Final Research Paper: The Bidirectional Relationship between Diabetes and Periodontitis: A

Comprehensive Review of Current Evidence

Caitlyn Olds

Dental Hygiene Program, Georgian College

DENT 2030: Introduction to Research for the Dental Hygienist

Matilda Berg

Thursday, April 13th, 2023

The Bidirectional Relationship between Diabetes and Periodontitis: A

Comprehensive Review of Current Evidence
Caitlyn Olds
ABSTRACT
Aim: The aim of this paper was to provide more significant evidence of the long-standing
relationship between Periodontitis and Diabetes. The treatment of non-surgical periodontal
therapy was also included to provide evidence of its effect on blood glucose levels.
Methods: The PICO question was “For individuals with Diabetes Type 1 or Type 2
(Population), is Periodontitis a risk factor that is directly linked (Comparison group) and are
there periodontal therapies (Intervention) that positively impact the systemic health (Outcome).”
A comprehensive review of qualitative, quantitative, mixed-methods, systematic reviews and an
umbrella review were used to provide evidence of the bi-directional link between Periodontitis
and Diabetes. Databases used: PubMed, NCBI, Google Scholar, CINAHL, Cochrane Registry of
Systematic Reviews, Gale Academic OneFile and Science Direct. Full text and peer-reviewed
articles only were used in this systematic review. 10 peer-reviewed scholarly articles were used:
10 systematic reviews/meta-analyses, and 1 umbrella review. All studies were published between
2013-2022 and were only used if published 2013 or later. Results: Within 11 records used, 6 SR,
1 umbrella review and 4 cohort studies were used. The SRs and UR all included the
inflammatory pathway in their argument, the relevance of non-surgical periodontal therapy, and
its impact on glycemic levels. 3 of the cohort studies included the knowledge and oral health
status of Diabetics and the interprofessional knowledge required to treat Diabetic and
Periodontitis clients. Discussion: Diabetes and Periodontitis have had a bidirectional relationship
occurring for approximately 20 years. The primary evidence discussed are: the inflammatory
pathway and the response orally and systemically between both co-morbidities; the incorporation
of Diabetes into the Periodontal Classification system developed by the American Academy of
Periodontology (AAP) and the European Federation of Periodontology (EFP); and the impact of
non-surgical periodontal therapy on glycemic levels. Conclusion: Although there is strong
evidence between both c-morbidities, more evidence is necessary to find a biological mechanism
that directly correlates Diabetes and Periodontitis. Keywords used: periodontitis, periodontal
disease; AND diabetes mellitus; diabetics; AND bidirectional relationship, systematic reviews,
study CHDA Research Agenda Category: oral-systemic links.
INTRODUCTION Periodontal disease affects 22% of the
diabetic population and is one of the most
prevalent chronic infections recorded among to provide evidence of the bi-directional link
the many risk factors for diabetics. Studies between Periodontitis and Diabetes.
going on for decades point to the strong
Search strategy:
correlation between periodontal disease and
a) For this systematic review, the
diabetes. It is of utmost importance to
electronic databases used were
increase the awareness of the diabetic
PubMed, CINAHL, NCBI, Google
population to the overall knowledge of their
Scholar, Cochrane Registry of
oral health and its impact on their diabetes
Systematic Reviews, Gale Academic
and vice versa. Dental professionals must
OneFile and Science Direct. Full text
educate their Diabetic clients on the
and peer-reviewed articles only were
potential risk of Periodontitis. The
used in this systematic review. All
inflammatory pathway, the incorporation of
studies included must be published
Diabetes into the Classification system for
in 2013 or later.
Periodontitis, and the positive effect of non-
b) Keywords used: periodontitis,
surgical periodontal therapy are all major
periodontal disease; AND diabetes
factors that provide evidence of the linkage
mellitus; diabetics; AND
between these two co-morbidities.
bidirectional relationship, systematic
METHODS
reviews, study
The PICO question in this systematic review
c) 11 peer-reviewed scholarly articles
was based on both types of Diabetes. “For
were used comprising of: 10
individuals with Diabetes Type 1 or Type 2
systematic reviews/meta-analyses,
(Population), is Periodontitis a risk factor
and 1 umbrella review. All studies
that is directly linked (Comparison group),
were published between 2013-2022.
and are there periodontal therapies
d) CHDA Research Agenda Category:
(Intervention) that positively impact the
oral-systemic links
systemic health (Outcome).”

