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Article

Diabesity and periodontal disease:


Relationship and management

Rajesh Chauhan, Mark Kennedy, Werner Bischof


There is an increased incidence of periodontal disease among people with diabetes and Citation: Chauhan R, Kennedy M,
Bischof W (2016) Diabesity and
obesity, and a growing body of evidence that suggests improving dental health may lead to periodontal disease: Relationship
improvements in glycaemic control. Healthcare professionals in dental and primary care and management. Diabetes &
Primary Care Australia 1: 5963
should work together to identify individuals with periodontal disease at risk of progressing to
chronic conditions, and ensure that those with diabetes and/or obesity are offered dental care Article points
in the same way people with diabetes are routinely offered retinal screening and foot care. 1. Periodontal disease is an
inflammatory condition that is
linked to diabetes and obesity.

T
2. The significance of the link is
he ever-growing burden of diabetes and Gingivitis inflammation of the gum is not widely understood among
obesity on health care and society has most-commonly associated with plaque build- healthcare professionals.
been widely reported in the medical up around a tooth and is usually reversible with 3. Dental practitioners should
literature and mainstream media, with these good oral hygiene. If left untreated, gingivitis be part of an integrated
healthcare team alongside
chronic conditions being described as global can lead to periodontitis.
primary care professionals
epidemics (World Health Organization, 2013). Periodontitis is the more advanced stage that engages in screening,
Though less widely discussed, periodontal of periodontal disease, occurring when provision of preventative
disease is also a major health burden, with microorganisms colonise and progressively advice and education, and
referrals for individuals at
epidemiological studies revealing more than destroy the periodontal ligament and alveolar risk of chronic conditions.
two-thirds of the worlds population have some bone, with pocket formation or recession (or 4. Improving dental health
form of chronic periodontal disease (Dahiya both) around diseased teeth. This process is may contribute to improved
et al, 2012). multifactorial and occurs in the presence of glycaemic control, reducing
the risk of diabesity-related
This article examines the potential microbial challenge alongside other genetic, complications, although further
bidirectional relationship between periodontal studies are needed to firmly
(a)
disease and diabesity, and highlights the role establish these relationships.
the dental practitioner can play alongside their
colleagues in primary care in both screening Key words
and caring for people with these conditions. - Dental health practitioner
- Diabesity
Periodontal disease - Periodontal disease
Periodontal disease is an infectious, oral
condition affecting the supporting structures (b)
of the teeth that is caused by the interaction
between pathogenic bacteria and the hosts
immune system. Oral bacteria are required,
but are alone insufficient, for disease initiation
(Graves, 2008); persistent host inflammatory
response is needed before the soft and
mineralised periodontal tissues become eroded
and disease is established (Graves, 2008; Liu et
Figure 1. Examples of (a) gingivitis and (b) periodontitis.
al, 2010). Authors
Note that the bleeding of the gums from gingivitis usually
Periodontal disease comprises gingivitis precedes receding gums and bone loss associated with See page 63 for author
(Figure 1a) and periodontitis (Figure 1b). periodontitis. information.

Diabetes and Primary Care Australia Vol 1 No 2 2016 59

SB Communications Group and the Primary Care Diabetes Society of Australia www.pcdsa.com.au
Diabesity and periodontal disease: Relationship and management

