Diabetes

By Elena Connolly

“Treatment of PD improves glycemic control in diabetic patients.” JADA, Vol. 138 http://jada.ada.org September 2007 29S

Diabetes mellitus (DM) is a metabolic disease characterized by the inability to control glucose homeostasis. The key disturbance stems from the inability to produce insulin, to use insulin properly, or both. The disease affects 23.6 million people in the United States per 2007 estimates, equating to about 7.8 percent of the population. Prevalence increases with age, as it is estimated that 24% of the population over the age of 60 has the diabetes.

The disease itself poses serious risks to a patient’s overall heath. Studies show that people with diabetes face a two-to-four times greater risk for developing heart disease and/or stroke when compared to those without the disease.

Diabetes is unique in that it has a bi-directional relationship with oral health. That is, the disease itself can lead to the development of periodontal disease, while the existence of gingivitis or periodontitis can actually contribute to poorer glycemic control. This increases not only the risk for complications, but also the risk for developing diabetes initially. It is important to understand the role that oral health may play in diabetes management in order to prolong quality health.

When bacteria in the mouth enter the circulatory system, an overall systemic inflammatory burden is created. This is the body’s natural response, and depending on the degree of the infection, requires involvement from several organs including the liver, lymph nodes, and kidneys. Studies have shown that patients with diabetes actually have an enhanced inflammatory response which puts more stress on the body . This also means a higher level of the same inflammatory biomarkers released. For example, in an animal model, when rats were injected with a specific periodontal pathogen into their connective tissue, there was prolonged inflammation and higher levels of inflammatory cytokines. Diabetic rats also had more significant and prolonged gingival inflammation.

The increased inflammation and release of biomarkers has a prolific effect on glycemic control. TNF-α, IL-6, and IL-1β are cytokines released during inflammation. They have been shown to have important metabolic effects on glucose and lipids. They also are involved in insulin action. In addition, chronic and low grade inflammation involving these same cytokines has been associated with the development of insulin resistance, diabetes itself, and its complications.

These markers are important because high levels can serve as a predictor of developing the disease later on, even in healthy individuals. Therefore, chronic inflammation due to periodontitis may make a patient more prone to diabetes even if they are otherwise healthy at the time.

There is direct evidence regarding periodontal infection and control of diabetes from studies using non-surgical methods of oral health practices. Out of the ten randomized clinical trials surveyed, six found a statistically significant effect of periodontal therapy on glycated hemoglobin.

Studies have shown a direct link between glycemic control and oral health. Taylor et al. found that those with Type 2 diabetes under either “good” or “moderate” control but had severe periodontitis were approximately six times more likely to have poor glycemic control after two-years than those who did not have a problem with oral hygiene. In short, oral health maintenance can be an effective way for a diabetic patient to keep glycemic levels under control.

Glycemic control is a very important aspect of diabetes management. In its absence, several serious complications may arise. Diabetes has been known to have a significant link to heart attack and stroke. Controlling glycemic levels can lower the risk for developing these types of complications. In the Diabetes Control and Complications Trial and The UK Prospective Diabetes Study, both found that attaining and maintaining good glycemic control can reduce the risk of microvascular complications and slow down its progression in patients with Type 1 and Type 2 diabetes. Risk of fatal or nonfatal heart attack was also reduced by 16 percent.

Further analysis showed that for every percentage point decrease of HbA1c, there was a 25% reduction in diabetes related deaths, 7% reduction in all-cause mortality, and 18% reduction in heart attack.Clearly, managing hemoglobin is an effective way of preserving health and limiting the risk for serious diabetic complications. As previously stated, oral health maintenance is a simple yet viable option for doing so.

In studies that analyzed the specific relationship between periodontal health and cardio-related complications in diabetics found convincing evidence supporting this notion. One study conducted by theNational Institute of Diabetes and Digestive and Kidney Diseases followed 628 individuals over a period of 11 years. They found that those with the most severe cases of periodontal disease had 3.2 times greater risk for cardio-related mortality, when compared to those with levels considered moderate or lower. This elevated level of risk remained even after controlling for other factors related to cardio-renal mortality such as age, sex, duration of diabetes, HbA1c, body mass index, hypertension, blood glucose, cholesterol, electrocardiographic abnormalities, and smoking.

In addition to linking periodontal disease with the emergence diabetic complications, there is strong evidence that shows a connection between poor periodontal health and developing Type 2 diabetes itself. Demmer and colleagues investigated this very association using the National Health and Nutrition Examination Survey and its Epidemiologic Follow-up Study. The average follow-up period was over the course of 17 years, from 1971 to 1992. They found that having periodontal disease was significantly associated with a 50-100% greater risk for developing Type 2 diabetes after controlling for other related risk factors.

Insurance company, Aetna teamed up with Columbia University to examine the connection, if any, between maintaining oral health and keeping insurance costs low. The study found that diabetic customers with periodontitis had higher monthly health costs than those without oral disease. Additionally, the retrospective risk for chronic conditions like diabetes was lowered once the patient was treated for periodontal disease.

Diabetic patients would greatly benefit from a regular oral health regime. It not only helps regulate and maintain glycemic control, but also helps protect from more serious complications in the future, such as heart attack or stroke. Healthy patients would also benefit from oral health maintenance, as it may prevent the development of diabetes later in life. Any individual with diabetes or at risk for diabetes should seriously consider the state of his or her periodontal health, and make a concerted effort to maintain good oral hygiene.

 

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