Relationship between Diabetes and Periodontal Disease - Literature review Example

Relationship between Diabetes and Periodontal Disease Table of Contents Page No Introduction ………………………………………………….... 3 1 Aim and Objective …………………………………………… 4 1.1.1 Aim/Research Question ……………………………… 4 1.1.2 Objectives ……………………………………………... 4 2. Methodology …………………………………………………… 4 3. Literature Review ……………………………………………… 7 3.1 Background ………………………………………………… 7 3.2 Pathology and etiology……………………………………… 11 3.3 Studies ……………………………………………………….. 13 3.4 Two-way relationship (bi-directional)……………………..... 16 3.5 Possible healing ……………………………………………... 19 4. Discussion ………………………………………………………... 20 5. Conclusion ……………………………………………………….. 24 6. References ……………………………………………………….. 25 List of Figures Figure 1 Periodontal pocket ……………………………………. 10 Figure 2 X-Ray of periodontitis ………………………………… 18 Figure 3 Picture of periodontitis ……………………………… 19 1. Introduction Evidence is emerging and growing on the relation between oral disease and other systemic conditions like diabetes. Periodontitis, a chronic, inflammatory disease, has come out as a risk factor for cardiovascular diseases and the two types of diabetes. (Williams et al. 2008, p. 1636) Diabetes Mellitus is a type of chronic illness which results from inability to produce insulin and metabolize carbohydrate and fat in the body. Research has found a relationship between diabetes and periodontal disease, which is a kind of bacterial infection in the tooth supporting tissues. This oral disease has two different types: gingivitis which is an inflammation of the gingival, and periodontitis which results in an inflammation in the periodontal tissues. (Al-Habashneh et al. 2009, p. 977) A meta-analysis revealed that people with diabetes had more periodontal disease, displayed “poor oral hygiene”, and possessed more severe gingival disease, than non-diabetics (Grossi, Offenbacher, & 2000, Fritz p. 767). Many studies have found the relationship between diabetes mellitus and periodontal disease. Belting and colleagues (as cited in Grossi et al., 2000, p. 768) found that periodontal disease was more prevalent among persons with diabetes than in non-diabetics. These studies, revealing the relationship of diabetes and periodontal disease and the various causes surrounding the relationship, are well discussed in the literature review and the discussion sections. 1.1 Aim and Objectives 1.1.1 Aim and Research Question The aim is positioned as research questions: Is there evidence suggesting that periodontal disease is a risk factor for diabetes? What are the factors leading to the development of the relationship between diabetes and periodontal disease? 1.1.2 Objectives 1.1.2.1 To determine what causes periodontal disease in diabetes 1.1.2.2 To understand the causes of the two diseases and their effects on the patient 1.1.2.3 To determine ways to prevent periodontal disease in diabetes and how to manage the illness. 2. Methodology It was important to develop clear research question/s which helped to find relevant literature for answering the question given in this dissertation. It was possible to provide a good research question that was specific and answerable and could provide the structure and guidance for literature review with the use of a theoretical framework. The study focused on a review of the literature and an analysis of past researches on the relationship of diabetes mellitus (DM) and periodontal diseases. Literature reviews provide knowledge of the important variables of the research subject. An effective literature review enables the researcher to unify past and present studies and bring to fruition a new knowledge. An excellent literature review provides a critical and analytical study of the data collected from the different sources. The literature review helped in synthesising several studies and producing a new knowledge out of the past studies. The review summarised and assessed the researcher’s work and determined its place in the body of the writing or the thesis proper. (Khan 2008, p. 42) 3. Literature review 3.1 Background Diabetes is an enormous burden for patients, families and the health care profession. There is a worldwide epidemic increase of those diagnosed with the disease forecasted year after year, and the burden threatens not only the health of people with diabetes but also the health of society itself. (Fonseca 2006) Diabetes is a metabolic malfunctioning where the outcomes are hyperglycemia and hyperlipidemia, causing several body pathologies such as coronary heart disease (CHD), myocardial infarction, and periodontal disease, among others. In diabetes, the endocrine system does not provide enough insulin, thus high levels of