Page points environmental and acquired risk factors. The plausibility of such a relationship is based on
1. There is evidence to suggest destructive tissue changes observed in cases increasing evidence showing that inflammation
a bidirectional relationship of periodontitis are the result of the hosts is linked to insulin resistance and precedes the
between diabetes and
periodontal disease;
inflammatory response to chronic oral infection. development of diabetes, and that inflammatory
however, more research is periodontal disease contributes to cumulative
needed to unequivocally Diabetes inflammatory burden (Wang et al, 2013). Thus,
establish a relationship
There is evidence to suggest a bidirectional the level of glycaemic control may be a key factor
between these conditions.
relationship between diabetes and periodontal in determining risk of periodontal disease, and
2. Meta-analysis and observational
evidence suggest that disease. However, interpretation of these data vice versa. However, further large, longitudinal
periodontitis may also be is not straightforward due to differences in studies are required to validate these findings.
related to the development of study designs. More research is needed to
type 2 diabetes (and possibly
gestational diabetes). unequivocally establish a relationship between Obesity
3. It has been suggested that the these conditions. The detrimental metabolic dysregulation
chronic conditions at hand Large epidemiological studies have shown commonly associated with obesity has been
metabolic dysregulation, that individuals with diabetes are three-times well described. Obesity contributes to insulin
periodontal disease and
diabetes are linked by changes
more likely to develop periodontal disease than resistance through the elevation of circulating
in the inflammatory state. those without (Shlossman et al, 1990; Emrich free fatty acids that inhibit glucose uptake,
et al, 1991) and the extent of glycaemic control glycogen synthesis and glycolysis (Tunes et al,
may determine risk. The NHANES (US 2010). Beyond the association with dyslipidaemia,
National Health and Nutrition Examination adipose tissue is recognised as an immune organ
Survey) III study demonstrated that adults that secretes numerous immunomodulatory
with poorly-controlled diabetes (HbA1c >9% factors (Wisse, 2004). Thus, it has been suggested
[74.9mmol/mol]) had a 2.9-fold increased that the chronic conditions at hand metabolic
risk of periodontitis than those without the dysregulation, periodontal disease and diabetes
condition, and that individuals with well- are linked by changes in the inflammatory state,
controlled diabetes had no significant increase and that a complex, bidirectional relationship
in risk (Tsai et al, 2002). Furthermore, those exists, with each being a risk factor for further
with both conditions show an increased severity systemic complications (Mealey and Ocampo,
of periodontal destruction compared with those 2007; Mealey and Rose, 2008; Dahiya et al, 2012;
without diabetes (Mealey, 2006; Lakschevitz Levine, 2013; Palle et al, 2013). Levine (2013)
et al, 2011). These findings lead to suggestions has suggested that because periodontitis may
that, when glycaemia is uncontrolled, diabetes stimulate inflammatory change in adipose tissue,
can reduce the bodys ability to appropriately the relationship between obesity, diabetes and
respond to the microbial challenge presented periodontal disease may actually be a triangular
by pathogenic oral bacteria, leading to a greater self-generating cycle of morbidity.
extent of periodontal destruction in this group
(Oppermann et al, 2012). Towards better management:
Suggestive of a bidirectional relationship Improving glycaemic control
between glycaemic control and periodontal and oral health
disease, the results of cross-sectional and It should be recognised that periodontal disease
prospective epidemiological studies have also is preventable through adequate oral hygiene and
found that periodontitis increases the risk of associated professional care where indicated. The
poor glycaemic control and is related to the early detection and management of gingivitis
development of complications in people with can prevent the progression to periodontitis. The
diabetes. Meta-analysis and observational current gold standard for treating periodontal
evidence suggests that periodontitis may also be disease involves managing oral infection with
related to the development of type 2 diabetes the choice of treatment depending on the extent
(and possibly gestational diabetes [Borgnakke of disease. Periodontitis is usually managed with
et al, 2013; Esteves et al, 2016]). The biological interventional, non-surgical therapies, together

60 Diabetes and Primary Care Australia Vol 1 No 2 2016

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Diabesity and periodontal disease: Relationship and management

