Combating diabetes and gum disease together with advanced oral medicine and clinical chemistry

As diabetes continues to surge worldwide, the link between diabetes and gum disease is becoming an increasingly important topic of scientific study. Ignoring dental care in diabetes management raises health risks and costs. Fortunately, new dental technology helps diagnose and treat illnesses faster, benefiting patients and society.

Nearly half of the global population struggles with gum inflammation, while approximately half a billion people worldwide are affected by diabetes.^1,2 According to the Centers for Disease Control and Prevention’s National Diabetes Statistics Report for 2022, approximately 28.7 million people have received a diabetes diagnosis in the US, while an alarming 8.6 million remain undiagnosed.

The close link between diabetes and gum disease presents not only individual health risks but also imposes significant economic burdens on society. But what exactly is the connection between these two conditions?

Dr. Tommi Pätilä, a cardiac and transplant surgeon at the New Children’s Hospital at HUS, in Finland, notes that diabetic patients have an increased risk of developing periodontitis. Conversely, periodontitis has a negative impact on diabetes treatment and management. Treatment for periodontitis in diabetics demands special attention and close collaboration with health-care professionals.

According to Dr. Pätilä, “It is important for diabetics to maintain good blood sugar levels as this can foster the healing of periodontitis and mitigate the risk of inflammation. In some cases, antibiotic treatment may also be necessary, and surgical procedures may be more intricate for people with diabetes compared to those without the condition.”

Understanding the diabetes-periodontal disease link

Research shows that individuals with diabetes often exhibit increased systemic inflammatory markers, such as aMMP-8 found in their gingival tissues and oral fluids. Elevated long-term blood sugar levels, a condition known as hyperglycemia, contribute to heightened oxidative stress, inflammation, and apoptosis (programmed cell death) in the body. Concurrently, heightened inflammatory markers, including tissue-destructive proteolytic and collagenolytic aMMP-8 associated with periodontitis, can exacerbate diabetes and compromise its management.^3-11

Dr. Timo Sorsa, professor of oral and maxillofacial diseases at the University of Helsinki and Karolinska Institute in Sweden, says a chronic inflammatory disease of the supporting tissues of the teeth progresses more rapidly and destructively in individuals with uncontrolled diabetes or those who have not yet been diagnosed. Periodontitis can also complicate diabetes management and increase treatment costs. Conversely, a healthy periodontium can balance diabetes and support its management.

Prof. Sorsa notes that the roles of aMMP-8 and adipokines have been considered when investigating the connection between diabetes and periodontitis. Adipokines are signaling molecules secreted by adipose tissue that regulate various physiological processes, including metabolism, inflammation, and immune function. These proteins can predispose one to both periodontitis and diabetes, especially in overweight or diabetic individuals.

The relationship between periodontitis and diabetes has similarly been explained by immune response dysfunctions.^12-14 Diabetics, especially those with severe periodontitis, have been found to have dysfunctions in immune cell activity, which can increase tissue damage and inflammation.

Different forms of diabetes, such as types 1 and 2 diabetes as well as gestational diabetes, affect the risk and progression of periodontitis differently. Individuals with type 2 diabetes have a higher risk of developing periodontitis, and good glycemic control is a key factor in managing this risk. Type 1 diabetics also have higher risks of developing periodontitis, and gestational diabetes can affect both maternal and fetal health.

According to research, periodontitis may even double the risk of developing gestational diabetes. The mechanism by which periodontitis influences gestational diabetes is not, however, fully understood.^15,16

Prof. Sorsa says elevated levels of inflammatory mediators including aMMP-8 in the bloodstream due to gum inflammation, combined with gestational diabetes, may serve as a basis for systemic, chronic inflammation.

The active-matrix metalloproteinase-8 mouth rinse point-of-care test (aMMP-8 POCT), developed by a team of scientists led by Prof. Sorsa, has demonstrated a positive correlation with glycated hemoglobin (HbA1c) values and can even aid in primary care referrals.

HbA1c values reflect average blood sugar levels over the past two to three months. This test measures the percentage of hemoglobin with glucose attached to it, offering insight into blood sugar control over time. It is commonly used for diabetes diagnosis and monitoring blood sugar levels in individuals with diabetes.

Oral health status revealed in minutes

Traditional diagnostic methods are not always sufficient to identify the risk of periodontitis and diabetes. Therefore, new biomarker-based rapid tests have been developed to help identify the risk of these diseases at an early stage.^3-11

The aMMP-8 immunoassays (PerioSafe and ImplantSafe/ORALyzer) are based on measuring the concentration of active MMP in mouth rinse. Prof. Sorsa says studies have shown that elevated levels of aMMP-8 may indicate both periodontitis and diabetes.

The aMMP-8 rapid test can be performed at the dentist's office, and the results are obtained immediately. This allows for early intervention in the development of periodontitis and assessment of the risk of diabetes. Additionally, the test provides patients with important information about their oral health and the risk of diabetes, which encourages better self-care and adherence to healthy lifestyles.

Prof. Sorsa says, “The test allows for the detection of signs of periodontitis even before symptoms occur, which provides an opportunity for early treatment and prevention of complications.” The test has proven to be useful in screening patients with type 1, type 2, and gestational diabetes.

