Dental practices should focus on patients with severe periodontitis for screening of prediabetes

Diabetes has been an ongoing global health issue that has been associated with various other health conditions. Multiple studies have demonstrated the connection between diabetes and one such oral condition, periodontitis. Periodontitis is a severe gum infection that damages the soft tissue and destroys the supporting structures of the teeth. Its prevalence is 2X higher in those over 50 years old and 2-3X higher in patients with diabetes than in a normal healthy person. It is mainly associated with uncontrolled diabetes making them susceptible to infections and impaired wound healing.

Diabetes is a preventable disease, thus early diagnosis of prediabetes is essential for the prevention of diabetes and related complications. Studies suggest that periodontitis is an early complication of diabetes and it may be used as a tool to screen patients for diabetes early on. Although most dental practices lack equipment for blood biochemistry, measurements of glycated hemoglobin (HbA1c) may assist to screen for diabetes in patients with diabetes. The study aims to analyze HbA1c levels and affirm the presence of prediabetes in participants with or without periodontitis from a university dental clinic using analysis of dry blood spots. In a study, a consecutive series of patients from the Department of Periodontology of the Academic Centre of Dentistry Amsterdam (ACTA) who were diagnosed with periodontitis were to be enrolled for the treatment. A total of 313 participants were included, among which 126 patients had mild/moderate periodontitis, 78 patients had severe periodontitis and 109 subjects did not have periodontitis. HbA1c values were obtained by the analysis of dry blood spots. Moreover, differences in mean HbA1c values and the prevalence of prediabetes between the groups were analyzed. Patients were classified as suffering from periodontitis using the Centers for Disease Control and Prevention American Academy of Periodontology (CDC-AAP) case definition.

A pilot study determined the sample size, including 49 healthy subjects and 33 patients with periodontitis. Clinical relevance was demonstrated with a mean difference in the HbA1c of 0.7% (7 mmol/mol) between patients with periodontitis and control subjects. Sample size was calculated based on a two-sided student’s t-test of 5% with 80% power and the mean of HbA1c of both controlled and periodontitis groups (5.5% [37 mmol/mol] and 6.2% [44 mmol/mol]) respectively, and an overall study population-based SD of 1.3% (15 mmol/mol). A minimum of 61 subjects per group was required. According to the American Diabetes Association (ADA) guidelines, HbA1c values were classified as normal (<5.7%), prediabetes (5.7– 6.4%), or diabetes mellitus (≥ 6.5%). The parametric and nonparametric tests compared the general and diabetes-related characteristics of the study population, HbA1c levels, and prediabetes prevalence within the study population and were corrected for multiple testing (Bonferroni).

A significantly higher HbA1c value of 6.1% ±1.4% (43 mmol/mol±15 mmol/mol) in mild or moderate periodontitis groups resulted and 6.3% ±1.3% (45 mmol/mol±15 mmol/mol) in severe periodontitis groups compared to the control group of 5.7%±0.7% (39 mmol/mol±8 mmol/mol, p=0.003). Also, a noteworthy overrepresentation of suspected diabetes (23% and 14%) and prediabetes (47% and 46%) in the severe periodontitis group and mild/moderate periodontitis group respectively were shown, in comparison to the control group (10% and 37%, p=0.010). Overall, 18.1% of patients with suspected new diabetes were found among subjects with severe periodontitis compared with 9.9% and 8.5% among subjects with mild/moderate periodontitis and controls respectively (p=0.024).

In conclusion, the dental practices should focus on patients with severe periodontitis for screening for prediabetes because that would considerably decrease the number of suspected new diabetes cases. Since early detection is the key to prevention of diabetes, it adds on to prevent other severe complications along with the treatment of periodontitis. Normally, patients with periodontitis showed higher hbA1c levels compared with individuals without periodontitis. Among the study subjects with severe periodontitis with unknown metabolic status, there were 18% suspected new diabetes cases. Periodontitis as an early sign of diabetes mellitus serves as a valuable risk indicator and thus, dental offices that treat patients with periodontitis are suitable location for screening for diabetes by a simple finger stick and validated HbA1c dry spot analysis.

