General Health

The Seesaw of Diabetes Mellitus and Periapical Infections

In diabetes mellitus, blood glucose levels rise beyond 120mg/ml and can lead to severe complications if not addressed immediately. These complications consist of retinopathy, diabetic neuropathy, glaucoma, the diabetic foot, etc. However, one of the lesser-known complications of diabetes is associated with the oral cavity which could include periapical lesions and periodontitis.

Periapical lesion is an inflammation that affects the soft and hard tissues surrounding the tooth and can further damage the supporting bones. Periodontitis is a gum infection which causes the teeth to loosen. The similarities between periapical lesions and periodontitis are:

  • Both are chronic inflammatory conditions of the oral cavity.
  • Both the infections are caused by gram negative anaerobes.
  • There is a rise in the inflammatory mediators in both the conditions which can adversely affect the body.

Many studies have shown the link between diabetes mellitus and oral infections such as periodontal disease and gingivitis and how they can conversely affect each other. On this basis, periapical infections can also be correlated with Diabetes mellitus.

The effect of diabetes mellitus on periodontal diseases

Periapical periodontitis is a chronic inflammatory condition of the apical region of the tooth caused by bacterial infections (such as A. actinomycetemcomitans, P. gingivalis) in the pulp region. According to a study, apical periodontitis in the Europe increases with the age of the patient. The treatment for periapical periodontitis is a root canal treatment that is surgical in nature.

Diabetes mellitus compromises the immune system as it disturbs the immune cell function and delays the wound healing process. Hence, diabetic patients are extremely susceptible to oral inflammatory issues.

Bender et al found the rapid development of periapical radiolucency in patients with poorly controlled diabetes whereas in well controlled diabetic patients, they heal as well as in healthy patients. Ueta et al discovered that in diabetic patients there was a higher incidence of severe periapical or periodontal infection and they emphasized that diabetes can exacerbate endodontic infections.

In a 2003 study, Fouad and Burleson concluded that diabetic patients who have undergone a root canal treatment have lesser likelihood of its success with the presence of an existing periradicular lesion.

The effect of periapical lesions on diabetes mellitus

Periodontitis may have a negative impact on glycaemic control in diabetic patients. Many studies claim that the condition show effects similar to those of obesity in diabetic patients. Periodontitis leads to insulin resistance by increasing cytokine immune response.

Bender et al also found that periapical inflammatory lesions are higher in diabetic patients. The local periapical infection and inflammation increases blood glucose levels leading the patient into an uncontrolled state of diabetes which can be treated by administering insulin. Insulin treatment can be retracted once the periapical inflammation has reduced.

Chronic periapical inflammation is accompanied by activating the innate immunity. Lipopolysaccharide or LPS from gram negative anaerobic bacteria causes periapical inflammation. It activates the intracellular pathways on neutrophils and macrophages and upregulates the levels of inflammatory cytokines like TNF-α, Prostaglandin E2, IL-Iβ, IL-6, IL-8. These cytokines flow into the system and interacts with Advanced Glycation end products (AGEs) and fatty acids which are found in elevated amounts in diabetes mellitus and thus, aggravates the condition.

When these pathways are activated within the adipocytes, endothelial cells, muscle cells, hepatocytes, and macrophages it could promote insulin resistance.

Diabetic patients are very susceptible to bleeding and have delays in wound healing after a dental procedure or operation. Hence, dentists have to take special care while diagnosing and treating oral conditions in diabetic patients.


Sanjana Raman graduated from D Y Patil University with a degree in dentistry. She believes in the power of promoting dental education and learning through discussing various related medical topics.

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