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J Periodontol 2013;84(4 Suppl.):S106-S112doi:10.1902/jop.2013.1340011

Diabetes and periodontaldiseases: consensus report ofthe Joint EFP/AAP Workshop onPeriodontitis and SystemicDiseasesChapple ILC, Genco R, and on behalf of working group 2 of the joint EFP/AAPworkshop. Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases.

AbstractBackground: Diabetes and periodontitis are complex chronic diseases with anestablished bidirectional relationship. There is long-established evidence thathyperglycaemia in diabetes is associated with adverse periodontal outcomes. How-ever, given the ubiquity of periodontal diseases and the emerging global diabetesepidemic, the complications of which contribute to signicant morbidity and pre-mature mortality, it is timely to review the role of periodontitis in diabetes.Aims: To report the epidemiological evidence from cross-sectional, prospective andintervention studies for the impact of periodontal disease on diabetes incidence,control and complications and to identify potential underpinning mechanisms.Epidemiology: Over the last 20 years, consistent and robust evidence has emergedthat severe periodontitis adversely affects glycaemic control in diabetes and glycaemiain non-diabetes subjects. In diabetes patients, there is a direct and dose-dependent rela-tionship between periodontitis severity and diabetes complications. Emerging evidencesupports an increased risk for diabetes onset in patients with severe periodontitis.Biological mechanisms: Type 2 diabetes is preceded by systemic inammation,leading to reduced pancreatic b-cell function, apoptosis and insulin resistance.Increasing evidence supports elevated systemic inammation (acute-phase and oxi-dative stress biomarkers) resulting from the entry of periodontal organisms andtheir virulence factors into the circulation, providing biological plausibility for theeffects of periodontitis on diabetes. AGE (Advanced Glycation Endproducts)RAGE (Receptor for AGEs) interactions and oxidative-stress-mediated pathwaysprovide plausible mechanistic links in the diabetes to periodontitis direction.Interventions: Randomized controlled trials (RCTs) consistently demonstrate thatmechanical periodontal therapy associates with approximately a 0.4% reduction inHbA1C at 3 months, a clinical impact equivalent to adding a second drug to a phar-macological regime for diabetes. RCTs are needed with larger numbers of subjectsand longer term follow-up, and if results are substantiated, adjunctive periodontaltherapies subsequently need to be evaluated. There is no current evidence to supportadjunctive use of antimicrobials for periodontal management of diabetes patients.Guidelines: Given the current evidence, it is timely to provide guidelines for peri-odontal care in diabetes patients for medical and dental professionals and recom-mendations for patients/the public.

Iain L. C. Chapple1, Robert Genco2

and on behalf of working group 2 of

the joint EFP/AAP workshop*1Periodontal Research Group & MRC Centre

for Immune Regulation, University of

Birmingham School of Dentistry, Birmingham,

UK; 2University at Buffalo, Oral Biology and

Microbiology and Immunology, Buffalo, NY,

USA

Key words: association; complications;

diabetes mellitus; gestational diabetes;

HbA1C; incident; intervention; mechanisms;

periodontal disease; periodontitis; type 2

diabetes

Accepted for publication 14 November 2012

The proceedings of the workshop were jointly

and simultaneously published in the Journal

of Clinical Periodontology and Journal of

Periodontology.

2013 European Federation of Periodontology and American Academy of PeriodontologyS106

Diabetes and Periodontitis

Diabetes mellitus is emerging as aglobal epidemic, whose complica-tions impact signicantly on qualityof life, longevity and healthcarecosts. It is estimated that 346 millionpeople currently suffer from diabetesworldwide and the World HealthOrganization (WHO) predicts thatthis will increase to 439 million,almost 10% of adults, by 2030(WHO 2011). The escalating humanand economic burden across boththe developed and developing worldnecessitates a multidisciplinaryapproach, including adjunctive mea-sures to managing diabetes and itscomplications. The onset of diabetesis preceded by inammation, whichleads to pancreatic beta-cell dysfunc-tion and apoptosis, as well asimpacting on the development ofinsulin resistance and ultimately dia-betes. It is logical that comorbiditiesthat contribute to systemic inam-mation are likely to increase the riskof developing diabetes, and impacton diabetes control and the develop-ment of diabetes complications, ulti-

mately affecting diabetes-associatedmorbidity and mortality.

