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Kendra Bruggink

Diabetes Mellitus and Periodontal Disease: Understanding

the Connection
There are many people who only think of gum disease, or periodontal disease
as an infection confined to the oral cavity. Research has now provided evidence
which supports that the pathway of inflammation links oral infections, such as
periodontal disease, to the entire body. One strong example of this link is the bidirectional relationship of diabetes mellitus and periodontal disease. Not only are
diabetic patients more susceptible to periodontal disease, but the presence of
periodontal disease makes it more difficult for patient to maintain glycemic control.
Periodontal disease is a chronic infection caused by the pathogenic bacteria
found in the dental plaque biofilm. These bacteria cause inflammation of the gum
tissue. When the plaque biofilm is not disrupted the inflammation leads to the
destruction of the gum tissue and the alveolar bone support of the teeth, usually
resulting in tooth loss.
Diabetes mellitus is a disease which does not produce or properly produce
insulin. Insulin is a hormone, needed to convert sugars and starches into useful
energy for the body. Insulin allows the body cells to take the glucose it needs.
Without insulin glucose remains in the blood instead of moving to the cells. There
are three types of diabetes: type I, type II, and gestational diabetes. Type I is when
the pancreas produces little to no insulin. Type II, the most common, occurs when
the body does not make secrete enough insulin or the body fails to use the
hormone. Gestational diabetes is a form of diabetes which only occurs during
pregnancy, in women with no prior diagnosis of diabetes. The goal of diabetic care
is to lower blood glucose levels.

Kendra Bruggink
When the body is suffering from diabetes, the structure of the blood vessels
is altered. This affects the blood flow, and eventually may weaken the gums and
bone which surround the teeth.
Bacteria associated with periodontal infections thrive on sugars, such as
glucose. Hyperglycemia (high blood sugar) in uncontrolled diabetics results in
increased glucose in the gingival crevicular fluid and blood. The high levels of
glucose in the fluid can help the pathogenic bacteria survive and multiply,
increasing the progression of periodontal disease.
In periodontal disease the presence of gram-negative bacteria in the plaque
biofilm initiate the bodies inflammatory response. Biochemical mediators are
attracted to the site. The mediators which play a role in both diabetes and
periodontal disease include polymorphonuclear leukocytes (PMNs), cytokines IL-8,
IL-6 and the tumor necrosis factor-a (TNF-a), prostaglandin E2 (PGE2), and the
matrix metalloproteinases (MMPs). The PMNs play an important role in the
maintenance of gingival and periodontal health. However it is found that in patients
with diabetes the function of PMNs is reduced and the chemotaxis of the PMNs to
the site of inflammation is defective. When the bacteria is not removed an increase
in the amount of biochemical mediators, such as cytokines, PGE2 and MMPs are
sent to the site of infection. The high concentration of these biochemical mediators
leads to the breakdown of tissue and alveolar bone over time.
Diabetic patients with controlled blood sugar levels (good glycemic control)
can prevent or delay the onset and slow the progression of periodontal disease.
Patients with uncontrolled diabetes have higher risks for infections and poor wound
healing. It is estimated that patients with poor glycemic control are at a 2-3 times

Kendra Bruggink
greater risk for developing a periodontal infection than non-diabetic patients. These
patients also have a poor response to nonsurgical and surgical periodontal
therapies, a more rapid recurrence of dry pockets, and less favorable long term
response to treatment. This is why it is key for diabetic patients to achieve and
maintain same level of glycemic control as patients without diabetes.

Gehrig, J., & Willmann, D. (2011). Foundations of periodontics for the dental
hygienist (3rd ed., pp. 173-176, 311-312). Philadelphia: Wolters Kluwer
Health/Lippincott Williams & Wilkins.
Herring, M., & Shah, S. (2006). Periodontal Disease and Control of Diabetes Mellitus. The
Journal of the American Osteopathic Association, 106, 416-421. Retrieved April 18, 2015, from

Southerland, J., Taylor, G., & Offenbacher, S. (2005). Diabetes And Periodontal
Infection: Making The Connection. Clinical Diabetes, 23(4), 171-178. Retrieved April
18, 2015, from