A comprehensive review of qualitative,

quantitative, mixed-methods, systematic RESULTS

reviews and one umbrella review were used Within 11 records used, 6 SR, 1 umbrella
review and 4 cohort studies were used. The
SRs and UR all had included the
inflammatory pathway in their argument,
and 1 of the SRs had included the evidence
of Diabetes being incorporated into the
classification system for Periodontitis. All 6
SR had included the relevance of non-
surgical periodontal therapy and its impact
on glycemic levels. 2 of the cohort studies
included the knowledge and oral health
status of Diabetics. 1of the cohort studies
included the GCF composition and the
comparison of non-Diabetic versus Diabetic
participants. 1 of the studies included the
interprofessional knowledge necessary to
treat Diabetic and Periodontitis clients.
DISCUSSION
Diabetes is a chronic disease that also
creates susceptibilities such as heart disease,
stroke, kidney disease and vision loss,
amputation of limbs and neuropathies. 1,2 It
is characterized by hyperglycemia and
hypoglycemia episodes when it is poorly
controlled due to pancreas malfunction.
Type 2 Diabetes is the most prevalent form
of Diabetes and accounts for 90% of cases in
Canada. This form is a metabolic disorder
and is an impairment of the pancreas to
produce enough insulin or its ability to
utilize the insulin produced. Unlike Type 2
Diabetes, Type 1 Diabetes Mellitus is an
autoimmune disease where the insulin-
producing cells are inhibited or destroyed,
ultimately causing the body not to produce
enough insulin. 2 According to Public
Health Agency of Canada (PHAC), 3
million Canadians were Diabetics in 2014.
Compared to 10 years prior, this is a 37.3%
increase in the prevalence of Canadians with
Diabetes. Age also plays a large factor in the
incidence as it has been known to increase
your risk for developing Diabetes. 2
The key component in controlling Diabetes
is glycemic control. The average HbA1c
level in 3 months is 6.5% or 48mmol/mol.
This is the percentage of total hemoglobin as
mmol/mol. 4
Periodontal disease is an irreversible
inflammatory condition that creates a
dysbiosis affecting your gums, underlying
bone structure and connective tissue.
Periodontitis is increasingly becoming more
prevalent among the population. According
to the Canadian Health Measures Survey,
approximately 7.1 million Canadians had
moderate to severe periodontal disease in
2009. More recent estimates suggest that the
prevalence of periodontal disease worldwide
is between 45% and 50% of the global
population.1,2 Recent Meta-analyses have
concluded that 5-10% of any population
suffers from the most severe form of
periodontitis. 2
There has been a long-standing bidirectional
relationship of over 20 years between
Diabetes and Periodontitis. 2 In the 1990’s,
chronic Periodontitis was added as the sixth
complication of Diabetes Melitus. 9
Periodontitis has been believed to be a risk
factor for Diabetes and impacts glycemic
control by raising blood glucose levels. 2
Poor diet, premature tooth loss, uncontrolled
blood glucose levels and an increase in
cardiovascular complications are all risks
associated in an individual with
Periodontitis and Diabetes.9 The relationship
between both diseases is complicated
because Diabetes is known as a metabolic
syndrome and is complicated with other
conditions grouped into metabolic
syndromes. Diabetes involves excess body
fat around the waist and abdomen, elevated
levels of plasma glucose and triglycerides,
hypertension, and reduced levels of high-
density lipoproteins. In turn, there has also
been a rising correlation between
periodontal disease and obesity, which also
could associate periodontal disease under
the umbrella of metabolic syndromes. 2
Inflammatory Pathway and its effect on
blood glucose levels
The most prevalent finding to assist in the
correlation between Diabetes and
Periodontitis is the inflammatory pathway.
Inflammatory markers are seen in those who
are experiencing both diseases, and it is
inferred that Diabetes impacts the oral
microbiome and ultimately worsens
