Value of interdisciplinary approach in the management of type 2 diabetes mellitus, periodontitis, and tooth loss: Narrative review : Indian Journal of Health Sciences and Biomedical Research kleu

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Value of interdisciplinary approach in the management of type 2 diabetes mellitus, periodontitis, and tooth loss

Narrative review

Sangappa, Sunila Bukanakere; Babu, Harsha Mysore1; Chacko, Sona Elizabeth2; Jithendra, Ashwini3; Kenkere, M. Srinath4

Author Information

Department of Prosthodontics, Convener Dental Education Unit, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, Mysore, Karnataka, India

1Department of Periodontics, Sri Hasanamba Dental College and Hospital, Hassan, Karnataka, India

2Pursuing DDS, Ivy League School, University of Pennsylvania, USA

3Mysore Medical College and Research Institute, Mysore, Karnataka, India

4Department of General Medicine, JSS Hospital, JSS Academy of Higher Education and Research, Mysore, Karnataka, India

Address for correspondence: Dr. Sunila Bukanakere Sangappa, Department of Prosthodontics, Convener Dental Education Unit, JSS Dental College and Hospital, JSS Academy of Higher Education and Research, Mysore - 570 004, Karnataka, India. E-mail: [email protected]

Received August 21, 2022

Accepted October 20, 2022

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Indian Journal of Health Sciences and Biomedical Research (KLEU) 16(1):p 30-36, Jan–Apr 2023. | DOI: 10.4103/kleuhsj.kleuhsj_527_22
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Abstract

The effects of diabetes mellitus (DM) Type 2 and periodontitis have been studied for several years. In this review, the bidirectional effects on both these chronic inflammatory diseases have been evaluated. Both the diseases are known to exacerbate the pathophysiology of each other and reduce the quality of life of individuals suffering from these conditions with added risk factors. Increased blood sugar levels act adversely on dental plaque and the immune system causing inflammation leading to periodontitis and bone loss which in turn affects insulin sensitivity. Identifying and treating one of these conditions will help in reducing the severity of the other. Literature search was performed from electronic databases through PubMed and Scopus of articles published since 1996–April 2022. We included the research studies toward studies relating to the importance of collaborative approach in the management of periodontal conditions in subjects with Type 2 DM as a major criterion among population globally. This article shows the significance of why dentists and physicians should collaborate with each other for managing the periodontal and diabetic conditions of the patients. Both the diseases can be immensely improved if the providers are knowledgeable about the concept and a team approach is utilized.

Introduction

Periodontal disease is an inflammatory disease that in the long term can destroy the supporting structures of the teeth.[1] A connection between systemic diseases periodontal disease has been researched for many years and this has created a better understanding of the disease among health-care professionals. Some of the recent discoveries that show the systemic influences of periodontal disease are its effects on heart disease, diabetes, the oral health of the mother and prematurity of the baby, the link between the mineral concentration of skeletal and oral bone structures. Due to the link between periodontal disease and systemic health, a new branch of periodontology called periodontal medicine has been defined.[2] Defining periodontal medicine as “a rapidly emerging branch of periodontology focusing on the new wealth of new data establishing a strong relationship between periodontal health or disease and systemic health or disease” establishes the interplay.[3] Type 2 diabetes mellitus (DM) and periodontal disease are closely interrelated and most commonly occurring.[1] Several studies shows the effect of increased blood sugar levels in the severity of periodontal disease, patients with well-controlled blood sugar have less severity compared to the ones with uncontrolled blood sugar levels.[4] DM has a global prevalence of 9.3% in 2019.[5] The majority of these cases are DM Type 2 and about half of the people are unaware of their disease. If Individuals with prediabetes or early diabetes are diagnosed and treated early, the progression of periodontitis could be stopped. The risk factors for both the conditions are the same and include increased age, sex male, low-socioeconomic status, obesity, genetic predisposition, changes in any of these factors will affect both the conditions. In these individuals, bacterial loads from the subgingival plaque and calculus destroy the hard and soft tissues around the teeth and the increased blood sugar levels will aggravate this process.[6] A long-term hyperglycemia has shown to result in generation of molecules called advanced glycated end products (AGE), these products and the bacteria present in the oral cavity together initiate immune responses. The dysregulated immune response is unable to hold back the bacteria and expedite periodontal destruction.[4] Proteins get modified by AGE products showing altered function. AGE binds to AGE receptors producing reactive oxygen and inflammatory cytokines.[7]

Data extraction and literature search strategy

A broad search of literature published between 1996 and 2022 from electronic databases through Scopus and PubMed was performed. These studies were conducted in different countries. The terms used to formulate the search strategies were Type 2 DM and Periodontitis and Tooth loss and Treatment and included all relevant studies in this review. The age group of subjects included ranged from 18 to 60 years. Output of the search was independently screened by reviewers to identify potentially eligible studies and any disagreements between the reviewers were resolved by the discussion. Linear correlation between peritoneal dialysis (PD) and age of patient, duration of diabetes, and level of glycemic status among population with T2DM was observed. Thus, this review aimed at evaluating the need of Interdisciplinary approach in the management of Type 2 DM, periodontitis, and tooth loss to improve the glycemic control. Summary of the inference of reviewed articles is detailed below.