with the use of antiseptic mouthwashes. Dental Impact of improved diabetes management Page points
scaling (polishing) and root planing (also known Of all systemic conditions, diabetes provides 1. Results are inconclusive
as debridement) are most commonly used. the greatest risk factor for periodontitis and is on whether periodontal
treatment such as scaling
Scaling involves removing plaque and tartar associated with increased prevalence, severity and root planing are effective
(hardened plaque) by scraping it from the tooth and progression of disease (Lalla and Lamster, in treating periodontitis in
and around the gum line. Root planing a more 2012). There is evidence to suggest that the level people with diabetes.
intensive type of cleaning removes bacteria of diabetes control can have an influence on the 2. Accepting that a link between
oral ill-health, poor glycaemic
from the root of the tooth. In more extreme response to periodontal treatment. The response
control and obesity-related
cases, periodontal surgery may be required to to scaling and root planing in people with well- metabolic dysregulation and
remove the affected tooth. Adjunctive systemic controlled diabetes appears similar to those increased pro-inflammatory
antibiotic therapy can be also be used to further without diabetes. Although many people with markers exists, managing
one or more of these factors
minimise infection. diabetes show improvement following treatment, should have a positive
individuals with poorer glycaemic control may impact on the others.
Impact of dental treatment have a more rapid recurrence of disease and a 3. Although many people with
Accepting that a link between oral ill-health, less favourable long-term prognosis (Mealey and diabetes show improvement
following treatment, individuals
poor glycaemic control and obesity-related Oates, 2006). with poorer glycaemic control
metabolic dysregulation and increased pro- may have a more rapid
inflammatory markers exists, some authors Towards better health: Implications for recurrence of disease and a less
favourable long-term prognosis.
have hypothesised that successful periodontal practice
treatment that also reduces systemic While the results of meta-analyses and
inflammation may improve diabetes control population-based studies suggest that
through a reduction in systemic insulin periodontal treatment is associated with
resistance (Mealey and Rose, 2008). improved glycaemic control, there is a
A recent Cochrane review (Simpson et al, paucity of trials of sufficient statistical power
2015) examined evidence relating to treatment to substantiate this claim. Further larger,
of periodontal disease for glycaemic control randomised trials are warranted in populations
in people with diabetes mellitus. The review with similar baseline levels of periodontal disease
showed that treatment of periodontal disease and glycaemic control (Preshaw et al, 2012).
by scaling and root planing did improve Though not yet fully substantiated, the
glycaemic control with a mean reduction in evidence to-date has been convincing for many.
HbA1c of 0.29% (3.2 mmol/mol) at 34 months. A growing number of recognised health care
However, there was insufficient evidence to bodies and institutions have seen fit to include
show maintenance of this benefit beyond oral care as an element of holistic care for the
4 months. The authors concluded that ongoing patient with long-term conditions, such as
professional periodontal treatment would be diabetes and obesity.
required to maintain clinical improvements The American Diabetes Associations (2016)
beyond 6 months. Standards of Medical Care in Diabetes highlights
There was no evidence supporting any one periodontal disease as a common comorbidity
periodontal therapy being more effective than of diabetes. These guidelines emphasise dental
others in improving glycaemic control in people practitioner involvement in a comprehensive
with diabetes at this time. The authors also diabetes evaluation, recommending that
concluded that further research is required to people with diabetes be referred for periodontal
determine whether adjunctive drug therapies examination. Furthermore, the European
should be used with periodontal treatment, to Federation of Periodontologys (EFP; 2014)
examine the long-term glycaemic benefits of manifesto, Perio and General Health following
ongoing periodontal treatment and to investigate recommendations from the first joint EFP/
the impact of such treatments on reducing American Academy of Periodontology (AAP)
periodontal inflammation in people with Working Group on Periodontitis and Systemic
diabetes. Health is a call to action for dental professionals

Diabetes and Primary Care Australia Vol 1 No 2 2016 61

SB Communications Group and the Primary Care Diabetes Society of Australia www.pcdsa.com.au
Diabesity and periodontal disease: Relationship and management

Page points to engage in the screening of, and education spacing or spreading of teeth and/or gingival
1. Dental professionals have for, people at risk of chronic disease, including abscesses).
the opportunity and the diabetes (Chapple and Genco, 2013). The
Dental rehabilitation to restore adequate
responsibility to assume
British Dental Association recently followed suit mastication for proper nutrition in people
an active role in the early
identification, assessment and (Chapple and Wilson, 2014). with diabetes who have extensive tooth loss.
management of their patients
Oral health education for all people with
who present with or are at Role of the dental professional diabetes. People with diabetes are at increased
risk of developing diabetes.
Oral health can indicate signs of metabolic risk of oral fungal infections and experience
2. Although the association
between diabetes and
or systemic ill-health. A recent pilot study poorer wound healing. Practitioners should
periodontal disease is long demonstrated that people at risk of developing advise that other oral conditions (such as dry
established, many people type 2 diabetes could be identified in primary, mouth and burning mouth) may occur.
are unaware of the strength
community and secondary dental care settings
Annual oral screening from the age of
of this relationship.
3. Physicians should be aware
(Preshaw, 2014), underlining the importance 67 years for children and adolescents
of the common signs and of the dental practitioner. Dental practitioners diagnosed with diabetes.
symptoms of periodontal have the opportunity and the responsibility to
disease, including gingival
assume an active role in the early identification, Role of the healthcare professional
bleeding, red/dark red
discoloration and inflammation assessment and management of their patients Although the association between diabetes
of gingiva, halitosis, an who present with or are at risk of developing and periodontal disease is long established
itching sensation in the diabetes (Lalla and Lamster, 2012). They are and periodontal disease has been described
gums, sensitivity to hot/
cold temperatures, presence
well placed to provide counselling on the oral as the sixth complication of diabetes for over
of toothache without caries complications of overweight, obesity and diabetes; two decades (Loe, 1993), many patients are
and any mobility, extrusion offer weight prevention and management advice unaware of the strength of this relationship
or migration of teeth.
and education; implement obesity and diabetes (Weinspach et al, 2013). The inclusion of
screening programmes (e.g. using weight-to- dental practitioners as foundation members of
height ratio or waist circumference measurements the primary care multidisciplinary care team is
to determine visceral adiposity and/or HbA1c currently not well established. Efforts should be
as an indicator of glycaemic control), and made to increase awareness among primary care
importantly, to appropriately refer patients to providers of the link between poor oral health
primary care practitioners. Guidelines have and systemic disease and vice versa. Alongside
been set out by the joint EFP/AAP for health better awareness of the signs and symptoms
professionals to use in diabetes practice and in of periodontal disease, primary care providers
dental practice (Chapple and Genco, 2013). The should proactively inquire when their patients
guidelines recommend: last visited a dental practitioner, particularly
Informing people with diabetes of the in individuals with visceral adiposity and/or
increased risk of periodontal disease and diabetes.
that having periodontal disease may make Physicians should be aware of the common
glycaemic control more difficult, and signs and symptoms of periodontal disease,
informing individuals that they are at higher including gingival bleeding, red/dark red
risk of diabetic complications. discoloration and inflammation of gingiva,
A thorough oral examination as part of the halitosis, an itching sensation in the gums,
initial evaluation of people with type 1, type 2 sensitivity to hot/cold temperatures, presence
and gestational diabetes. of toothache without caries and any mobility,
A periodontal examination for all newly extrusion or migration of teeth. If the patient
diagnosed individuals with type 1 and type 2 has any of the above, they should be referred
diabetes (with annual review) as part of their to a dentist or a periodontist. Perhaps more
ongoing management of diabetes. importantly, physicians could further help
A prompt periodontal evaluation for people their dental colleagues by providing the results
with diabetes presenting with overt signs and of laboratory tests (e.g. HbA1c) to dentists on
symptoms of periodontitis (i.e. loose teeth, request, if not routinely (Dahiya et al, 2012).