glucose are present in the blood. This is known as hyperglycemia or the body’s resistance to insulin. (Talbert et al. 2006, p. 2) There are two types of diabetes: type 1diabetes wherein patients are treated with insulin, and type 2 diabetes where patients are not dependent on insulin treatment. Type 2 is caused when an individual’s body resists the insulin, and the pancreas does not produce enough insulin. The pathophysiology for the various forms of diabetes is the absence of insulin action. People with diabetes have weak response to bacterial infections which increases the risk of periodontal disease. Type 2 diabetes, also termed adult-onset diabetes, begins with the development of insulin resistance. The cells cannot properly use the available insulin, thus increasing the demand for insulin production as the pancreas eventually fails to produce sufficient insulin. (Boyer 2008) How insulin works in the body demonstrates the way diabetics acquire the disease. Insulin is a hormone secreted by the pancreas; normally this is produced in small amounts but on a continuous basis. As the individual consumes a meal, the pancreas releases insulin and the body reacts by removing the excess glucose, storing it in the liver and muscle or converting it to fat. The glucose can be released back to the blood stream, and insulin brings the glucose to the cells. If the individual has diabetes, the process is different: there is excess glucose in the bloodstream because of lack of insulin or insufficiency of insulin produced by the pancreas. People with type 2 diabetes have a slow progression of the disease as their bodies slowly respond to insulin. (Talbert et al. 2006, p. 2) When there’s too much glucose in the blood, the body is prone to infection and the infection is known as Candida. Periodontitis infection becomes severe. In men, it can also cause a different type of infection in their sex organ, and even in women. Moreover, the immune system is not normal in fighting off infections. The measurement of the blood sugar should not exceed 14mmol/L. (Hanas & Fox 2008, p. 31) 3.1.1 The start of periodontal disease Periodontal disease is a common disease on humans; its stimulants are called periodontopathogens. The tissues that support the tooth are weakened and destroyed which creates a breakdown of the collagen fibres of the ligament, forcing it to enlarge the periodontal pocket situated beneath the tooth. Periodontitis is a slow occurrence but progresses until it destroys the whole gingiva; the destruction cannot be reversed. During its early formation, the patient almost feels nothing and unaware until it becomes severe. The pockets become deep canals until the fibres are all destroyed. Advanced periodontitis has symptoms of bleeding and gliding of teeth until all the teeth have to be removed. (Preshaw et al. 2012, p. 22) When there is prolonged hyperglycemia, the body reacts resulting in complications. The reaction is based on a biochemical state known as Advanced Glycation Endproducts (AGEs), which are glucose and cannot be reversed. They build up in plasma and tissues. (Talbert et al. 2006, p. 3) There are two kinds of periodontal disease: gingivitis, a situation in which the inflammation can be reversed with proper mouth hygiene – it is not severe and is only limited within the gingival; and, periodontitis, a severe form of infection occurs, the tissues are destroyed and there is ‘alveolar bone resorption’ (Preshaw et al. 2012, p. 22). Figure 1 The periodontal pocket SOURCE: Periodontitis and diabetes: a two-way relationship, by Preshaw et al. (2012, p. 22) In periodontal disease, a particular type of bacteria attacks the biofilm inside the periodontal pocket. Anaerobic infection occurs, triggering an inflammation that destroys the tissues. The mouth’s surface is enlarged. Systemic responses occur as the disease becomes severe. Periodontal pathogens provoke the systemic immune as an inflammation occurs. Inflammatory mediators also circulate through the system. (Williams et al. 2008, p. 1636) The circumstances in periodontal disease become severe due to some risk factors, like: When there is ignorance about oral health and the diabetes disease, coupled with lack of oral health care and insufficient dental treatment; Smoking; Hormonal factors in women and adolescent girls; Diabetes disease and related diseases or complications, like myocardial infarctions, kidney disease, and the like; Obesity; Poor nutrition, too much alcohol, and bad eating habits; Stress and depression; Wrong medicine intake. (Dunning 2009, p. 490) Symptoms of periodontal disease include inflammation of the gums, bleeding during brushing of teeth, destruction of the tissues and ligaments, loose