Inammatory periodontal dis-eases are the most common chronicinammatory conditions of humansworldwide. The destructive form ofperiodontal disease, periodontitis,affects approximately 50% of adultsand over 60% of over 65 year olds,with severe periodontitis impacting1015% of populations. Periodontaldisease is a microbially initiatedchronic inammatory disease, inwhich dysregulated immune-inam-matory processes are responsible forthe majority of host tissue destruc-tion, and ultimately tooth loss.There is increasing evidence that sys-temic inammation results from theentry of oral microbial agents andtheir virulence factors into the circu-lation. This is evidenced by elevatedserum levels of C-reactive proteinand other acute-phase reactants andraised biomarkers of oxidative stress.It is therefore biologically plausiblethat non-resolving chronic inamma-tion derived from periodontal dis-ease impacts on diabetes control(elevated HbA1C) and complica-

Conict of interest and source of funding

Group participants declare no conict of interest. The workshop was funded by an unrestricted educational grant from Colgate-Palmolive to the European Federation of Periodontology and the American Academy of Periodontology.

*Working group participants: Tord Berglundh, Sweden; Peter Eickholz, Germany; Steven Engebretson, USA; Dana Graves, USA;Sarah Grossi, USA; Hatice Hasturk, USA; Thomas Kocher, Germany; Evanthia Lalla, USA; Ira Lamster, USA; Niklaus Lang,China; Brian Mealey, USA; Joerg Meyle, Germany; Willem Nesse, The Netherlands; David Paquette, USA; Philip Preshaw, UK;George Taylor, USA; John Taylor, UK; Ubele Van der Velden, The Netherlands; Clemens Walter, Switzerland; Borgnakke Wen-che, USA; Pekka Ylostalo, Finland.

tions, as well as beta-cell function,insulin resistance and developmentof type 2 diabetes.

It is well established that hyper-glycaemia affects periodontal out-comes. A body of evidence,predominantly over the last 1520 years supports signicant indepen-dent associations between periodontalinammation and glycaemic sta-tus (even in individuals withoutdiabetes), and complications of diabe-tes. There is also emerging evidencefor an independent associationbetween periodontitis and incidentdiabetes. In addition, there is evidencethat periodontitis adversely affectsdiabetes glycaemic control and wors-ens complications. There is a lack ofclarity in the literature regarding thestrength of the latter association andthe clinical signicance of the effectsof periodontal therapy on diabetesand its outcomes. Therefore, it istimely to systematically review the lit-erature on epidemiology of periodon-tal diseases and diabetes; the impactof periodontal interventions on diabe-tes outcomes and; potential mechanis-tic links between these two chronic

2013 European Federation of Periodontology and American Academy of Periodontology

Diabetes and periodontitis S107

inammatory diseases, consistent withexamining biological plausibility.

The remit of this working groupwas to critically examine the currentevidence base for the periodontaldiseasediabetes paradigm with aview to establishing pragmatic guide-lines for patient care, accepting thecurrent state of the eld and thelikely need for change as furtherresearch emerges. Two reviews haveevaluated in a systematic manner theepidemiological evidence for direc-tional associations between peri-odontal diseases and diabetes(Borgnakke, Yiostalo, Taylor &Genco 2013) and the evidence forbenecial effects of periodontaltreatment on diabetes outcomes(Engebretson & Kocher 2013). Athird narrative review has criticallyaddressed potential mechanistic linksbetween periodontal diseases anddiabetes (Taylor, Preshaw & Lalla2013). While there is only emergingevidence for associations betweenperiodontal disease and type 1 diabe-tes, and little evidence for the associ-ation between periodontitis andgestational diabetes, these elds wereexcluded from detailed analysis.Therefore, this consensus documentfocuses specically on the relation-ship between periodontitis and type2 diabetes.