Prevalence and incidence of periodontitis and type 2 diabetes mellitus in association globally and in India

Periodontitis is a noncommunicable globally prevalent chronic inflammatory disease of the periodontium that affects all age groups resulting in tissue destruction surrounding the teeth. The Global Burden of Disease Study indicates 57.3% raise in global burden of periodontitis across 1990–2010. Harald Loe, declared periodontitis to be the 6th complication of DM in 1993.[8] Periodontitis hampers the quality of life and self-esteem by predisposing subjects to the risk of partial or complete edentulism leading to masticatory dysfunction impacting socioeconomic status and health-care costs.[9,10] The National Oral Health Survey has reported the prevalence of 89.6% and 79.9% among those aged 35–44 and 65–74 years, respectively for chronic periodontitis.[11] It is alarming that despite access to oral health care the prevalence of Periodontitis appears to be high with an definitive risk of inflammatory burden.[12]

National[13] and international[14] studies have demonstrated periodontal disease to induce increased severity and periodontal disease prevalence in subjects with Type 2 DM. According to previous studies conducted in south India the prevalence of chronic periodontitis is reportedly 45.9% suggestive to be higher in diabetics as compared to those without (37.8%).[15] Literature has evidenced odds ratio that is 2.1 times higher of chronic periodontitis in diabetics in a case control study at Bengaluru.[16] The prevalence of Type II diabetes is a major concern among complete and partial denture wearers. Most detected at about 40–50 years of age the incidence of this disease is estimated to rise to 5.4% of the population by 2025 worldwide.[17] With a prevailing rate of undiagnosed one-third diabetic subjects it necessitates managing and diagnosing patients with diabetes by dental professionals.[18,19]

Factors influencing chronic periodontitis and diabetes mellitus type 2

Abnormal development and maturation of collagen are commonly seen in diabetic patients, collagen is the most common protein that is present in the periodontium, this fact can be one of the reasons for impaired healing of periodontium in diabetic patients.[20] As a response to periodontal disease, the affected cells produce a variety of enzymes. Some of these enzymes are aspartate aminotransferases, alkaline phosphatase (ALP), acid phosphatase, alanine aminotransferases, lactate dehydrogenase (LDH), gamma-glutamyl transferase, and creatine kinase. These enzymes are released to the gingival crevicular fluid and saliva. ALP is a membrane-bound glycoprotein. Increased level of ALP is an indicator for bone loss and periodontal disease. Ishikawa and Cimasoni identified ALP as a biomarker for periodontitis. A study on the involvement of ALP in periodontitis shows that there is a highly significant variation in the mean of ALP levels in healthy and individuals with periodontitis. A cross-sectional observational study was done on 45 individuals, who were grouped into three categories: healthy individuals, diabetes type 2 individuals with periodontitis, and nondiabetic individuals with periodontitis. The saliva and serum of these individuals were collected and analyzed for the levels of ALP and the results showed that there was a higher increase in the diabetic patients. The increase in the ALP levels should be due to constantly increased blood sugar levels that resulted in increased periodontitis and bone loss.[21] It is also found that diabetic patients have a higher level of prostaglandin, tissue factor, interleukins (L-1beta, IL-1 beta/IL-10 ratio, and IL-6) and an increased number of pathogens related to periodontitis such as Porphyromonas gingivalis, T. and Aggregatibacter actino-mycetemcomitans and denticola, Tannerella forsythia when compared to nondiabetic individuals.[4] Diabetes affects osteoblastic and osteoclastic activities during bone remodeling. Under normal conditions these activities are balanced but in patients with uncontrolled diabetes due to an increase in AGEs and reactive oxidative stress the bone resorption increases and bone deposition decreases that finally results in bone loss.[7]

Association between periodontitis and diabetes-pathophysiology

It is underlined Type 2 DM is established as a major cause for periodontal disease with an estimated threefold increased manifestation in comparison to nondiabetics. Associated risk of tooth loss and subsequent edentulousness has raised concerns of undermined quality of life emphasizing the need for early diagnosis of this disease condition. DM has been indisputably substantiated as a paramount risk factor for periodontitis[22,23,24] Approximately three-fold increase of periodontal diseases in diabetics compared with nondiabetic individuals[25] can aggravate insulin resistance and affect glycemic control [Figure 1].[26]

