Correlation between periodontitis and diabetes

Diabetes is one of the most common widespread diseases in Germany. More than six million patients officially suffer from the metabolic disease. However, the number of unreported cases is estimated to be significantly higher. In addition to the current statistics, the latest forecasts are also a cause for concern. According to the United Nations, the disease is set to increase by around 50 percent worldwide by 2024. This means that 415 million cases will become 642 million. It is not without reason that the United Nations is predicting the first disease caused without infection that could develop into a global threat to humanity.

In addition to health problems, the metabolic disease also causes considerable financial damage. Around 35 million euros are spent each year on treatment, care, incapacity to work and early retirement. After all, the autoimmune reaction triggers numerous serious secondary diseases such as heart and vascular problems, amputations, new blindness and kidney failure. For three quarters of all patients, the metabolic disease ends in a fatal heart attack or stroke.

Doctors distinguish between two different types: Type 1 and type 2. In type 1, the pancreas can no longer produce insulin. The patient must supply their body with the missing insulin for the rest of their life. In type 2, on the other hand, the body produces insulin on its own, but its effect is limited. The pancreas tries to compensate for the deficiency by overproducing insulin. However, it cannot withstand the strain in the long term. It either produces less insulin or stops producing it altogether.

Unlike type 1, type 2 is strongly influenced by personal lifestyle. With plenty of exercise, a balanced diet and a normal weight, the risk of type 2 decreases or the severity of the disease decreases so that the person affected is no longer dependent on medication.

Diabetes and Periodontitis are closely linked. Not least because of their many similarities, such as the chronic course, the destructive changes and the reduced quality of life of those affected. Over the past decade, a strong interaction between the two diseases has even been demonstrated.

How does diabetes affect periodontitis?

Diabetes is characterized by chronic hyperglycaemia (abnormally high levels of sugar in the blood), which is caused by impaired insulin secretion and/or action. We need insulin for metabolic processes. If its secretion/effect is impaired, this promotes the formation of so-called AGE (advanced glycation endproducts). AGEs often bind to cell surface receptors (RAGE) and trigger inflammation there.

AGEs (Advanced Glycation Endproducts) are waste products that are mainly produced by the combination of protein and sugar. A particularly large number of these are produced, for example, when food is heated above 120° (a topic for all frying and grilling enthusiasts!). These AGEs can only be partially metabolized by the kidneys, the rest is stored in the body and can lead to health problems in the long term.

AGEs are increasingly detectable in the periodontium and gingiva of diabetics. According to the available studies, diabetes increases the risk of periodontitis by a factor of 3. In addition, periodontitis progresses faster in diabetics, while the periodontium of diabetics reacts less well to periodontitis treatment. This explains the more severe periodontal disease progression in the presence of diabetes. Periodontitis is therefore also a diabetic complication. However, there is also the reverse relationship, which proves the correlation between diabetes and periodontitis. Periodontal disease increases the blood sugar level due to an increased HbA1c value in the inflamed periodontal tissue. The inflammatory molecules in the diseased periodontium reduce the effect of insulin. This has the following effects on three risk groups:

• Non-diabetics with a certain disposition (hereditary predisposition) can develop into pre-diabetics more quickly.
• Pre-diabetics are more likely to become diabetics.
• Well-controlled diabetics become diabetics with inadequate blood sugar control.

Severe periodontitis makes it more difficult to control blood sugar levels. In the presence of periodontitis, a faster development into a diabetic is also to be expected with a corresponding predisposition. Last but not least, diabetic complications will increase.

Diabetics are up to three and a half times more likely to develop periodontitis than healthy people. This is due to an altered sugar metabolism, which can have a lasting effect on oral health. A lack of insulin favors the formation of deposits on the capillaries. These, in turn, can damage the vessel walls and thus impede blood flow. Less oxygen and nutrients pass through the gums, causing the body's natural defenses to weaken. As the body's protective mechanism is weakened, bacteria penetrate the oral cavity unhindered, multiply and cause chronic inflammation of the periodontium in the long term.

