Emerging evidence suggests that oral health, often overlooked by clinicians, is closely linked to overall health—and this connection has important implications for people with type 2 diabetes (T2D). While most studies are observational and cannot prove cause and effect, the associations are strong enough for researchers to conclude that the link is real.
Endocrinologists and other specialists, as well as primary care physicians, should ask about oral health, if not look directly at the mouth, experts say. “One of the most important things to ask people with diabetes is when was their last dental visit and if they will be next,” said Robert Gabbay, MD, PhD, Chief Scientific and Medical Officer of the American Diabetes Association (ADA ). Medscape Medical News. The ADA supports oral health care through 2024 standards of care.
Systemic Effect
“Periodontitis is a potential risk factor for various problems related to the cardiovascular, pulmonary, endocrine, musculoskeletal, central nervous, and reproductive systems,” wrote the authors of a recent revision on the effects of periodontitis on major organ systems. While not specific to the diabetes link, the review points to some of the latest evidence that “oral health affects overall health and…dental health should never be considered a separate, remote, and less important part of health.”
According to this perspective, and looking specifically at T2D, a recent study More than 17,000 patients with T2D participating in a screening program in Korea found that periodontitis and an increased number of carious teeth were independent risk factors for stroke or myocardial infarction (adjusted hazard ratios, 1.17 and 1.67, respectively) .
Dental disease and poor oral hygiene were also associated with an increased risk of heart failure among people with T2D in large cohort studyand the authors suggested that managing oral health may prevent the development of heart failure.
ONE recent revision suggested that periodontitis exacerbates and promotes the progression of chronic kidney disease, a disorder that affects 1 in 3 people with diabetes.
Studies have also shown that diabetes is associated with cognitive impairmentand a review of oral health and progression of dementia concluded, “Collectively, the experimental findings suggest that the connection between oral health and cognitive ability cannot be underestimated.”
Two-way effects
Research has shown that the association between periodontal disease and T2D is likely bidirectional, although there is little awareness of this bidirectional relationship among patients and providers.
ONE recent revision of this two-way relationship focused on microvascular complications, oral microbiota, pro- and anti-inflammatory factors in T2D and periodontal disease and concluded that “these two diseases require specific/complementary therapeutic solutions when they occur in combination, with new clinical trials and epidemiological research is necessary to better control this interrelated pathogenic issue.”
However one Australian study showed that 54% of 241 participants in a survey had never received any information about the two-way relationship between periodontal disease and diabetes and had no understanding of the association.
What is Mechanism?
How does T2D affect the teeth and vice versa? “Basically, people with T2D have high blood sugar, and the sugar comes out in the saliva, and that promotes the growth of bacteria in the mouth and the formation of plaque on the teeth and gum disease,” Samir Malkani, MD, clinical chief of endocrinology and diabetes at said UMass Chan School of Medicine in Worcester, Massachusetts Medscape Medical News.
“Patients get gingivitis, they get periodontitis, and since the gums and the jaw are a single unit, if the gum disease becomes very severe, then there’s jawbone loss and the teeth can fall out,” he said. There is also inflammation in the mouth, and “when you have generalized inflammation, it affects the whole body.”
Recent research in Europe suggested that “although the mechanisms behind these associations are partly unclear, poor oral health is probably maintenance of systemic inflammationCommon oral infections, periodontal disease and cavities are associated with inflammatory metabolic profiles that are associated with increased risk of cardiometabolic disease and predict future adverse changes in metabolic profiles, according to the authors.
Awareness, Accessibility, Collaboration
Despite the evidence, the link between oral health and diabetes (of any type) is not on the minds of clinicians or patients, Malkani said. Show a systematic evaluation which included 28 studies of about 28,000 people in 14 countries. The review found that people with diabetes have “poor oral health knowledge, poor oral health attitudes and fewer visits to the dentist, [and] they rarely receive oral health education and dental referrals from care providers.”
The social determinants of health have “big influence” on whether people will develop T2D and its related complications, including poor oral health, according to the National Committee on Clinical Care Report presented to the US Congress in 2022. The committee was tasked with making recommendations for federal policies and programs that could more effectively prevent and control diabetes and its complications.
