and periodontal disease. ³ In addition, BMI is positively vanced as children become adolescents, exposing young and significantly related to the severity of attachment patients to greater risk for periodontal disease, which in loss after adjusting for age, gender, income, education, turn complicates glycemic control and increases risk for race and ethnicity, and smoking. ³ This increased risk systemic injury. Programs to promoteperiodontal disease does not vary after adjusting for cholesterol, triglycer- prevention and treatment should be provided to young ides, and CRP. ³ An analysis of NHANES III data indicated diabetic patients. ⁴² that waist-to-hip ratio, BMI, fat-free mass, and subcutaneous fat (centraladiposity) were significantly correlated Certain subgroups of diabetic people are at higher risk with periodontal disease, suggesting that abnormal fat for developing periodontal disease. These include patients metabolism plays a role in the pathogenesis of periodon- with poor oral hygiene, patients with a long history of dia-tal disease. ³ Additional research mirrors these risk rela- betes, patients with complications of diabetes (i.e., reti-tionships. Al-Zahrani⁴ and colleagues found that young nopathy, angiopathy, nephropathy, neuropathy, delayed individuals ( 18-34 years old) with abdominal obesity would healing), patients with poorly controlled diabetes, (high waist circumference) had an adjusted odds ratio of teenagers, and pregnant women. ³⁷

2. 27 for having periodontal disease. This suggests that
obesity could be a potential risk factor for periodontal In diabetic patients, the risk of infection may be directly
disease, especially in younger individuals. ⁴ Saito⁴⁰ and related to fasting blood glucose levels. One study found
colleagues found that individuals with upper body obe- that patients with fasting blood glucose levels below 206
sity (i.e., high waist-to-hip ratios) are at increased risk mg/dL had no increased risk, and patients above 230 mg/
for periodontal disease. Clearly, promoting healthy nu- dL had an 80% increased risk of developing infection. ⁴³
trition and appropriate physical activity may prevent or Intensive glycemic control can prevent or delay the onset
decrease the rate of progression of periodontal disease. and slow the progression of microvascular complications
Patient education material that alerts patients about the associated with both types 1 and 2 diabetes. ⁴⁴ Likewise,
role of obesity in increasing the risk for gum disease may good glycemic control is associated with improved peri-
be accessed and downloaded from the Clinical Decision- odontal status. ¹⁹ Insulin-dependent diabetics may also be
Making Tools section at www.thesystemiclink.com. genetically predisposed to an exaggerated inflammatory
response to gram-negative bacterial infections. ¹⁷ Com-

Secondary Prevention pared with non-diabetic individuals, insulin-dependent Secondary prevention of diabetes is aimed at minimiz- diabetic patients exhibit this hyperinflammatory response ing the risk diabetic patients have for macro- and micro- when challenged with an equivalent bacterial burden. ¹⁷ vascular complications. Interventions focus primarily on There is also evidence suggesting that chronic periodontal gaining and sustaining glycemic control to the same level infection contributes to the state of insulin resistance.^{45, 46} as a healthy, non-diabetic individual. ⁴¹ Recognizing the Accordingly, medical providers need to identify patients less obvious signs of uncontrolled glucose levels, such as at risk for periodontitis and incorporate referral proto-poor healing and unresolved infection, and correlating cols into routine practice. Physician recognition that peri-these findings with classic signs and symptoms of uncon- odontal disease is a chronic gram-negative infection with trolled diabetes can enable dental providers to identify a direct impact on glycemic control is the first step in de-patients with previously undetected diabetes. veloping important collaboration with dental providers.

 

Metabolic control appears to be an important factor in the To provide a more graphic description of the opportunity development and progression of gingivitis. ³⁷ For this rea- for systemic seeding of periodontal bacteria throughout son, it is important that children with diabetes be moni- the vasculature, it has been estimated that the epithelial tored carefully for glycemic control. In a study group of surface area potentially exposed to virulent, gram-nega- 182 children and adolescents with diabetes and 160 non- tive bacteria associated with chronic periodontitis ranges diabetic control subjects, Lalla⁴² and colleagues found that in size from 8 cm² to 20 cm^{2 (ref 47)} roughly the average size diabetes remained highly correlated with periodontitis, of an adult palm. For diabetics with poor glycemic control, especially in 12- to 18-year-olds, and BMI was significant- exposure to a gram-negative infection of this size would ly correlated with destruction of the periodontium. These pose an obvious threat to systemic health. For this rea-observations suggest that periodontal destruction may son, healthcare providers from both medicine and den-start very early in life for diabetics and become more ad- tistry must be familiar with the glycemic control (HbA1c)