dysbiosis or the shift in oral microbiome. 2
It has been shown that people with Diabetes
and periodontitis have less control of their
glycemic levels than those who experience
Diabetes. 2 The research explains that both
comorbidities have inflammation occurring
at both local and distant sites. 2 Periodontitis
starts out as a low-grade immune response
and progresses to a systemic level of
inflammation. 2 The systemic inflammation
caused by periodontitis will then cause an
even greater exaggeration of inflammation
within the immune inflammatory response
that occurs within insulin resistance in
Diabetics. 2, 3 This overall inflammatory
response then impacts the severity of the
Diabetes. 3 It is also thought that this
criterion is based on a host-mediate
response, which is subject to the host's
environment and can be exacerbated by the
condition itself. 2, 3 This is often due to poor
oral hygiene care, and in the presence of
plaque accumulation, the inflammatory
response will trigger systemic inflammation
causing the effect on the blood glucose. 2, 3
Other risk factors associated with Diabetes
exacerbating the complications are poor diet,
high BMI, smoking, and adverse medication
effects.9 Recent studies that were conducted
by the primary author (KKP) investigated
the complications of Diabetes. 5200 Ontario
participants were monitored to determine
their likelihood of developing an acute or
chronic complication. The participants self-
reported their overall oral health ranging
from “poor to fair” and “good to excellent.”
Those who reported “poor to fair” oral
health had a 30% greater chance of diabetes
complications than those who reported
“good to excellent” oral health. 3 The two
co-morbidities have also negatively
impacted the healing wounds in the oral
cavity. This is caused by proinflammatory
cytokines associated with Diabetes, which
impact the health and immune response in
the tissues. 8
Severe or advanced periodontitis is three-to-
four times more likely in individuals with
Diabetes. This may also be associated with
the frequent occurrence of diabetic episodes
that involve receiving treatment at the
hospital. 9
Incorporation into the Classification of
Periodontitis
Evidence that both co-morbidities are
relevant is that Diabetes has been
incorporated into one of two risk factors
along with smoking for the grading system
for the classification of Periodontal diseases
by the American Academy of
Periodontology (AAP) and the European
Federation of Periodontology (EFP). 2 If a
client is a Diabetic and has an HbA1c
greater than 7.0%, this is considered when
identifying the progression of periodontitis
and other associated factors.2
Gingival crevicular fluid and its molecular
components have also been investigated
between Diabetic and Periodontitis
participants versus Diabetic individuals.6
Using infrared spectroscopy, (measurement
and identification of organic compounds),
samples of GCF from a non-diabetic healthy
patient and a diabetic were gathered, and the
composition was compared. 6 This showed a
correlation between both diseases and re-
confirmed previous studies that showed
increased protein levels in GCF from
diseased sites of individuals without
Diabetes and GCF protein concentrates
within the severity of the disease. 6
Because amide I and amide II bands are two
major bands of the protein in the IR
spectrum, it seems that hyperglycemia and
periodontal inflammation, together or
separately, are related to increased levels of
proteins in GCF. 6 Several protein molecules
consisting of immuno-inflammatory roles,
(e.g., cytokines, chemokines, matrix
metalloproteinases, and tissue breakdown
products, such as fibronectin, collagen
fragments, and hydroxyproline), are
involved in periodontal diseases and can be
stimulated by pathogens and hyperglycemia.
6
Effects of Periodontal Therapy
Treatment for periodontitis includes
non-surgical periodontal therapy (NSPT),
NSPT combined with antibiotics or
antimicrobials and surgical intervention. 4
Among many systematic reviews
referenced, subgingival instrumentation has
been shown to lower glycemic levels.4 One
