The bidirectional relationship between periodontitis and diabetes: an example of the oral-systemic link
The oral-systemic link is the connection between oral health and overall body health. The oral cavity provides a perfect entry point for pathogens such as bacteria and viruses to enter the bloodstream and other systems of the body- this means that the links between diet, dentistry and disease are very significant to health outcomes.
An overview of periodontitis and diabetes:
Periodontitis is a chronic inflammatory disease of the tooth-supporting tissues, eventually leading to the loss of connective tissue attachment and alveolar bone. It is initiated by the pathogenic dental plaque biofilm above and below the gum margin where the plaque calcifies with time to form calculus, which worsens the disease.(1) Whilst this disease is irreversible, some treatments for periodontitis include the scaling, root planing, antibiotics or surgery.
Diabetes is a metabolic disorder characterised by chronic hyperglycemia( higher blood glucose levels) along with changes affecting carbohydrate,fat and protein metabolism. This results from issues with insulin secretion, the action of insulin, or both. Over a long period of time, high glucose levels in your blood leads to development of the complications associated with diabetes that occur from damage and failure of various organs and body systems.(1) Diabetes can be diagnosed by measuring glycated haemoglobin (HbA1c). This provides clinicians with an overall picture of what a person's average blood glucose levels have been over a period of weeks/months. The higher the HbA1c, the greater the risk of developing diabetes-related complications.
What is the connection between periodontitis and diabetes?
The risk of periodontitis is increased by 2-3 times in people with diabetes compared to individuals without, and the level of glycaemic control is key in determining risk. Also, the risk for periodontitis increases with poorer glycaemic control. It is considered that upregulated inflammation that results from each condition adversely affects the other forming a bidirectional relationship between both diseases.
Diabetes increases the risk for periodontitis by contributing to increased inflammation in the periodontal tissues. Elevated blood glucose levels in poorly controlled diabetics result in an increase of protein glycosylation leading to increased formation of Advanced Glycation End products (AGE)- these are glucose products that have the ability to attract and stimulate inflammatory cells to produce inflammatory cytokines(e.g. interleukin-1β (IL-1β), tumour necrosis factor-α (TNF-α), and IL-6). All of these factors result in local tissue damage, an increased destruction of the periodontal connective tissues and loss of alveolar bone, hence worsening periodontitis.
Diabetes increases the risk for periodontitis by contributing to increased inflammation in the periodontal tissues. Elevated blood glucose levels in poorly controlled diabetics result in an increase of protein glycosylation leading to increased formation of Advanced Glycation End products (AGE)- these are glucose products that have the ability to attract and stimulate inflammatory cells to produce inflammatory cytokines(e.g. interleukin-1β (IL-1β), tumour necrosis factor-α (TNF-α), and IL-6). All of these factors result in local tissue damage, an increased destruction of the periodontal connective tissues and loss of alveolar bone, hence worsening periodontitis.
Considering the impact of periodontitis on diabetes, a possible mechanism that links both diseases is that oral bacteria and their products, together with inflammatory cytokines and other mediators produced locally in the inflamed periodontal tissues enter the blood circulation and contribute to upregulated systemic inflammation. As a result, insulin signalling is affected and there is increased insulin resistance. The increased HbA1c levels then contribute to increased risk of diabetes complications (that include periodontitis) establishing the two-way, bidirectional relationship between the diseases.
The figure below shows a summary of some of the possible mechanisms that connect periodontitis and diabetes.
Diagrams A and B show how the management of periodontitis can affect diabetes. Diagram A shows that when periodontitis is untreated, bacteria along with pro-inflammatory mediators and cytokines enter the blood circulation and result in increased systemic inflammation, alongside impaired insulin signalling and increased insulin resistance. This leads to elevated HbA1c levels and increased diabetes complications.(2)
However, diagram B shows that through periodontal treatment, there are reduced levels of circulating bacteria and antigens, and decreased circulating levels of cytokines and inflammatory mediators. Consequently, the systems are in a less inflamed systemic state, leading to improved insulin signalling and decreased insulin resistance. As a result the reduction in HbA1c levels means diabetes is more controlled and hence less diabetes complications.(2) This image has been taken from Preshaw and Bissett 2020.(2)
However, diagram B shows that through periodontal treatment, there are reduced levels of circulating bacteria and antigens, and decreased circulating levels of cytokines and inflammatory mediators. Consequently, the systems are in a less inflamed systemic state, leading to improved insulin signalling and decreased insulin resistance. As a result the reduction in HbA1c levels means diabetes is more controlled and hence less diabetes complications.(2) This image has been taken from Preshaw and Bissett 2020.(2)
Why don’t general dental practitioners(GDP’S) test for diabetes in periodontitis patients?
It is important to consider the role of the dental team in the wider context of management of patients with diabetes and periodontitis. However, barriers to testing for diabetes in patients with periodontitis currently involve problems with the infrastructure within the NHS, differing perspectives of dentists’ social/professional roles and insufficient training as discussed in a study by Rattu and Hurst (2022). (3)
NHS structure and technology limitations:
Many GDP’s from the Rattu and Hurst 2022 study felt that co-management of periodontitis and diabetes could be implemented successfully in the health service if an electronic and cross-disciplinary index was easily accessible for all professions to get a better overall view of the patients health. (3)
Due to limited appointment times and increasing patient and NHS contract demands, there may be insufficient time to commit to testing (3)
Resources and funding:
There is a lack of educational resources and public campaigns to raise awareness of the bidirectional link between periodontitis and diabetes. Public knowledge needs to be enhanced to improve patient acceptance of GDPs becoming involved in their patients' diabetes management. (3)
There needs to be increased funding to be able to implement training, equipment etc required for testing.(3)
The two way relationship between periodontitis and diabetes is a great example to show how oral health impacts the rest of the body and vice versa. Traditionally, the oral cavity was thought of as separate from the rest of the body but it is now evident that the mouth is a vital but underestimated system that can highlight key health issues in other parts of the body too. With adequate funding,resources, and a change of NHS infrastructure , there is great potential to improve the co-management of diabetes and periodontitis within primary healthcare.
Written by Nistha Patel
References:
(1)Preshaw, P. M., Alba, A. L., Herrera, D., Jepsen, S., Konstantinidis, A., Makrilakis, K., & Taylor, R. (2012). Periodontitis and diabetes: a two-way relationship. Diabetologia. 55(1), 21–31.
(2)Preshaw, P. M. & Bissett, S.M. (2020). Periodontitis and diabetes. BDJ Team. 7, 27–35.
(3)Rattu, V. & Hurst, D. (2022). Why don't general dental practitioners test for diabetes in periodontitis patients? How infrastructure, role identity and self-efficacy can prevent effective shared care. The BDJ . 232, 798–803.
Further information on the topic:
It’s All in Your Mouth by Dominik Nischwitz
An insightful book displaying the significance of oral health to overall health. Its content covers research on the microbiome and the mouth, the role of nutrition in oral health and the principles of biological dentistry. This book is accessible to a wide audience from healthcare professionals to people who just want to know more about the impact of their oral health on their bodies.
Gum disease and other diseases:
https://www.periohealthpartners.com/periodontal-disease-link-between-serious-diseases
https://www.perio.org/for-patients/gum-disease-information/gum-disease-and-other-diseases/
Periodontal disease is not only associated with diabetes, but also with other systemic diseases such as cardiovascular disease and Alzeimers disease. The websites above provide descriptions of the relationships between gum disease and other systemic diseases.
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