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The association between diabetes mellitus and periodontal disease has been studied for many decades. The link between the two conditions is complex, and as understanding of it deepens, the approach to patient management has begun to change. But change is slow, and there is a long way to go in dentistry as a profession. In managing any patient with periodontitis, especially the one with (or at risk for) diabetes, one must learn to think beyond teeth and gums. One must learn to manage not just the disease, but the person with the disease.
Aging and Chronic Diseases
Changes in population over the past decades, and as we move forward, are important for all healthcare professionals to understand and consider. The world population is growing, and the growth is more notable in less-developed countries.1 A major public health success is that, overall, infant mortality rates have significantly dropped and more children grow up to become adults. At the same time, life expectancy has increased, so adults live longer lives, but the total fertility rate (ie, the average number of children per woman) has dropped. Therefore, population growth is primarily in the older age groups, a phenomenon that has been described as “trading young for old.”
The global population is aging. According to United Nations data,2 since the beginning of recorded history, young children had always outnumbered their elders. But now, for the first time, people 65 years and older will outnumber children younger than 15 years. The number of older adults worldwide is projected to triple by mid-century. In the United States, their number is expected to slightly more than double by then. People 65 years and older represented 15% of the US population in 2015 and are projected to increase to 24% of the total US population by 2060.
In the early part of the 20th century, the major health threats were infectious and parasitic diseases that most often claimed the lives of infants and children. Currently, noncommunicable diseases that more commonly affect adults, particularly older adults, impose the greatest burden on global health.
The chances of spending later years in good health and well-being vary, but there has been a dramatic increase in the prevalence of many chronic conditions around the world, including in the more-developed countries. Thus, the distinction is now made between life expectancy and healthy life expectancy. According to US data by the National Council on Aging, 92% of older adults have at least one chronic disease and 77% have at least two.3
These statistics suggest that oral health professionals will need to examine and treat increasing numbers of older adults, many of whom will present with complex medical histories and multiple comorbidities.
The Diabetes Paradigm
Diabetes is a common, chronic health condition. Given the higher prevalence and severity of periodontal disease among patients with diabetes, many of these patients also seek oral health services, and the number is sure to increase over time.
According to the International Diabetes Federation,4 the number of people affected by diabetes in 2015 was 415 million and the projection for 2040 is a rise to 642 million. Among older individuals, those aged 65 to 79 years, the number of people with diabetes is expected to more than double over this period, reaching 200 million by 2040. It is estimated that as many as 47% of all those affected by the disease remain undiagnosed. The most recent data from the Centers for Disease Control and Prevention (CDC)5 state that 30.3 million people are affected by diabetes in the United States and that 24% of them remain undiagnosed. Across all ages, diabetes prevalence in the United States is 9.4%, but it is 25% in those 65 years and older.
Prediabetes, an intermediate metabolic state between health and diabetes, is characterized by mild hyperglycemia and insulin resistance. Its prevalence is much higher than that of frank diabetes. According to the CDC,5 prediabetes affects 34% of all adults in the United States (84 million people), 48% of those 65 years or older. Most of those affected, 88%, remain undiagnosed. Prediabetes has been described as a “silent precursor”: it goes unrecognized and puts people at high risk for type 2 diabetes and, independently, vascular disease.6 The good news is that prediabetes is reversible and that even small changes can have a large impact. Multicenter trials have demonstrated that the risk for progression to diabetes can be lowered by approximately 60% with relatively simple changes in body weight and physical activity.7,8
Diabetes is an established risk factor for periodontitis.9,10 It leads to a hyper-inflammatory response to the subgingival bacterial challenge and impairs repair. Periodontal destruction can start very early in life in patients with diabetes, and its severity depends on the level of glycemic control.11 Improved diabetes outcomes can result in improved periodontal status and response to therapy. The association between diabetes and periodontitis has been described as two-way; periodontitis has been shown to adversely affect glycemic control in diabetes and contribute to the development of its other complications.12 This is potentially explained by an increase in systemic inflammation, which promotes insulin resistance. Furthermore, the American Diabetes Association (ADA) recommends screening for and treatment of modifiable risk factors for cardiovascular disease in people with diabetes.13 Studies to date support an association between periodontitis and atherosclerotic vascular disease that is independent of known confounders,14 so periodontitis is one of those modifiable risk factors to watch out for.
Many common themes have been described for diabetes and periodontitis. Interestingly, a decade ago, Hein and Small first described the two as “syndemic conditions.”15 The term syndemic was introduced in the mid-1990s to describe a set of two or more linked health problems that synergistically contribute to excess burden in a population. “A syndemic orientation can guide more efficient and effective initiatives, because healthcare providers will not approach diseases as discreet problems and will be prompted to collaborate across and beyond professional boundaries,” Hein and Small noted.
There is a difference between the terms “comorbid” and “syndemic.” It is possible for two diseases to be comorbid but not syndemic. With syndemic conditions, there is some biologic interaction that exacerbates the negative health effects of any of or all the diseases. Thinking of diabetes and periodontitis as syndemic conditions significantly changes the way to understand their association and the way to manage patients affected by these diseases.
