Diabetic Nephropathy and Periodontal Disease

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Diabetic nephropathy and periodontal disease: CH Turner, MSc, BDS, MDS, FDSRCS

There are a large number of papers in the literature linking diabetes and periodontal disease in a two-way process, the one affecting the other (1) and vice versa (2). Periodontal disease has been called the sixth complication of diabetes (3); xerostomia and an increased risk of caries is an additional factor.

Although the mechanism of the direct link is not fully understood the chronic bacterial challenge of periodontal disease is a persistent source of inflammatory mediators (4), and may lead to endothelial dysfunction (5).

There are fewer studies when the individual complications are considered. However, diabetics on haemodialysis are at greater risk of periodontal disease and other oral manifestations and have increased oral health problems (6). For severe periodontal disease there is a 2.6 times greater risk of macroglobulinaemia and 4.9 times for end stage renal disease (ESRD) (7) and a significantly higher index of decayed, missing or filled teeth (DMFT) (8).

In a Japanese study 40 per cent of dialysis patients had diabetic nephropathy, a lower glomerular filtration rate with a higher periodontal index (CPI) and a positive correlation between CPI score and serum creatinine (9).

This study proposed that the CPI should be the periodontal index of choice given its World Health Organisation status (10) and universality. Helpfully they classified periodontal disease as low risk with a CPI score of 0 or 1, medium with a score of 2 or 3, and high with a score of 4 or 4*. This should be a benchmark for future studies.

In summary, periodontitis predicts the development of overt nephropathy and ESRD in a dose dependent manner in individuals with little or no pre-existing kidney disease (7). Periodontal management can contribute to the prevention of severe renal disease (9).

It follows that all patients with diabetic nephropathy should have a periodontal screening, and, where appropriate, periodontal treatment for this preventable disease because this can reduce the need for diabetic medication.

It is surprising therefore, that in the UK the National Institute of Clinical Excellence (NICE) omits screening for dental problems from their list of requirements for annual checks for diabetic patients and has declined a request from the author to correct this omission.

Many doctors are unaware of the link between diabetes and periodontal disease and are not asking patients what dental care they might, or might not, be receiving. The latter group of patients could be placed at a disadvantage.

Doctors and dentists need to work together much more closely than has been the case to date, to share their HbA1c and CPI results and monitor outcomes together (11). The conclusion is quite simple, help patients learn how to control their plaque on a daily basis because this controls periodontal disease.

This underlines the importance of oral health and adequate periodontal treatment in maintaining the quality of life and prolonging survival in patients receiving dialysis (12).

References.

1. Preshaw B et al Periodontitis and diabetes – a two-way street. Diabetologia 55: 21, 2012.

2. Grossi SG, Genco RJ. Periodontal disease and diabetes mellitus; a two-way relationship. Ann Periodontal 3: 51, 1998.

3. Löe H. Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care 16: 329, 1999.

4. Cekici A et al. Inflammatory and immune pathways in the pathogenesis of periodontal disease. Periodontology 2000 64: 57, 2014.

5. Gernost G et al. Periodontal treatment improves endothelial dysfunction in patients with severe periodontitis. Am Heart J 149: 1050, 2005.

6. Mahajan S et al. A comparison of oral health status in diabetic and non-diabetic patients receiving haemodialysis – a systemic review and meta-analysis. Diabetes Metab Syndr 15: 102256, 2021.

7. Swapna NA et al. Oral health status in in haemodialysy patients. J Clin Diag Res9: 2047, 2013.

8. Shultis Wa et al. Effects of periodontitis on overt nephropathy and end stage renal disease in type 2 diabetics. Diabetes Care 30: 306, 2007.

9. Yoshioka M et al. Association between oral health status and diabetic neuropathy-related indices in Japanese middle-aged men. J Diabetes Res, June 7, 2020.

10. Barmes D. CPITN – a WHO initiative. Int Dent J 44: 523, 1994.

11. Siddiqi J et al. Diabetes mellitus and periodontal disease: The call for inter-professional education and inter-professional collaborative care. J Interprof Care 10: 1, 2020.

12. Miyata Y et al. Periodontal diseases in patients receiving dialysis. Int J Mol Sci 20: 3085, 2019.