Diabetes and Its Impact on Periodontal Care

Patients with advanced periodontal breakdown pose a unique challenge to the restorative dentist. Tooth loss, increased mobility, and severe attachment loss complicate efforts to restore a patient’s function and esthetics. Arriving at the proper diagnosis and prognosis for patients with poor oral and overall health will improve the way clinicians rehabilitate an otherwise terminal dentition.

Systemic health has a tremendous impact on the periodontal/restorative interface. Diabetes mellitus, cardiovascular disease, obesity, and other inflammatory conditions can contribute to the rate of disease progression and responsiveness to treatment. Learning to identify and manage systemic conditions as part of a multidisciplinary team can improve outcomes in periodontal care and positively impact the patient’s quality of life.

Diabetes mellitus is a dysregulation of carbohydrate and lipid metabolism due to an inability to secrete or respond to insulin. Type 1 diabetes mellitus (T1DM) is the result of an absolute insulin deficiency via autoimmune destruction of pancreatic beta cells. In a cross-sectional study of patients living with T1DM for more than 50 years, only 13.5% had severe periodontitis — lower than most prevalences of the same cohort. It is hypothesized there are residual, functional beta cells in T1DM patients that protect against autoimmune stress and tissue destruction.¹

Chronic periodontitis is often considered the sixth complication of type 2 diabetes mellitus (T2DM), a condition that increases systemic inflammation in different ways as glucose tolerance gradually decreases. The primary cells of the innate immune system become less active, thereby leaving the periodontium vulnerable to the dental biofilm. Infection onset triggers a massive cytokine release from macrophages, leading to impaired collagen turnover and bone loss over time.² Multiple cross-sectional studies among Pima Indians show a near threefold increase in clinical and radiographic parameters of periodontitis for T2DM patients.^3,4 In the same population, an almost 11-time increased risk for bone loss in patients with a hemoglobin A1c (HbA1c) ≥ 9% was identified.⁴ Patients with poorly controlled T2DM are clearly more susceptible to the sequelae of a down regulated immune response.

On average, an 0.5% reduction in a patient’s HbA1c can be anticipated with nonsurgical and surgical treatment. The largest multicenter randomized controlled trial for patients with moderate to severe periodontitis and T2DM found a 0.3% to 0.6% reduction in HbA1c levels after one year of interventional periodontal care, as compared to those who received supragingival prophylaxis alone. Additionally, these patients had a diminished 10-year cardiovascular disease risk.⁵ However, the state of glycemia is more important than having T2DM alone. A recent meta-analysis found no significant differences in clinical outcomes after initial therapy for well-controlled T2DM patients compared to healthy controls.⁶

Tighter management of glycemic control results in better periodontal and overall health. In fact, an HbA1c ≤ 6.5% is the desired range for T2DM patients, per the American Association of Clinical Endocrinologists. Systemic complications, such as neuropathy, atherosclerosis, and poor wound healing, occur thereafter. Since the vast majority (70.1%) of T2DM patients present with HbA1c > 6.5%, advanced screening and consultation should be considered to meet this threshold before surgery is pursued.⁷ Reducing inflammation via nonsurgical therapy and improved self-care should be prioritized in poorly controlled patients.

Individuals with severe forms of periodontitis should be screened for diabetes as part of their initial exam, along with other risk factors that include obesity, age, ethnicity and family history. For example, those with signs of polydipsia, polyurea, and/or polyphagia with a casual blood glucose > 200 mg/dL should be referred. However, this only provides a snapshot of their glycemic control. Chairside HbA1c readings are better point-of-care tests because they reflect HbA1c levels over a 12-week period, without the need for separate medical consultation. As of 2017, oral health professionals who use these monitoring devices chairside must register the practice as a laboratory and receive a Clinical Laboratory Improvement Amendment Certificate of Waiver every 2 years. Both chairside tests are now associated with billable procedure codes.

References

1. Shinjo T, Ishikado A, Hasturk H, et al. Characterization of periodontitis in people with type 1 diabetes of 50 years or longer duration. J Periodontol. 2019;90:565–575.
2. Sczepanik, FS, Grossi ML, Casati M, et al. Periodontitis is an inflammatory disease of oxidative stress: we should treat it that way. Periodontol 2000. 2020;84:45–68.
3. Emrich LJ, Shlossman M, Genco RJ. Periodontal disease in non-insulin-dependent diabetes mellitus.J Periodontol. 1991;62:123–131.
4. Taylor GW, Burt BA, Becker MP, et al. Severe periodontitis and risk for poor glycemic control in patients with non-insulin-dependent diabetes mellitus. J Periodontol.1996;67(Suppl 10):1085–1093.
5. D’Aiuto F, Gkranias N, Bhowruth D, et al. Systemic effects of periodontitis treatment in patients with type 2 diabetes: a 12 month, single-centre, investigator-masked, randomised trial. Lancet Diabetes Endocrinol. 2018;6:954–965.
6. Hsu YT, Nair M, Angelov N, Lalla E, Lee CT. Impact of diabetes on clinical periodontal outcomes following non–surgical periodontal therapy. J Clin Periodontol.2019;46:206–217.
7. Geisinger ML, Morris AB, Kaur M, et al. Glycemic control among patients with physician-managed type 2 diabetes. Gen Dent.2018;66:52–55.

This information originally appeared in Saltz A. Periodontal medicine: from teeth to total body health. Decisions in Dentistry. 2021;7(3):25–31.