“Overall health starts with a healthy mouth”

Maintaining good oral hygiene and scheduling regular dental check-ups are imperative for individuals with diabetes. Dr. Pätilä notes, “Overall health starts with a healthy mouth. It is, therefore, important to regularly clean the mouth thoroughly.” (Note: Dr. Pätilä is one of the Finnish scientists behind the development of the new light-activated oral health-enhancing Lumoral method. Lumoral is not currently available in the US.)

Because 95% of dental diseases are caused by bacteria in dental plaque, eliminating oral plaque regularly improves dental hygiene as well as prevents and treats periodontal disease.

“If we want to improve the results of dental care treatments, we need to focus on removing the plaque that is left on the teeth after brushing them,” says Prof Sorsa.

Dr. Pätilä adds, “Regular and thorough brushing and flossing are key to maintaining oral health. Using an antibacterial light-activated method as an adjunct therapy when treating dental and gum diseases significantly enhances treatment efficacy.”

Editor’s note: This article first appeared in Clinical Insights newsletter, a publication of the Endeavor Business Media Dental Group. Read more articles and subscribe.

References

1. Diabetes. World Health Organization. https://www.who.int/health-topics/diabetes
2. Nazir MA. Prevalence of periodontal disease, its association with systemic diseases and prevention. Int J Health Sci (Qassim). 2017;11(2):72-80.
3. Chee B, Park B, Bartold PM. Periodontitis and type II diabetes: a two-way relationship. Int J Evid Based Healthc. 2013;11(4):317-329. doi:10.1111/1744-1609.12038
4. Ryan ME, Ramamurthy NS, Sorsa T, Golub LM. MMP-mediated events in diabetes. Ann N Y Acad Sci. 1999;878:311-334. doi:10.1111/j.1749-6632.1999.tb07692.x
5. Sorsa T, Ingman T, Suomalainen K, et al. Cellular source and tetracycline-inhibition of gingival crevicular fluid collagenase of patients with labile diabetes mellitus. J Clin Periodontol. 1992;19(2):146-149. doi:10.1111/j.1600-051x.1992.tb00454.x
6. Safkan-Seppälä B, Sorsa T, Tervahartiala T, Beklen A, Konttinen YT. Collagenases in gingival crevicular fluid in type 1 diabetes mellitus. J Periodontol. 2006;77(2):189-194. doi:10.1902/jop.2006.040322
7. Brownlee M. The pathobiology of diabetic complications: a unifying mechanism. Diabetes. 2005;54(6):1615-1625. doi:10.2337/diabetes.54.6.1615
8. Dandona P, Aljada A, Bandyopadhyay A. Inflammation: the link between insulin resistance, obesity and diabetes. Trends Immunol. 2004;25(1):4-7. doi:10.1016/j.it.2003.10.013
9. Hotamisligil GS. Molecular mechanisms of insulin resistance and the role of the adipocyte. Int J Obes Relat Metab Disord. 2000;24(Suppl 4):S23-S27. doi:10.1038/sj.ijo.0801497
10. Rotter V, Nagaev I, Smith U. Interleukin-6 (IL-6) induces insulin resistance in 3T3-L1 adipocytes and is, like IL-8 and tumor necrosis factor-alpha, overexpressed in human fat cells from insulin-resistant subjects. J Biol Chem. 2003;278(46):45777-45784. doi:10.1074/jbc.M301977200
11. Heikkilä P, Niskanen L, But A, Sorsa T, Haukka J. Oral health associated with incident diabetes but not other chronic diseases: a register-based cohort study. Front Oral Health. 2022;3:956072. doi:10.3389/froh.2022.956072
12. Lauhio A, Färkkilä E, Pietiläinen KH, et al. Association of MMP-8 with obesity, smoking and insulin resistance. Eur J Clin Invest. 2016;46(9):757-765. doi:10.1111/eci.12649
13. Naguib G, Al-Mashat H, Desta T, Graves DT. Diabetes prolongs the inflammatory response to a bacterial stimulus through cytokine dysregulation. J Invest Dermatol. 2004;123(1):87-92. doi:10.1111/j.0022-202X.2004.22711.x
14. D'Aiuto F, Parkar M, Andreou G, et al. Periodontitis and systemic inflammation: control of the local infection is associated with a reduction in serum inflammatory markers. J Dent Res. 2004;83(2):156-160. doi:10.1177/154405910408300214
15. Lalla E, Cheng B, Lal S, et al. Diabetes mellitus promotes periodontal destruction in children. J Clin Periodontol. 2007;34(4):294-298. doi:10.1111/j.1600-051X.2007.01054.x
16. Chaparro A, Realini O, Hernandez M, et al. Early pregnancy levels of gingival crevicular fluid matrix metalloproteinases-8 and -9 are associated with the severity of periodontitis and the development of gestational diabetes mellitus. J Periodontol. 2021;92(2):205-215. doi:10.1002/JPER.19-0743

Nina Garlo-Melkas, MSc, is a health and science journalist who works as communications manager at Koite Health Ltd., a quickly growing health technology company and innovator in light-activated antibacterial solutions for treating and preventing oral diseases.