Clinical implications

Oral health care professionals. Maintaining and improving oral health and glycemic control are fundamental to the well-being of patients who have diabetes and periodontitis. Due to the high incidence of diabetes and the increased prevalence of periodontitis in older adults who have poor glycemic control, periodontists or dental hygienists should be able to screen patients for diabetes.12 Patients with diabetes should be given preventive periodontal regimens that are adequately intense and sustainable to remove periodontal inflammation, and these regimens should be coordinated with general clinical diabetes management.17 Patient education, smoking cessation, and regular brushing and flossing of teeth are other components of periodontal disease prevention in patients with diabetes.6

Primary health care providers. NPs and PAs are adept at assessing, monitoring, and treating patients with diabetes. Assessment and monitoring of patients with diabetes should include oral health evaluations. Boyd and colleagues concluded that medical providers should be trained to identify oral infections such as periodontitis, so that treatment can be started early to help avert diabetic complications.13

As shown in Table 2, patients should be assessed for loose teeth, bleeding gums, and gum disease, and they should be encouraged to visit a dentist or periodontist at least twice a year.4 NPs and PAs must communicate and collaborate with dental professionals to ensure that patients are getting the most appropriate therapy. This collaboration is paramount due to the increasing evidence of the comorbidity between periodontal disease and diabetes.4 Patients must be participants in their care through self-education, self-monitoring, and self-management.6 Hopefully, changed behaviors will improve positive outcomes for both periodontitis and diabetes. Health care providers should provide patients with information about gum disease prevention and advise them to seek treatment for periodontitis as soon as signs and symptoms occur.24 The evidence suggests that education and behavioral change are key factors for plaque reduction and glycemic control.

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Many patients with diabetes have, or are at risk for, periodontal disease. The AGEs produced during extended hyperglycemia have been implicated in the development of periodontitis. Inflammatory processes caused by periodontitis may lead to alveolar bone destruction, metabolic imbalance, and systemic complications such as CVD. The reciprocal relationship between periodontitis and diabetes over time leads to severe periodontal damage and poor glycemic control. Multiple treatment options are available, including mouth rinses, SRP, with or without antibiotics, and surgical reflection of soft tissue flaps. The impact of periodontal treatment on glycemic control seems to be positive, with the difference in A1c levels before and after periodontal treatment ranging from −0.30% to −0.80%.18,22,23 SRP with adjuvant antibiotic or chlorhexidine mouth rinse has led to A1c reductions in several studies.16,17,19 Preventive strategies for periodontitis include daily flossing and brushing of one’s teeth, elimination of sugary foods and drinks, and avoidance of secondhand smoke. Clinicians, including NPs and PAs, must work in collaboration with oral health professionals to effectively educate patients in preventing periodontal diseases, to screen for diabetes and periodontitis, and to manage both conditions while encouraging patients to practice healthy behaviors that prevent periodontal disease and improve health outcomes.

Clavel Nelson, FNP-BC, MSN, DNP, is a family nurse practitioner at Community Education Centers in Newark, N. J. She was a DNP student at the University of South Alabama when she conducted the translational research and wrote the article.

Brenda Holloway, RN, FNP-BC, MSN, DNSC, is a professor at the University of South Alabama, College of Nursing, in Mobile. 


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  2. Thornton-Evans G, Eke P, Wei L, et al. Periodontitis among adults aged ≥30 years—United States, 2009-2010. MMWR Surveill Summ. 2013;62(suppl 3):129-135.

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  8. Chee B, Park B, Bartold PM. Periodontitis and type II diabetes: a two-way relationship. Int J Evid Based Healthc. 2013;11(4):317-329.

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  12. Lamster IB, Lalla E, Borgnakke WS, Taylor GW. The relationship between oral health and diabetes mellitus. J Am Dent Assoc. 2008;139(suppl):19S-24S. 

  13. Boyd LD, Giblin L, Chadbourne D. Bidirectional relationship between diabetes mellitus and periodontal disease: State of the evidence. Can J Dent Hygiene. 2012;46(2):93-102.

  14. Douglass AB, Maier R, Deutchman M, et al. A National Oral Health Curriculum, 3rd ed. Society of Teachers of Family Medicine: 2010. Available at

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  16. Al-Zahrani MS, Bamshmous SO, Alhassani AA, Al-Sherbini MM. Short-term effects of photodynamic therapy on periodontal status and glycemic control of patients with diabetes. J Periodontol. 2009;80(10):1568-1573.

  17. Madden TE, Herriges B, Boyd L, et al. Alterations in HbA1c following minimal or enhanced non-surgical, non-antibiotic treatment of gingivitis or mild periodontitis in type 2 diabetic patients: A pilot trial. J Contemp Dent Pract. 2008;9(5):9-16.

  18. Simpson TC, Needleman I, Wild SH, et al. Treatment of periodontal disease for glycaemic control in people with diabetes. Cochrane Database Syst Rev. 2010;12(5):CD004714

  19. Botero JE, Yepes FL, Ochoa SP, et al. Effects of periodontal non-surgical therapy plus azithromycin on glycemic control in patients with diabetes: a randomized clinical trial. J Periodontal Res. 2013;48(6):706-712.

  20. Dag˘ A, Firat ET, Arikan S, et al. The effect of periodontal therapy on serum TNF-α and HbA1c levels in type 2 diabetic patients. Aust Dent J. 2013;54(1):17-22.

  21. Engebretson SP, Hyman LG, Michalowicz, et al. The effect of nonsurgical periodontal therapy on hemoglobin A1c levels in persons with type 2 diabetes and chronic periodontitis: a randomized clinical trial. JAMA. 2013;310(23):2523-2532.

  22. Gilowski L, Kondzielnik P, Wiench R, et al. Efficacy of short-term adjunctive subantimicrobial dose doxycycline in diabetic patients—­randomized study. Oral Dis. 2012;18(8):763-770.

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All electronic documents accessed on February 12, 2015.