Practice Pearls:

• Early diagnosis of prediabetes mellitus is essential for the prevention of diabetes complications.
• Periodontitis may be a first sign of type 2 diabetes.
• On average, patients with periodontitis showed higher glycated hemoglobin (HbA1c) plasma levels compared with individuals without periodontitis.
• Among the subjects with severe periodontitis whose metabolic status was unknown, 18% of suspected new diabetes cases were identified.

References:

1. Davenport L. Dentists Note Severe Periodontitis ‘May Point to Early Diabetes. Medscape Log In. Medscape Medical News, 2 Mar. 2017. Web. 9 Mar. 2017.
2.  Lam DW, LeRoith D. The worldwide diabetes epidemic. Curr Opin Endocrinol Diabetes Obes.  2012;19:93–6.
3.  Mayo Clinic Staff. Periodontitis. Mayo Clinic. MFMER, 4 Feb. 2014. Web. 9 Mar. 2017.
4.  Teeuw WJ, Kosho MX, Poland DC, Gerdes VEA, and Loos BG. Periodontitis as a possible early sign of diabetes mellitus. BMJ Open Diabetes Research and Care.  2017;5:e000326.

Adults with type 2 diabetes and microvascular complications have an increased risk for severe periodontitis compared with those without microvascular complications.

Poor glycemic control is also associated with severity and prevalence of periodontitis in adults with type 2 diabetes, according to the researchers. The larger question is what comes first? Does diabetes cause periodontitis or does periodontitis increase our risk of diabetes?  Over the years, Diabetes In Control has published at least 12-15 articles on the subject. (Do a search at Diabetesincontrol.com)

Shuji Inoue, MD, PhD, in Japan, and colleagues evaluated 620 adults with type 2 diabetes who presented to diabetes clinics at 21 institutions to determine associations between periodontitis, microvascular complications and glycemic control.

Overall, 34.5% of participants had retinopathy, 25.8% had nephropathy and 29.8% had neuropathy. Half of all participants had at least microvascular complication. Glycemic control was poor in 47.2% of participants, fair in 24.5%, good in 21.8% and excellent in 6.5%.

Compared with participants without microvascular complications, participants with all three microvascular complications had a higher prevalence of periodontitis (P < .01), but no significant difference was found for the prevalence of periodontitis between participants without microvascular complications and those with one or two.

Severe periodontitis was more prevalent in participants with three microvascular complications (49.4%) compared with those with one (37.8%) or two (36.9%). Participants with two  or three microvascular complications had greater periodontitis severity compared with participants without complications.

Participants with poor glycemic control had a greater prevalence of periodontitis (71%) compared with participants with excellent glycemic control (50%; P < .01). Severe periodontitis was more prevalent in participants with poor glycemic control (40.6%) compared with those with fair glycemic control (28.3%), good glycemic control (28.1%) and excellent glycemic control (28%). Participants with good (P < .05), fair (P < .01) and poor glycemic control (P < .01) had greater periodontitis severity compared with participants with excellent glycemic control.

Research suggests that control of periodontal disease can play a key role in the control of diabetes. Thus, dentists must be aware of the signs and symptoms of diabetes, and understand the importance of maintaining periodontal health for anyone with diabetes.

Numerous studies have found a positive relationship between poor glycemic control in persons with type 2 and increased periodontitis. One five-year longitudinal study found increased attachment loss in adolescents with diabetes, whereas non-diabetic subjects had stable attachment levels.

A cross-sectional study of over 1,400 subjects found people with diabetes to have 2.3 times increased risk for attachment loss. In 48 studies on children and adolescents with type 1 diabetes, all but one found an increased prevalence of periodontal disease compared to children without diabetes. Of the eight reports limited to people with type 2, all found significantly poorer periodontal health in people with diabetes. In fact, after controlling for other risk factors, the odds of having periodontitis in people with diabetes was increased by two and a half to four times. Similar findings have been reported elsewhere.