teeth, constant halitosis, caries, and much more. (Dunning 2009, p. 490) Periodontal disease includes xerostomia and caries. Xerostomia is caused by the deficiency in salivary flow caused by diabetes. This is complicated by the occurrence of caries, but diabetes and caries are not closely related. Xerostomia decreases when diabetics produce good glycaemic control. Diabetes lowers the immune system and during this time infection by Candida becomes prevalent. (Lopes et al. 2012, p. 83) People with diabetes have to focus on oral health and hygiene, among others, because periodontal disease occurs along with diabetes, and a vicious cycle may occur, such as, diabetes makes the patient susceptible to periodontal disease, which triggers hyperglycemia, which weakens the tissues and organs, including the mouth cavity. But there is a chance if the disease is well managed and prevented. (Danesh et al. as cited in Dunning et al., 2009, p. 490). The facts stated above tell us that periodontal disease is still treatable, but it all depends on the patient. Sometimes the disease is undetectable at its early stage, and it requires education on the part of the patients. There are two diseases we are dealing here – periodontitis and diabetes – which are interrelated and have a close relationship with each other. The studies and researches on these two diseases will tells us how to deal with both, and how to conquer and control the diseases in our bodies. 3.2 Pathology and etiology of periodontal disease Periodontal disease is a common complication in diabetes for both insulin-dependent and non-insulin dependent diabetes mellitus. Periodontitis is an oral infection in the gingival caused by the presence of microorganisms in dental biofilms. Plaque formation, a primary feature of periodontal disease, is composed of different species of bacteria, several hundreds of them, that form and bound to one another into an exopolymer matrix. This is known as the biofilm which causes the tissues to break, refusing treatment, thereby causing bleeding and loss of the tissues and bones. (Albert et al. 2006, p. 3) Periodontal disease has been regarded as an overlooked complication of diabetes (Dunning 2009, p. 489). It is common among diabetics, particularly those who have optimal control of the sickness. Diabetics have poor immune system and more susceptible to infections. Hyperglycemia allows bacteria to infect tissues that support the teeth. It also tends to accumulate plaque and dry mouth. Because of this weakness, people with diabetes must adhere to strict oral hygiene, and care should be provided to patients to control their glucose and have regular dental check. (Rolfes, Pinna, & Whitney 2012, p. 726) Periodontitis is characterised by inflammation in the periodontium, leading to the growth of inflammatory cytokines. Cytokines triggers progression of the disease and are produced by cells like ‘macrophages/monocytes, dendritic cells, lymphocytes, PMNs, endothelial cells and fibroblasts’ (Abbas & Lichtman as cited in Pradeep et al., 2010, p. 280). Pyrogenic cytokines blocks ‘lipoprotein lipase activity, resulting in decreased transportation of blood lipids from the circulating cells’ which triggers hyperlipemia. (Talbert et al. 2006, p. 4) Periodontitis is the result of systemic diseases like diabetes and atherosclerosis. It has also been found to be related with cardiovascular diseases. Recent studies also pointed out periodontitis as a risk factor for atherosclerosis (Friedewald et al. as cited in Nagano et al., 2011, p. 108). Periodontal diseases are caused by periodontopathogens. The microbial dental plaque activates a reaction of the patient’s body by attacking inflammatory cells, such as the “T lymphocytes, macrophages and polymorphonuclear leukocytes, plasma cells, endothelial cells and fibroblasts” (Pradeep, Manojkumar, Garima, & Raju 2010, p. 277). All these create cytokines which destroy periodontal tissues. The P. gingivalis and other pathogens cause the periodontal tissues to break. Hyperglycemia and hyperlipidemia exacerbates diabetes and periodontal disease by producing glycation endproducts or cell surface receptors. Periodontitis can result in tooth loss. Other studies have revealed that periodontal disease in its worse stage can lead to more diabetic complications. (Lalla et al. 2004, p. 755) Advanced periodontitis shows symptoms of gingival ‘erythema and eodema’, including bleeding and recession in the gingiva. The tooth becomes mobile, drifts, and the pockets deepen until they lose hold of the tooth. Studies found that tooth retention affects 10-15% of adults in many populations studied. Moderate form of the disease affects about 40-60% of adult population. Dentists