ORIGINAL ARTICLE

Intisari Sains Medis 2020, Volume 11, Number 1: 108-111

P-ISSN: 2503-3638, E-ISSN: 2089-9084

Periodontitis as early detection of diabetes mellitus:

a literature review
CrossMark
Ade Indah Pratiwi*
Published by DiscoverSys

ABSTRACT

Background: Diabetes mellitus (DM) is a growing health problem and individuals without periodontitis. Diabetes and periodontitis
its prevalence is dramatically increasing, particularly in Indonesia. It are complex chronic diseases with an established bidirectional
can affect every organ in the body, and one of the oral manifestations relationship. There is long-established evidence that hyperglycemia
is periodontitis characterized by the loss of tissue attachment. This in diabetes is associated with adverse periodontal outcomes. Here, we
review aims to identify further the periodontitis as early detection of show that periodontitis is an early sign of diabetes mellitus and may,
diabetes mellitus therefore, serve as a valuable risk indicator. A dentist who got patient
Methods: A review of relevant literature was performed to elaborate with periodontitis is a suitable location for screening for diabetes by a
on periodontitis involvement in diabetes mellitus. A total of 25 simple finger stick and validated HbA1c dry spot analysis.
qualified published literature of all years were collected from several Conclusion: Literature from a different type of study concluded that
electronic database and manual search and included in this review. periodontitis is one of the oral manifestations that could be used as
Results: On average, patients with periodontitis showed higher early detection in diabetes mellitus
glycated haemoglobin (HbA1c) plasma levels compared with

Keywords: diabetes mellitus, periodontitis, periodontal disease

Cite this Article: Pratiwi, A.I. 2020. Periodontitis as early detection of diabetes mellitus: a literature review. Intisari Sains Medis 11(1): 108-111.
Postgraduate student, Department DOI: 10.15562/ism.v11i1.623
of Physiology, Universitas Udayana,
Bali, Indonesia
INTRODUCTION destruction in periodontitis results in a breakdown
of the collagen fibres of the periodontal ligament,
Diabetes mellitus (DM), particularly type-2 DM, resulting in the formation of a periodontal pocket
is a growing health problem and its prevalence is between the gingiva and the tooth.
dramatically increasing. The prevalence of diabetes Periodontitis is a slowly progressing disease, but
mellitus in Indonesia increased annually based on the tissue destruction that occurs is mostly irre-
Riskesdas in 2013.1 Indonesia occupies 4th place versible. In the early stages, the condition is typi-
with the number of diabetics the biggest after India, cally asymptomatic; it is not usually painful, and
China and the United States. In 2030, Indonesia is many patients are unaware until the condition has
expected to have people with DM as many as 21.3 progressed enough to result in tooth mobility.3 The
million people.1 In addition, type-2 DM is the most pockets deepen as a result of the further destruction
type often found in dental practice, about 90% of of fibres of the periodontal ligament and the resorp-
all DM patients in Indonesia.2 Epidemiological data tion of the alveolar bone that occurs in parallel with
confirm that diabetes is a significant risk factor the progressing attachment loss. ‘Pocket’ is not
for periodontitis; susceptibility to periodontitis evident on simple visual inspection, and assessment
is increased by approximately threefold in people using a periodontal probe is essential. Advanced
with diabetes. This is a clear relationship between periodontitis is characterized by gingival erythema
the degree of hyper-glycaemia and periodontitis. and oedema, gingival bleeding, gingival recession,
tooth mobility, drifting of teeth, suppuration from
An overview of periodontitis periodontal pockets, and tooth loss.4
*
Correspondece to:
Ade Indah Pratiwi; Postgraduate Periodontitis is one of periodontal disease as the Moderate periodontitis is the most conditions
student, Department of Physiology, most common diseases known to humankind. affecting 40-60% of adults with highly prevalent but
Universitas Udayana, Bali, Indonesia; Periodontal disease includes two significant entities, primarily hidden in chronic inflammation.5 Severe
gecindahpratiwi@gmail.com gingivitis and periodontitis. Gingivitis is inflamma- periodontitis that threatens tooth retention affect-
tion of periodontal disease characterized by revers- ing 10-15% of adults in the most population stud-
Received: 2019-09-17 ible gingiva destruction, but present periodontitis ied.5 Prevalence of periodontitis increased with age
Accepted: 2020-01-04 destruction of the tooth-supporting structure may up to the point that 70.1% of adults ≥ 65 years old
Published: 2020-03-03 with irreversible and also may tooth loss.3 Tissue were affected by periodontal disease.6 Men exhibit