The committee “approached its charge through the lens of a socioecological and an expanded model of chronic care,” the report’s authors wrote. “It was clear that diabetes in the US cannot be viewed simply as a medical or health care problem, but must also be addressed as a societal problem that cuts across many sectors, including food, housing, commerce, transportation and the environment.”
Diabetes is also associated with higher dental costsanother factor that affects a person’s ability to receive care.
A recent questionnaire study from Denmark found that people with T2D were more likely than those without diabetes to rate their oral health as poor, and that the risk of self-reported poor oral health increased with lower educational attainment. Higher educational attainment and household disposable income were indicators of high socioeconomic status and a lower likelihood of rating their oral health as poor, again highlighting disparities.
The authors concluded that “diabetes and dental care providers should engage in multidisciplinary collaboration across all areas of health care to ensure coherent diabetes treatment and management.”
But such partnerships are easier said than done. “One of the challenges is our fragmented health system, where oral health and medical care are separate,” Gambai said.
For the most part, the two are separate, Malkani agreed. “When dealing with most complications of diabetes, such as heart, eye or kidney involvement, we can have multidisciplinary care — they all fall under the general discipline of medicine and if I refer to a fellow in ophthalmology or a cardiologist or a vascular surgeon , they can all be in the same network and from an insurance point of view”.
But for dental care, referrals are interprofessional rather than interdisciplinary. “I have to make sure the patient has a dentist because dentists are usually not part of medical networks, and if the patient doesn’t have dental insurance, then cost and access can be a challenge.”
Recent systematic evaluation from Australia on interprofessional education and interprofessional collaborative care found that more than a third of medical professionals were “unaware” of the link between oral health and disorder. Additionally, only 30% reported ever referring their patients for an oral health evaluation. And there has been little, if any, interprofessional collaborative care between physicians and dentists in the management of patients with T2D.
Face the teeth
“We always talk to our T2D patients about the importance of an eye exam, a foot exam and a kidney test,” Malkani said. “But we also have to make sure they go to the dentist. Normally, people get their teeth cleaned twice a year. But if you have diabetes and poor oral health, you may need to have your teeth cleaned every three months. And insurance often will pay for it.”
Furthermore, consistent with the bidirectional link, treatment of periodontitis may help with glycemic control. The authors of a 2022 update of a Cochrane review on periodontitis treatment for glycemic control wrote that they “doubled the number of studies and participants” since the 2015 update to 35 studies randomizing 3249 participants to periodontal treatment or control. This “led to a change in our conclusions about the primary effect of glycemic control and our level of certainty in that conclusion.”
“We now have moderate-certainty evidence that periodontal therapy using subgingival devices improves glycemic control in people with periodontitis and diabetes by a clinically meaningful amount compared with no therapy or usual care. Further trials evaluating periodontal treatment versus no treatment/usual are unlikely to change the overall conclusion reached in this review.’
“Dentists also have a responsibility,” added Malkani. “If they see someone with severe gum disease or tooth decay, especially at a younger age, they should tell that person to check their blood sugar and make sure they don’t have T2D.”
Actually, a recent revision found that complications of T2D such as dry mouth and periodontal problems negatively affect well-being and that “dentists can play an essential role in making diabetic patients aware of these problems and improving their quality of life.”
Basic statistics
The US Centers for Disease Control and Prevention pointed out these incidents about diabetes and oral health:
- Adults age 20 and older with diabetes are 40% more likely have untreated cavities than similar adults without diabetes.
- About 60% of US adults with diabetes have had a medical visit in the past year, but no visit to the dentist.
- Extending health care coverage for periodontal treatment to people with diabetes could save every person about $6000 (2019 USD) over their lifetime.
- Adults aged 50 years and older with diabetes lack of functional dentition (have fewer than 20 teeth) 46% more often and have severe tooth loss (eight or fewer teeth) 56% more often than those without diabetes.
- Adults age 50 and older with diabetes are more likely to report having a difficulty eating due to dental problems.
- Annual dental expenses for an adult with diabetes is $77 (2017 USD) higher than for an adult without diabetes. This cost translates to $1.9 billion for the United States.
