Diabetes & Periodontal Disease: FDJ Letter

King and Chasma report a doubled risk for diabetics to develop periodontal disease (1). This may be an underestimate. Battancs et al claim that the risk is 3-4 times and 10 times for diabetics who smoke (2). King and Chasma call for better communication between doctors and dentists, echoing other earlier similar calls (3, 4). These authors also say there are few referrals from doctors to dentists. I agree.

We need to consider why the latter may be the case. In my opinion, the explanation may hinge on the fact that the majority of doctors have probably not been taught about any link between the two diseases. For example, when questioned on the issue, staff from both my former and current general medical practices were completely unaware. This link is ‘not something widely known amongst physicians and diabetes physicians as well I would say’ (John Wass, professor of endocrinology at the University of Oxford, personal communication, 2022). It gets worse:

• The NHS web page on diabetes fails to mention either periodontal disease or the complications of xerostomia and burning mouth syndrome (5).
• The charity Diabetes UK mentions periodontal disease on its website but not in great detail although there has been some improvement since I wrote to the chief executive in December 2021 (6).
• Dental checks are omitted from the other diabetic conditions that the National Institute for Health and Care Excellence (NICE) requires to be checked annually by doctors (cardiovascular, eye, kidney and foot problems, and erectile dysfunction) (7). NICE refused my request for this addition in 2020. Another request was lodged on 16 March 2022 by petition to the House of Commons (8).

With this background, how are diabetics who do not attend for dental care going to find out about the additional risks to their health? The scientific evidence linking the two diseases in a bidirectional relationship is strong (9). The issues that need consideration are:

• making doctors aware of the links between diabetes and dental disease;
• helping doctors identify diabetic patients who are at higher risk of oral health deterioration and encouraging referrals to dentists for those who do not receive regular dental care. When doctors have diabetics with glycated haemoglobin (HbA1c) results that are persistently over 6.5% despite appropriate treatment, they should consider periodontal disease as a possible contributory factor and make a dental referral (4).
• determining what information should be shared between professionals;
• finding ways to involve diabetics in their overall healthcare.

Things will only improve when rules and advice are changed at a national level.

Doctors and dentists are busy professionals with considerable demands on their time. Both parties need to recognise those diabetic patients who are at higher risk and communicate with each other. This could be achieved by encouraging diabetics to keep their own HbA1c and basic periodontal examination results, and to share them with their professional advisors.

This will be all very well for those diabetics who do seek regular dental care but what about the majority who don’t? They may be unaware of dental risks if their doctors are unable to give them suitable advice. The same may also be true for pharmacists although this has not been researched.

While dentists have been encouraged to look after their diabetic patients in innovative ways, clinicians face a challenge to the capacity in the system. I would suggest that the following questions should be given consideration with the aim of possibly influencing national strategies:

• How are doctors to be made aware of oral complications of diabetes (ie: periodontal disease and xerostomia)? The benefit would be the identification of high risk patients and referral for a dental opinion.
• If there are to be increased number of referrals from doctors, how can the dental profession create additional sustainable capacity?
• This may require changes in longstanding working practices. Are six-monthly checks for dental patients necessary? How many of these patients should have been empowered to control their own plaque effectively and have their recall appointment time extended for one year or perhaps longer? (10). Such a change could release clinical time for others in greater need.

The care of diabetic individuals is already a significant and growing burden on healthcare resources. Doctors and dentists need to work together to identify those patients at greatest risk because successful periodontal treatment (owing to the bidirectional relationship) has been shown to improve glycaemic control (11). Despite persuasive scientific evidence, how long will it take to implement these changes?

References

1. King R, Chasma F.
   Diabetes and periodontal disease.
   FDJ 2022; 13: 78-81.
2. Battancs E, Gheorghita D, Nyiraty S et al.
   Periodontal disease in diabetes mellitus: a case–control study in smokers and non-smokers.
   Diabetes Ther 2020; 11: 2715-2728.
3. Siddiqi A, Zafar S, Sharma A, Quaranta A.
   Diabetes mellitus and periodontal disease: the call for interprofessional education and interprofessional collaborative care – a systematic review of the literature.
   J Interprof Care 2022; 36: 93-101.
4. Turner C.
   Diabetes mellitus and dental health: a review. (PDF).
   Geriatr Med J 2021 Nov 16.
5. Diabetes.
   https://www.nhs.uk/conditions/diabetes (cited June 2022).
6. Diabetes UK.
   Diabetes and gum disease.
   https://www.diabetes.org.uk/guide-to-diabetes/complications/gum-disease (cited June 2022).
7. National Institute for Health and Care Excellence.
   Type 2 Diabetes in Adults: Management (NG28).
   London: NICE; 2015.
8. UK Parliament.
   Periodontal disease and diabetes.
   https://hansard.parliament.uk/Commons/2022-03-16/debates/22031672000203/PeriodontalDiseaseAndDiabetes (cited June 2022).
9. Grossi SG, Genco RJ.
   Periodontal disease and diabetes mellitus: a two-way relationship.
   Ann Periodontol 1998; 3: 51-61.
10. Turner CH.
    Implant maintenance.
    The Dentist pp62-64.
11. Genco RJ, Graziani F, Hasturk H.
    Effects of periodontal disease on glycemic control, complications, and incidence of diabetes mellitus.
    Periodontol 2000 2020; 83: 59-65.