cohort study conducted had shown a .43%
reduction in HbA1c levels at 3-4 months of
NSPT, .30% at 6 months and .50% at 12
months in comparison to those who had
received no care.4 The benefits seen
clinically within this study were a reduction
in plaque index, gingival index, clinical
attachment loss, bleeding on probing and
probing pocket depth. 4 NSPT, the primary
intervention of periodontitis, also showed a
reduction in markers of systemic
inflammation, including C-reactive protein.4
Another study found in an umbrella review
had results of a 0.26 to 0.65% reduction in
HbA1c levels at three months of NSPT
treatment. 2 Li et al stated in their systematic
review that that a 1% reduction in HbA1c
levels means a potential 35% decrease in
diabetic complications.2 A 0.2% decrease in
A1c values could decrease the mortality rate
by 10%.2 These statistics alone can motivate
a client to understand the significance of
their oral health and its relationship to their
Diabetes.2
Lack of client knowledge
A systematic review was completed in
Australia, where they investigated the
knowledge, attitudes, and practices of
Diabetics. 7 28 studies consisting of 27,894
participants with Diabetes were studied and
concluded a lack of awareness among the
patients. The results concluded that
Diabetics had inadequate oral health
knowledge, a lack of positive oral health
attitudes, and fewer visits to their dental
office. 7 In combination of all 28 studies,
Diabetics were found to have poor
compliance with oral hygiene and dental
visits; 49.35% of the participants self-
reported brushing twice a day and 25.1%
reporting to floss once daily. 54% of all
participants had visited the dentist in the last
12 months. 7 Another survey conducted in
Sydney, Australia contained 260 participants
living with Diabetes. 10 More than half of the
participants were found to have inadequate
oral health knowledge related to diabetes
most notably, around the bidirectional link
of diabetes and oral health. 10 This is
consistent with our systematic review, which
concluded that individuals with diabetes
have lower oral health knowledge than those
without diabetes. 10 In conclusion, NSPT
intervals must occur no greater than three
months due to evidence that portrays a
positive impact on the glycemic control.2
The inflammatory pathway, the
incorporation of Diabetes into the
Classification system for Periodontitis, and
the positive effect of non-surgical
periodontal therapy all strongly correlate
with the bidirectional relationship between
Diabetes and Periodontitis.1, 2, 3, 10, 11
Although there is strong evidence found,
more research is required to assess for the
biological mechanism that connects
Diabetes to Periodontitis directly. 1, 3, 5
Where do dental hygienists go from here?
Based on all evidence from the systematic
reviews, educating clients on the increased
risk of periodontitis and creating a positive
environment by motivating the client to
facilitate the needs of their oral health and
overall systemic health.1, 2, 3, 5 Screening your
Diabetic clients and being aware of the
associated complications within Diabetes is
extremely important as a health care
professional. 1, 3, 5 Awareness of early signs
of diabetes in the oral cavity is also
extremely important for Dental hygienists to
monitor their clients. 1, 3, 5 When treating
clients who experience both Diabetes and
Periodontitis, it is essential to be attentive
and meticulous during periodontal
maintenance appointments to mitigate the
effects of periodontitis. 1, 3, 5 Health
promotional resources, the conduction of
risk assessments, and necessary referrals are
imperative to provide your client with the
knowledge to manage their oral and
systemic health. 7,10, 1
References:
1. Parbhakar KK, Rosella LC, Singhal
S, Quiñonez CR. Dental and medical
care visits among persons with
diabetes in Ontario, Canada, who
self-report oral health status.
Canadian Journal of Dental Hygiene
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examining the relationship between
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