Epidemiological Evidence (for type 2diabetes)

What is the evidence for the effect of

periodontal disease on diabetes control,

complications and incidence?

Diabetes control and hyperglycaemia

Severe periodontitis is associatedwith increased HbA1C in individualswith and without type 2 diabetes. Inpeople without diabetes, progressionof periodontitis over 510 years wasassociated with increasing HbA1Cand impaired glucose tolerance.Those with periodontitis at baselineand demonstrating periodontal dis-ease progression had a largerHbA1C increase than those withoutperiodontitis over a 5-year period(0.143% versus 0.005%).

Diabetes complications

There is evidence for a direct rela-tionship between the severity of peri-odontitis and complications of type2 diabetes. Moderate-to-severe peri-

odontitis is associated with increasedrisk for macroalbuminuria, end-stagerenal disease, calcication of athero-sclerotic plaques, carotid intima-medial thickness and cardio-renalmortality. Limited evidence exists foran association between periodontaldisease and diabetes complications inadults with long-duration insulin-dependent diabetes mellitus.

Incidence

Emerging evidence suggests anincreased risk for the development ofdiabetes in individuals with severeperiodontitis, relative to no or mildperiodontitis after adjustment forpotential confounders.

Is there a type and/or threshold of

periodontal disease that is associated

with increased risk of diabetes

complications?

Studies do not address the issue of aminimal threshold level of periodon-tal disease at which an effect on riskof complications is likely. Consider-ing the available evidence, subjectswith gingivitis are often combinedwith periodontally healthy subjectsin the control/reference group. Inone study where subjects with gingi-vitis was a separate category, therewas no evidence that gingivitis wasassociated with altered glycaemia.Although the denition of periodonti-tis differs among studies, a consistentnding is that severe periodontitisimparts a signicant risk for diabetescomplications. Again based on thesestudies, the threshold appears to be inthe transition between moderate tosevere disease.

It has to be realized that thresh-old levels of periodontal diseaseaffecting individuals with diabetesmellitus may be patient dependent.

Which clinical biochemical markers of

diabetes are affected by periodontal

diseases?

HbA1C has consistently been usedas the measure of glycaemia. Occa-sionally, fasting or random plasmaglucose and oral glucose tolerancetests have also been used. Insulinresistance has been evaluated by thehomeostasis model assessment. Thisconsensus report therefore focusseson HbA1C as the outcome measureof diabetes control.

Summary

Overall, there is consistent androbust evidence that severe peri-odontitis, adversely affects bloodglucose levels expressed as HbA1Cin individuals with and without dia-betes. Moderate-to-severe periodon-titis is associated with an increasedrisk for the development of diabetes.Evidence supports a dose-dependentrole for periodontitis and diabetescomplications.

Impact of Periodontal Treatment onDiabetes Outcomes

What is the potential impact of

periodontal treatment on diabetes

outcomes and what is the clinical

signicance of any effect?

Reduction in HbA1C is an estab-lished outcome measure of successfuldiabetes treatment. Evidence derivedfrom RCTs shows that periodontaltreatment results in a mean reduc-tion in HbA1C of 0.36% (95% CI0.19, 0.54) at 3 months (Engebretson& Kocher 2013). This result is con-sistent with previous meta-analyses.

Levels of HbA1C reductionobtained within the short term follow-ing periodontal interventions areequivalent to those achieved by addinga second drug into a pharmacologicalregime. If such reductions followingperiodontal therapy can be sustainedover the longer term, then this maycontribute to reduced diabetes-associ-ated morbidity and mortality.

What is the specic level of periodontal

resolution following periodontal therapy

that is associated with improvements in

diabetes outcome?

While periodontal therapies result inreduction in HbA1C level, diabetespatients on average benet fromperiodontal therapy. At present, nospecic level of disease resolutionhas been associated with thisoutcome (HbA1C reduction).

Is there evidence to recommend a specic

periodontal treatment regimen over and

above mechanical debridement as being

more benecial towards diabetes

outcomes?

