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Table of Contents
Year : 2020  |  Volume : 17  |  Issue : 4  |  Page : 267-271

Diabetes Mellitus and Periodontitis: Relevance of the Diabolic Duo in India

1 Department of Periodontology, Sudha Rustagi College of Dental Sciences and Hospital, Faridabad, Haryana, India
2 Department of Dentistry and Clinical Research, Max Super Speciality Hospital, New Delhi, India
3 Apollo Centre for Obesity, Diabetes and Endocrinology, Indraprastha Apollo Hospital, New Delhi, India

Date of Submission28-Sep-2020
Date of Acceptance10-Nov-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Sangeeta Dhir
Department of Dentistry and Clinical Research, Max Super Speciality Hospital, 2 Press Enclave Road, Saket, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/am.am_118_20

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Diabetes and periodontitis are highly prevalent diseases. Chronic nature, along with shared risk factors, magnifies the complexity of both the diseases. Periodontal treatment results in clinically relevant reductions in HbA1c, and the presence of diabetes worsens the periodontal health and vice-versa. This paper presents an overview on the pathogenic mechanisms, impact of intervention, and significance of interprofessional collaborations for holistic management in diabetes and periodontitis.

Keywords: Diabetes, oral health, perio-diabetes HbA1c, periodontal disease, periodontitis, professional collaborations, type 2 diabetes

How to cite this article:
Bansal S, Dhir S, Wangnoo SK. Diabetes Mellitus and Periodontitis: Relevance of the Diabolic Duo in India. Apollo Med 2020;17:267-71

How to cite this URL:
Bansal S, Dhir S, Wangnoo SK. Diabetes Mellitus and Periodontitis: Relevance of the Diabolic Duo in India. Apollo Med [serial online] 2020 [cited 2021 Jan 18];17:267-71. Available from: https://www.apollomedicine.org/text.asp?2020/17/4/267/305382

  Introduction Top

Diabetes Mellitus is a metabolic disorder of multiple etiology characterized by chronic hyperglycemia (elevated blood glucose levels) with disturbances of carbohydrate, fat, and protein metabolism resulting from defects in insulin secretion, insulin action, or both.[1] Persistent hyperglycemia leads to long-term damage, dysfunction, and failure of various organs and body systems. Type 1 diabetes results from insulin deficiency due to the autoimmune destruction of the β-cells of the islets of langerhans in the pancreas. Insulin deficiency leads to an inability to control blood glucose levels, and hyperglycemia develops. Type 1 diabetes has a genetic predisposition and tends to develop mainly in childhood, adolescence, or in young adults and accounts for 5%–10% of all cases of diabetes. Type 2 diabetes (historically referred to as noninsulin-dependent diabetes mellitus) accounts to around 90% of diabetic cases, and is caused by impaired insulin secretion and increased insulin resistance (i.e., less insulin is produced, body cells are increasingly resistant to the effects of insulin, leading to hyperglycemia because insulin signals body cells to take in glucose from the blood). Diabetes is one of the fastest-growing global health emergencies of the 21st century. In 2019, it was estimated that 463 million people will have diabetes, and this number is projected to reach 578 million by 2030, and 700 million by 2045.[2] Furthermore, it estimates another 352.1 million people worldwide to have a prestage of diabetes, called impaired glucose tolerance, a figure which is likely to rise to 531.6 million by 2045. All this, despite the fact that 50% of all individuals with diabetes are undiagnosed, especially in developing countries. There are several oral manifestations of diabetes such as periodontitis, dental caries, oral mucosal diseases (e.g., candida infections, lichen planus, and recurrent oral ulceration), salivary dysfunction, xerostomia.[3]

Periodontitis is an inflammatory disease of the supporting tissues of the teeth caused by specific microorganisms or groups of specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with increased probing depth formation, recession, or both.[5] Moderate periodontitis and severe periodontitis affect 40%–60% and 10%–15% of adults, respectively. [5,6] Several plausible mechanisms link diabetes and periodontits and latter has been considered as the sixth complication of diabetes.[7] Periodontitis is also considered a modifying risk factor for systemic health.[8] The risk of periodontitis is three-fold in people with diabetes when compared to nondiabetics.[9]

