The writer of this column recently had some unfortunate but interesting news. Doug went for an annual dental checkup at Boston University Dental School and was told he has periodontitis. Not good news, but after discussing it with a periodontitial professor there, he learned that diabetes and periodontitius are deeply interrelated. The professor told him that the condition of one has a direct effect on the other.
Doug thought that information was worth further study and worthy of a story on the subject. He contacted Dr. Nancy L. Newhouse, DDS, MS, President of the American Academy of Periodontology and also a practicing periodontist in Independence, MO. Below is their conversation.
I understand that diabetes affects periodontitis and vice versa. For my layman's audience, would you please explain interrelated influences and clinical outcome of each?
The relationship between diabetes and periodontal disease does go both ways. Periodontal disease may make it more difficult for people who have diabetes to control their blood sugar; and diabetes can make a person more susceptible to periodontal disease. People with diabetes are more sensitive to contracting infections. As a result, people with diabetes may be at higher risk of developing periodontal disease. Periodontal disease is often considered a complication of diabetes, and those who don’t have their diabetes under control are especially at risk. Bottom line, if a person has diabetes, they should take care of their periodontal health. They should brush and floss daily, tell their dental professional they are living with diabetes, and schedule an annual comprehensive periodontal evaluation to prevent or diagnose early presence of gum disease.
1) I read the following on a paper from the NIH website: "Diabetes has impaired defense mechanisms involving micro- and macro-vasculatures. The increased susceptibility to infection and reduced healing capacity with altered collagen metabolism may explain the increased level of periodontal destruction." Would you discuss in everyday language what collagen metabolism is and provide an explanation of micro- and macro-vasculatures?
Fibroblasts are a type of cell that is responsible for the synthesis of collagen and elastin. Collagen and elastin are components of what is referred to as the connective tissue. Collagen, at a microscopic level, is a tough thread-like material that has limited ability to stretch and contract whereas elastin is similar to a rubber band in its ability to stretch and contract.
When the “threads” of collagen are grouped together they comprise tendons and ligaments. When not grouped together but rather organized in a random pattern the “threads” hold the outer layers of our skin to the underlying muscle layer; they help hold the cells that comprise various body organs in proper relationships, such as heart muscle cells and the walls of arteries. Maintaining cellular organization insures that the organ will function properly.
Capillaries and larger blood vessels, such as veins and arteries, contain varying amounts of collagen. Indeed, capillaries are actually a single cell layer surrounded by collagen. Larger vessels, such as arteries, actually contain collagen and elastin as a component of the vessel wall.
The terms microvascular and macrovascular refer to the size of blood vessels.
Microvascular groups together the smaller diameter blood vessels, such as capillaries, venules and arterioles. These are the vessels that are responsible for perfusion of all body tissues with oxygen and initiate the removal of the “waste products” produced by cell metabolism, e.g., lactic acid, ammonia, urea, etc. The also initiate the transport oxygen depleted blood back to the heart and lungs.
Macrovascular refers to the larger diameter blood vessels that are primarily responsible for transporting and distributing blood throughout the body. Examples of large blood-oxygen carrying vessels would be the aorta, the femoral artery, tibial artery, etc. There are corresponding large veins that transport blood back to the heart and lungs for re-oxygenation.
Improperly controlled diabetes impacts the metabolism of fibroblasts (and most cells of the body) which, in turn, results in poorly structured collagen. Diabetes also results in a process called glycation that leads to complications in nerve conduction, kidney function, oxygenation of body tissues and removal of metabolic waste products. Consequently, diabetes can lead to poor kidney function, neuropathy, poor tissue oxygenation, and vascular problems such as accelerated atherosclerosis, leading to stroke and heart attacks, and aggravation of pre-existing periodontal disease or increased susceptibility to the disease.
The gum tissues and bone surrounding teeth are perfused by blood just as other organ systems in the body and dependent on fibroblasts and collagen like any other organ system. Consequently, periodontal disease and diabetes have a bidirectional interaction. For example, as one disease is treated the other disease tends to be less aggressive or severe. In contrast, as one disease becomes more severe – the other does likewise. Obviously, to the extent possible, it is best to treat both diseases. By doing so, it becomes easier for the patient to control their diabetes and maintain a healthy lifestyle
3) How prevalent is periodontitis in diabetics verses non-diabetics?
A recent study from the Centers for Disease Control (CDC) based on the 2009-2010 National Health and Nutritional Examination Survey (NHANES) found that over 64 million adults age 30 and older have periodontal disease. That data is currently being broken down into different segments of the population, including people with diabetes and people without, in order to provide us with a more concrete snapshot of periodontal disease prevalence among various groups. We hope to have this information soon. This will allow the AAP to see a better picture at the state of periodontal health in the United States population, including those with diabetes.
4) What statistics or information can you share with my audience relating to the importance and influence of proper dental hygiene in diabetic patients?
Everyone – including people living with diabetes - should brush and floss daily, share their medical history with their dental professional, and schedule annual comprehensive periodontal evaluations to prevent or diagnose the presence of gum disease. While we don’t have data yet for people with diabetes, here are some statistics from the 2009-2010 NHANES data on the prevalence of periodontal disease.
• Prevalence was significantly higher in males (56.4%) versus females (38.4%).
• Prevalence was highest among Mexican-Americans (66.7%).
• Prevalence was highest among current smokers (64.2%).
5) Are complications more common in type I or type II diabetics? Why?
A study published in the Journal of Clinical Periodontology (http://www.ncbi.nlm.nih.gov/pubmed/19622096) determined both Type 1 and Type 2 diabetes were associated with increased prevalence compared with non-diabetics, however there isn’t much data comparing periodontal disease with Type 1 versus Type 2 diabetes.
6) Finally, what are the best tactics for managing periodontitis for diabetics?
The best tactic for managing periodontitis for people living with diabetes is to take care of their teeth and gums and keep their diabetes under control. A person living with diabetes must follow an at-home periodontal health routine of flossing and brushing daily; have regular check-ups with their dental professional, including an annual comprehensive periodontal evaluation; and work with their medical professional to keep their diabetes under control.
Periodontal treatment has been shown to improve blood sugar levels in people with diabetes, suggesting that treating periodontal disease could decrease insulin requirements. If diabetes is well controlled, treatment will be similar to the treatment of someone who doesn’t have diabetes. In the early stages of gum disease, treatment usually includes scaling and root planning, a procedure in which plaque and calculus are removed from the pockets around the tooth and near the gums. People with diabetes may want to schedule their dental appointments early in the morning after they have eaten a normal breakfast in order to stabilize and prevent a severe or sudden drop in blood sugar levels. Upon determining a treatment plan, the periodontist and physician will work together to help control both diabetes and periodontal disease.