108 Open access: http://isainsmedis.id/

 ORIGINAL ARTICLE

worse periodontal status than women [(56.4% vs Effect of Periodontitis on Glycemia

38.4%), as well as those with limited education Longitudinal studies have demonstrated that
(66.9%) and income (65.4%)]. The risk factor of severe periodontitis is associated with poorly
periodontitis increased with smoking habits. It controlled glycemia, higher HbA1c levels and
harms many aspects of daily living and quality of development of systemic diabetic complications.13
life, affecting confidence, social interaction and It also has been reported that periodontitis is
food choices.7 associated with a slight elevation of HbA1c in
People with diabetes have other risk factors of non­ diabetic subjects (periodontitis may poten-
periodontitis such as condition associated with tially increase the incidence of diabetes), although
compromised immune responses (e.g. HIV), nutri- a clear-cut association could not be established.14
tional defect, osteoporosis, medication because of Studies assumed that periodontal infection might
drug-induced gingival overgrowth, genetic factor impair glycemic control by increasing insulin
and local factor.8 The incidence of periodontitis tissue resistance.15
increases and can be more severe in patients who Diabetes and periodontitis are complex chronic
have DM. This is not always directly proportional diseases with an established bidirectional relation-
to plaque and calculus because periodontitis is also ship. There is long-established evidence that hyper-
influenced by environmental factors including the glycemia in diabetes is associated with adverse
condition of the teeth that are crowded, metabolic, periodontal outcomes.16 Type 2 diabetes is preceded
genetic, and age. Many studies show a reciprocal by an ill-defined period of systemic inflammation,
relationship between periodontitis and DM by leading to reduced pancreatic beta cell function,
comparing between periodontitis in the DM group increased beta cell apoptosis, and insulin resistance.
and periodontitis in the Non-DM group.9 Periodontitis may stimulate systemic inflammation,
the oral cavity providing a means for the entry of
Aetiology of periodontitis periodontal organisms and their virulence factors
Plaque accumulation on teeth produces gingivitis, into the circulation.
but the degree of inflammation and destruction of Inflammation-mediated oxidative-stress
the alveolar bone that supports teeth depend on the pathways and advanced glycation end products
host susceptibility.10 The inflammatory response (AGEs)-receptor for AGEs (RAGE) interactions
is characterized by secretion of host-derived provide plausible links in the periodontitis to
mediators of inflammation and tissue breakdown. diabetes direction. The periodontium is a highly
Interleukin-1β, interleukin-6, prostaglandin E2 vascular tissue and any inflammation there may
(PGE2), tumour necrosis factor alpha (TNF-α), serve as a gateway to the systemic circulation for
receptor activator of nuclear factor κB ligand bacterial products and locally produced inflam-
(RANKL), and matrix metalloproteinases (MMP- matory mediators.12 The infectious challenge
8, MMP-9, and MMP-13) are the most commonly contributes to insulin resistance by modification
implicated mediators of inflammation.11 of insulin receptor substrate-1 by serine phosphor-
Hyperglycemia increases the concentration of ylation, altered adipocyte function with increased
glucose in the saliva and the gingival crevicular production of free fatty acids, and diminution of
fluid. This leads to the proliferation of bacteria in endothelial nitric oxide production. The process
the oral cavity. Hyperglycemia itself also has an may further alter pancreatic β-cell function, either
indirect adverse effect, stimulating the immune acting directly or through stimulation of free fatty
system’s cells to release inflammatory cytokines.12 acid production.12
Elevated levels of proinflammatory mediators
in the periodontal pockets result in osteoclastic Correlation between diabetes and
destruction. Diabetic microangiopathy, impaired periodontitis
immune response, and lower resistance to infec- Diabetes affects every organ in the body, and one
tions contribute to the development of periodonti- of the oral manifestations is periodontitis charac-
tis in poorly controlled diabetics.12 terized by the loss of tissue attachment The disease
The continuous exposure of collagen fibres in characterized by an increased susceptibility to
the supporting periodontal ligaments to aldose infection, poor wound healing, and increased
sugars induces their nonenzymatic glycation and morbidity and mortality associated with disease
oxidation. This glycation leads to changes in the progression. Diabetes also recognized as an import-
physical properties of these molecules, reducing ant risk factor for more severe and progressive
collagen solubility and increasing the degradation periodontitis, infection or lesions resulting in the
of connective tissues. This results in accelerated destruction of tissues and supporting bone that
deterioration of both connective tissue and bone.12 forms the attachment around the tooth.17

