There is a connection between periodontal (gum) disease and the successful management of diabetes. This information is important to any physician working with diabetic patients.

Periodontal Treatment Improves Metabolic Control in Diabetics

Chronic oral infections complicate management of diabetes.

dentists have long observed that diabetic patients tend to have more gum infections than do non-diabetics. Research shows that in diabetics, periodontal disease is more severe and more prevalent than in non-diabetics (1). Research shows that gum disease complicates the management of diabetes, and that diabetes can worsen the management of periodontal disease. This evidence supports viewing the gum disease – diabetic relationship as bidirectional (2).

This information sends a strong signal to dentists and physicians managing diabetic patients. Medical doctors should inquire as to the dental status of their patients and should insist that these patients are receiving routine therapies to control and combat chronic oral infections. A clinical trial in 2006 compared two groups of periodontal patients, one with and one without diabetes. Both groups found improved gum health with proper perio treatment, and the diabetic patients showed improved metabolic control at 3 and 6 months after periodontal treatment (3).

Basic periodontal health care delivered by a dentist and dental hygienist, along with improved daily home care, improves the diabetic management of Type 2 diabetic patients. Dentists aware of this research and who are proactive with their patients, are insisting that patients with gum disease receive proactive medical management to control their diabetes.

1- Diabetes Monitor 2- Taylor G., Bidirectional Interrelationships Between Diabetes and Periodontal Diseases, Annals of Perio, 2001, Vol. 6, No. 1. 3- Clinical and Metabolic Changes After Conventional Treatment of Type 2 Diabetic Patients With Chronic Periodontitis. Faria-Almeida R, et.al, J. of Perio. 2006.050084

Important Points:

• Gum disease increases systemic inflammation.
• Diabetics have more gum disease
• Gum disease complicates diabetic management
• Periodontal treatment lowers HbA1c levels

Dr. David Weaver
Rivergate Dental Care
133 North Creek Blvd.
Goodlettsville, TN 37072

Phone: 888.411.SEDATE
Fax: 615.851.3535

Recent research suggests the troubling incidence of premature death in diabetics with periodontal disease. Physicians and dentists aware of this condition will insist their diabetic patients successfully manage gum disease.

Gum Disease is Strong Predictor of Mortality in Diabetic Patients

Diabetic pts with gum disease have ~700% increase in mortality!

Diabetes is a known complicating factor for gum disease. Research now shows that chronic gum infections can seriously impact the control of diabetes (1). Periodontal disease is more severe and occurs with higher frequency in diabetic patients (2). Periodontal disease contributes to increased mortality associated with diabetes. Gum infections are a strong predictor of death from cardiorenal disease in diabetics.

After adjusting for factors such as duration of diabetes, hypertension, tobacco use and other factors, scientists conclude that gum disease is strongly predictive of mortality from heart and kidney disease (3). Patients with severe periodontal disease had a 28.4 % death rate representing a 700%+ increase in death compared to diabetics without gum disease.

Diabetics with gum disease makes them twice as likely to die from heart and kidney disease (5). Gum inflammation allows harmful bacteria and cytokines to enter the bloodstream, creating systemic inflammation.

Prudent health care dictates that dentists and physicians recognize both the direct and indirect relationships of these conditions, and that every effort is made to obtain control of gum disease.

1- Soskolne WA, Klinger A, et. al., The Relationship Between Periodontal Diseases and Diabetes. Annals of Perio 2001.6.1.91. 2- www.diabetes.niddk.nih.gov/dm/pubs/america/pdf/chapter23.pdf 3- Jan 2005 ADA News Release; www.ada.org/prof/resources/pubs/adanews/adanewsarticle.asp?articleid= 1219 4-  Saremi A, et.al., Periodontal Disease and Mortality in Type 2 Diabetes, Diabetes Care, Vol 28, No.1, Jan 2005. p27-32. 5-10/03 ADA News Release, Jeffcoat M. www.ada.org/public/media/releases/0310_release07.asp

Important Points:

• Periodontal treatment lowers HbA1c levels
• Diabetics have 700% increase in mortality if they have periodontal disease.
• Diabetics with gum disease 2x likely to die from cardio/renal disease

Dr. David Weaver
Rivergate Dental Care
133 North Creek Blvd.
Goodlettsville, TN 37072

Phone: 888.411.SEDATE
Fax: 615.851.3535

There is a connection between diabetes and oral infections such as gum disease. Periodontal disease complicate diabetic control and elevates pro-inflammatory cytokine proteins in the body. Treatment lowers these levels.