62 Diabetes and Primary Care Australia Vol 1 No 2 2016

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Diabesity and periodontal disease: Relationship and management

Conclusion Liu YC, Lerner UH, Teng YT (2010) Cytokine responses against A number of
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team to screen, and
engagement between the dental professional and
primary care team could free-up up time in the provide preventive
Mealey BL, Ocampo GL (2007) Diabetes mellitus and
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Rajesh Chauhan is Specialist in
European Federation of Periodontology (2014) Perio and General
Health. EFP, Madrid, Spain. Available at: http://bit.ly/SnDJfK Wang X, Bao W, Liu J et al (2013) Inflammatory markers and risk Oral Surgery, Lister Hospital,
(accessed 30.05.14) of type 2 diabetes: a systematic review and meta-analysis. Stevenage and Queen Elizabeth II
Diabetes Care 36: 16675 Hospital, Welwyn Garden City,
Graves D (2008) Cytokines that promote periodontal tissue Hertfordshire, and a General
destruction. J Periodontol 79(8 Suppl): 1585S1591S Weinspach K, Staufenbiel I, Memenga-Nicksch S et al (2013) Dental Practitioner, Watton
Level of information about the relationship between diabetes Place Clinic, Watton-at-Stone,
Lakschevitz F, Aboodi G, Tenenbaum H, Glogauer M (2011) mellitus and periodontitis results from a nationwide Hertfordshire, UK; Mark
Diabetes and periodontal diabetes and periodontal diseases: diabetes information program. Eur J Med Res 18: 6
Kennedy is Honorary Clinical
interplay and links. Curr Diabetes Rev 7: 4339
Associate Professor, University
Wisse BE (2004) The inflammatory syndrome: the role of
of Melbourne, Melbourne, Vic;
Lalla E, Lamster IB (2012) Assessment and management of adipose tissue cytokines in metabolic disorders linked to
patients with diabetes mellitus in the dental office. Dental obesity. J Am Soc Nephrol 15: 2792800 Werner Bischof is a Periodontist
Clinics of North America 56: 81929 and Associate Professor, La Trobe
World Health Organization (2013) Obesity and Overweight. University, Bendigo, Vic, and
Levine RS (2013) Obesity, diabetes and periodontitisa Fact Sheet Number 311. WHO, Geneva, Switzerland. Clinical Advisor, Specialist Care,
triangular relationship? Br Dent J 215: 359 Available at: http://bit.ly/18pCdAN (accessed 23.04.14) Dental Health Services Victoria.

Diabetes and Primary Care Australia Vol 1 No 2 2016 63

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