While meta-analyses have includedstudies that employed a wide rangeof periodontal therapies, professionalmechanical debridement was the


S108 Chapple and Genco

intervention common to all studies.Adjunctive antibiotic therapy doesnot currently appear to confer addi-tional benets. Therefore, there isinsufcient evidence to suggest a spe-cic periodontal treatment regimeand we conclude that individualswith type 2 diabetes benet fromprofessional mechanical debridementin conjunction with sustained effec-tive home care.

Given the current evidence base, how

should periodontal care feature in the

management of diabetes control?

Periodontal therapy in individualswith type 2 diabetes is safe and effec-tive in improving periodontal clinicaloutcomes. Available short-term evi-dence suggests that HbA1C levelscan be reduced as a result of peri-odontal therapy. Additional RCTsare needed to make denitive clinicalrecommendations for periodontaltherapy in the management of diabe-tes. In the meantime, it would beprudent to identify diabetes withinthe dental setting. Likewise, in themedical setting, patients with diabe-tes should be evaluated for the pres-ence of periodontitis.

Mechanistic Links BetweenPeriodontal Diseases and Diabetes

Are the periodontal microbiota affected by

diabetes control?

According to the currently availableliterature, there is no compelling evi-dence that diabetes has any signi-cant impact on the oral microbiota.A major limitation in current knowl-edge is that existing studies have notexamined the entire periodontal mi-crobiome.

What is the impact of the periodontal

microbiota on diabetes outcomes?

Whether the periodontal microbiotahas any direct impact on diabeteshas barely begun to be addressedand there is currently inadequateevidence to support such an effect.

What is the role of cytokines and other

mediators in the mechanistic association

between diabetes and periodontitis?

There is evidence from clinical andexperimental studies to support the

role of specic cytokines in therelationship between diabetes andperiodontitis. In patients with peri-odontitis, diabetes is associated withelevated levels of several cytokinesand other mediators in saliva andgingival crevicular uid (GCF). Sim-ilar ndings are evident in gingivaltissue samples from animal models.

There is evidence that periodonti-tis in non-diabetic individualsincreases systemic levels of inamma-tory mediators. Whether this occursin diabetic subjects remains to beclaried. Findings from animal exper-iments involving the use of specicantagonists support a cause-and-effect relationship between diabetes-related cytokine dysregulation andperiodontal breakdown. Most studiesto date, however, have focused on alimited number of mediators.

What is the role of oxidative stress in the

mechanistic association between diabetes

and periodontitis?

Hyperglycaemia enhances oxidativestress in periodontal tissues and clin-ical and experimental studies havedemonstrated that periodontitis pro-motes measures of systemic oxidativestress. Results from animal experi-ments indicate that the use ofantioxidant micronutrients reducesdiabetes-enhanced periodontal inam-mation and bone loss.

What is the role of AGEs in the

mechanistic association between diabetes

and periodontitis?

Diabetes drives the formation ofAGEs, which directly and indirectlypromote inammation, includingperiodontitis. Findings from clinicalstudies and animal experiments sug-gest that AGERAGE interactionleads to the exaggerated inamma-tory response and periodontal tissuedestruction seen in diabetes. Animalexperiments using RAGE blockadeindicate a mechanistic link betweenRAGE activation and periodontalbreakdown.

What are the limitations to the existing

evidence base for periodontitisdiabeteslinks, in either direction?

It is timely to conrm in clinical tri-als mechanisms underlying theimpact of diabetes on periodontitis

that have been established in animalexperiments. The complex effects ofhyperglycaemia and insulin resis-tance on the many different celltypes involved in periodontitis arelargely unknown.

As clinical evidence emerges for anegative impact of periodontitis ondiabetes outcomes, there is an imper-ative for more mechanistic studies toexplain this direction of the associa-tion.