have long recognised the significance of diagnosing diabetes before treating their patients. Oral conditions are related to diabetes. (Preshaw 2012, p. 23) Periodontitis, which negatively affects the quality of life, is now prevalent in the UK population. Diabetes causes periodontitis; it has been estimated that chances of occurrence is three times more for diabetics. Severe hyperglycaemia is linked with severe periodontitis. It can be said that periodontitis is a common, inflammatory disease which affects people’s lives, including their self-esteem, confidence, their relationship with others, and their food choices. (Preshaw 2012, p. 23) 3.3 Studies on the relationship of diabetes and periodontal disease The mouth speaks – it reflects symptoms of systemic diseases. This is where food makes its first entry, and this is the first to react in case there’s a mistake in the choice of food. Many studies have demonstrated links between oral disease and diabetes mellitus (Lopes et al. 2012, p. 82). The relationship between diabetes and periodontal disease has been the subject of several studies since 1862 when Sieffert (as cited in Grossi et al., 2000, p. 768) found that there was a relation between diabetes and changes in the mouth’s cavity. Before 1920, researchers reported of high prevalence of periodontal disease on patients with diabetes. Then from this time going to the 1940s, a paper clearly established what was termed diabetic periodontopathy (Grossi et al. 2000). Later studies focused on both diseases as risk factors. In a study among Pima Indians who lived in the Gila River Indian Community, researchers found that participants with type 2 diabetes had greater risk of having periodontitis. The disease was found to be destructive to the teeth of the subjects. This study on American Indians has caught the attention of the academic world and researchers studying the relationship of periodontal disease and diabetes because of the population’s very high incidence of type 2 diabetes mellitus coupled with periodontitis. They found an odds ratio of 95% using bone loss in measuring periodontitis (Emrich et al. as cited in Dumitrescu, 2010, p. 146). The predominant fact to support the evidence is that diabetes was a risk factor for rigorous periodontal disease. The study on American Indians included children and youth, and found positive linkages between the two diseases (Nelson et al., Shlossman et al. as cited in Merchant et al., 2011, p. 530). There were other findings of the study like severe periodontal disease, cardiovascular, renal and diabetes diseases found in the subjects. Other studies conducted in the United States focused on the relationship of type 1 and type 2 DM with periodontal disease, and combining the two types. With this approach, there were differences in the periodontal disease by diabetes type. In the study of Merchant and colleagues (2011), focusing on periodontal damage and diabetes among adolescents, they found that periodontal damage was less minimal when there was good glycaemic control among type 1 and type 2 diabetic subjects. This was found on subjects who had oral health observance like tooth brushing twice a day or more. (Merchant et al. 2011, p. 531) Other studies provided evidence for the relationship. In one study, it was found that participants with high-level of periodontal disease had also higher degree of diabetes compared with subjects with no periodontal disease (Salvi et al. as cited in (Dumitrescu & Inagaki 2000, p. 146). Loe and Genco (as cited in Taylor & Grossi, 2002) argued that people with diabetes had higher incidence of gingivitis and that this was more prevalent with diabetics who had a very low metabolic control. Taylor and Grossi reported eight studies which suggested a very low periodontal health in subjects with diabetes. Emirich et al. (as cited in Taylor & Grossi) said that people with diabetes had three times more periodontal disease than people with no diabetes. Other studies reported the influence of ethnic classification, for example there was high prevalence of periodontitis among African Americans with type 2 diabetes, a consistency reported by Fernandes et al. and Merchant et al. (2011). (Taylor & Grossi, 2002) Studies on children and youth with type 1 diabetes found the relation between diabetes and periodontal disease. A study by Merchant et al. (2011) suggested that a relation exists between periodontal disease and beta cell function in type 2 diabetic children and youth. Some studies suggest that periodontal disease increases the level of diabetes and put metabolic control into complication (Grossi & Genco as cited in Knight, 2007, p. 46). Evidence has it that there is a two-way relationship between periodontal disease and diabetes. Other studies on the relationship of diabetes and periodontal disease include those of Southerland et al. (as cited in Dunning 2009, p. 489), which proved that diabetes is an important risk factor for serious, periodontal disease leading to periodontitis; of Andersen et al. (as cited in Dunning) which showed that periodontal disease may add up to the development of impaired glucose tolerance (IGT) leading to diabetes; and of Löe (as cited in Dunning, p. 489) which argued that periodontal disease has been overlooked in many diabetes management strategies, education activities, or complication programs. 