  Diabetes and Periodontitis – The Bidirectional Relationship Top

Commonality between both the diseases is not related only to their high prevalence and increasing global statistics but also to the underlying issue of under diagnosis, especially in developing countries. It can be translated to the fact that these two diseases cumulatively present a huge economic burden in the near future. There exists a strong bidirectional relationship between the two disease giants [10,11] secondary to their chronic inflammatory nature and shared risk factors. Poor oral health has been found in diabetics.[12] Uncontrolled glycemic levels significantly increase the severity of periodontitis in type 2 diabetes mellitus.[13] The National Health and Nutrition Examination Survey III, after controlling the confounders, found that adults with HbA1c >9% had a significantly higher prevalence of severe periodontitis than those without diabetes (odds ratio = 2.90 [1.40–6.03]).[14]

[Figure 1]">  Overview of Pathogenic Mechanisms Linking Periodontitis and Diabetes [Figure 1] Top
Figure 1: Mechanisms linking periodontitis and diabetes

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Effect of diabetes on periodontitis

The basic mechanisms in the underlying tissues in diabetes involves mass production of AGE's ( advanced glycation endproducts ) These products deposit in the periodontal tissues leading to the RAGE(receptor for AGE) interaction. RAGE is predominantly forund on macrophages. AGE-RAGE complex activates the local immunoinflammatory response.[15] This results in increased oxidative stress, increased release of cytokines (interleukin [IL]-1 β, IL-6, tumor necrosis factor-alpha), and disruption of receptor activator of nuclear factor-κB ligand/osteoprotegerin axis, which finally causes the bone resorption. [16,17] Cytokines released from the adipose tissue (proinflammatory adipokines) contribute to the pro-inflammatory environment.[18] Cumulative impact leads to the breakdown of the periodontal connective tissues, resorption of alveolar bone, and exacerbation of periodontitis.

Effect of periodontitis on diabetes

Periodontal bacteria with pro-inflammatory mediators and cytokines enter the circulation and contribute to an upregulated systemic inflammatory state. This results in impaired insulin signaling and increased insulin resistance, leading to elevated HbA1c levels and increased diabetes complications periodontal bacteria and their products, together with inflammatory cytokines and other mediators produced locally in the inflamed periodontal tissues, enter the circulation and contribute to upregulated systemic inflammation. This leads to impaired insulin signaling and insulin resistance, thus exacerbation of diabetes. Increased HbA1c levels, in turn, contribute to increased risk of diabetes complications (including periodontitis),[17] creating a two-way, bidirectional relationship between the diseases [Figure 1]. [17,18] The effect of periodontitis on diabetes risk and glycemic control was analyzed in one of the recent meta-analysis and systematic review.[19]

  Impact of Periodontal Treatment on Diabetic Status Top

Periodontal treatment (i.e mechanical debridement / removal of pathologic root surface deposits) leads to reduction in microbial load by lowereing the levels of circulating bacteria and their released toxins. Subsequently there is reduction in the systemic levels of pro-inflammatory cytokines and inflammatory mediators after periodontal therapy. [20,21] The treatment of periodontitis in patients with diabetes has been shown to reduce HbA1c by 3–4 mmol/mol (0.3%–0.4%) after 3–4 months.[4] These reductions are clinically relevant, as they equate to reduced risk of diabetes complications. The reductions in HbA1c and improved glycaemic control following periodontal treatment is presumed to be a cumulative impact of reduced bacterial challenge and systemic inflammation systemically, which further improves insulin resistance and insulin signaling [Figure 2].[17]
Figure 2: Effect of periodontal treatment on diabetic control

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  Periodontitis Diabetes Continuum-The Indian Perspective Top