Another risk factor is reduced salivation. Diabetics produce less saliva or suffer from dry mouth. This symptom can be attributed to the side effects of certain medications. If the natural flow of saliva is impaired, the tooth enamel is more exposed to aggressive bacteria. The risk of periodontitis increases. If left untreated, periodontitis quickly leads to tooth loss in those affected. The bacteria penetrate deep into the tissue and bone, settle and permanently weaken the periodontium. The damaged tooth becomes loose and falls out. However, only very few people are aware of this danger. Only a third of all patients understand that chronic inflammation in the mouth and tooth loss are consequences of their metabolic disease.

Effects on heart health

Study data shows that diabetics with severe periodontal disease are more likely to suffer from diabetes complications than a control group with only gingivitis. These complications have a devastating effect on heart health:

• The mortality rate of diabetics with a severely damaged periodontal apparatus increases by a factor of 2.3 due to ischemic heart disease.
• The risk of diabetic nephropathy (progressive kidney disease) increases by a factor of 8.5 in those affected.
• Periodontal disease is responsible for coronary heart disease to the same extent as underlying diabetic disease, hypertension, obesity, hyperlipidemia and advanced age.

Periodontal disease can directly trigger diabetes mellitus. Patients with periodontal disease develop it much more frequently than periodontally healthy individuals.

Improvement of glycemic control through periodontal treatment

Glycemic control (control of blood sugar levels) has been shown to improve through the effective treatment of periodontal infections. This improves the diabetes status. Effective periodontal treatment lowers blood sugar levels. Non-surgical periodontal therapy also has a positive effect on the insulin resistance of type 2 diabetics. It lowers the HbA1c baseline value cited above, which in turn leads to lower blood glucose levels.

Interdisciplinary treatment approach for periodontal disease in diabetics

Periodontal and diabetic disease are systemic, influence each other and cross sector, organ and specialist boundaries. For this reason, an interdisciplinary approach is required to treat diabetics with periodontal disease. Dentistry and diabetology must work closely together in such cases. Dentists are required to identify the affected patients at risk in good time. Diabetologists should make them aware of the need for regular dental examinations. Dentists can identify the symptoms of a diabetic disease from oral signs. The anamnestic questionnaire can also be expanded accordingly; standardized questionnaires are recommended. In addition, a dentist who diagnoses severe and recurrent periodontitis in a patient can of course also carry out a blood glucose test. If the test reveals elevated blood sugar levels, the dentist will immediately refer the patient to a diabetologist or ask them to inform their family doctor of the findings. The aim is to optimally adjust blood sugar levels as quickly as possible in the case of an undiagnosed diabetic condition. This avoids a more severe course of diabetes, usually excludes secondary diseases and leads to the successful completion of periodontitis therapy. Conversely, general practitioners or diabetologists refer their patients to the dentist to have periodontal symptoms clarified. The dentist will then make a complete periodontal assessment and, if indicated, initiate systematic periodontal therapy. This is carried out in an interdisciplinary manner in coordination with the metabolic therapy. Cooperation between the diabetologist and the dentist is essential in such cases.

How does diabetes affect the treatment of periodontitis?

Unfortunately, diabetics with poorly controlled blood sugar levels cannot expect periodontal treatment to be successful quickly. This is due to the correlations described above. As long as the AGE continues to trigger inflammation in the periodontium, it cannot heal permanently. Conversely, the increased HbA1c value caused by periodontal disease will continue to affect the blood sugar level. Diabetes and periodontal therapy must therefore be coordinated in order to achieve a gradual improvement.

Conclusion: Intensive monitoring of the dental health of diabetics is essential

Diabetics should have their dental health strictly monitored, particularly with regard to periodontal disease. People with a hereditary predisposition to diabetic disease are also addressed. The correlation between the two diseases can have devastating consequences - in the worst case, it can end fatally with a heart attack.

Chronic inflammation of the gum pockets makes the cells more resistant to insulin, worsens blood sugar levels and makes it difficult for patients to adjust their medication to stabilize their blood values. This makes it all the more important for those at risk to have periodontitis treated immediately. The sooner, the better. A visit to the dentist is recommended at the very first signs such as bleeding gums, redness and swelling as well as bad breath.