Scientific Oral Inflammation and Diabetes Advisory Panel Maria Emanuel Ryan, DDS, PhD, Department of Oral Biology and PathologyStony Brook University School of Dental Medicine
Ray Williams, DMDChair, Department of Periodontology
Diabetes mellitus is a chronic metabolic disorder
contributing to bacterial proliferation and oral
affecting carbohydrate, fat, and protein metabolism.
inflammation. Second, hyperglycemia increases the
It is characterized by hyperglycemia (i.e., elevation
formation of advanced glycation end-products
of blood glucose concentration) caused by the
(AGEs); the overexposure of proteins (such as
defective secretion of insulin (type I), or impaired
collagen) or lipids to aldose sugars induces non-
insulin action due to tissue resistance (type II). While
enzymatic glycation and oxidation.6 These
there is no known cure for diabetes, appropriate
glycosylated products can create complex molecular
measures can be taken to control blood glucose levels
arrangements, reducing collagen solubility and
and prevent both acute and chronic complications.
increasing levels of pro-inflammatory mediators
Poor glycemic control in diabetic patients has several
responsible for the degradation of connective tissues
repercussions, including some on oral health. Patients
throughout the body of the diabetic, including the
with diabetes are prone to develop oral complicationssuch as gingivitis and periodontal disease, fungal
Factors Accentuating Periodontal
infections (oral candidiasis, lichen planus), dental
Disease in Diabetic Patients
caries, tooth loss, enlarged parotid glands, xerostomia,
taste dysfunction, and burning mouth syndrome.1,2
The most prominent oral symptom associated
with diabetes is the increased prevalence and severity
• Angiopathy (heart disease and stroke)
of periodontitis; it is recognized as one of the major
complications of diabetes.3-5 Persistent poor glycemic
control has been associated with an increased
incidence and more rapid progression of gingivitis
and periodontitis with associated alveolar bone loss.2
The degree of metabolic control and the duration of
(e.g., adolescence, pregnancy, menopause)
diabetes are closely associated with the severity of
The pathogenesis of periodontal disease involves
two components: bacterial infection and the host
response. Bacteria present in periodontal pockets
initiate an oral inflammatory response that can lead
oral cavity. Changes to collagen metabolism result in
to the deterioration of the supporting periodontal
accelerated degradation of both non-mineralized
tissues. When the host response is comprised of an
connective tissue and mineralized bone.6 Research
excess of pro-inflammatory mediators known as
has demonstrated the presence of elevated levels of
cytokines, prostanoids, and enzymes, the destruction
pro-inflammatory mediators in the gingival crevicular
of periodontal tissues occurs. This results in increased
fluid of periodontal pockets of poorly controlled
pocket depths, loss of clinical attachment, and
diabetics, compared to non-diabetics or well-
radiographic evidence of bone loss.7 In patients with
controlled diabetics, resulting in significant
poorly controlled diabetes, periodontal destruction
periodontal destruction with an equivalent bacterial
challenge.3,6,8 For clinicians and diabetic patients, this
means that the oral hygiene of the diabetic must be
Hyperglycemia and Oral Health
optimized to prevent further stimulation of an already
The effects of hyperglycemia on oral health are
primed and heightened host response.
two-fold. First, it causes an increase in the
The interaction of AGEs with target cells, such as
This article was prepared with the assistance of
concentration of glucose in the saliva and the gingival
macrophages, via cell-surface polypeptide receptors
BioMedCom Consultants, inc., Montreal, Canada.
crevicular fluid of the periodontal pocket,
stimulates the production of cytokines and matrix
Copyright 2005 Colgate-Palmolive Company. All rights reserved.
metalloproteinases, including collagenases and
further stimulates periodontal disease. Poor
first step is reduction and control of bacteria, both
other connective tissue-degrading enzymes.3 This
metabolic control of diabetes can also increase
supragingival and subgingival, in the tooth
exacerbation of the pro-inflammatory response
the risk for other complications of diabetes, such
pockets and spaces around teeth. Scaling and
in diabetics can lead to delayed wound repair
root planing helps remove bacterial plaque and
and amplify damage to connective tissues.6 This
neuropathy, and delayed wound healing.
associated toxins from the tooth and root surfaces,
is important to consider when evaluating the
Prevention and control of oral infection and
response of poorly controlled diabetic patients
inflammation, i.e., periodontal disease, is essential
accumulation that is common on rough surfaces.
to periodontal therapy. The pro-inflammatory
The second step is inhibition of the enzymes that
response may be further heightened by the
destroy periodontal tissue so that connective
It is also thought that elevations of AGEs in
monocytes which differentiate into the chronic
gingival tissue increases vascular permeability.11
modulation therapy). Clinical trials have
An inflamed periodontium is highly vascular
demonstrated the efficacy of some tetracycline
Degradation of newly synthesized collagen
and may serve as a portal to the systemic
analogs to inhibit a series of host-derived, tissue-
in connective tissues and alterations in the
circulation for bacterial products (bacteremias)
mediators,5,8 thereby reducing the connective
predisposition to periodontal disease and
mediators.10 Other connections between a poor
tissue damage associated with periodontitis.