Working Together
The facts are straightforward: type 2 diabetes is preventable and has several easily identifiable risk factors16:
• age > 40 years (or younger for high-risk race/ethnicity individuals)
• high-risk race/ethnicity (African American, Hispanic/Latino, Alaska Native, American Indian, Asian American, or Pacific Islander)
• family history of diabetes (first-degree relative)
• overweight/obesity
• habitual physical inactivity
• prediabetes
• hypertension (blood pressure ≥ 140/90 mm Hg or therapy for hypertension)
• dyslipidemia (high-density lipoprotein cholesterol ≤ 35 mg/dl or triglycerides ≥ 250 mg/dl)
• history of gestational diabetes or poly- cystic ovary syndrome
• history of cardiovascular or other diabetes-associated conditions
Management of established diabetes is complex, and achieving treatment goals is challenging. Large numbers of individuals are at risk, and large numbers remain undiagnosed. All stages of prevention are critical in diabetes: primary prevention, which focuses on risk reduction and health promotion; secondary prevention, aimed at early identification and treatment; tertiary prevention, with a goal to improve quality of life and delay terminal complications/death; and even primordial prevention, which is about prevention of risk factors themselves. The conclusion? Every healthcare professional has a responsibility and a contribution to make in the fight against diabetes and its complications, including periodontitis.
Diabetes Identification in the Dental Setting
The majority of the adults in the United States visit a dentist at least once a year and return for multiple, often non-emergent, visits. Dental settings can be healthcare locations actively involved in diabetes screening and risk factor assessment. Dental professionals can inform and advise patients, refer those at risk to medical colleagues for diagnostic workup and care, and importantly, follow up on the outcome and continue to educate after a potential diagnosis.
Early evidence for the feasibility of diabetes identification in dental settings came from National Health and Nutrition Examination Survey-based studies17; it afforded the author and colleagues the opportunity to test the concept for the first time prospectively, in a real-life clinic population. The goal was to develop and evaluate the performance of a targeted approach to identify unrecognized dysglycemia (diabetes and prediabetes) among dental patients.18,19 The author and colleagues screened 1,263 dental patients who were not previously told they had diabetes or prediabetes and were 40 years and older, if non-Hispanic white, or 30 years and older, if Hispanic or non-white. A total of 1,121 had at least one self-reported risk factor (family history of diabetes, hypertension, high cholesterol, or overweight/obesity); they continued to receive a periodontal examination and a point-of-care glycated hemoglobin (A1C) test (which would be considered as one of the variables in the identification algorithm). These patients were invited to have a blood draw for a diagnostic test, and 1,097 either returned for a fasting plasma glucose test or had a same-day high-performance liquid chromatography (HPLC) A1C test. Using ADA criteria, 6.6% were identified with potential diabetes and 39.7% with prediabetes.
The performance of different identification models was then tested; three were more closely observed (Figure 1).19 The first one used only two dental variables and correctly identified 75% of dysglycemia cases. Correct identification increased to 90% with the addition of a point-of-care (finger stick) A1C test, as expected. Identification was even more accurate when only frank diabetes was the outcome.
Sensitivity is the most important performance characteristic in this dental setting approach because the dental professional does not deliver a formal diagnosis or treat the hyperglycemia. The role of the dentist is to alert the patient of the risk and the need to see a physician for management of risk factors and further diagnostic workup.
In separate analyses, the ability of the models was assessed not only to detect, but also to characterize hyperglycemia (ie, to discriminate between each of the three potential outcomes: health versus prediabetes versus potential diabetes). The analyses revealed that the point-of-care A1C test result added significant value in this task.
Other approaches to screening in dental settings have been since reported in the literature.20,21 Some included the use of gingival blood.22 That is not always feasible, but it presents an alternative for clinicians and patients who feel uncomfortable with collecting or providing a finger-stick blood sample. Earlier work assessing the attitude of dentists towards diabetes screening and management suggested a recognition that these activities are important but noted some reluctance toward more active involvement.23,24 A more recent study, by the Dental Practice-Based Research Network,25 in 28 practices in the United States and Sweden concluded that implementation of diabetes screening in dental practices is feasible and that both patients and dental providers believe that the dental visit is a good opportunity for early diabetes identification.
Toward Improving Health Outcomes and Health-related Quality of Life
The next logical question is, Can dentists impact patient behavior and improve health outcomes? A challenge with diabetes identification outside traditional medical settings has always been the need for follow-up with a physician for a definitive diagnosis and timely initiation of lifestyle management and/or pharmacotherapy. In 2015, the author and colleagues published a pilot study26 that assessed the effectiveness of a simple intervention aiming to modify behavior and glycemic status in patients who present at a dental clinic with diabetes risk factors and previously undiagnosed hyperglycemia. The study design is summarized in Figure 2. A total of 101 subjects were randomized. Participants in the basic (control) intervention group were informed about risk factors and their A1C result and were advised to see a physician for further evaluation. Those in the enhanced intervention (test) group received a more comprehensive explanation of the implications of their baseline findings, some advice on lifestyle modifications, and a written detailed report for their physician. They were also called at 2 and 4 months to be reminded that they needed to see their physician, if they had not already done so.
