This article aims to underline the importance that preventive medicine is increasingly gaining. In the dental sector, the perio-medicine is also evolving thanks to the numerous scientific studies being carried out to assess the correlations between periodontal disease and systemic diseases. In this context, I want to talk about the new guidelines drawn up by a representative group of EFP (European Federation of Periodontology) and IDF (International Diabetes Federation) that have been published in the Journal of Clinical Periodontology: “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”. New guidelines for physicians, oral healthcare workers and patients: recommendations for the global multidisciplinary team caring for people with diabetes and periodontitis.
The data, tables and information that you will find in the article have been extrapolated from the new guidelines, recommendation of the American Diabetes Association, documento congiunto SIdP AMD SID, National Institute of Clinical Excellence United Kingdom and WHO website which you can find at the end of the article in the bibliography.
TOP 10 CAUSES OF DEATH GLOBALLY
Of the 56.4 million deaths worldwide in 2015, more than half (54%) were due to the top 10 causes.
Ischaemic heart disease and stroke are the world’s biggest killers, accounting for a combined 15 million deaths in 2015.
Chronic obstructive pulmonary disease claimed 3.2 million lives in 2015, while lung cancer (along with trachea and bronchus cancers) caused 1.7 million deaths. Diabetes killed 1.6 million people in 2015, up from less than 1 million in 2000. Deaths due to dementias more than doubled between 2000 and 2015, making it the 7th leading cause of global deaths in 2015
(DATA FROM WHO – 2015)
DIABETES AND PERIODONTITIS
Diabetes and periodontitis are chronic non‐communicable diseases independently associated with mortality and have a bidirectional relationship. Non-communicable diseases (NCDs) are the leading cause of death (72% or 39.8 million). Cardiovascular mortality is on the rise as we have seen in the table previously.
There is a strong association between periodontitis and chronic non-communicable diseases of ageing because they share similar risk factors.
In 2015 5.0 million deaths are caused by diabetes and there are 415 million of adults from 20-79 with diabetes, 193 million undiagnosed and 318 million with impaired glucose tolerance.
It is estimated that in 2040 642 million people will live with the disease.
FROM THE RESEARCH TO CLINICAL PRACTICE
There is a dual directionality of influence reported. In the article “Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines” the bidirectionality of diseases is underlined, and I have listed the scientific evidence that comes from research.
- Hyperglycaemia is associated with an increased risk and severity of periodontitis
- People with diabetes have a poorer periodontal outcome following periodontal therapy
- Elevated levels of pro-inflammatory mediators in poorly controlled diabetes can play a role in the increased periodontal destruction
- Improving the control of diabetes reduces oxidative stress and circulating cytokine levels
- Severe periodontitis was associated with elevated serum levels of HbA1C
- Severe periodontitis is associated with dyslipidaemia
- Severe periodontitis is associated with oxidative stress markers in the serum of people with diabetes
- Severe periodontitis increases the risk of developing type 2 diabetes
- Impact of periodontal treatment upon serum HbA1C levels reduction of 0,36% (Kocher 2013): periodontal treatment significant reduction of HbA1C levels in people with diabetes à reduction from 0,27% to 048% in 3-4 months. The magnitude of short-term HbA1C reductions obtained following periodontal interventions is like that achieved by adding a second medication to a pharmacological regimen!
- Patients with periodontitis exhibit a higher chance of developing prediabetes and diabetes
- Successful periodontal treatment reduces circulating levels of CRP and TNF-alfa in people with diabetes (Polak & Shapira 2017)
AMONG PEOPLE WITH DIABETES, IS PERIODONTITIS ASSOCIATED WITH MORE DIABETES COMPLICATIONS?
The majority of studies report a higher association between worse periodontal conditions and diabetes complications like retinopathy, nephropathy (more renal complications), neuropathic, foot ulceration – cardiovascular diseases.
The article states that it's possible and we must manage periodontitis in people with diabetes.
KEY OF SUCCESS IN PREVENTION: INTERPROFESSIONAL AND INTERDISCIPLINARY COOPERATION
GUIDELINES FOR PHISICIANS
The real news is that the evaluation of periodontitis has to become an integral part of the physician visit that must ask for sign and symptoms of periodontitis, impart oral health education and should be told that periodontal disease risk is increased in patients with diabetes and that periodontitis has a negative impact on metabolic control and increase risk of complications. They should advice the patient to go to the dentists and ask about a prior diagnosis of periodontal disease.
Every patient with confirmed diagnosis of diabetes should be informed of their increased risk for periodontitis.
