Introduction

While you may know that lifestyle changes such as diet and exercise can help manage your diabetes and blood sugar levels, did you know that good oral health can help as well? 

If you are diabetic and struggling to manage your blood sugar, you might want to consider that gum disease could potentially be contributing to the problems. Research has shown that periodontal care is an essential part of diabetes management. 

Read on to learn more about the intricate relationship between periodontal health and diabetes, including the signs and symptoms of periodontal disease, how periodontal disease can worsen diabetes complications, and the different periodontal care strategies for diabetic patients. 

Overview

Periodontal disease (also called gum disease) is the inflammation and infection of your gums and the bone that supports your teeth and can lead to serious complications including gum recession, bone loss and loss of your teeth. This disease affects many people worldwide but causes a significant concern for diabetic patients as there is a notable link between diabetes and gum disease. 

Diabetes is a condition that causes high blood sugar levels which can increase your risk of developing periodontal disease. This makes it very  important to maintain good oral hygiene and reduce the  elevated risk of periodontal disease. However, in turn, periodontal disease can also cause potentially serious diabetic complications by increasing your blood sugar levels. Therefore, preventing and treating periodontal disease can help you control your blood sugar levels - which is essential in diabetes.¹

This article explores the nuances of periodontal care for diabetic patients, emphasising its pivotal role in managing both oral health and diabetes control. 

What is periodontal disease?

Periodontal disease, or gum disease, is a condition characterised by infection and inflammation of the tissues surrounding your teeth, this includes the surrounding soft tissues as well as the bone in which teeth are anchored. 

What are the symptoms of periodontal disease?

Early signs of gum disease include red, swollen and tender gums that may bleed easily when brushed or flossed. This early and reversible stage of gum disease is called gingivitis. Treatment at this stage is straightforward forward involves mainly adequate cleaning habits by brushing and flossing, and the use of anti-bacterial mouth rinses.

However, if left untreated, gingivitis can progress to develop into  a more serious and non-reversible stage of gum disease called periodontitis. Harmful bacteria infiltrate your gums to areas which are difficult to reach by brushing and flossing, further spread occurs into the surrounding bone and causes breakdown. As the supporting bone is lost to infection, the gums pull away from the teeth causing gum recession. Bone loss may result in tooth mobility and they can even fall out. In fact, periodontal disease is one of the leading causes of tooth loss.²

What causes periodontal disease?

The main cause of periodontal disease is a buildup of plaque on your teeth, normally caused by poor oral hygiene. Plaque buildup leads to gingivitis which progresses to infection of the supporting periodontal fibres and alveolar bone. 

On top of this, there are a number of risk factors that increase your chance of developing periodontal disease, including:³

• Smoking or tobacco use
• Stress
• Obesity
• Genetics (you are more likely to get periodontal disease if one or more of your family members also have it)
• Cardiovascular disease
• Autoimmune diseases (e.g. lupus, Crohn’s disease)
• Diabetes

What is the link between diabetes and periodontal health?

Periodontal disease and uncontrolled diabetes create a vicious cycle whereby diabetes increases the risk of periodontal disease and, in turn, periodontal disease makes it harder to control your diabetes and can increase the risk of diabetes complications.

Diabetes increases your risk of periodontal disease

If you have diabetes, you face an increased risk of developing periodontal disease (about 3-4 times greater risk).^4,5 Diabetes is characterised by elevated blood sugar levels, either due to insufficient insulin production (type 1 diabetes) or because the insulin in your body is not working correctly to reduce your blood sugar levels (type 2 diabetes). The heightened blood sugar levels in diabetes can lead to more sugar being present in your saliva which attracts harmful bacteria to your mouth. These bacteria produce acid that attacks tooth enamel and causes gum damage, inflammation and infection. 

Additionally, diabetes lowers your body’s resistance to infection, increasing the likelihood of gum infection and for you to develop periodontal disease.^6,7

Periodontal disease increases your risk of diabetes complications

In turn, untreated periodontal disease can also increase the risk of developing serious complications of diabetes.¹ Gum disease can increase your blood sugar, making it more difficult to control your sugar levels. This is important as elevated blood sugar levels can lead to many other complications of diabetes, including:⁸

• Eye problems (diabetic retinopathy)
• Nerve damage (diabetic neuropathy)
• Foot problems
• Heart attack and stroke
• Kidney problems (diabetic nephropathy)
• Sexual problems

The risk of developing complications from diabetes can be reduced by keeping your blood sugar under control. Therefore, by maintaining healthy teeth and gums, one can reduce your risk of developing periodontal disease and related complications.

Periodontal care strategies for diabetic patients

This connection between periodontal health and diabetes means that it is important to take your oral health seriously. Tailored periodontal care strategies are therefore essential for diabetic patients to reduce the risk of potential complications. 

At-home periodontal care

Make sure your dentist is aware of your diabetes diagnosis and work with them to create a healthy plan for your teeth. 

Get advice on how to take care of your teeth at home and how often to go for dental check-ups. Regular and consistent oral hygiene practices are important to control plaque accumulation and reduce inflammation, reducing the risk of developing periodontal disease. 

