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Periodontal patients often present treatment and maintenance challenges due to the chronic, non–curable nature of periodontal disease. When managing a perio patient with diabetes, the challenges go up several notches due to the mutually destructive effects of these two diseases. Favorable treatment outcomes may not occur if we fail to take blood sugar control into account. Managing these patients is a very large responsibility, but it is also a great opportunity to impact patients' health beyond the oral cavity.
Diabetes is characterized by disorders in the metabolism of carbohydrate, fat, and protein. Diabetic complications, which are life changing and life threatening, are directly related to blood sugar control. Poorly controlled individuals have a higher incidence of complications such as retinopathy, nephropathy, neuropathy, cardiovascular diseases, infections, cataracts, and periodontal disease.
It is important to recognize that diabetes cannot cause periodontal disease, but it can increase the likelihood of disease development and progression. Similarly, periodontal disease cannot cause diabetes, but it can increase the likelihood of diabetic complications by increasing insulin resistance, leading to hyperglycemia.
Factoring the level of glycemic control into treatment planning decisions for perio patients with diabetes is important because the likelihood of a favorable treatment outcome is much lower when the patient has hyperglycemia. When diabetic patients are well controlled, the risk of periodontal disease development and progression is the same as a nondiabetic individual.
Diabetes and periodontal disease share several important properties. Both diseases are chronic, noncurable, and controllable. The most significant similarity is the adverse effect each has on the other. These mutually destructive effects are the crux of the problem with diabetes and periodontal disease. Diabetes is the No. 1 systemic risk factor for periodontal disease through several mechanisms.
In hyperglycemic conditions, the body's ability to kill perio pathogens and repair damaged gingival tissue is severely impaired. Additionally, the inflammatory mediators responsible for perio tissue destruction are elevated in hyperglycemic states.
On the other hand, periodontal disease worsens blood sugar control by increasing insulin resistance, which prevents the transport of glucose from the blood vessels into the cells. The resulting sugar back–up in the bloodstream creates the hyperglycemic conditions.
The significant problems associated with these two diseases emphasize the critical importance of preventing perio disease from developing in the first place, and treating and maintaining oral health for those with periodontitis. Identifying and aggressively addressing gingivitis takes on additional importance for these patients. Utilizing the various tools in our ever–expanding toolbox is important to tip the balance in our patients' favor.
Items including power brushes, antimicrobial rinses, interdental cleaners, and locally applied and systemic antibiotics are among the choices available to all clinicians. Bacterial DNA testing of diabetic individuals with perio disease is vitally important to determine if we have truly reached the endpoint of therapy. We may achieve favorable clinical resolution, but if we fail to achieve bacterial reduction, as determined by pre– and post–op DNA testing, the likelihood of disease recurrence is elevated (OralDNA Labs, Nashville, Tenn., www.oraldna.com).
Periodontal maintenance and daily plaque control are the two primary determinants of the longevity of successful treatment results. Elevated risk of perio disease recurrence will impact our decisions regarding maintenance interval and protocol, and home–care recommendations.
Complications of poorly controlled diabetes are life changing. In the United States, diabetic retinopathy is the leading cause of blindness, diabetic nephropathy is the primary reason for kidney dialysis, and diabetic neuropathy is the leading cause of amputations. Successfully managing the oral contribution to blood sugar control, by preventing and aggressively treating periodontal disease, can improve the quality of life for these patients.
The primary reason why it is so important to prevent periodontal disease from developing in the first place, and aggressively addressing existing periodontitis in diabetic individuals, is because 65% of poorly controlled diabetics die from a heart attack or stroke. Further research should fill in the gaps in our knowledge of the bidirectional relationship between periodontal disease and diabetes. Trying to manage these two diseases is an enormous responsibility, but we should welcome the opportunity to improve our patients' health beyond the oral cavity. We are treating people, not mouths.
Dr. Richard Nagelberg has practiced general dentistry in suburban Philadelphia for more than 27 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations. He lectures extensively on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact him at [email protected].
