Clinical Context
The bidirectional relationship between diabetes and periodontitis is well-established. Diabetes increases periodontal disease risk and severity through hyperglycemia-driven immune dysfunction, impaired healing, and microvascular changes. Conversely, periodontitis—with its chronic inflammatory burden—worsens glycemic control. Treating gum disease can improve HbA1c, a finding supported by multiple trials and meta-analyses showing 0.3-0.4% HbA1c reductions following periodontal therapy.
Standard non-surgical periodontal therapy involves scaling and root planing (SRP) to remove bacterial biofilm and calculus from root surfaces. While effective, outcomes in diabetics are often suboptimal compared to non-diabetics, prompting interest in adjunctive therapies to enhance healing. Systemic or local antibiotics, antiseptics, and various regenerative agents have been studied with variable results.
Hyaluronic acid (HA) is a glycosaminoglycan with anti-inflammatory, antioxidant, and wound-healing properties. It’s a natural component of gingival connective tissue and plays roles in tissue repair and immune modulation. Topical HA gel applied to periodontal pockets after scaling could theoretically enhance healing, reduce inflammation, and improve outcomes. This RCT tested HA gel as an adjunct to standard periodontal therapy in diabetic patients.
Study Summary (PICO Framework)
Summary:
In type 2 diabetics with stage-II periodontitis, non-surgical periodontal therapy plus hyaluronic acid gel significantly improved both HbA1c and periodontal clinical parameters compared to periodontal therapy alone, with no significant adverse effects.
| PICO | Description |
|---|---|
| Population | Adults with T2DM and stage-II periodontitis. |
| Intervention | Non-surgical periodontal therapy (PMPR) + hyaluronic acid gel. |
| Comparison | PMPR alone. |
| Outcome | Significant improvement in HbA1c and periodontal parameters with HA adjunct. No adverse effects. |
Clinical Pearls
1. The diabetes-periodontitis connection creates a treatment opportunity. Improving periodontal health can improve glycemic control—and this study shows that enhancing periodontal outcomes (with HA adjunct) further improves HbA1c beyond standard periodontal therapy. The mouth is a modifiable contributor to systemic inflammation affecting diabetes. Don’t overlook oral health in diabetes management.
2. HbA1c improvement from dental treatment rivals some medications. The HbA1c reductions seen with periodontal therapy (and enhanced with HA adjunct) are clinically meaningful—comparable to adding some diabetes medications. For patients resistant to medication intensification or seeking non-pharmacological approaches, periodontal care should be emphasized as part of comprehensive diabetes management.
3. Hyaluronic acid provides a safe, well-tolerated adjunct. HA gel is biocompatible, naturally occurring in tissues, and associated with no significant adverse effects in this study. Unlike systemic or local antibiotics (which raise resistance concerns), HA provides adjunctive benefit through anti-inflammatory and healing mechanisms without antibiotic-related drawbacks.
4. Stage-II periodontitis represents moderate disease—early-moderate intervention matters. This study focused on stage-II periodontitis (moderate severity), not end-stage disease. Treating periodontitis at this stage, rather than waiting for severe disease, may yield better outcomes for both oral and systemic health. Screen diabetic patients for periodontitis and refer early.
Practical Application
Recommend periodontal evaluation for all diabetic patients: Periodontitis is highly prevalent in diabetes and often underdiagnosed. Annual dental evaluation with periodontal screening should be part of standard diabetes care. Explain to patients that gum disease can worsen their diabetes, making treatment a “two-for-one” benefit.
Communicate with dental colleagues about diabetic patients: Inform dentists about patients’ diabetes status, HbA1c levels, and medications. Conversely, ask about periodontal findings when patients return from dental visits. Coordinate care—dental treatment is medical treatment for diabetics with periodontitis.
Discuss adjunctive therapies like HA gel with periodontists: If a diabetic patient requires periodontal treatment, discuss whether adjunctive HA gel is available and appropriate. While not universally used, evidence like this study supports its potential benefit in diabetic patients who may have impaired healing with standard therapy alone.
Track HbA1c before and after periodontal treatment: Consider checking HbA1c before and 3 months after comprehensive periodontal treatment in diabetic patients. This can quantify the glycemic benefit and reinforce for patients the importance of maintaining oral health. Improvements in HbA1c can be motivating for continued dental care adherence.
How This Study Fits Into the Broader Evidence
Meta-analyses consistently show that periodontal treatment improves glycemic control in diabetics, with HbA1c reductions of approximately 0.3-0.4% on average. This effect size is clinically meaningful and comparable to adding some diabetes medications. The diabetes-periodontitis connection is recognized in ADA guidelines and international diabetes management recommendations.
Hyaluronic acid has been studied as an adjunct to periodontal therapy in various populations, with generally positive results for clinical outcomes like probing depth reduction and clinical attachment gain. This study extends the evidence specifically to diabetic patients and demonstrates glycemic benefit beyond periodontal improvement alone.
Other adjunctive therapies studied in periodontal treatment include local delivery antibiotics (minocycline, doxycycline), antiseptics (chlorhexidine), photodynamic therapy, and probiotics. Head-to-head comparisons are limited, but HA has theoretical advantages of being non-antibiotic and naturally occurring.
Limitations to Consider
Sample size and follow-up duration aren’t detailed—sustainability of improvements is important. The specific HA gel formulation and application protocol affect reproducibility. Stage-II periodontitis was studied; effects may differ in more or less severe disease. Blinding of outcome assessors (for clinical periodontal measures) affects bias risk. Cost and availability of HA gel products vary. The HbA1c improvement magnitude isn’t specified—clinical significance depends on effect size.
Bottom Line
Adding hyaluronic acid gel to non-surgical periodontal therapy improved both periodontal clinical parameters and HbA1c in type 2 diabetic patients with stage-II periodontitis, compared to periodontal therapy alone, with no adverse effects. This study reinforces the importance of periodontal care as part of comprehensive diabetes management and suggests HA gel may be a useful adjunct for diabetic patients undergoing periodontal treatment. For clinicians managing diabetes, ensuring patients receive appropriate dental care—and communicating with dental colleagues about enhanced treatment options—can contribute to improved metabolic control.
Source: Reem Al-Abbadi, et al. “Non-surgical periodontal therapy with and without hyaluronic acid gel in type 2 diabetic stage-II periodontitis patients: a randomized clinical trial.” Read article here.
