment of periodontal disease is a favourable measure to maintain good glycaemic control in diabetics, as well as to prevent side effects associated with diabetes,” according to this expert. 

And so periodontal disease increases the risk of complications linked to diabetes. Thus, for example, there is a five-fold increased risk of end-stage renal disease in patients who have both diabetes and periodontitis, compared to those who have diabetes without associated periodontal disease. Therefore, Dr. Cristina Serrano recaps that “the treatment and/or prevention of periodontal disease has important therapeutic implications in patients with diabetes.” 

BASIS FOR A “DANGEROUS LIAISON” 

This close relationship between diabetes and periodontal disease is currently being studied. According to Dr. Rodríguez-Casanovas, “both diseases are multifactorial, with both a causal factor and other aggravating factors. In both cases, a hyperinflammatory response is caused by hyperstimulation of the immune system involving a series of immune signals known as proinflammatory cytokines.” 

In recent years there have been many scientific studies analysing the relationship between periodontitis and other systemic diseases. It has been shown, for example, that periodontal pathogens are able to reach the bloodstream from the gums. These bacteria can cause chronic systemic inflammation, either directly (stimulating atheroma production) or indirectly (causing a systemic inflammatory response by releasing acute phase proteins such as C-reactive protein [CRP]). 

As Dr. Cristina Serrano explains, this condition of systemic inflammation “may have an adverse effect on the control of diabetes because it produces increased insulin resistance similar to that caused by obesity, stimulating the immune system and producing hyperglycaemia.” 

TAKING SPECIAL CARE 

All this leads us to advise diabetics to take meticulous care with their oral health. As Dr. Rodríguez-Casanovas sums up, “If I have diabetes, my oral health must be as well cared for as my diet or my feet.” Once diabetes is diagnosed, a periodontal examination is required, and if the patient has periodontitis, treat it as you would any other diabetes complication because this will positively affect the control of their disease. 

Likewise, periodontal maintenance therapy should be carried out at least twice a year. It is essential for diabetics to incessantly maintain good oral hygiene through dental and interdental brushing at least twice a day, and to get professional check-ups as part of their diabetes treatment. Prompting these habits is especially relevant, particularly since adequate information on the relationship between diabetes and periodontal disease is not yet being provided to diabetics. 

As Dr. Cristina Serrano warns, “When diabetes is diagnosed, patients are not usually told about periodontal disease and its implications, nor are they usually told to go to the dentist to have a check-up.” 

THE ROLE OF THE DENTIST 

In this context, Dr. Héctor Rodríguez-Casanovas’ opinion is that “Dentists can help prevent diabetes by informing all patients of the relationship between diabetes and periodontal disease, and by encouraging them to maintain excellent oral hygiene, through proper toothbrushing and interdental cleaning, and by prompting regular visits to the dentist at least twice a year.” 

Furthermore, considering that oral health and general health are closely related, the dentist can also play a key role in informing patients about the harmful effects of smoking, about good eating habits and about the importance of getting sufficient physical exercise. “All this will benefit both the patient’s periodontal and overall health, preventing the onset of diabetes,” says Dr. Serrano. 

As for early diagnosis, dentists can contribute very actively to the detection of cases of unidentified diabetes. It is essential to advise patients with periodontal disease, those who are overweight, smokers or those who do not get sufficient physical exercise to undergo a blood test and a glycosylated haemoglobin assessment. The earlier diabetes is diagnosed, the easier it will be to control and to prevent future adverse effects, such as cardiovascular or kidney disease. 

For this reason, SEPA and SED are working together and have set up a specific “Diabetes and Periodontal Disease” working group. The main objective is to reach as many endocrinologists, family doctors and nurses as possible, as well as dentists and dental hygienists, to provide them with information and training on the importance of diabetic patients keeping their gums healthy. 

One specific initiative is a protocol currently being validated by the SEPA research clinics network with the aim of diagnosing cases of unidentified diabetes in high-risk periodontitis patients (as assessed by a test known as FindRisk). A glycosylated haemoglobin test is requested for these patients, with the aim of reducing the incidence of late diagnosis of diabetes and to enable the dentist to become an active collaborator in the promotion of general health and in the early detection of systemic diseases, thus becoming allies of other health professionals.