General advice for maintaining periodontal health:

• Brush your teeth at least twice a day with fluoride toothpaste
• Floss your teeth at least once a day to remove plaque in between teeth- if you have gum recession, use interdental brushes instead of floss to clean between your teeth
• Check your mouth regularly for signs of gum disease and see your dentist if you have any of these signs:
  • Red or swollen gums
  • Bleeding gums
  • Loose teeth
  • Bad breath
  • Mouth pain
• Stop smoking - smoking can weaken your immune system, further increasing your risk of periodontal disease and worsening your diabetes⁹
• Check your blood sugar levels regularly and try to keep them in your target range
• Follow a healthy and balanced diet which is low in sugar
• Have regular dental check-ups 

Non-surgical periodontal treatment

If you are diagnosed with periodontal disease, it needs to be managed. In most cases, conventional non-surgical periodontal treatment is sufficient to reduce inflammation and treat gum disease. This treatment has been shown to be very effective in diabetic patients in both treating gum disease and lowering blood sugar levels.¹⁰ Non-surgical treatment might involve:

• Scaling: This procedure removes tartar and bacteria from your tooth surfaces and below your gum line. Scaling can be done by using special hand instruments or a special device called an ultrasonic scaler.
• Root planing: Used to remove tartar from your tooth root surfaces and smoothen the root surface to help prevent further plaque buildup and help your gums to reattach to your teeth 
• Laser periodontal therapy: A small laser can be used to remove any diseased or inflamed gum tissue from around your tooth root and kill the bacteria under your gums
• Antibiotics: Topical (e.g. mouth rinses or antibiotic gel) or oral antibiotics (e.g. tablets or capsules) may be required to control any bacterial infection

Surgical periodontal treatment

In more advanced and severe cases of periodontal disease, surgical periodontal treatment may be required to remove the tartar build-up and bacteria from your teeth and below the gums, and repair the damage caused by the disease. Some common surgical periodontal procedures include:¹¹

• Flap surgery or pocket reduction surgery: Small cuts are made into your gums and a flap is raised to expose the tooth roots for more effective scaling and root planing. The underlying bone might also be reshaped before the gum tissue is stitched back into place. 
• Soft tissue (or gum) grafts: A small amount of tissue from another part of your mouth (e.g. the palate) or synthetic tissue is attached to the gum if this tissue has been lost (gum recession). This is used to reduce further gum and tooth loss and cover any exposed roots.
• Bone grafting: If periodontal disease has destroyed the bone around your teeth roots, a bone graft can be used to replace this missing bone. 

This is done using small bits of your own bone (autogenous bone graft) or from animal bone substitutes (xenografts) or artificial material (alloplastic grafts). This helps to prevent tooth loss by holding your tooth in place and promotes regrowth of natural bone.

• Guided tissue regeneration: A mesh-like material is placed between your bone and gum tissue to stimulate growth of new bone in areas destroyed by bacteria.

Periodontal treatment aftercare

After periodontal disease treatment, your periodontist or dentist will give you a list of detailed care instructions. These will vary depending on the treatment procedure you have had, but general advice is to keep the area clean and take any prescribed medication as advised.

Finally, it is important to contact your periodontist if you develop any unexpected side effects, such as:

• Uncontrolled bleeding
• Persistent, severe pain
• Fever
• Infection at the treatment site

Summary

Periodontal disease (or gum disease) is the chronic inflammation and infection of the gums and bones that support the teeth and is one of the leading causes of tooth loss worldwide. The risk of developing periodontal disease is significantly elevated in diabetic patients. However, in turn, periodontal disease can also affect your blood sugar levels and increase the risk of complications in people with diabetes. Periodontal treatment can include non-surgical treatment such as scaling and root planing to remove plaque and tartar, as well as surgical treatments and more invasive procedures in more advanced cases.. Periodontal care should be part of the routine management of diabetes, along with regular dental check-ups and good oral hygiene practices. 

Frequently asked questions:

What is periodontal disease?

Periodontal disease is a destructive infective process which affects the tissues surrounding teeth. Infection progresses from gum disease to involve the underlying bone which supports the teeth.  Periodontal disease leads to bone loss and tooth mobility.

What is a bone graft?

A bone graft is used to replace an area of destroyed bone which leaves behind a defect. Various natural and artificial products are used as bone grafts.

What is an autogenous bone graft?

Autogenous bone grafts are considered the golden standard when bone is needed to treat and fill bony defects. The patient's own bone can be harvested from intra-oral or extra-oral sites and transplanted to the required area.

What is a xenograft?  

Xenografts are bone substitute products which are transplanted from one species to another. For periodontal bone grafting, bovine bone is often used.

What is an allopast?

Alloplasts are synthetic or man-made products that are used bone substitutes in guided tissue and bone regeneration.

What is root planing?

Root planing is a procedure whereby the tooth root surface is ‘scraped’ clean of plaque and calculus deposits. This encourages regeneration of bone and attachment of the periodontal fibres onto a clean, bacteria-free root surface.