Periodontal disease: The sixth complication of diabetes.

Sir,

The association between oral health and systemic health is bidirectional; systemic illnesses, especially metabolic disorders, affect oral health, and it appears that oral health may affect systemic health.[1] The term “diabetes mellitus” (DM) describes a group of disorders characterized by elevated levels of glucose in the blood and abnormalities of carbohydrate, fat and protein metabolism.[2] DM is a metabolic disorder characterized by impaired action, secretion of insulin or both, resulting in hyperglycemia presents with the classical triad of symptoms: Polydypsia, polyuria and polyphagia which are often accompanied by chronic fatigue and loss of weight thus DM is a true metabolic disorder and, thus, affects every tissue in the body.[1] The pathogenesis of periodontal disease is complex because it reflects a combination of the initiation and maintenance of the chronic inflammatory process by a diverse microbial flora and its numerous bacterial products. The subsequent host response to this infection mediates a complex cascade of tissue-destructive pathways.[3] Additional factors contributing to this multifaceted local disease process in the oral cavity include a number of systemic diseases, especially diabetes, that can exaggerate the host response to the local microbial factors (for example, endotoxin), resulting in unusually destructive periodontal breakdown.[4] Periodontal disease also is associated with hyperglycemia; the poorer the control of DM is, the greater the risk of developing periodontal disease. In fact, aggressive periodontitis is recognized as the sixth complication of diabetes according to Loe[5]who concluded that multiple epidemiological studies have demonstrated that both type 1 and type 2 diabetes are predictors of periodontal disease when the systemic condition is poorly controlled,[3] the other five complications are retinopathy, neuropathy, nephropathy, cardiovascular disease and peripheral vascular disease.[1] Many studies have been published describing the bidirectional inter-relationship exhibited by diabetes and periodontal disease.[6] Studies have provided evidence that control of periodontal infection has an impact on improvement of glycemic control evidenced by a decrease in demand for insulin and decreased hemoglobin A--1c levels.[6-9] In addition to periodontal infection and gingival inflammation, a number of other oral complications have often been reported in patients with diabetes. These include xerostomia, dental caries, Candida infection, burning mouth syndrome, lichen planus and poor wound healing.[6] Thus it can be accomplished that DM pessimistically affects each microvasculature beds, and the soft tissues and bones supporting the teeth are susceptible. There is also strong evidence that the presence of periodontal disease is associated with increased cardiovascular morbidity in patients with DM. The evidence reviewed supports viewing the relationship between diabetes and periodontal diseases as bidirectional. Further rigorous, systematic study is warranted to establish that treating periodontal infections can be influential in contributing to glycemic control management and possibly to the reduction of the burden of complications of DM.[10]