In all cases, the level of diabetic control was a significant factor. Subjects with diabetes who were able to maintain consistent glycemic levels had no greater risk than did healthy subjects. For both type 1 and type 2 diabetes, there does not appear to be any correlation between the prevalence or severity of periodontal disease and the duration of diabetes.

The literature provides consistent evidence of greater prevalence and severity of periodontal disease in people with diabetes, both types 1 and 2. As these studies were conducted in distinctly different settings, with heterogeneous subjects and using a number of different measures of periodontal disease, we can state with confidence that people with diabetes have an increased susceptibility to periodontitis related to diabetes control.

Research suggests that control of periodontal disease plays a key role in the control of diabetes. Thus, dentists must be aware of the signs and symptoms of diabetes, and understand the importance of maintaining periodontal health for anyone with diabetes.

Practice Pearls:

• In patients with type 2 diabetes, the number of microvascular complications was associated with the severity of periodontitis, but not its prevalence.
• Poor glycemic control was associated with both the prevalence and severity of periodontitis.
• Prevention and control of periodontal disease must be considered an integral part of diabetes control.

Nitta H, et al. J Diabetes Investig. 2017;doi:10.1111/jdi.12633.

Firatli E. The relationship between clinical periodontal status and insulin-dependent diabetes mellitus. Results after 5 years. Journal of Periodontology 1997;68(2):136-40

Exclusive Interview from AACE Orlando

This is a 5-part transcript. Part 1 | Part 2 | Part 3 | Part 4 | Part 5

Steve Freed: So you keep saying that it’s important to keep the blood sugars normal. So what is a normal A1C and then what should the A1C be for a person who wants to get pregnant? And for a person who becomes pregnant?

Dr. Jovanovic: The normal A1C is less than 5.3%. For a woman with type 1 diabetes she’s asking the question of what’s the A1C that will prevent congenital anomalies, or birth defects and probably that’s an A1C less than 5.8%. Because, as the baby is forming and developing, two cells become four cells, but they won’t if the blood is sticky with a lot of sugar. Two cells will become three cells will become five cells, and that’s how you make a malformation, is too much sugar in the blood stream. Cells need to have a media that has almost no sugar in it, so that the cells can divide. So actually to prevent malformations is harder. So women with type 1 diabetes really need to be told to plan pregnancy, normalize their blood-glucose, and then have permission to get pregnant. And the best way to do that is to use the basal body temperature thermometer, so that you know that this month your A1C is normal, your blood sugars are great and this month you can go for it. But then you have to know exactly when you’re ovulating because it’s not fair to work that hard and miss the opportunity. So I usually tell them to buy the thermometer that tells them when they’re ovulating, because the temperature actually changes just right before the egg is popped.

Steve Freed: It’s interesting what you say that a normal A1C for a healthy person is 5.3. ADA says it should be below 7, AACE says it should be 6.5 and that’s for normal. But we’re talking normal, and now we’re talking pregnancy. So you’re feeling obviously a normal A1C is a good thing and that people should have an A1C and obviously it’s individualized, you can’t say everybody, you know, if you’ve had diabetes for 30 years you’ve got seven morbidities, you’re on 32 medications, and an A1C of 9, it can’t be dangerous obviously to put it down quickly.

Dr. Jovanovic: There is no exception. I’m not saying you have to put it down quickly, but you can’t say gee I’m 90 and therefore I don’t have to take care of my diabetes. You probably will live till a 110 and if you don’t take care of your diabetes you’re going to be in a nursing home blind with no feet and that’s going to be more health care costs. There is no exception. A normal blood sugar has to be the goal for everybody, from birth until death.

Steve Freed: That’s interesting, I really appreciate that because I don’t think I’ve ever heard another doctor or medical professional, diabetes educator, dietitian say that we should all have A1Cs at 5.3% or close to it. And my personal feeling is that with all the new treatments that we have available plus insulin because that’s a no-brainer, but people don’t want to go on insulin. With all the new technology with all the CGMs and with everything that’s available that there’s absolutely no reason why anyone in this country should have an elevated blood sugar. Yet I would say if we knew what the average blood sugar was for everybody with diabetes in this country, because a lot of people don’t go to doctors, it’d be over 90%.

