SYMPOSIUM ARTICLE

Oral Health and Type 2 Diabetes

Renata S. Leite, DDS, MS, Nicole M. Marlow, MSPH and Jyotika K. Fernandes, MD

Guest Editor
Kathie Hermayer, MD, MS

Abstract: Type 2 diabetes mellitus has been described as a new epidemic. ORAL IMMUNOLOGIC AND
Approximately 285 million people worldwide suffer from diabetes, and INFECTIOUS DISEASES
this number is predicted to increase by approximately 50% by year 2030. Periodontal Disease
This article will review oral health manifestations of diabetes and discuss Chronic periodontal disease results in progressive
associations between periodontal disease and diabetes. Although there is destruction of the supporting tissues of the teeth and pocket
a strong body of evidence that supports the relationship between oral formation, recession or both, which may lead to tooth loss
health and type 2 diabetes mellitus, oral health awareness is lacking because of extensive destruction of alveolar bone. It is well
among patients with diabetes and other health professionals. There is documented that periodontal disease is considered to be one of
a need for the treating physician to be educated about the various oral the main reasons for tooth loss among individuals with
manifestations of diabetes so that they can be diagnosed early and timely diabetes.2–5 A meta-analysis of 4 studies with a total of 3524
referrals to oral health specialists can be made. The established link adults (.18 years old) showed that those with diabetes have
between periodontitis and diabetes calls for an increased need to study a 2-fold higher risk of developing periodontal disease compared
ways to control both diseases, particularly among populations with health with those without diabetes.6 Additionally, there are considerable
disparities and limited access to oral and health care. racial disparities regarding the rates of periodontal disease within
Key Indexing Terms: Periodontal health; Diabetes; Periodontal therapy. patients with diabetes and periodontal disease. National preva-
[Am J Med Sci 2013;345(4):271–273.] lence estimates of periodontal disease for African Americans with
T2DM have been reported at 59.7%7; whereas, Fernandes et al8
reported significantly higher rates for African Americans of
H yperglycemia in diabetes has been shown to be an important
risk factor for the manifestation of vascular complications.
The 5 classic complications associated with DM include retinop-
Gullah ancestry with T2DM (70.6%).
Several mechanisms have been proposed to explain the
increased susceptibility to periodontal diseases among patients
athy, neuropathy, nephropathy, cardiovascular complications with uncontrolled diabetes mellitus (DM), including alterations
(coronary arterial disease, stroke and peripheral vascular disease) in host response, collagen metabolism and vascularity. Individ-
and delayed wound healing. Periodontal disease has recently been uals with poorly controlled T2DM present an exaggerated
recognized as the “sixth complication” of DM.1 inflammatory response to the bacterial challenge of periodonti-
Diabetes is a common disorder with concomitant oral tis. A hyperinflammatory response coupled with impaired
manifestation that impacts dental care, and there is concern about wound healing and repair may enhance the inflammatory
the ability of oral manifestations to profoundly affect metabolic reaction and periodontal tissue destruction for these patients.9,10
control of the diabetes state. Physicians working to optimize the Several controlled clinical trials have confirmed that subjects
metabolic control of these patients should recognize the impact of diagnosed with diabetes have a greater prevalence of periodontal
controlling the progression of these oral complications. This diseases compared with healthy individuals.8,11,12 In addition,
warrants a comprehensive plan that involves close collaboration severe periodontitis may increase the risk of poor glycemic con-
between physicians and oral health care providers, which will trol.13,14 The host inflammatory response appears to be the critical
hopefully lead to better glycemic control among this patient determinant for susceptibility to and severity of periodontitis in
population and also lower the impact of personal and societal systemically compromised individuals,15,16 such as patients with
burden, of these potentially disabling comorbid conditions. Oral T2DM. There is also evidence suggesting that periodontitis-
complications of diabetes can be devastating for the patient. induced bacteremia will cause elevations in serum proinflammatory
These may include, but are not limited to candidiasis, dental cytokines and reactive oxygen species leading to etiopathogenesis
caries, tooth loss, gingivitis, lichen planus, neurosensory disor- of metabolic syndrome and increased insulin resistance.
ders (burning mouth syndrome), periodontitis, salivary dysfunc- The chronic inflammatory state induced by untreated
tion and xerostomia and taste impairment. periodontitis may contribute to insulin resistance, worsening
glycemic control.17 A recent report by Bandyopadhyay et al,18
From the Division of Periodontics, College of Dental Medicine, Center for using a study population of Gullah African Americans with
Oral Health Research (RSL, NMM), College of Dental Medicine, Division of T2DM and no recent clinical history of periodontal therapy,
Biostatistics and Epidemiology (NMM), College of Medicine, and Division of
Endocrinology, Diabetes, and Medical Genetics (JKF), College of Medicine, concluded that there are significant associations between peri-
Medical University of South Carolina, Charleston, South Carolina. odontal disease progression and diabetes control status.
Presented in part at the Diabetes Initiative of South Carolina Untreated periodontitis poses an inflammatory challenge to
Symposium, September 20-21, 2012, Charleston, SC.
This study was supported by grant P20 RR-017696 (South Carolina the patient, and the reduction of periodontal inflammation has
COBRE for Oral Health) and M01 RR001070 from National Center for potential positive benefits to the patient both locally and sys-
Research Resources which is part of the U.S. National Institutes of Health. temically.19 Grossi et al20 reported that adults with DM who
The authors have no financial or other conflicts of interest to disclose. received ultrasonic scaling and curettage in combination with sys-
Correspondence: Renata S. Leite, DDS, MS, Division of Periodontics,
College of Dental Medicine, Medical University of South Carolina, 173 Ashley temically administered doxycycline therapy demonstrated, at
Avenue, BSB 119, MSC 507, Charleston, SC 29425 (E-mail: [email protected]). 3 months, significant reductions in mean HbA1c, reaching