3.3.1 The two-way relationship Various researchers have found the two-way relationship between diabetes and periodontitis: diabetes increases the chances for periodontitis, and periodontal infection has influence on glycaemic control. Other researchers call it ‘bi-directional’, both inflammatory diseases are risk factors. (Lopes et al. 2012, p. 83) Other complications include ischaemic heart disease and diabetic nephropathy which are found three times in diabetics with severe periodontitis than diabetics without severe periodontitis. (Preshaw et al. 2012, p. 21) Most of the research has been conducted on people with type 2 diabetes that causes peridontitis, as these two diseases fully develop during middle age (40s or 50s). But this is not to say that type 1 diabetes does not increase the risk of periodontitis on children and youth. Children and adolescents with type 1 diabetes are also at risk of periodontal disease. A study found that approximately 10% of children who were below 18 years of age with type 1 diabetes had increased periodontitis or bone loss compared with participants below 18 years of age without diabetes. Severe periodontitis affects 10-15 % of the adult population; it affects how people live. (Preshaw et al. 2012) Severe hyperglycaemia has linkage with severe periodontitis. The relationship might be explained through some aspects of ‘immune functioning, neutrophil activity, and cytokine biology’. Another thing, diabetics with severe periodontitis have three-fold increase in end-stage renal disease and twofold increase in macroalbuminuria than diabetics without periodontitis (Preshaw et al. 2012, p. 222-23). Cytokines are proinflammatory, an outcome of periodontal disease, which help in exacerbating the body’s ability in the use of insulin, thus worsening the high glycaemic control. Diabetics with periodontal disease are 6 times higher risk of bad glycaemic control compared with diabetics without periodontal disease (Taylor et al. as cited in Lopes et al., 2012, p. 83) Moreover, higher blood glucose levels sped up the structuring of AGEs. The interaction of AGEs help develops other diabetic complications. Higher levels of AGES help deteriorate periodontal state. High levels of glycaemia have effects on the level of periodontal disease. Periodontal diseases may bring more inflammation and acute viral infections are found to increase insulin resistance. (Dumitrescu 2010, p. 146) Figure 2 X-ray pictures of periodontitis. The topmost picture shows a 42-year old individual afflicted with type 2 diabetes and severe peridontitis. There is wide spread and irregular example of bone loss. The lower picture shows a young man with no periodontitis and the bones are normal. SOURCE: Periodontitis and diabetes: a two-way relationship, by Preshaw et al. (2012, p. 23) Figure 3 Picture of periodontitis of a 22-year old individual with type 1 diabetes. There is inflammation and the tissues are already destroyed. SOURCE: Periodontitis and diabetes: a two-way relationship, by Preshaw et al. (2012, p. 23) 3.4 Possible healing A pilot study was made to determine if a method was effective in reducing inflammatory markers known as TNF-α and IL-6 in patients with type 2 diabetes; the method was scaling and root planning or S&RP. This process removes the plaque and calculus mechanically to decrease the inflammatory response, and this is accompanied with antimicrobial therapies. Some studies found that by applying this method a significant shift in the composition of microbial flora was recorded. The endotoxins in the subgingival parts are removed and the tissues begin to heal. Type 2 diabetics should have regular checkups and maintenance visits by clinician and appropriate oral care so that the infection and the damage to the periodontium can be kept under control. The bacteria and blood sugar can be reduced through some therapeutic approach. (Talbert et al. 2006) The point in applying therapies is prevention. The early stage of periodontal disease must be anticipated because the disease works in progression and sometimes not