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Linking Dental Services to Treatment Outcomes for Diabetes: A Rapid Response Review

Rapid Evidence Product Nov 1, 2024
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In the past several years, there has been increasing appreciation for the interconnectedness of oral health and whole body wellness, highlighted by the US Surgeon General's report in 20001. Many subsequent efforts have established a connection between oral diseases, especially periodontitis, and impacts on a variety of systemic diseases.1 The goal of this report is to review evidence on the efficacy of dental care/treatment in improving outcomes for patients with Diabetes.

Diabetes mellitus (DM) characterized by high blood sugar levels (HbA1c > 6.5%) affects approximately 37 million adults in the United States2 and 500 million globally.3,4 Diabetes is a chronic metabolic disease that occurs either when the pancreas does not produce enough insulin or when the body cannot effectively use the insulin it produces. It is also termed as the "silent epidemic" causing a range of other diseases and health complications, including lower limb amputations, blindness, chronic kidney disease, and cardiovascular diseases5. Type II diabetes mellitus is a highly prevalent metabolic disorder characterized by the loss of ability to adequately control blood glucose levels due to insulin resistance in body tissues and typically emerges in adulthood. This is in contrast to type I diabetes mellitus (formerly commonly known as juvenile diabetes), where an autoimmune response results in the destruction of insulin-secreting β cells in the pancreas, requiring life-long insulin therapy.6 Combined, these diseases affect ~10% of adults with 90% of the cases being type II diabetes, resulting in a substantial global disease burden.2

Diabetes was the eighth leading cause of death in the United States in 2021 when considering death certificates that listed diabetes as a direct cause, however the mortality rate tripled when considering diabetes as an underlying or contributing cause.2,7 Indeed, it is this spectrum of comorbidities that constitute the majority of the health burden of diabetes and factors that exacerbate the hyperglycemic damage to the vasculature are critical intervention loci in the management of diabetes.3 These inflammatory exacerbating factors are now thought to include atherosclerosis, obesity, hypertension, changes in the gut microbiota, and others.8 A key question in this review is whether oral inflammatory disease may contribute to or exacerbate the pathology of diabetes mellitus, and to collect evidence on dental treatments influencing diabetes outcomes.

Chronic oral diseases (COD) are a range of conditions that affect the mouth, including dental caries, gingival infection, periodontal disease, and tooth loss.4 They are among the most common chronic diseases in the United States and can have a significant impact on overall health. COD are significantly more common and more severe in diabetic patients,5 with particular associations having been identified between diabetes and gingivitis and periodontitis. In addition, there may be increased risk in diabetes patients of systemic opportunistic infections after dental procedures such as implants to replace lost teeth.6 High glucose levels in saliva from uncontrolled diabetes can feed bacteria in the mouth, which can create plaque that causes tooth decay, and even tooth loss. Dry mouth, also known as xerostomia, can be caused by high blood sugar levels in people with diabetes. Dry mouth can also increase the risk of tooth decay. Patients with diabetes are three times as likely to have oral candidiasis relative to healthy subjects7. Periodontitis is estimated to impact up to 90% of all adults worldwide and encompasses a range of severities ranging from mild gingivitis to severe loss of connective tissue resulting in painful inflammation and tooth loss. The most severe manifestations of periodontal disease are estimated to impact 5-15% of adults globally with perhaps even greater 4 prevalence in the United States.8 One of the key factors in the development of periodontitis is a subdued granulocytic response to bacterial challenge in the oral cavity, resulting in increased plaque formation and eventually gum disease.9 Indeed, one of the major clinical effects of diabetes is immune suppression, especially in polymorphonuclear cells due to alterations in immunometabolism.10

Increasing evidence suggests that COD has a more complex relationship with diabetes than was previously appreciated, with the two being locked into a feedback loop where increasing COD severity results in greater systemic inflammation, which reduces glycemic control3. People with diabetes have a 2–3-fold greater risk for periodontitis11 compared to people without diabetes, but also a higher incidence of caries due to dry mouth. The progression and severity of periodontitis are also greater in people with poorly controlled diabetes. According to the American Academy of Periodontology, 50% of diabetics up to the age of 35 suffer from periodontal disease, a figure that rises to 80% at the age of 45–54 years, compared to 60% in the healthy population. A growing body of data indicates that oral inflammation has an impact on general diseases.12 This results in diabetes patients with severe COD having a significantly increased risk of all-cause mortality, highlighting the impact of oral health on cardiovascular, immune, and renal function. Figure 1 is a proposed causal model representing the factors that demonstrate an interplay between diabetes and oral disease. The relationship between oral health treatment and diabetes management has long been investigated in several studies but the exact correlation between oral health management and diabetes has not been comprehensively addressed.

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Project Timeline

Linking Dental Services to Treatment Outcomes for Diabetes: A Rapid Response Review

Oct 30, 2024
Topic Initiated
Nov 1, 2024
Rapid Evidence Product
Page last reviewed October 2024
Page originally created October 2024

Internet Citation: Rapid Evidence Product: Linking Dental Services to Treatment Outcomes for Diabetes: A Rapid Response Review. Content last reviewed October 2024. Effective Health Care Program, Agency for Healthcare Research and Quality, Rockville, MD.
https://effectivehealthcare.ahrq.gov/products/treatment-outcomes-diabetes/rapid-research

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