Periodontitis and systemic health: the link with heart disease and diabetes

by Dr Nihad Pljevljak | Oct 10, 2025

Periodontitis is not just a disease of the teeth. Over the last twenty years, scientific research has consistently shown that this inflammatory gum disease is independently associated with cardiovascular disorders, diabetes and many other systemic conditions. The mouth acts as a gateway for bacteria and inflammatory mediators which, once they enter the bloodstream, can upset the balance of the whole body.

The biological mechanism behind the mouth–body connection

As periodontitis progresses, the harmful bacteria living in the gum pockets do not stay confined to the mouth. Through a process called transient bacteraemia, these micro-organisms enter the bloodstream every time we chew, brush our teeth or undergo dental procedures. Even more important is the role of inflammatory mediators, such as the cytokines IL-6 and TNF-α, which are produced locally but act throughout the body, together with C-reactive protein.

Inflamed periodontal tissue constantly releases these inflammatory mediators into the blood, creating a state of chronic low-grade inflammation that predisposes to degenerative diseases. This mechanism explains why patients with severe periodontitis show raised levels of systemic inflammatory markers even when they have no other illness.

Periodontitis and cardiovascular disease: a clinically relevant association

The link between periodontal disease and cardiovascular disease is now backed by a solid body of scientific evidence. Epidemiological studies indicate that patients with periodontitis have a higher risk of a first cardiovascular event, such as heart attack and stroke; estimates of the size of this risk vary between studies.

Atherosclerosis driven by oral inflammation

Traces of DNA, RNA or antigens from periodontal pathogens, in particular Porphyromonas gingivalis and Aggregatibacter actinomycetemcomitans, have been found inside atherosclerotic plaques. According to experimental studies, these micro-organisms may contribute to plaque instability by activating macrophages and producing metalloproteinases that break down the extracellular matrix.

The systemic inflammation triggered by periodontitis may encourage atherosclerosis through mechanisms under study such as:

Endothelial dysfunction: inflammatory cytokines damage the inner lining of the blood vessels
Increased clotting: higher levels of fibrinogen and factor VII, which encourage the formation of blood clots
LDL oxidation: promoting the formation of foam cells, the precursors of atherosclerotic plaque
Platelet activation: greater platelet aggregation, with a higher risk of thrombosis

Periodontal therapy lowers markers of systemic inflammation (C-reactive protein, IL-6) and improves measures of endothelial function; according to the 2020 EFP consensus, however, there is not yet enough evidence to say whether it reduces cardiovascular events.

The vicious circle between periodontitis and diabetes

The relationship between periodontitis and diabetes is a textbook example of a two-way disease. A meta-analysis of longitudinal studies indicates that diabetes with high blood sugar increases the risk of periodontitis starting or progressing by an average of 86% (RR 1.86), while periodontitis worsens blood sugar control in diabetic patients, creating a vicious circle that is hard to break without an integrated approach.

Why diabetes predisposes to periodontal disease

Diabetic patients have changes that encourage periodontitis to progress:

Formation of AGEs (Advanced Glycation End-products): glycation products that build up in the periodontal tissues, altering the immune response and collagen turnover
Microangiopathy: reduced blood supply to the gums, which impairs tissue oxygenation and healing
Altered immune response: neutrophils and macrophages work less well and are less able to clear harmful bacteria
Xerostomia: reduced saliva flow, which weakens the mouth's natural defences

How periodontitis undermines blood sugar control

Untreated periodontitis interferes with diabetes management through well-documented mechanisms. Chronic inflammation induces peripheral insulin resistance driven by pro-inflammatory cytokines, TNF-α in particular. Cohort studies show significantly higher glycated haemoglobin (HbA1c) levels in diabetic patients with periodontitis than in those with healthy gums, making blood sugar targets harder to reach.

Randomised clinical trials indicate that mechanical periodontal therapy, sometimes combined with antimicrobials, lowers HbA1c in diabetic patients: according to the 2022 Cochrane review, the average absolute reduction is about 0.43% at 3-4 months and about 0.30% at 6 months (moderate-certainty evidence), in line with the EFP-IDF consensus (0.27-0.48% at 3 months). This is a clinically meaningful result, which underlines the importance of a multidisciplinary approach.

An innovative approach: integrated screening and precision medicine

The emerging model for managing periodontitis calls for a change of perspective: no longer dentistry alone, but integrated oral medicine. At Nea Bios Dental Clinic in Rome EUR Laurentina, this approach translates into advanced clinical protocols.

Next-generation diagnostic tests

Modern periodontal diagnosis goes beyond traditional clinical probing. Adding molecular microbiological tests makes it possible to identify the specific pathogens involved and tailor antibiotic therapy. Analysing salivary inflammatory markers (aMMP-8, calprotectin) is being researched as a possible non-invasive assessment of disease activity and the risk of progression.

Technologies such as cone beam computed tomography (CBCT) allow a precise three-dimensional assessment of bone loss, which is essential for planning targeted regenerative procedures. Combined with artificial intelligence for predictive analysis, these tools represent the future of precision periodontology.

Evidence-based treatment protocols

Treating periodontitis requires a step-by-step, personalised approach:

Cause-related phase: deep scaling of the periodontal pockets with ultrasonic and hand instruments, without routine add-ons such as antimicrobial photodynamic therapy, which the EFP guideline advises against. The aim is to remove the bacterial biofilm and the tartar below the gum line that keep the inflammation going.

Re-evaluation and systemic therapy: once the tissues have healed, the clinical response is assessed. Systemic antibiotic therapy (for example amoxicillin-metronidazole) is not recommended routinely: the EFP guideline reserves it for specific groups of patients, such as generalised stage III periodontitis in young adults.