noticeable during the early stage. People with diabetes must have the proper oral health before complications occur. Multi-disciplinary teams in charge of treating people with diabetes have focused on areas of prevention and healing, like good nutrition, exercise, monitoring, regular medication, problem solving skills, health habits and dealing with risks. But there are health professions in charge of diabetics who still have little knowledge of periodontal disease and its relation with diabetes. (Lopes et al. 2012, p. 83) Continuous education and knowledge sharing is a must for people in charge of taking care of diabetics and for diabetic educators. People with diabetes have to continuously learn about their health situation and make education and knowledge of the disease, along with its complications, a part of everyday life. 4. Discussion Diabetes mellitus (DM) is an illness with many complications, one of which is periodontitis. Periodontal disease has been seen prevalent in people with DM, and also prevalent in the UK population. Diabetes is related with gingivitis and periodontitis. This is because of the increased risk of infection, a damaged synthesis of collagen and glycosaminoglycan and the reduced use of granular neutrophils (Commisso et al. 2011, p. 68). But periodontal disease is not only the result of diabetes, rather, it is also a risk factor for diabetes and other systemic diseases, such as cardiovascular diseases. (Williams et al. 2008, p. 1637) Periodontitis is characterised by the inflammation of the periodontal tissues caused by the subgingival biofilm. Inflammation is present in both types of diabetes and periodontitis. This is exacerbated by higher level of hyperglycaemia. Treatment or prevention of periodontal disease should be on improving glycaemic control. (Preshaw 2012, p. 25) Periodontitis greatly affects diabetes and glycaemic control; higher level of periodontitis is associated with poor glycaemic control. The relationship is a two-way process as was proven in the data gathered from the Gila River Indians. Periodontitis also compromises the way people with diabetes manage their sickness. Other non-oral complications, such as ‘retinopathy, diabetic neuropathy, proteinuria and cardiovascular complications’ are also connected with the severity of periodontitis (Karjalainen et al., Moore et al., & Thorstensson et al. as cited in Preshaw et al., 2012, p. 24). The empirical studies conducted on this relationship provided evidence that there is really that relationship. It has been found that the mouth speaks for itself, meaning when there is something wrong with the mouth, there are symptoms of systemic disease. The mouth is the passage of whatever we input our body, therefore it reacts when there are some excesses of food, and also the kind of food we eat. Meta-analyses of the different findings also found that periodontitis is high where diabetes is severe, or when there is high level of glycaemic control. Diabetes affects periodontal occurrences including bleeding, probing depths, loss of tissues and loss of teeth. But there were some findings by the European Workshop on Periodontology (Salvi et al. as cited in Al-Habashneh et al., 2010, p. 976) which stated that the relationship of diabetes and periodontitis was supported by empirical findings on the increased severity ‘but not extent of periodontitis in subjects with poorly controlled diabetes’ (Al-Habashneh et al., p. 976). This is opposed to the findings of several studies that poorly controlled diabetes results in severe periodontitis (Dumitrescu 2010, p. 146). However, this writer is of the opinion that the studies proved the relationship. Diabetes is linked with the changes in the mouth’s cavity, or a high prevalence of periodontal disease among diabetics, and that glycaemic control and periodontitis are linked. One population that became the subject of a study was the Pima Indians. This study became popular because of the noticeable linkage between diabetes and periodontal disease. High level of periodontal disease was also reported linked with high degree of diabetes. Moreover, higher incidence of gingivitis is also caused by diabetes with very low metabolic control. Children and adolescents have not escaped the epidemic. In fact, they are prone to the disease. Periodontal disease is most common to children and youth with diabetes. Some findings revealed the two-way relation: periodontal disease increases diabetes and exacerbates many complications. Glycaemic control is significant in the relationship between diabetes and periodontal disease. When glycaemic control worsens, depression in diabetic people occurs. Patients who are severely insulin deficient tend to be