The American Journal of the Medical Sciences  Volume 345, Number 4, April 2013 271
Leite et al

approximately 10% from the pretreatment values. Systematic review ages and tobacco use, whereas a high fluid intake diet should be
studies have also concluded that nonsurgical periodontal therapy encouraged. The use of mouthwashes that are specific to the
with or without antibiotics led to a mean reduction in the HbA1c treatment of dry mouth and alcohol free may also alleviate the
of 0.4% after 3 to 4 months relative to no treatment.21,22 Diabetes- oral discomfort of xerostomia. Therapy with immunologically
related microvascular complications are estimated to reduce by 35% active saliva substitutes has demonstrated to be helpful for
for every 1% point decrease in HbA1c levels; furthermore, 1% abso- reducing bacterial plaque, gingivitis and positive oral yeast
lute decrease in HbA1c level may decrease the risk of any diabetes- counts.37 Patients with xerostomic complaints should be
related death by 21%.23 referred to a dentist for a strict maintenance of their oral health.
As xerostomia has a significant effect on a person’s quality of
Dental Caries life, all health care workers should be sensitive to those com-
Dental caries are common chronic disease conditions that plaining of dry mouth and treat or refer them accordingly.
cause pain and disability across all age groups. If left untreated,
dental caries can lead to pain, infection, tooth loss and, eventually, NEUROPATHY CONSEQUENCES IN THE
edentulism. The presence of these oral manifestations can hinder ORAL CAVITY
quality of life, nutrition and, potentially, glycemic control. It is A common complaint among DM patients is burning
important to know that patients with DM are susceptible to other mouth syndrome, an orofacial neurosensory disorder of
oral conditions, such as periodontal and salivary disorders (dry unknown cause, characterized by a bilateral burning sensation
mouth), which could increase their risk of developing new and of the oral mucosa usually in the absence of clinical and
recurrent dental caries. A review of the literature indicates that laboratory findings.38 Management of burning mouth syndrome
there is no clear association between DM and dental caries, but should have an interprofessional approach to improve patient’s
several studies have reported a greater history of dental caries in well being and quality of life. The treatment protocol for xero-
people with DM.24,25 Decreased salivary secretion, increase of stomia is frequently used for the treatment of burning mouth
carbohydrate in the parotid gland saliva, growth of oral yeasts, syndrome, allowing for the palliative care of the symptoms.
increased counts of Streptococcus mutans and Streptococcus lac- Taste detection is determined hereditarily, but it can be
tobacilli are some of the factors implicated to be responsible to influenced also by occurrence of neuropathy.39 This sensory
predispose diabetics to higher incidence of dental caries.26 dysfunction can inhibit the ability to maintain a proper diet
and can lead to poor glycemic control. Taste impairment has
Oral Mucosal Diseases also been associated with the development of obesity,39 and it
Diabetes is also associated with the development of certain has been reported during the course of diabetes.40
oral soft tissue lesions, although these associations are not The use of oral hygiene devices may be impaired by
consistently reported across different diabetic populations.27 There peripheral neuropathies and by diabetic retinopathy, which may