Bradford Hill Criteria for Evidence ofCausality

The consensus of this group on theissue of causality is that, while thedetermination of causality is the ulti-mate goal, it is not central to consid-erations of the linkage betweencomplex diseases such as periodonti-tis and diabetes. Risk factors affectincidence, severity and progressionof disease by increasing the probabil-ity that these outcomes will occur. Itis important to determine whetherperiodontitis is independently associ-ated with adverse diabetes outcomes.It is also critical to demonstrate theimpact of periodontal interventionson adverse diabetes outcomes.

Recommendations for Future

Research

A strong evidence base exists from epi-demiological studies that periodontitisand diabetes are directly associated,and that periodontal interventionsprovide benecial effects on diabetesoutcomes. However, the evidencecould be further strengthened byfuture studies incorporating the fol-lowing design features:

Randomized, multicentre studiesthat are properly powered;

Development of large cohorts toassess the impact of periodontaldisease upon macro- and micro-vascular complications of diabetes;

Inclusion of populations with dif-fering characteristics, such as over-weight and obese populations withdifferent distributions of adiposetissue, differing ratios of type 1and type 2 diabetes, race, ethnicityand geographical location, toimprove generalizability;

Accounting for periodontal diseasedenitions that include extent,severity and denitions of cases;



In association studies, consider-ation of full-mouth periodontalexaminations rather than partialmouth sampling and includingprobing depth and loss of clinicalattachment measurements: theseare essential in intervention trials;

Characterization of baseline dia-betes characteristics additional toHbA1C (e.g. duration of diabetesstatus).

Consistency in the recording ofdetails on general medication useand changes in use in all studyvolunteers;

Consistency with respect to theminimum number of teethrequired for subject inclusion;

Stratication for relevant majorrisk factors (i.e. obesity, smoking);

Documentation of crossovereffects on the control group;

Denitionofperiodontal treatmentoutcomes deemed to characterizesuccessfulperiodontal therapy;

Development of biobanks for bio-logical samples from clinical stud-ies to facilitate subsequent analysis;

The recording of information onnutritional and quality-of-lifeoutcomes;

Recording and reporting of infor-mation on other oral conditions(e.g. periapical periodontitis).

With respect to studies designedto assess the impact of periodontalinterventions on diabetes outcomes,additional design features include:

Comprehensive assessment ofchanges in clinical measures ofperiodontal inammation and inbiochemical markers of inam-mation in blood and saliva;

Inclusion of type 1, gestationaland other types of diabetes;

Further interventional studiesinvestigating the impact of differ-ent periodontal treatment andprevention protocols on the onsetand progression of diabetes andits complications.

In studies designed to exploremechanistic links between periodon-tal diseases and diabetes, furtherconsideration should be given to:

Addressing the complexity, path-ogenic composition and dynamicsof the microbial biolm;

Assessment of the effects of bac-teremia on diabetes control andthe effect of diabetes on thedevelopment of, and response tobacteremia;

Investigation of the potentialeffects of periodontitis on insulinresistance;

Exploration of the potentialeffects of periodontitis on insulinproduction;

Addressing the complexity oflocal and systemic regulatorypathways affected by diabetesand periodontitis;

Examining the effects of diabeteson cellular functions in periodon-titis;

Application of longitudinaldesigns in clinical studies employ-ing metagenomic techniques andsystems biology to unravel mech-anistic links between diabetes andperiodontitis in humans.

Mechanistic studies investigatinginteractions between diabetes andperiodontitis should also take intoaccount duration of diabetes, levelof glycaemic control and extent andseverity of periodontitis.

Guideline A

[Suggested Guidelines for physiciansand other medical health professionsfor Use in Diabetes Practice]

Oral health of my patientsBecause of the increased risk for

developing periodontitis in patientswith diabetes the following recom-mendations are made:

Patients with diabetes should betold that periodontal disease risk isincreased by diabetes. They shouldalso be told that if they suffer fromperiodontal disease, their glycae-mic control may be more difcult,and they are at higher risk for dia-betic complications such as cardio-vascular and kidney disease.

As part of their initial evaluation,patients with type 1, type 2 and ges-tational diabetes (GDM) shouldreceive a thorough oral examina-tion, which includes a comprehen-sive periodontal examination.