more unstable. Further investigations have to focus on glycaemic control that causes complications in diabetes. These factors have been the results of longitudinal studies focusing on diabetes and progressive bone loss. Periodontal disease is characterised by inflammation which influences glycaemic control. Diabetic people with infection in the periodontal tissues have high level of glycaemic control compared with diabetics without periodontitis. (Commisso et al. 2009, p. 69) There are opposing views, however, on the context of glycaemic control. Some studies found ‘no relationship between the level of glycaemic control and periodontal status’ which may lead us to conclude that more studies should be afforded about this relationship. These findings were revealed in the studies of Hove and Stallard, Barnett et al., Backley et al., Hayden and Buckley, Sastrowijoto et al., and Pinson et al. (Dumitrescu 2010, p. 146). Oral health contributes to the overall health. Even in myocardial infarction, a cardiovascular disease, oral health is important to the treatment of the disease. It was found in a study that participants with acute myocardial infarction had significantly more dental problems, such as periodontitis, than participants without MI. Up to this time, there are still numerous studies investigating the relationship between periodontal disease and diabetes, or such other diseases with complications of inflammations or infections. (Williams et al. 2008, p. 1636) Diabetics who know how to manage their disease should be able to recognise the symptoms of periodontal disease which include swollen, soft, red tissues that surround the teeth, bleeding during toothbrush, or during eating of hard food, receding gums as the ligaments and tissues around the teeth are destroyed, loose teeth, among others. (Dunning 2009, p. 490) There is the need for health in our mouth (oral health). Health care providers should talk about it with their patients and encourage them to have a healthy mouth by regular tooth brushing. Oral and systemic health proves the relationship between periodontal disease and diabetes. Diabetes is a disease becoming an epidemic and periodontal disease one of its outcomes. With diabetes prevalent in the UK, it’s no wonder periodontal disease is also prevalent. People with diabetes should understand this need of oral health. Complications occur when they disregard this menial job of tooth brushing. 5. Conclusion Based on several studies, there is a close relationship between diabetes (types 1 and 2) and periodontal disease. Several periodontal diseases are related with diabetes. The study of Lalla and colleagues (2004) on American children and seniors found that the oral disease problem is common in Northern Manhattan. Several studies have proven the relationship between diabetes and periodontal disease. The situation in the oral cavity tells the health of the individual. A vicious cycle occurs in the relation between diabetes and periodontal disease: diabetes triggers periodontal disease, contributing to hyperglycemia, affecting the tissues and organs, leading to the destruction of the gingiva. There were epidemiological studies that found diabetes to be risk factor for periodontitis and diabetics with poorly controlled diabetes had higher risk of having periodontitis and alveolar bone loss. The relationship is a two-way process: both are risk factors, meaning diabetes is risk for periodontal disease, and periodontitis a risk for diabetes. Treatment is effective if there is early diagnosis while prevention is still the best option. This is very important in diabetics with periodontitis as destruction of tissues and bone loss are irreversible. The quality of life of people in severe diabetes, complicated by other diseases especially periodontal disease, is sacrificed because of the many complications. Periodontitis is a complication which worsens diabetes. When patients have these complications, they become dysfunctional and depressed. Depression has some correlates with glycaemic control. Based from the findings above, prevention is the best option diabetics have to avoid periodontitis. It is also in the early formation that the disease can be controlled. It was found in the literature that in the first stage of the disease, the patient almost feels nothing and unaware till it becomes uncontrollable. The pockets beneath the tooth deepen; the gum bleeds, the tooth glides and has to be removed. Moreover, dentists and physicians have targeted oral health and cleanliness as the key to prevention and conquering the disease. Diabetes regimen and lifestyle management are important to healing diabetes and periodontal disease. References Aveyard, H 2010, Doing