periodontal status and systemic health sequelae
Conclusion
metabolic control and the presence of other
have been studied; adverse pregnancy outcomes
Diabetes is a complex disease with a wide
complications (e.g., retinopathy and
and cardiovascular disease are both known
range of potential complications, including effects
nephropathy) can be predictive of the periodontal
complications in diabetics. Recent research has
on oral health. Integrated strategies for the
status. Concurrent risk factors (plaque, smoking,
prevention and treatment of periodontal disease
periodontitis have a higher risk of giving birth
involving the removal of periodontal pathogens
to preterm low-birth-weight babies. Other studies
and host modulation therapy greatly reduce the
considered in the assessment of the periodontal
have shown that the risk of major cardiovascular
risk for severe periodontitis, and can help in the
events, such as heart attack and stroke, is
overall management of the diabetic patient. A
The presence of AGEs has also been linked
significantly higher in those with severe
diabetic patient who maintains rigorous glycemic
to thickening of the basement membrane and
periodontal disease.9 It has become apparent that
control and good oral health has the same risk
altered vasculature. These changes may be
prevention and treatment of periodontitis are
of severe periodontitis as a non-diabetic patient,
associated with enlargement of the parotid
essential to optimal systemic health, particularly
emphasizing the importance of diabetes and oral
glands and decreased salivary flow seen in
diabetics, which facilitates plaque accumulation
Management of Diabetes and Oral Inflammation
and increases the risk for caries, gingivitis,
References
Control of blood glucose is the fundamental
periodontitis, and candidiasis. Degenerative
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leukocyte migration to gingival tissue, decreasing
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will not only reduce glucose concentration in
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oxygen diffusion and elimination of metabolic
serum, gingival crevicular fluid, and saliva, but
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periodontitis by decreasing dental healing
inflammation.11 Prevention and control of
tetracycline analogues. Dissertation Abstracts International 1999;59(8).
capacity.6 Collectively, diabetes creates specific
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periodontal disease must be considered an
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integral aspect of diabetes management, since
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inflammation associated with overproduction
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improved oral health can lead to improvements
of inflammatory mediators and degradation
in the overall health of diabetic patients.11
8. Ryan ME, Usman A, Ramamurthy NS, Golub LM, Greenwald RA. Excessive
enzymes, all of which participate in worsening
matrix metalloproteinase activity in diabetes: Inhibition by tetracycline
Given the increased susceptibility of diabetic
analogues with zinc reactivity. Curr Med Chem 2001;8(3):305-316.
patients for oral inflammation, emphasis should
9. Li X, Kolltveit KM, Tronstad L, Olsen I. Systemic diseases caused by oral
infection. Clin Microbiol Rev 2000;13(4):547-558. Oral-Systemic Interactions
be placed on reduction of bacterial infection and
10. Taylor GW. The effects of periodontal treatment on diabetes. JADA
While a systemic condition like diabetes can
gingivitis. An optimal prevention plan should
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affect oral health, there is growing evidence that
include twice-daily brushing and flossing to
J Can Dent Assoc 2002;68(3):161-164.
remove bacterial plaque from teeth.12 Adentifrice
12. Ryan ME. Non-Surgical Approaches for the Treatment of Periodontal
Diseases. In: Scannapieco FA, ed., The Dental Clinics of North America.
repercussions.9 This bi-directional relationship
containing triclosan/copolymer (Colgate Total®
is especially important for the metabolic control
Toothpaste) has been shown to be very effective
13. Gaffar A, Scherl D, Afflitto J, Coleman EJ. The effect of triclosan on mediators
of gingival inflammation. J Clin Periodontol 1995;22(6):480-484.
of diabetes. Studies of active inflammatory
in controlling bacterial infection, reducing
connective tissue disease have shown that
inflammation can trigger insulin resistance.10
slowing the progression of periodontitis.13
Cytokines, such as tumor necrosis factor (TNF)-
Restriction of oral infection and inflammation as
a, have been reported to interfere with lipid
manifested in periodontitis contributes to the
metabolism and to cause insulin resistance, while
maintenance of normal blood glucose levels,
interleukins (IL)-1b and IL-6 antagonize insulin
which aids in the overall management of diabetic
response can thus hinder glycemic control in
For the treatment of periodontitis, a two-step
diabetic patients, in turn creating a vicious cycle
process aimed at the two components of the
of events that compromises diabetes control and
disease offers the most favorable outcome.12 The
Zsíranyagcsere-zavarok, diagnózis és terápiaA szív- és érrendszeri betegségek kialakulása a betegek életminõségét– az LDL-receptorhoz – kötõdik. A felvett koleszterin gátolja a kolesz-rontja és élettartamát csökkenti. Az utóbbi évek klinikai vizsgálatai aztterinszintézis kulcsenzimét, a HMG-CoA-reduktázt (ezért a sejt nemigazolták, hogy kifejlõdésük meggáto
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