For all newly diagnosed type 1 andtype 2 diabetes patients, subse-quent periodontal examinationsshould occur (as directed by the

dental professionals) as part oftheir ongoing management of dia-betes. Even if no periodontitis isdiagnosed initially, annual peri-odontal review is recommended.

Diabetes patients presenting withany overt signs and symptoms ofperiodontitis, including looseteeth not associated with trauma spacing or spreading of theteeth and/or gingival abscessesor gingival suppuration, requireprompt periodontal evaluation.

Patients with diabetes who haveextensive tooth loss should beencouraged to pursue dentalrehabilitation to restore adequatemastication for proper nutrition.

Oral health education should beprovided to all patients with dia-betes.

For children and adolescentsdiagnosed with diabetes, annualoral screening is recommendedfrom the age of 67 years byreferral to a dental professional.

Patients with diabetes should beadvised that other oral conditionssuch as dry mouth and burningmouth may occur, and if so, theyshould seek advice from their den-tal practitioner. Also patients withdiabetes are at increased risk oforal fungal infections and experi-ence poorer wound healing thanthose who do not have diabetes.

Guideline B

[Suggested guidelines for use in den-tal practice]

My patient with diabetes

Patients with diabetes should betold that they are at increasedrisk for periodontitis. Theyshould also be told that if theysuffer from periodontal disease,their glycaemic control may bemore difcult, and they are athigher risk for other complica-tions such as cardiovascular andkidney disease.

Patients presenting with a diag-nosis of type 1, type 2 or gesta-tional diabetes should receive athorough oral examination,which includes a comprehensiveperiodontal evaluation.

If periodontitis is diagnosed, itshould be properly managed. Ifno periodontitis is diagnosed ini-



tially, patients with diabetesshould be placed on a preventivecare regime and monitored regu-larly for periodontal changes.

Patients with diabetes presentingwith any acute oral/periodontalinfections require prompt oral/periodontal care.

Patients with diabetes who haveextensive tooth loss should beencouraged to pursue dentalrehabilitation to restore adequatemastication for proper nutrition.

Oral health education should beprovided to all patients with dia-betes.

Patients with diabetes should alsobe evaluated for other potentialoral complications, including drymouth, burning mouth and can-didal infections.

For children and adolescentsdiagnosed with diabetes, anannual oral screening for earlysigns of periodontal involvementis recommended starting at theage of 6 years.

Patients who present without adiabetes diagnosis, but with obvi-ous risk factors for type 2 diabe-tes and signs of periodontitisshould be informed about theirrisk for having diabetes, assessedusing a chair-side HbA1C test,and/or referred to a physician forappropriate diagnostic testingand follow-up care.

Guideline C

[Recommendations for patients withdiabetes at the physicians practice/ofce]

Why should I have my gumschecked?

If your physician has told youthat you have diabetes, you shouldmake an appointment with a dentistto have your mouth and gumschecked. This is because people withdiabetes have a higher chance of get-ting gum disease. Gum disease canlead to tooth loss and may makeyour diabetes harder to control.

You may have gum disease if youhave ever noticed:

Red, bleeding or swollen gums; Pus from the gums; Foul taste; Longer looking teeth; Loose teeth;

Increasing spaces between yourteeth;

Calculus (tartar) on your teeth.

If you have noticed any of theseproblems, it is important to see a den-tist as soon as possible. Gum diseasemay be present and get worse with noapparent symptoms to you, so even ifyou do not think you have gum diseasenow, you should still get regular dentalcheck-ups as part of managing yourdiabetes. Your dentist will be able topick up early signs of gum disease.

You also need to clean your teethand gums very carefully at home.

If you have diabetes, you mayalso suffer from dry mouth, burningmouth, yeast infections of the mouthor poor healing of mouth wounds.

It is important to keep yourmouth and your whole body ashealthy as possible with regular den-tal and medical care.