GUIDELINES FOR ORAL HEALTH PROFESSIONALS IN THE DENTAL OFFICE
- People with diabetes should be advised that they have an increased risk of gingivitis and periodontitis
- Anamnesis and medical history, diabetes therapy
- Ask when they last had their blood glucose levels checked. You must hold a copy of their last HbA1C result
- Oral health education
- Do a PSR: periodontal screening and recording
- NSPT should be provided: may help for improve glycaemic control
- Screening for diabetes in the dental office
The novelty is therefore that of cooperating among various figures in the health sector for a medicine that is increasingly preventive and that puts together several professional figures.
At the end of the article the authors proposed the use in the dental office of the type 2 diabetes risk assessment form:
It is important to know how to carry out effective and efficient screening and what are the criteria for asking the patient to carry out more detailed analyses.
CRITERIA FOR TESTING FOR DIABETES OR PREDIABETES IN ASYMPTOMATIC ADULTS
- Testing should be considered in all adults who are overweight (BMI>25 Kg/m2 and have additional risk factors:
- Physical inactivity
- First-degree relative with diabetes
- High-risk race/ethnicity (African American, Latino, Native American, Asian American, Pacific Islander)
- Women who delivered a baby weigthing > 9 lb or diagnosed with GDM
- Hypertension (>140/90 mmHg or on therapy for hypertension)
- HDL cholesterol level <35mg/dL
- Women with polycystic ovary syndrome
- A1C>5,7%, IGT, or IFG on previous testing
- Other clinical conditions associated with insulin resistance (es: severe obesity, acanthosis nigricans)
- History of CVD
- For all patients, particulary those who are overweight of obese, testing should begin at age 45 years
- If results are normal, testing should be repeated at a minimun of 3-years intervals, with consideration of more frequent testing depending on initial status (those with prediabetes should be tested yearly) and risk status.
In the absence of typical symptoms of the disease the diagnosis of diabetes should be made with the confirmation of: - fasting blood glucose ≥126 mg/dl confirmed on at least two different occasions - blood glucose ≥200 mg/dl two hours after oral glucose loading (performed with 75 g) - HbA1c ≥48 mmol/mol (6.5%) (with standardized dosage of HbA1c).
Although dentists and dental hygienists cannot diagnose diabetes, they must be able to know what the diabetes diagnosis criteria are, the tests they use and the threshold values described below.
CRITERIA FOR THE DIAGNOSIS OF DIABETES
A1C >6,5%. The test should be performed in a laboratory using a method that is NGSP certified and standardized to the DCCT assay
2 hours PG>200 mg/dL during an OGTT. The test should be performed as described by the WHO, using a glucose load containing the equivalent of 75g anhydrous glucose dissolved in water
FPG>126 mg/dL. Fasting is defined as no caloric intake for at least 8 hours
In a patient with classic symptoms of hyperglycaemia or hyperglycaemic crisis, a random plasma glucose >200mg/dL.
In America, academics and physicians are developing a new prototype on salivary analysis to assess diabetes called iQuickIt.
iQuickIt Saliva Analyzer is designed to provide a painless non-invasive control of blood and saliva glucose levels. The plasma glucose levels, salivary levels a of glucose nd HbA1C are all three reliable to monitor blood glucose control.
Diabetes is the sixth leading cause of death in the world: early screening could help patients avoid the most serious complications of diabetes and maintain their natural teeth.
What is the role of the health professional? We must do screening tests for diabetes, make a periodontal record and educate people on proper oral health manoeuvres, but our role does not end here. Oral health professionals should address with their patient all modifiable lifestyle risk factors: smoking cessation, weight reduction, proper nutrition.
- Anz 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;45:138–149. https://doi.org/10.1111/jcpe.12808
- Classification and Diagnosis of Diabetes American Diabetes Association Diabetes Care 2015 Jan; 38(Supplement 1): S8-S16. https://doi.org/10.2337/dc15-S005
3. Documento congiunto SID AMD SIdP pdf http://www.sidp.it/media/ta2tkaw.pdf
- Graziani, P., Gennal, S., Solini, A., & Petrini, M. (2017). A systematic review and meta- analysis of epidemiologic observational evidence on the effect of periodontal disease on diabetes: An update of the review of the EFP- AAP workshop. Journal of Clinical Periodontology, https://doi.org/10.1111/jcpe.12837
- Polak, D., & Shapira, L. (2017). An update of the evidence for pathogenic mechanisms that may link periodontitis and diabetes. Journal of Clinical Periodontology, https://doi.org/10.1111/jcpe.12803.
- Saito, T., Shimazaki, Y., Kiyohara, Y., Kato, I., Kubo, M., Iida, M., & Koga, T. (2004). The severity of periodontal disease is associated with the development of glucose intolerance in non- diabetics: The Hisayama study. Journal of Dental Research, 83, 485–490.
- https://www.gumforgum.it/diabete.php# (video)
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