Diabetes Elevates Levels of Systemic Inflammation

Oral infections increase cytokines and complicate diabetic management.

Systemic inflammation plays an important role in the development of type 2 diabetes. Evidence points to an increased cytokine response especially the pro-inflammatory cytokines IL-1, IL-6, and TNF-alpha, the latter of which may play an important role in insulin resistance (1). Porphyromonas gingivalis, one of the microorganisms responsible for this infection, is able to invade endothelial cells and is a potent signal for monocyte and macrophage activation and the subsequent production of cytokines.

Once established in the diabetic host, chronic periodontal infections complicate diabetes control and increases the occurrence and severity of cardiovascular complications (2).

The medical literature supports the idea that treatment of chronic oral infections is essential in people with diabetes. Antimicrobial therapy significantly reduced the number of microorganisms in periodontal pockets. The results indicate that anti-microbial treatment is effective in improving metabolic control in diabetics (3).

Physicians managing diabetic conditions in their patients should consider assessment of oral infection status to be fundamental for appropriate treatment decisions.

1- Iwamoto Y, Nishimura F., The Effect of Antimicrobial Periodontal Treatment on Circulating Tumor Necrosis Factor-Alpha and Glycated Hemoglobin Level in Patients With Type 2 Diabetes. J Periodontol 2001;72:774-778. 2- Grossi SG. Treatment of Periodontal Disease and Control of Diabetes: An Assessment of the Evidence and Need for Future Research. Annals of Periodontology 2001, Vol. 6, No. 1, Pages 138-145. 3- Ibid, Iwamoto

Important Points:

• Inflammation impacts diabetes
• Periodontal infections create systemic inflammation
• Antimicrobial perio treatment improves metabolic control in diabetics

Dr. David Weaver
Rivergate Dental Care
133 North Creek Blvd.
Goodlettsville, TN 37072

Phone: 888.411.SEDATE
Fax: 615.851.3535

It is important for close medical and dental management of diabetic status. People with insulin resistance are at greater risk for developing periodontal disease.

Diabetics More Likely to have Periodontal Disease

Periodontal disease is the “sixth” complication of diabetes

Gum disease is an infection condition that creates a localized area of inflammation around teeth. Diabetics are more likely to have gum disease than are non-diabetics (1). The risk is compounded for those people whose diabetes is not under control.

People with normal glucose tolerance 10 years previously, who subsequently developed impaired glucose tolerance were significantly more likely to have deep gum pockets. Research shows that the presence of gum disease is closely related to current glucose tolerance status and the development of glucose intolerance (2).

The effective treatment of gum infection is associated with a reduction in level of glycated hemoglobin (3). When chronic oral infections are successfully treated, bacterial populations in gum tissues are reduced, resulting in lowered systemic inflammation and improved metabolic control in diabetes (4).

Control of periodontal infections should thus be an important part of the overall management of diabetic patients.

1- Poorly controlled Type 2 diabetics twice as likely to develop periodontal disease. Am Acad of Perio. 2- The Severity of Periodontal Disease is Associated with the Development of Glucose Intolerance in Non-diabetics. Dent Res 83(6):485-490,2004. 3- Sara Grossi, et.al, Treatment of Periodontal Disease in Diabetics Reduces Glycated Hemoglobin. J Perio 1997;68:713-719 4- Iwamaoto Y, et.al., The Effect of Antimicrobial Periodontal Treatment on Circulating TNF-a and Glycated Hemoglobin Level in Patients With Type 2 Diabetes. J Perio 2001;72:774-778.