F1-5
Figure 1:
How diabetes can contribute to the development of periodontal disease 26

Chronic hyperglycemia that results in the production of AGEs produced can result in vascular modifications, hyperinflammatory responses, altered healing, and increased predisposition to infections.[26] The hypothesis of activation of RAGE to contribute to pathogenesis of periodontitis in diabetic patients is supported by Lalla et al.[27] Loss of effective tissue integrity, vascular dysfunction, hyperproduction of proinflammatory cytokines, and barrier function result due to increased accumulation of AGEs and their interaction with RAGE in diabetic gingiva leads. This relationship between periodontitis and diabetes appears bidirectional and emphasizes on the need for early detection of both [Figure 2].[28,29]

F2-5
Figure 2:
Schematic presentation of bidirectional relationship[29]

Mechanisms that underpin the link between periodontitis and diabetes are little understood, however, involve aspects of immune functioning, neutrophil activity, and cytokine biology [Figure 3].[30]

F3-5
Figure 3:
Schematic depicting etiologic factors and cascade of events contributing to periodontitis that are altered by diabetes[30]

Chronic periodontitis-standards used for detection and classification

Periodontitis progresses slowly and often remains asymptomatic leaving patients unaware of the condition until it results in tooth mobility. As the disease progresses, the periodontal pocket deepens leading to loss of attachment and resorption of alveolar bone. Further advancement in the disease process could lead to suppuration, gingival recession, tooth mobility, and eventual tooth loss if not treated [Figure 4].[31]

F4-5
Figure 4:
Periodontal pocket in periodontitis[31]

Chronic periodontitis is ideally detected in the initial stages of the disease.[31] Since 2003, Case definitions of periodontal diseases using the Centers for Disease Control and Prevention, in partnership with the American Academy of Periodontology (AAP) working group classification, divides cases as No periodontitis- when No evidence of mild, moderate, or severe periodontitis, Mild periodontitis- ≥2 interproximal sites with AL ≥3 mm, and ≥2 interproximal sites with PD ≥4 mm (not on same tooth) or one site with PD ≥5 mm, Moderate periodontitis- ≥2 interproximal sites with AL ≥4 mm (not on same tooth), or ≥2 interproximal sites with PD ≥5 mm (not on same tooth) and Severe periodontitis ≥2 interproximal sites with AL ≥6 mm (not on same tooth) and ≥1 interproximal site with PD ≥5 mm.[32]

Due to a lack of awareness on the importance of periodontal health, many patients seek “symptom-driven” care for advanced disease through periodontal therapy. The initial stages of the disease are usually asymptomatic and a considerable number of individuals do not seek professional help.[33] The diagnosis of periodontitis is generally done by measurement of clinical parameters, which indicates the present disease activity and past disease severity, thereby limiting its use in early diagnosis.[34] Even though pocket depth is not an index of disease activity.

Conventionally, screening for periodontal disease is performed by pocket probing of representative teeth, six points encompassing each tooth and recording the presence or absence of bleeding even though the pocket depth is not an index of disease activity.

Chronic periodontitis: Drawbacks that exist in regulating the requisites of the public at large with the current standards to the with relevance to local, national, and international context

Following drawbacks exist – First, need for recording the findings precisely with highly trained hands, Second, expenses for radiographic equipment and laboratory investigations that are time-consuming, Third, subjective evaluations due to variation in probing force, relative attachment level during periodontal probing, visual errors in identifying the cemento-enamel junction. Fourthly errors in recording due to gingival inflammation Fifth, community periodontal index that puts patient to risk of bacteremia due to probing, Sixth, these clinical parameters and disease remaining inconspicuous in incipient stage, could go undetected.[35]

Interprofessional relationships in diabetic and periodontitis cognizance and patient care

Comprehensive care for dental problems and diabetes involves a multidisciplinary approach with patient and the entity of health-care professionals. A significant association is established between glycemic control and oral infections as well as with the duration of diabetes and denture-associated manifestations. Significantly higher number of missing teeth is also evidenced in diabetics than in the controls that was related to inadequate metabolic control and lack of oral health awareness.[36]

With emphasis on minimizing the impact of diabetic complications, it is commonly recommended in India for screening undiagnosed diabetes.[37] Borrell et al.[38] researched the clinical periodontal findings that can facilitate in identifying patients with undiagnosed diabetes. It is deemed important for dental professionals to contend the interlink between general and oral health, with their patients including the association between diabetes and periodontitis, and the requirement for co-management of this condition by system of health-care practioners.[39,40] It is also stated that in conditions of longstanding and uncontrolled diabetics. Medical health-care providers need to appraise the potential sequelae of long-term diabetes, untreated oral infections and emphasize the maintenance of oral health.[41]