Guideline D

[Recommendations for patients atthe dental surgery/ofce who havediabetes or are found to be at riskfor diabetes]

You have diabetes or you havebeen told by your dentist you are atrisk for diabetes

People with diabetes have ahigher chance of getting gum dis-ease. If you have been told by yourdentist that you have gum disease,you should follow up with necessarytreatment as advised. This mayrequire several appointments. Likediabetes, gum disease is a chroniccondition and requires lifelong main-tenance. You also need to clean yourteeth and gums very carefully athome. If left untreated, gum diseasecan lead to tooth loss and may alsomake your diabetes harder to con-trol.

Gum disease may be present andget worse with no apparent symptomsto you, so if your dentist told you thatyou do not have gum disease now,you should still get regular dentalcheck-ups as part of managing yourdiabetes. Your dentist will be able topick up early signs of gum disease.

You may have gum disease if youever notice:

Red, bleeding or swollen gums;

Pus from the gums; Foul taste; Longer looking teeth; Loose teeth; Increasing spaces between your

teeth;

Calculus (tartar) on your teeth.

People with diabetes may alsosuffer from dry mouth, burningmouth, yeast infections of the mouthor poor healing of mouth wounds.

If you do not have diabetes, butyour dentist identied some riskfactors for diabetes including signsof gum disease, it is important toget a medical check-up as advised.Your medical doctor can orderblood tests to see if you have diabe-tes and not know it, and can pro-vide proper advice and care basedon the results. Make an appoint-ment to see your medical doctor assoon as possible. And remember toinform your dentist about the out-come of your visit to the medicaldoctor.

It is important to keep yourmouth and your whole body ashealthy as possible with regulardental and medical care.

References

Borgnakke, W. S., Ylostalo, P. V., Taylor, G. W.& Genco, R. J. (2013) Effect of periodontaldisease on diabetes: systematic review of epi-demiologic observational evidence. Journal ofClinical Periodontology and Journal of Peri-odontology 40 (Suppl 14), 135152.

Engebretson, S. & Kocher, T. (2013) Evidencethat periodontal treatment improves diabetesoutcomes: a Systematic Review and Meta-analy-sis. Journal of Clinical Periodontology and Jour-nal of Periodontology 40 (Suppl 14), 153163.

Taylor, J. J., Preshaw, P. M. & Lalla, E. (2013) Areview of the evidence for pathogenic mecha-nisms that may link periodontitis and diabetes.Journal of Clinical Periodontology and Journalof Periodontology 40 (Suppl 14), 113134..

World Health Organization (2011) Fact Sheet No.312. Diabetes [WWW document]. Available at:http://www.who.int/mediacentre/factsheets/fs312/en/ [accessed on 23 August 2012].

Address:Iain L. C. ChappleSchool of DentistryCollege of Medical and Dental SciencesThe University of BirminghamSt Chads QueenswayBirmingham, B4 6NN,UKE-mail: [email protected]



Clinical Relevance

Scientic rationale for the study:Periodontal disease and diabetesare directly and independentlyassociated chronic diseases of highprevalence in the population. Dia-betes is predicted to increase inprevalence in the next 15 years toepidemic levels leading to substan-tial morbidity and premature mor-tality. Therefore it is timely tosystematically review the impact ofperiodontitis and its treatmentupon diabetes control, complica-tions and incidence.

Principal ndings: Severe periodonti-tis adversely effects diabetes control(HbA1C) and also glycaemia in non-diabetes patients. There is a directand dose-dependent relationshipbetween periodontitis severity anddiabetes complications in diabetespatients and emerging evidence thatsevere periodontitis may predisposeto the development of diabetes.Mechanistic links between periodon-titis and diabetes involve AGE-RAGE interactions, oxidative stressand altered cytokine networks. Peri-odontal treatment reduces plasma

HbA1C at 3-months by levelsequivalent to adding a second drugto a pharmacological regime.Practical implications: Guidelines aredocumented for physicians, dentalsurgeons and patients with diabetesor at risk of diabetes, concerningperiodontal care and management oforal health. Larger randomised trialsare recommended over extendedobservation periods to strengthenthe evidence for this bidirectionalrelationship and for the impact ofperiodontal therapy on diabetes con-trol, complications and incidence.



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