Important Points:

• Diabetics have more gum disease
• Glucose intolerance and gum disease are related
• Perio treatment reduces HbA1c levels

Dr. David Weaver
Rivergate Dental Care
133 North Creek Blvd.
Goodlettsville, TN 37072

Phone: 888.411.SEDATE
Fax: 615.851.3535

New research exists which shows a connection between chronic oral infections and cardiovascular disease. The so called “Oral-Systemic Connection” links gum diseases with increased risk for heart attacks and strokes.

Periodontal Disease is Independent Risk Factor for Heart Disease

Perio Tx reduces systemic inflammation and risk of heart disease & stroke.

Periodontitis is an often undiagnosed chronic infection in the mouth. It is believed to be the most common chronic inflammatory disease in humans. Oral bacteria produce endotoxins which inhibit cell cycle progression and induce pro-inflammatory cytokine networks (1) such as CRP, IL-6, and activated neutrophils (2) and macrophages.

Research has also shown that appropriate treatment for gum disease significantly reduces the levels of inflammatory proteins (CRP) associated with a heightened risk of heart disease (4). Research has shown that people with gum disease have a 25% increased risk of heart disease compared to those with minimal to no periodontal disease (3).

C-reactive protein and other systemic markers of inflammation have been identified as risk factors. Because they increase inflammatory activity in atherosclerotic lesions (5), and are known to cause and worsen the progression of atherosclerotic heart disease, any condition known to raise their systemic levels should be immediately suspect. Periodontal disease stands as an independent risk factor for cardiovascular disease.

1- Henderson B, et. al., Molecular Pathogenicity of the Oral Opportunistic Pathogen A.A. Ann Rev of Microbiology Vol. 57: 29-55 2- Loos B, et.al., Elevation of Systemic Markers Related to Cardiovascular Diseases in the Peripheral Blood of Periodontitis Patients. J Perio 2000 Oct; 71(10):1528-34. 3- DeStefano F, Anda RF et al, Dental disease and risk of coronary heart disease and mortality. Brit Med J 306:688-691, 1993 4- Grossi, S, et al. Periodontal Therapy Lowers Levels of Heart Disease Inflammation Markers. ADA News 04/21/2004. 5- Ibid, Loos.

Important Points:

• Gum disease increases systemic inflammation
• CRP increases risk of heart disease
• Perio treatment lowers systemic inflammation

Dr. David Weaver
Rivergate Dental Care
133 North Creek Blvd.
Goodlettsville, TN 37072

Phone: 888.411.SEDATE
Fax: 615.851.3535

Emerging science is highlighting the important connection between the mouth and the health in the rest of the body, particularly heart disease. As inflammation in the body increases, so does the risk for developing cardiovascular disease.

Heart and Gum Disease Share Important Link

Heart and Gum Disease Share Important Link

The medical literature is emerging with numerous studies which support the conclusion that coronary heart disease is linked with periodontal disease (a). In fact, dental health is significantly worse in patients with acute myocardial infarction (b).

It is now known that atherosclerosis is an inflammatory disease, and that inflammation and infection are factors that induce or promote inflammation and artherogenesis (c). Heart disease is no considered to be more than just a lipid disorder (d). Indeed the lifetime burden of low-grade chronic inflammation from chronic pathogens is thought to create risk of athrosclerosis and thrombosis (e).

Deep periodontal pockets are characteristic of progressive gum disease. They have been linked with ECG abnormalities, suggesting a heightened risk of cardiovascular disease. Elevated levels of the inflammatory cytokines, including CRP associated with periodontitis may cause inflammatory changes to atherosclerotic lesions, increasing the risk of cardiac events (f).

With these findings physician and dentist should work together to control these risk factors, especially in at-risk patients.

a- Briggs JE, et.al, J Periodontol 2006.77.1.95. b- Mattila KJ, et.al., Brit Med J 189; 298:779-81. c- Ross R, NEJM Vol.340:115-126 Jan 14, 1999. d- Steinberg D, Nature Medicine?8, pp. 1211-1217 (2002). e- Herzberg MC, Annals of Periodontology, 2001, Vol. 6, No. 1, Pages 16-19. f- ADA News Release

Important Points:

• Gum disease increases systemic inflammation.
• ECG abnormalities more common in people with gum disease.
• Tx for periodontal disease reduces risk of complications

Dr. David Weaver
Rivergate Dental Care
133 North Creek Blvd.
Goodlettsville, TN 37072

Phone: 888.411.SEDATE
Fax: 615.851.3535

Recent research is shedding light on the mechanism of action for thrombus formation, and how it is caused by elevations in systemic inflammation. Dentists and Physicians should help patients to decrease all sources of chronic systemic inflammation causes.