The importance of oral health on the overall general health of the individual has emerged as a vital concept in recent years. There is a paucity of awareness about the importance of periodontal/oral health among medical health-care professionals and patients.[22] A recent study assessing oral health in adult diabetics revealed that 85% of the participants suffered from at least one oral disease and people with diabetes had poor oral health as compared to nondiabetics.[12] Dental caries was present in 79% of the subjects. The prevalence of severe periodontitis was higher in diabetics (43%) as compared to nondiabetics.[12] Taking a clue from the evidence-based scientific data (epidemiologic, pathogenic-mechanistic, interventional) between the two disease giants, various scientific organizations in the past 10 years have published recommendations and guidelines for evolving a model based on interprofessional referrals and multidisciplinary care for holistic management of diabetes and periodontitis [Table 1]. Several countries have also implemented this in their public health system. India is deemed the world diabetic capital.[27] Among the 72 million diabetics, around 1 million die due to diabetes or its associated complications. The coexistence of severe periodontitis and uncontrolled diabetes poses a clinical challenge in the Indian subcontinent for effective and successful treatment and its prognostic implications. Oral and periodontal health still remains not so well discussed and clinically highlighted disease in diabetic clinical setups and consequentially remains a serious handicap and an unmet need in diabetes practice.[28] With these alarming statistics, awareness for this bidirectional relationship should be a priority among the medical and dental peers. Assiduous efforts are required in India to expedite the progress in the relatively less explored periodontitis-diabetes realm. One such effort was the inter-professional society symposium exclusively on periodontitis and diabetes held in India. This pioneering platform connected several clinicians and academicians both from the medical and dental fraternity.[26]
Table 1: Select publications on the recommendations for the management of diabetes and periodontitis

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Interdisciplinary management for diabetes and periodontitis-Recommendations for awareness and sensitization of physicians and dental peers in India:

  • Collaborative clinical research studies on periodontitis and diabetes
  • Conducting continuing medical education/continuing dental education
  • Developing public awareness modules through public meetings
  • Print and digital platforms
  • Incorporation of dental/oral health screening in diabetic patients as a part of regular visits and vice versa on screening the diabetic history in patients suffering from periodontitis
  • Encourage cross-referrals among the medical and dental professionals on co-management protocols
  • Policymakers to consider oral health integration in the essential realm of NCD (noncommunicable diseases)
  • Data collection across various dental/diabetic practices should be initiated to ascertain the overall health and economic burden posed by periodontal disease and diabetes
  • Incorporation of the importance of oral health and diabetes in the undergraduate curriculum of medical and dental education should also be contemplated. Moving forward, this would be a quantum leap in sensitizing the upcoming future generation about the associative two-way link between the diseases
  • The timing also seems propitious for the development of clinical practice guidelines by respective professional organizations/national societies. This would help the clinicians to raise their standards of delivering comprehensive patients care.

  Conclusions Top

Diabetes increases the risk for periodontitis, and glycemic control is crucial in determining the level of risk. With the increasing burden of poor oral health and diabetes in India, it is prudent to incorporate the oral health assessment in diabetes care programs and vice versa.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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International Diabetes Federation. IDF Diabetes Atlas. 9th ed. Brussels, Belgium: International Diabetes Federation; 2019. Available from: http://www.diabetesatlas.org. [Last accessed on 2019 Jan 23].  Back to cited text no. 2
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Rawal I, Ghosh S, Hameed SS, Shivashankar R, Ajay VS, Patel SA, et al. Association between poor oral health and diabetes among Indian adult population: Potential for integration with NCDs. BMC Oral Health 2019;19:191.  Back to cited text no. 12
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Polak D, Shapira L. An update on the evidence for pathogenic mechanisms that may link periodontitis and diabetes. J Clin Periodontol 2018;45:150-66.  Back to cited text no. 17
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Graziani F, Gennai S, Solini A, Petrini M. A systematic review and meta-analysis of epidemiologic observational evidence on the effect of periodontitis on diabetes An update of the EFP-AAP review. J Clin Periodontol 2018;45:167-87.  Back to cited text no. 19
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Bissett SM, Stone KM, Rapley T, Preshaw PM. An exploratory qualitative interview study about collaboration between medicine and dentistry in relation to diabetes management. BMJ Open 2013;14;3:e002192.  Back to cited text no. 22
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Chapple IL, Genco R, Berglundh T, Eickholz P, Engebretson S, Graves D et al. Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP workshop on periodontitis and systemic diseases. J Clin Periodontol 2013;40 Suppl 14:S106-12.  Back to cited text no. 24
Sanz M, Ceriello A, Buysschaert M, Chapple I, Demmer RT , Graziani F et al. Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the international diabetes federation and the European federation of periodontology. J Clin Periodontal 2018;45:138-49.  Back to cited text no. 25
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[PUBMED]  [Full text]  
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[PUBMED]  [Full text]  
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