Published by DiscoverSys | Intisari Sains Medis 2020; 11(1): 108-111 | doi: 10.15562/ism.v11i1.623 109
ORIGINAL ARTICLE

The level of glycemic control is of key impor- reductions in HbA1c are associated with a reduced
tance in determining increased risk. For example, in risk of diabetes complications. For example, each
the US National Health and Nutrition Examination 1% reduction in HbA1c or poor glycemic control
Survey (NHANES) III, adults with an HbA1c in type-2 diabetes mellitus has been associated with
level of >9% had a significantly higher prevalence reductions in risk of 21% for any endpoint related
of severe periodontitis than those without diabe- to diabetes, 21% for deaths related to diabetes, 14%
tes (OR 2.90; 95% CI 1.40, 6.03) after controlling for myocardial infarction and 37% for microvascu-
for age, ethnicity, education, sex and smoking.18 lar complications.24,25
The majority of research has focused on type 2
diabetes mellitus as a risk factor for periodontitis,
CONCLUSION
probably because both diseases have historically
tended to develop in patients in their 40s and 50s.18 Diabetes and periodontitis are the two most
However, type 1 diabetes mellitus also increases the commonly encountered chronic disease.
risk of periodontitis, and all patients with diabetes Considering how closely interlinked these are, it is
(including children and young adults) should be imperative to look for one when encountering each
considered to be at increased risk of periodontitis.19 other. The early identification of subjects at high risk
One early study identified that around 10% of chil- for diabetes mellitus or with undiagnosed diabetes
dren (<18 years) with type 1 diabetes mellitus had mellitus is crucial to implement measures that may
increased attachment loss and bone loss compared prevent or delay progression from pre-diabetes to
with controls, despite comparable plaque scores.19 overt diabetes mellitus and reduce the incidence
Dentists have long been aware of the importance of chronic complications. Severe periodontitis is
of a diagnosis of diabetes in their patients, and more frequently found in diabetic subjects with
various oral conditions are associated with diabe- high HbA1c levels and systemic diabetic complica-
tes, including xerostomia and candidal infections tions; however, the influence of periodontal treat-
as well as periodontitis. In the early 1990s peri- ment on HbA1c is not that well established. There
odontitis was sometimes referred to as the ‘sixth is long-established evidence that hyperglycemia
complication of diabetes’, and in 2003 the ADA in diabetes is associated with adverse periodontal
acknowledged that periodontal disease is often outcomes. Here, we show that periodontitis is an
found in people with diabetes.16,20 early sign of diabetes mellitus and may, therefore,
serve as a valuable risk indicator. A dentist who got
Periodontal treatment is associated with patient with periodontitis is a suitable location for
improved glycemic control screening for diabetes by a simple finger stick and
Several meta-analyses have confirmed that effective validated HbA1c dry spot analysis.
periodontal therapy can result in reduced HbA1c.
The first reported on ten interventional studies with CONFLICT OF INTEREST
a combined population of 456 patients; the authors
identified a weighted mean reduction in HbA1c of There is no competing interest regarding the
0.66% as a result of periodontal therapy.21 In 2008, a manuscript.
meta-analysis of nine studies involving 485 patients
reported a substantial reduction in HbA1c of FUNDING
0.46% following periodontal treatment.22 In 2010, a
meta-analysis of five studies involving 371 patients None
also reported a significant weighted mean reduc-
tion in HbA1c of 0.40% over a follow-up period of AUTHOR CONTRIBUTION
3–9 months after periodontal therapy.23
Taken collectively, the evidence supports the Ade Indah Pratiwi is responsible for the study from
notion that improvements in metabolic control can beginning the conceptual framework, searching
be anticipated following effective treatment of peri- literature, analyze, and synthesis the literature
odontitis (although there are few studies available, review in narrative form.
and some studies lack power).24 The mechanisms
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