Dr. Jovanovic: That’s true. That doesn’t make it right.

Steve Freed: But how could that be if we have all this knowledge and all this technology. It just it’s kind of mind boggling and I’ll sit down with a patient and their A1C is 9.7 or 8.5, and there’s absolutely no reason. Number 1 is they don’t even know what a carbohydrate is, so that certainly, education is a key component to control your diabetes, because without the education you’re doomed for failure no matter what happens. Because I just… once a person knows how to read a food label, they can lower their A1C significantly just with knowledge.

Dr. Jovanovic: See you can give my talk.

Steve Freed: So getting on to, some of the tips, because you’re so knowledgeable when it comes to diabetes for the general practitioner, for the patient. What are some of the key things that you can share that will help other medical professionals really come to the point that we need to be much more aggressive when it comes to diabetes.

Dr. Jovanovic: Well, first of all, I think physicians don’t realize that every woman in her child-bearing years could get pregnant. So if a physician is give an ACE for hypertension, he really has to ask the woman are you on birth control pills? Because if she gets pregnant and she’s on a drug that will cause a malformation, he’s liable, so the first thing a physician really has to know is that women in their child-bearing years need to be asked the question are you going to have any more babies? No, no, no, doc. If you’re not, are you on birth control? They might say something like, well gee I have my tubes tied or I don’t have a uterus, the physician can relax. But if a woman says, well I don’t want any more babies but still doc, I want you to take care of me, You have to prescribe a birth control pill and then you can use any drug you want. Because a woman could always get pregnant and not tell the physician, who is then liable, because he’s prescribed the drug that is not safe in pregnancy. So I think that’s the one thing you can tell physicians is think pregnancy first before you think anything else.

Steve Freed: What are some of the other things that you like to have them be aware of?

Dr. Jovanovic: Not to reprimand the patient. When the patient comes to the doctor and asks for help, the doctor shouldn’t be saying, oh your blood sugars are terrible. But the truth is the doctor has to look at the blood sugars. Women work really hard to write down all of their blood sugars and the doctor never looks at them. I tell women to write down the last three days and put them under the nose of the doctor and make the doctor look at the blood sugars because she knows she needs help with her fasting or help after breakfast. But the doctors never look at all this. Although sometimes what they do is they take the glucose monitor and push the button, but the readings are all backwards. So unless he’s writing them down backwards, he won’t be able to know which blood sugar belongs to what. So she has to write down her blood sugars before she goes to the doctor and she has to ask the doctor to look at the blood sugars and help her with sugar control. And he says, well, you know, we’ll do that next time. That’s not why she’s there. She’s there to ask for help and he has to help her with her blood sugars. So that’s the thing that you need to do. And usually I ask my patients, you say you saw Dr. Jones while I was out of town, did Dr. Jones look at your blood sugars? She said no and I had them under his nose.

This is a 5-part transcript. Part 1 | Part 2 | Part 3 | Part 4 | Part 5

In this week’s Homerun Slides, preventive measures to fight dental infections and delayed wound healing.

To download the complete set in PowerPoint format, just use this link:

DiabetesandPeriodontitisPart6

Catch up on past Homerun Slides for Diabetes and Periodontitis series.

To download part 1, click here: Diabetes and Periodontitis Part 1

To download part 2, click here: Diabetes and Periodontitis Part 2

To download part 3, click here: Diabetes and Periodontitis Part 3

To download part 4, click here: Diabetes and Periodontitis Part 4

To download part 5, click here: Diabetes and Periodontitis Part 5

In this week’s Homerun Slides, glycosylated proteins (AGEs) and manifestations of periodontal disease.

To download the complete set in PowerPoint format, just use this link:

DiabetesandPeriodontitisPart5

Catch up on past Homerun Slides for Diabetes and Periodontitis series.

To download part 1, click here: Diabetes and Periodontitis Part 1

To download part 2, click here: Diabetes and Periodontitis Part 2

To download part 3, click here: Diabetes and Periodontitis Part 3

To download part 4, click here: Diabetes and Periodontitis Part 4