Thrombus Formation Increases with Systemic Inflammation

CRP causes rupturing of heart vessels and thrombus formation.

Scientists are now in agreement that systemic inflammation promotes the development and progression of vascular plaque formations. In fact, inflammation plays a central role as a determinant of the pathophysiology underlying acute thrombotic cardiovascular events. In addition to the local effects of inflammation in the plaque itself, systemic aspects of inflammation upsetting the homeostatic balance, increase thrombotic risk. CRP promotes matrix degradation and may thus contribute to vascular plaque vulnerability (a). Plaque disruptions have a greater chance to produce an occlusive thrombus under such conditions (b).

This means as inflammatory proteins thin the plaque cap of the endothelial lining and promote rupturing of the plaque, tissue factors are released into the blood stream which promote clotting factors and the production of occlusive thrombus formation, either at the site of vascular injury, or downstream (c).

The fact that the easily measured CRP marker signals the presence of inflammation present somewhere in the body means that physicians and dentists should be particularly attuned to testing for it and investigating its cause. Because chronic oral infections are known to contribute to elevations in systemic inflammation, every effort should be made to treat this modifiable condition.

a- Williams TN, et.al., Arteriosclerosis, Thrombosis, and Vascular Biology. 2004;24:61. b- Libby P. Circulation. 2001;104:365. c- Peter Libby MD, Scientific American, May 2002, p50-59.

Important Points:

• Thrombus formation due to plaque rupture.
• Inflammation destabilizes blood vessels.
• Heart disease impacted by chronic infections.
• Gum infections should be eliminated and controlled

Dr. David Weaver
Rivergate Dental Care
133 North Creek Blvd.
Goodlettsville, TN 37072

Phone: 888.411.SEDATE
Fax: 615.851.3535

Current literature establishes the link between chronic oral infections and cardiovascular disease, including cerebrovascular disease-strokes. Physicians and dentists should help clear up causes of systemic inflammation in at-risk patients.

Non-hemorrhagic Strokes Linked to Gum Diseases

Gum disease is linked to strokes via systemic inflammation.

The available evidence is beginning to present compelling evidence that periodontal disease is a risk factor for atherosclerosis (a). Due to systemic inflammation and its pervasive effects on endothelial dysfunction throughout the body, cerebrovascular accidents such as occlusive strokes have been investigated for its relationship to periodontal disease.

It has been discovered that people with gum infections are more likely to have thickened carotid arteries, which can lead to stroke (b).

This new field of study is concluding that there is a relationship between oral conditions such as chronic oral infections, and ischemic stroke and peripheral vascular disease (c).

Sufficient evidence exists to conclude that gum disease places patients at risk of experiencing strokes (d), suggesting that periodontal disease is an important risk marker (e), if not risk factor, for overall CVA and in particular, non-hemorrhagic stroke (f).

a- Beck JD. Ann Periodontol. 1998 Jul;3(1):127-41. b- Elkind M, Columbia Univ. N.Y. @ American Academy of Neurology 51st annual meeting Toronto CA, 4/21/1999. c- Joshipura K. J Am Dent Assoc, Vol 133, No suppl_1, 23S-30S. d- Rose LF, et.al. J Am Dent Assoc, Vol 133, No suppl_1, 37S-44S. e- Lee HJ, et.al. Journal of Perio, 2006, Vol. 77, No. 10, pp.1744-1754. f- Wu T, et al. Arch Intern Med.?2000;160:2749-2755.

Important Points:

• Strokes and high CRP levels are related.
• Gum disease is linked to cerebrovascular disease.
• Physicians and Dentists should remove causes for elevations in systemic inflammation

Dr. David Weaver
Rivergate Dental Care
133 North Creek Blvd.
Goodlettsville, TN 37072

Phone: 888.411.SEDATE
Fax: 615.851.3535

Present research shows that gram-negative oral pathogens cause pregnancy complications indirectly through inflammatory cytokines, and locally through translocated oral bacteria.