a literature review in health and social care: a practical guide (2nd edition), Open University Press, England. Boyer, B 2008, “Diabetes”, in B Boyer & M Paharia (eds), Comprehensive handbook of clinical health psychology, John Wiley & Sons, Inc., pp. 179-189. Commisso, L, Monam, M, & Mannucci, E, ‘Periodontal disease and oral hygiene habits in a type 2 diabetic population’, International Journal of Dental Hygiene, vol. 9, pp. 68-73, viewed 10 March 2013, Academic Search Premier database, EBSCOHost, DOI 10.1111/j.1601-5037.2009.00439.x. Davidson, J 2000, Clinical diabetes mellitus: a problem oriented approach, Thieme Medical Publishers Inc., New York. Dumitrescu, A & Inagaki, K 2010, “Interrelationships between periodontal disease and mortality, cardiovascular disease, metabolic syndrome, diabetes mellitus”, in A Dumitrescu (ed), Etiology and pathogenesis of periodontal disease, Springer, London, pp. 125-158. Dunning, T 2009, ‘Periodontal disease – the overlooked diabetes complication’, Nephrology Nursing Journal, vol. 36, no. 5, pp. 489-496, viewed 10 March 2013, via Academic Search Premier database. Fonseca, V (ed) 2006, Clinical diabetes, Elsevier Inc., Philadelphia. Gerrish, K & Lacey, A 2010, “Research and development in nursing”, in K Gerrish & A Lacey (eds), The research process in nursing, Blackwell Publishing Ltd., Oxford, UK. Grossi, S, Offenbacher, S, & Fritz, M 2000, “Oral disorders in diabetes mellitus”, in J Davidson (ed), Clinical diabetes mellitus: a problem oriented approach, Thieme Medical Publishers, Inc., New York, pp. 767-774. Hanas, R & Fox, C 2008, Type 2 diabetes in adults of all ages, Class Publishing, London. Holloway, I & Wheeler, S 2010, Qualitative research in nursing and healthcare (3rd edition), Blackwell Publishing Ltd., West Sussex, UK. Khan, J 2008, Research methodology, APH Publishing, New Delhi. Knight, J 2007, ‘Diabetes and periodontitis’, The Dental Assistant, viewed 10 March 2013, via Academic Search Premier database. Lalla, E, Park, D, Papapanou, P, & Lamster, I 2004, ‘Oral disease burden in Northern Manhattan patients with diabetes mellitus’, American Journal of Public Health, vol. 94, no. 5, pp. 755-758, viewed 11 March 2013, via ABI/INFORM Complete. Loe, H & Genco, R 1995, “Oral complications in diabetes”, in R Aubert (ed), Diabetes in America, Diane Publishing, United States of America, pp. 501-506. Lopes, M, Southerland, J, Buse, J, Malone, R, & Wilder, R 2012, ‘Diabetes educators’ knowledge, opinions and behaviors regarding periodontal disease and diabetes’, Journal of Dental Hygiene, vol. 86, no. 2, pp. 82-90, viewed 10 March 2013, via Academic Search Premier database. Merchant, A, Jethwani, M, Choi, Y, Morrato, E, Liese, A, & Mayer-Davis, E 2011, ‘Associations between periodontal disease and selected risk factors of early complications among youth with type 1 and type 2 diabetes: a pilot study’, Pediatric Diabetes, vol. 12, pp. 529-535, viewed 10 March 2013, Academic Search Premier database, EBSCOHost, DOI 10.1111/j.1399-5448.2010.00736.x. Pradeep, A, Manojkumar, T, Garima, G, & Raju, A 2010, ‘Serum levels of oncostatin M (a gp 130 cytokine): an inflammatory biomarker in periodontal disease’, Biomarkers, vol. 15, no. 3, pp. 277-282, viewed 11 March 2013, via Academic Search Premier database, EBSCOHost, DOI 10.3109/13547500903573209. Preshaw, P, Alba, A, Herrera, D, Jepsen, S, Konstantinidis, A, Makrilakis, K, & Taylor, R 2012, ‘Periodontitis and diabetes: a two-way relationship’, Diabetologia, vol. 55, pp. 21-31, viewed 11 March 2013, via ProQuest database, DOI 10.1007/s00125-011-2342-y. Rhoades, E 2011, ‘Commentary: literature reviews’, The Volta Review, vol. 111, no. 3, pp. 353-368, viewed 2 November 2012, via Academic Search Premier database. Rolfe, S, Pinna, K, & Whitney, E 2012, Understanding normal and clinical nutrition, Wadsworth Cengage Learning, California. Talbert, J, Elter, J, Jared, H, Offenbacher, S, Southerland, J, & Wilder, R 2006, ‘The effect of periodontal therapy on TNF-αIL and metabolic control in type 2 diabetics, Journal of Dental Hygiene, vol. 80, no. 2, pp. 1-16, viewed 11 March 2013, via Academic Search Premier database, EBSCOHost. Taylor, G & Grossi, S 2002, “Treatment of periodontal disease”, in R Williams, W Herman, & A Kinmonth (eds), The evidence base for diabetes care, John Wiley & Sons, Ltd., West Sussex, England, pp. 523-536. Williams, R, Barnett, A, Claffey, N, Davis, M, Gadsby, R, Kellett, M, Lip, G, & Thackray, S 2008, ‘The potential impact of periodontal disease on general health: a consensus view’, Current Medical Research and Opinion, vol. 24, no. 6, pp. 1635-1643,viewed 14 March 2013, via ProQuest Central database, EBSCOHost, DOI 10.1185/03007990802131215. Read More