Why You Should Talk to Your Diabetic Patients About Gum Disease

For patients with diabetes, it is even more important to remember the relationship between oral health and general health

With Frank A. Scannapieco DMD, PhD and Purnima Kumar DDS, PhD

Hyperglycemia can change bacteria that live under the gum.

Sometimes, Purnima Kumar, DDS, PhD, a professor of periodontology at The Ohio State University, thinks physicians forget that the mouth is part of the body, and an important one at that. “The mouth is one of the factors in overall health,” she says.

For patients with diabetes, it is even more important to remember the relationship between oral health and general health, she notes, as there is a growing body of evidence that those with type 2 diabetes are more likely to have periodontitis, and increasing data showing that having gum disease can negatively impact glycemic control. There is already established science that gum disease can also lead to cardiovascular disease (1) – something that those with diabetes have a higher risk of having, making oral health of vital importance in those patients to prevent that downward spiral.


Studies have shown that oral microbiota changes in patients who have both periodontitis and type 2 diabetes, more than if either condition existed alone (2). A new study (3) shows that patients with type 2 diabetes and gum disease show changed response in certain immune cells. A higher proportion of CD11b+ or CD4+ cells secreted IFNγ/IL-10 or IL-8, respectively in patients with both conditions compared to those with periodontitis alone. This particular finding does provide a potential pathway for treatments, the authors note.

While there are fewer large, well-designed studies proving that glycemic control gets worse in patients with both diabetes and gum disease, there is, indeed, evidence (4, 5). Increased bacterial lipopolysaccharides can cause immune responses that have metabolic effects, some of which have already been identified as a factor in the development of type 1 diabetes.


Kumar explains that wound healing, immune response, and the ability of tissue to repair itself are all compromised in the oral tissue of those with type 2 diabetes. “Hyperglycemia can change bacteria that live under the gum,” she says. The more pathenogenic the microbiome, the less bandwidth patients have to respond to it. “It can cause a sequence of events that can eventually involve the circulatory system, which can lead to insulin resistance. It’s a vicious cycle.”

While every dentist learns about the relationship between periodontitis and diabetes (as well as other inflammatory diseases such as rheumatoid arthritis, heart failure, and myocardial infarction) it isn’t something most endocrinologists know, Kumar says. “I do grand rounds on this regularly. And in practice, I see these patients regularly and often know more about their glycemic control than their physicians.”

It’s not that diabetes causes periodontitis, but it can “aggravate factors that can cause it,” she notes. “If a patient has excellent oral health – they brush and floss daily, and see a dentist twice a year – then they may be fine. But if they don’t, it can cause problems in the mouth and in overall health.”

She recommends every provider who works with patients who have type 2 diabetes should ask them when they last saw a dentist, whether they have bleeding gums, or if they have experienced gum abscesses.


Should they develop periodontitis, there are treatment options. Initially, dentists will recommend deep cleanings below the gum line every three months if possible. If that doesn’t resolve the issue, then the dentist or periodontist can insert nanoparticles of doxycycline under the gum. This has been shown to be an effective treatment.

The most recent study on the treatment (6) looked at doxycycline nanospheres in patients with both diabetes and periodontitis and found that, when given the treatment after a deep cleaning, there was a marked improvement in deep pockets and a reduction in some inflammatory markers. There was also a significant reduction in periodontal pathogens. This study also found a lower mean percentage of A1c in the doxycycline patients three months after treatment than in those who had placebo nanoparticles. The authors note that this treatment doesn’t preclude the need for deep cleaning, but can be an added therapy that may reduce gum disease and its symptoms.

Should the cleaning and antibiotic treatment fail, the next option is gum surgery, says Kumar.

It may be a good idea for every patient with type 2 diabetes to see their dentist more frequently than twice a year if possible, even if they don’t have signs of any gum disease, says Frank A. Scannapieco, D.M.D., Ph.D., professor and chair at the department of oral biology in the SUNY Buffalo School of Dental Medicine. He tells his patients with type 2 diabetes to see the dentist three or four times a year if possible.

There are some simple questionnaires in the public sphere that doctors can use to help determine the oral health of their patients, Scannapieco says. These include questions about loose teeth and bad breath, the last dental visit and any pain in the teeth or jaw, as well as the previously mentioned questions about abscesses and bleeding when they brush or floss. The Centers for Disease Control (CDC) has one on its website.

If a patient answers yes to more than a couple of the questions, they should be referred to a dentist as soon as possible, he says. “Don’t prescribe antibiotics. Let the dentist deal with it. They have been given the appropriate education, while most physicians get, at most, an hour or two about oral health during medical school.”

Every patient with diabetes should do the following: see a dentist three or four times a year if possible, brush, and instead of flossing, consider using interdental cleaning brushes. “It’s more effective,” Scannapieco says. They should also use an antimicrobial mouth rinse (Listerine and Cepacol are two popular brands). “They should do everything they can to keep their mouth clean. More than a person without the disease would.”

The underlying mechanism of periodontitis is inflammation, he says. “If you have gum disease, you are raising the inflammation throughout your body. This is often overlooked by physicians. We need more large studies to provide data on the link between periodontitis and poor glycemic control,” he says. But in the interim, he wants doctors to step up their survey of their patients with diabetes. “I’ve been doing and seeing this for 40 years, and it’s frustrating. If they do this they will be doing a public service.”


Continue Reading:
Diabetes and Heart Failure: What Endocrinologists Need To Know
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