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Diabetes in America

  • Catherine C. Cowie
  • Sarah Stark Casagrande
  • Andy Menke
  • Michelle A. Cissell
  • Mark S. Eberhardt
  • James B. Meigs
  • Edward W. Gregg
  • William C. Knowler
  • Elizabeth Barrett-Connor
  • Dorothy J. Becker
  • Frederick L. Brancati
  • Edward J. Boyko
  • William H. Herman
  • Barbara V. Howard
  • K. M. Venkat Narayan
  • Marian Rewers
  • Judith E. Fradkin
  • Wenche S. Borgnakke
  • Robert J. Genco
  • Paul I. Eke
  • George W. Taylor
PMID: 33651538



The vast majority of the U.S. adult population suffers from periodontal diseases, as about 90% suffer from the reversible form, gingivitis, whereas almost 50% of adults age ≥30 years are affected by periodontitis, which is the chronic periodontal breakdown of both soft and hard tissues that support the teeth. Diabetes prevalence is assuming epidemic proportions with 30.2 million or 12.2% of the U.S. adult population age ≥18 years having diabetes in 2015, of whom about one-quarter are unaware of their diabetes; an additional one-third (84.1 million) have prediabetes, of whom about 90% are unaware. Due to the great prevalence of both diseases, it is important for health care professionals and lay people alike to be aware of both periodontal diseases and diabetes and their two-way interactions in which they mutually and adversely affect each other to understand how to prevent, treat, and manage both diseases. Since periodontitis and diabetes share the same risk factors, any improvement in a risk factor should beneficially affect both conditions. This concept is shown by a decrease in the level of inflammation upon nonsurgical periodontal treatment, which improves both periodontal health in individuals with type 2 diabetes and those without diabetes, as well as glycemic control in type 2 diabetes and in people with prediabetes. Gingivitis is a reversible inflammation of the soft tissues surrounding the teeth in response to dental plaque, whereas periodontitis is a chronic, inflammatory disease that in response to dental plaque causes breakdown of the soft and hard tissues surrounding the teeth in susceptible individuals. This destruction often occurs without any pain or other symptoms. Nonetheless, if left untreated, it can lead to loosening of the tooth and eventually to its total loss, with adverse effects on nutrition, self-esteem, and function. Moreover, the number of teeth lost is strongly associated with atherosclerotic cardiovascular disease, and advanced tooth loss, especially edentulism (loss of all teeth), is associated with premature all-cause mortality. Periodontitis causes local and systemic inflammatory responses that lead to development or worsening of hyperglycemia and hence contribute to increased blood glucose levels in healthy individuals; development of prediabetes, type 2 diabetes, and gestational diabetes; decreased glycemic control in overt diabetes; and worsening of diabetes complications. Diabetes is also a chronic, inflammation-related metabolic disease diagnosed by hyperglycemia. Such elevated blood glucose levels negatively impact the inflammatory response to dental plaque, leading to more severe gingivitis and periodontitis. Hence, periodontitis and diabetes mutually and adversely affect each other. Importantly, the risk factors are largely identical for these two diseases, so when identifying and improving risk factors related to one of the two diseases, the other could be present and its severity lessened. Such improvements could consist of quitting smoking, decreasing intake of added sugar, reducing any inflammation, and getting sufficient sleep at healthy times per the circadian rhythm. Routine, nonsurgical, periodontal treatment (“deep cleaning”) that can be performed by dental health care professionals in general dental practice or in periodontists’ specialty offices—together with proper home oral hygiene care—can lead to improved glycemic control in type 2 diabetes. Hyperglycemia can also contribute to impaired healing of lesions around the apex (tip) of the teeth with chronic infection and inflammation persisting in the jaw bone. Extraction of teeth that suffer from chronic periodontitis or periapical periodontitis leads to decreased levels of inflammatory biomarkers. Moreover, diabetes and the use of diabetes medication can lead to dry mouth, which contributes to development of caries, periodontitis, and thrush (candidiasis). Diabetic neuropathy can lead to burning mouth syndrome (glossodynia) and taste impairment (dysgeusia) and may be involved in trigeminal nerve pain and temporomandibular joint disorders. Both periodontitis and diabetes lead to potentially severely diminished quality of life. Nonetheless, people with diabetes have fewer dental visits than their peers without diabetes. It is important for both dental and medical care providers to keep in mind the possible coexistence of periodontitis and dysglycemia (hyperglycemia), as both diseases negatively affect each other. Proper, mutual referral is essential, as both diseases can be improved, if the informed providers collaborate in a patient-centered, interprofessional team approach in the interest of the best possible oral and systemic health for their mutual patients. Therefore, it may make both medical and financial sense to include the attainment of a healthy mouth in diabetes management, as well as screening for diabetes in the dental office, with the potential for substantial decreases in the burden of both human disease and suffering, as well as financial costs, to the benefit of the individuals, their caregivers, and society overall.