Regenerative phase: regenerative surgical techniques using biomaterials (resorbable membranes, enamel matrix derivatives, growth factors) to restore bone support in advanced lesions.

Supportive periodontal therapy: maintenance at intervals of 3 to a maximum of 12 months, set according to individual risk as recommended by the EFP guideline, essential to prevent relapse. This phase is often underestimated, yet it is key to maintaining results in the long term.

Multidisciplinary collaboration: the winning model

The best care for patients with periodontitis and systemic conditions requires teamwork between specialists. Dialogue between dentist, diabetologist, cardiologist and GP is no longer optional but necessary.

Dr Nihad Pljevljak, registered with the Rome Order of Physicians and Dentists (Ordine dei Medici Chirurghi e Odontoiatri di Roma) and holder of a PhD in Oral and Dental Diseases from Sapienza University of Rome, applies this integrated approach every day. His ten years of experience in the EUR district have allowed him to build a network of local specialists, ensuring coordinated care pathways for patients with complex conditions.

When a diabetic patient comes to the clinic for a periodontal assessment, a full screening is carried out that covers not only an examination of the mouth but also information on recent HbA1c, current medication and any complications. This information is shared with the patient's diabetologist, creating a synchronised treatment plan.

Prevention: the most effective investment in overall health

Primary prevention of periodontitis is a key strategy for general health too. The evidence indicates that treating periodontitis reduces systemic inflammation and improves blood sugar control in diabetics, while its effect on preventing cardiovascular events has not yet been proven.

Recommendations for prevention include:

Careful oral hygiene at home: brushing twice a day with a manual or electric toothbrush: the EFP guideline considers an electric toothbrush a valid alternative for patients in maintenance
Daily interdental cleaning: correctly sized interdental brushes (recommended by the EFP guideline where the space allows) or floss to remove biofilm from areas the toothbrush cannot reach
Regular professional check-ups: for healthy people, as often as the dentist advises; for patients with a history of periodontitis, supportive therapy at intervals of 3 to 12 months depending on risk
Not smoking: smoking is one of the main modifiable risk factors for periodontitis; according to a meta-analysis of longitudinal studies it increases the risk by an average of 85% (RR 1.85), and the EFP guideline recommends support to quit during treatment
Controlling systemic risk factors: optimising blood sugar control in diabetics, managing stress, correcting nutritional deficiencies

Early diagnosis is essential: bleeding gums when brushing are not normal and are the first sign of inflammation. Ignoring this symptom can lead to silent progression of the disease, with irreversible loss of the tissues that support the teeth.

Towards a new model of integrated oral health

Modern medicine is finally recognising that oral health is not separate from general health. The concept of periodontal medicine stresses that treating oral infections is not just a matter of appearance or function, but a public health measure with measurable effects on the whole body.

The international consensus reports of the EFP with the International Diabetes Federation and with the World Heart Federation recommend a periodontal assessment for people with diabetes and with cardiovascular disease. Likewise, patients with severe periodontitis may benefit from an assessment of cardiovascular and metabolic risk factors, even when they have no symptoms.

Putting this approach into practice requires ongoing training for professionals, patient awareness and healthcare systems that encourage communication between specialists. It has been suggested that integrating oral health into care pathways for chronic diseases could generate savings in healthcare costs, as well as improving clinical outcomes.

The difference made by established specialist experience

Tackling periodontitis with an awareness of its systemic impact requires skills that go beyond operative technique. It takes an overall vision, the ability to interpret the signals the body sends through the mouth and the skill to build personalised treatment plans.

At Nea Bios Dental Clinic in Rome EUR Laurentina, Via Cesare Pavese 135, Dr Nihad Pljevljak's approach combines scientific rigour with care for the person. His excellent academic training, crowned by a PhD in Oral and Dental Diseases, translates into clinical protocols in line with the latest scientific evidence. His experience with high-profile patients, including public figures who have chosen to entrust themselves to his care, reflects the reliability and discretion that characterise the clinic.

Don't wait for symptoms to become obvious. Periodontitis often progresses silently, while its systemic effects build up over time. A full periodontal assessment can make a difference not only to your smile, but to your cardiovascular and metabolic health.

Our reception is open Monday to Friday from 9:00 to 13:00 and 14:00 to 18:00 to give you detailed information and help you book a specialist visit. Investing in the health of your gums means protecting your heart and your metabolism. Contact Nea Bios Dental Clinic today and start an integrated health pathway with a team that truly understands the link between the mouth and the body.

Sources

Sanz M, Marco Del Castillo A, Jepsen S, et al. Periodontitis and cardiovascular diseases: Consensus report. J Clin Periodontol. 2020;47(3):268-288. PubMed
Sanz M, Ceriello A, Buysschaert M, et al. Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the International Diabetes Federation and the European Federation of Periodontology. J Clin Periodontol. 2018;45(2):138-149. PubMed
Simpson TC, Clarkson JE, Worthington HV, et al. Treatment of periodontitis for glycaemic control in people with diabetes mellitus. Cochrane Database Syst Rev. 2022;4(4):CD004714. PubMed
Nascimento GG, Leite FRM, Vestergaard P, et al. Does diabetes increase the risk of periodontitis? A systematic review and meta-regression analysis of longitudinal prospective studies. Acta Diabetol. 2018;55(7):653-667. PubMed
Leite FRM, Nascimento GG, Scheutz F, et al. Effect of Smoking on Periodontitis: A Systematic Review and Meta-regression. Am J Prev Med. 2018;54(6):831-841. PubMed
Sanz M, Herrera D, Kebschull M, et al. Treatment of stage I-III periodontitis-The EFP S3 level clinical practice guideline. J Clin Periodontol. 2020;47 Suppl 22:4-60. PubMed