The study found no significant differences between the two interventions. Overall, 84% of subjects identified with potential diabetes or prediabetes at baseline reported visiting their physician within the 6-month follow-up period. One-third of the physicians failed to retest, but the majority advised patients on diet, weight/blood pressure control, and physical activity.
Most participants were originally identified as possibly having prediabetes. In this group, and among those who returned for the 6-month visit, 30% had improved to A1C levels below the prediabetes cut-off of 5.7%, 62% still had A1C levels in the prediabetes range, and only 8% had progressed to or above the 6.5% diabetes cut-off. Only 7 patients were originally identified as potentially having diabetes, and in all of them, A1C levels had improved to prediabetes levels at 6 months. Interestingly, 49% of participants reported at least one positive lifestyle change: 42% reported changing exercise habits, 22% changing diet, and 26% watching their weight based on the study’s advice.
Despite the study’s limitations (small sample size, absence of an “untreated” control group, self-reported behavioral outcomes, and limited generalizability to different populations), these findings are encouraging. The study concluded that oral healthcare providers have a role in diabetes risk assessment and management and can make a difference, but they must work across professional boundaries, as true members of the healthcare team.
Raising Awareness, Leading Education Efforts
Awareness of diabetes effects on oral health is limited among patients with diabetes. Such individuals are less likely to visit a dentist in a given year; the leading reason for not seeing a dentist is lack of perceived need.27 Only a small number of patients with diabetes are aware of the increased risk for periodontitis versus their knowledge of the risk for other systemic complications.28,29 Similar data exist for medical professionals30; they did not learn about oral health in training, and lack of time and knowledge are significant barriers in their advising patients about the importance of oral health.
The 2012 Workshop on Periodontitis and Systemic Diseases organized by the American Academy of Periodontology and the European Federation of Periodontology led to not only the publication of individual reviews of epidemiologic, treatment, and mechanistic studies, but also consensus reports with clinical recommendations for oral health professionals, medical health professionals, and patients at a physician’s or dentist’s office.31 According to these recommendations, patients with diabetes should be informed that they are at increased risk for periodontitis. If they already have periodontitis, they need to know that glycemic control may be more difficult and that they are at higher risk for other complications. The importance of health-promoting behaviors should be emphasized: these include glucose, blood pressure, and cholesterol control; lifestyle changes (healthy diet, exercise, oral hygiene); and regular professional checkups and care. As part of their initial medical evaluation, all patients with diabetes should be referred to receive a comprehensive oral/periodontal evaluation. Subsequent periodontal examinations should occur annually as part of diabetes ongoing management. For children with diabetes, annual oral screening is recommended beginning at age 6 to 7 years.
Importantly, the 2017 American Diabetes Association Professional Practice Committee guidelines include several references to the oral health and needs of patients with diabetes13:
• A “patient-centered communication style that uses active listening, elicits patient preferences and beliefs, and assesses literacy, numeracy, and potential barriers to care” is of importance.
• People with diabetes should receive healthcare from a team that may include (among others) physicians, nurses, dietitians, dentists, and mental health professionals.
• Comprehensive medical evaluation includes assessment of presence of common comorbidities and dental disease. Periodontal disease is more severe, and may be more prevalent, in patients with diabetes. Current evidence suggests that periodontal disease adversely affects diabetes outcomes, although evidence for treatment benefits remains controversial.
• Referrals for initial care management include one to a dentist for comprehensive dental and periodontal examinations.
Summary
In closing, much research work in the past decade has highlighted a new role and set of responsibilities for members of the dental profession that need to take place in the management of dental patients affected by, or at risk for, diabetes. Summarized below are some ideas (based on this body of work) whosetime has come:
• Programs designed to promote oral health awareness and periodontal disease prevention and treatment must be provided to all patients with diabetes, including children/adolescents and their families.
• Dental professionals are missing opportunities for diabetes risk reduction and early detection. Using simple screening algorithms, they can identify unrecognized dysglycemia in dental patients at risk and refer such patients to a physician for evaluation and appropriate care.
• Diabetes risk assessment, education, and medical referral of dental patients previously unaware of their status may promote healthy behaviors and have positive glycemic outcomes.
• Patient-centered, collaborative care across and beyond professional boundaries is the responsibility of all healthcare professionals.
References
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3. National Council on Aging. Healthy Aging Facts. https://www.ncoa.org/news/resources-for-reporters/get-the-facts/healthy-aging-facts/. Accessed June 30, 2017.
4. International Diabetes Federation. IDF Diabetes Atlas. 7th ed. http://www.diabetesatlas.org/key-messages.html. Accessed June 30, 2017.
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About the Author
Evanthia Lalla, DDS, MS
Professor of Dental Medicine
Division of Periodontics
Section of Oral, Diagnostic and Rehabilitation Sciences
Columbia University College of Dental Medicine
New York, New York