Oral Pathogens Linked to Adverse Pregnancy Outcomes

Inflammation cytokines increase pregnancy complications.

Persistent gum disease in the mother is associated with preterm birth and growth restriction, especially if the infection is persistent through the second trimester of pregnancy (1).

Extrapolated data suggest that as much as 18% of the preterm, low birthweight infants born annually might be attributable to periodontal disease (2). As such, emerging research finds that maternal periodontal disease is a modifiable risk factor for preterm birth and fetal/newborn growth restriction (3).

Studies show that this effect can happen from the effect of pro-inflammatory proteins in the general circulation (4). Other studies support the conclusion that oral pathogens can serve as a primary fetal infectious agent eliciting prematurity (5).

Oral bacteria, primarily Gram-negative anaerobes and their bacterial endotoxins and lipopolysaccharides create local inflammatory mediators which increase systemic inflammatory mediators that can then lead to preterm birth through their oxytocic effects (6).

Periodontal infection is also associated with systemic dissemination of oral pathogens that migrate to the fetus directly resulting in prematurity.

1- Jeffcoat MK, et al., JADA 2001; 132:875-880. 2- Boggess KA, Matern Child Health J. 2006 September; 10(Suppl 7): 169-174. 3- Offenbacher S, et.al. Ann Periodontol. 2001 Dec;6(1):164-74. 4- Ibid. Boggess 5- Madianos RPN, et.al.

Important Points:

• Inflammatory cytokines affect pregnancy
• PGE2, IL-1, IL-6, CRP create low birthweight preterm babies
• Physicians should screen for gum disease.

Dr. David Weaver
Rivergate Dental Care
133 North Creek Blvd.
Goodlettsville, TN 37072

Phone: 888.411.SEDATE
Fax: 615.851.3535

Current science has demonstrated the impact that maternal infections have on the health and viability of pregnancy outcomes. Maternal gum diseases can create unfavorable pregnancy outcomes and affect the well-being of the offspring for life.

Pregnancy Outcomes Tied to Maternal Infections

Research links chronic gum disease to premature low birthweight infants.

The literature has clearly established the role that infections play in pregnancy complications. Microbes can work directly or through activation of maternal and fetal immune processes.

Emerging evidence studying gingival levels of PGE2 and IL-1, links chronic gum disease and premature delivery (1). Periodontal disease is now suggested as an important risk factor for preterm low birthweight pregnancy complications (2). Furthermore, active maternal periodontal disease during pregnancy has been associated with an increased risk for the development of preeclampsia (3).

Evidence of subclinical infections such as gum disease as a cause of preterm labor is raised by finding elevated blood CRP and abnormal amniotic fluid organic acid levels in patients in preterm labor. The study of prostaglandins and their metabolites, endotoxin and cytokines leads to the suggestion of certain biochemical mechanisms for preterm labor in the setting of maternal infection (4).

Because obstetric complications are a significant health care expense, and because of the life-long impact they have on affected infants throughout life, physicians and dentists should work to reduce periodontal infections which can create unfavorable pregnancy outcomes and affect the well-being of the offspring (5).

1- Bogess KA. Contemporary OBGYN Aug.1,2003. 2- Davenport ES, et.al. J Dent Res 81(5): 313-318, 2002 3- Boggess KA, et.al. Obstetrics & Gynecology 2003;101:227-231 4- Gibbs RS, et.al., Am J Obstet Gynecol 166:1515-28, 1992. 5- Bobetsis YA, et.al., JADA, Vol 137, 10/ 2006 Supp, pp.7s-13s.

Important Points:

• Gum disease increases systemic inflammation.
• Treatment reduces risk of complications.
• Gum infection linked to low-birth weight and pre-term babies.
• Physicians should screen for gum disease.

Dr. David Weaver
Rivergate Dental Care
133 North Creek Blvd.
Goodlettsville, TN 37072

Phone: 888.411.SEDATE
Fax: 615.851.3535