Periodontitis, edentulism, and glycemic control in type 2 diabetics

Type 2 diabetics undergoing periodontal treatment have shown predictable improvements in glycemic control. Need of point-of-care testing eliminating the need to draw blood, reducing the total time involved by identifying at-risk groups more effectively increases the access to treatment, and improves the quality of care delivered by allowing treatment to begin immediately.[42] Early detection of periodontitis is very important to track and monitor morbidity.

Significance of glycated hemoglobin in chronic periodontitis

The level of HbA1c is important while determining the treatment modality. According to the Japanese society of periodontology, 6.9% of HbA1c is considered safe for periodontal surgeries and regenerative therapy. These should be avoided if the glycemic index of the patient is below the threshold value. A case report of periodontitis and chronic generalized periodontitis, a 66-year-old male whose glycated hemoglobin was 7.8%, and an initial periodontal therapy was done on him. During the reevaluation, it was noted not only that his pocket depths were shallower but also his HbA1c has reduced to 6.9%.[3] High HbA1c reduces cell growth and migration, causes hypoxia, weakens immunity, elevated oxidative stress, diminishes angiogenesis and blood perfusion, impair matrix metalloproteinases, and causes inflammation, which retards wound healing. Thus, dentists can treat uncontrolled diabetic patients with nonsurgical periodontal treatment just like how they would treat a patient with controlled HbA1c. However, while using any surgical or regenerative therapy the blood sugar level should be controlled. This is the reason why the dentist should have updated HbA1c values during each phase of the treatment.[6] The glucose levels in the blood and the gingival crevicular fluid are very close to each other. The HbA1c of diabetic people in a study was 7.72% ± 1.71% and 7.89% ± 1.78% in the gingival crevicular fluid and blood, respectively. Obtaining gingival crevicular fluid is noninvasive, analyzing the gingival crevicular fluid for glucose levels in the during periodic periodontal evaluation can help the dentist to make appropriate decisions on the treatment plan.[43]

Treatment and diagnosis of periodontitis and diabetes mellitus type 2

Antidiabetic drugs and lipid-lowering drugs reduce inflammation and C-reactive protein. It will reduce the symptoms of periodontitis but some of them may cause dry mouth which can lead to caries formation, oral candidiasis, and periodontitis.[8] Magnolol is an antioxidant and has anti-inflammatory effects. It is a polyphenolic binaphthalene compound obtained from Magnolia officinalis. Reactive oxidative stress that is induced by advanced glycation end products can be reduced with the use of magnolol. It also reduces pro-inflammatory cytokines and improves the wound healing ability and thereby down-regulates periodontitis and hyperglycemia.[1] Indocyanine-mediated antimicrobial photodynamic therapy also helps in the reduction of chronic periodontitis in individuals with controlled and uncontrolled DM. It reduces bleeding and regains clinical attachment loss and improves wound healing.[44]

Early diagnosis of DM is very important to prevent the progression of periodontitis as they are very closely related. Obesity, periodontitis, bone loss are very much associated with undiagnosed DM. These characteristics can aid the dentist to identify individuals at higher risk for taking on DM. Thus, dental clinics are a good setting to screen patients for undiagnosed DM and provide relevant health education. The dentists should be more involved in diagnosing DM.[45] Al-Rawi et al., reported miRNAs in the saliva of patients with DM as a predictive biomarker for periodontitis, 4 miRNAs were found to be higher in patients with diabetes/periodontitis. miRNAs 146 a/b, 155 and 203 are definitive, easy and noninvasive biomarkers that can be used to detect periodontitis.[46] Although studies have evidenced salivary inflammatory biomarkers such as IL, LDH, tumor necrosis factor α, and salivary hemoglobin elevated in periodontitis, their credibility to aid in diagnosis in condition of Type 2 DM is yet to be ascertained.

Conclusion

Professional health-care workers and laymen should both be aware of the interactions between DM and periodontitis. The medical care workers should promote a healthy mouth that is free of inflammation and any infection and dentists should always take DM into consideration for diagnosis and treatment planning. This will help to treat both diseases, increase public health, decrease financial costs and benefit overall society.

Financial support and sponsorship

This study was supported by ICMR extramural research project funding.

Conflicts of interest

There are no conflicts of interest.

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Keywords:

Management; periodontitis; salivary biomarkers; tooth loss; type 2 diabetes mellitus

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