are reports of greater prevalence of fissured tongue, irritation impair daily oral hygiene. The use of an electric toothbrush and
fibroma, traumatic ulcers,27 lichen planus,28 recurrent aphthous other alternative hygiene methods and a strict dental mainte-
stomatitis29 and oral fungal infections, such as oral candidiasis.30 nance schedule are important in the long-term oral health of
These associations may be due to chronic immunosuppression, these patients.
delayed healing and/or salivary hypofunction.31 They additionally
represent an opportunity to coordinate diabetes care between CONCLUSIONS
physicians and oral health care providers. Several studies41–45 have indicated deficiencies in general
oral health awareness among patients with diabetes. Additionally,
SALIVARY DYSFUNCTION most of these studies41,42,44 showed that a very low number of
Salivary function is essential for the maintenance of oral patients diagnosed with diabetes visit the dentist regularly for peri-
and systemic health.32,33 It is important for digestion, mastication, odontal checkups, and many patients were unaware of the effect of
taste, speech, deglutition and preservation and protection diabetes on oral health. Allen et al43 reported that awareness of
of mineralized and mucosal tissues.32 Xerostomia is a subjective periodontal diseases among diabetes patients is very low com-
sensation of oral dryness, so a systematic approach should be pared with their reported knowledge of increased risks for heart
employed to determine the etiology of this condition, with dis- disease, eye disease, kidney disease and circulatory problems.
tinction made between subjective complaints alone and those with Periodontal diseases and DM are closely associated and
measurable salivary gland dysfunction. Xerostomic complaints are highly prevalent chronic conditions. Inflammation is a critical
may be due to thirst (a common manifestation of DM), oral player in the association, and its importance is just now coming
sensory dysfunctions, dehydration, decreased salivary flow (hypo- to light. Diabetes clearly increases the risk of periodontal diseases
salivation) and/or altered saliva composition. Chavez et al34 found as demonstrated by several plausible mechanisms. Less clear is
trends toward decreased salivary flow rates as HbA1c values the impact of periodontal disease on glycemic control and the
increased, whereas other studies have reported that the use of mechanisms through which this occurs. Evidence-based care
one or more xerostomic medications resulted in significantly emphasizes the importance of clinically relevant preventive and
lower flow rates.33,35 Although many medications and treatment therapeutic measures for the management of DM and periodontal
modalities list xerostomia as a possible side effect, very few have diseases. The involvement of oral health care professionals in
been tested for objective changes in salivary flow.36 strategies to identify individuals at risk for diabetes will extend
Management of xerostomia should be directed to relief of preventive and screening efforts necessary to slow the develop-
symptoms, control of oral diseases and improvement of salivary ment of these diseases and, notably, provide a portal for
function. If xerostomia is a side effect of medication use, the individuals who do not see a physician on a regular basis to
possibilities of modifying drug scheduling, dose adjustment or enter into the general health care system.
changing medications should be explored, whereas some relief
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