Dentists Note Severe Periodontitis 'May Point to Early Diabetes'

Liam Davenport

March 02, 2017

Dental patients with severe periodontitis may have undiagnosed type 2 diabetes, Dutch researchers have discovered in a study that suggests targeted screening of individuals with worse gum disease could be a feasible way of picking up cases of diabetes at an early stage.

Using a highly accurate finger-stick test for HbA1c, researchers found that they could identify new cases of diabetes.

Their results in over 300 patients showed not only that HbA1c increased significantly with increasing severity of periodontitis but that patients with severe periodontitis were twice as likely to have suspected diabetes as patients with milder gum disease or healthy controls.

The study, by lead author Wijnand J Teeuw, DDS, head of the periodontology clinic, Academic Center for Dentistry, University of Amsterdam, the Netherlands, and colleagues, was published online February 22 in BMJ Open Diabetes Research & Care.

The new research reinforces previous findings that periodontitis is linked to other serious conditions such as heart disease and myocardial infarction.

Furthermore, it builds on work suggesting that screening for diabetes at the dentist's office is feasible, thus offering greater opportunities to identify cases of undiagnosed diabetes, given that approximately 70% of Americans seek some kind of dental care at least once a year.

For example, a US study of over 400 patients indicated that oral blood collected during a routine dental procedure gives an HbA1c reading as accurate as traditional finger-stick readings.

The possibility for diabetes screening at the dentist was also bolstered by the recent development of a novel 14-item questionnaire designed specifically for use in the dentist's office to identify patients at high risk for medical conditions with oral involvement.

Study coauthor Susan Maples, DDS, from Holt, Michigan, previously told Medscape Medical News that she believes "dentists would be happy" to perform screening, "especially if they can negotiate with insurance companies about reimbursement."

One Step Further

As Dr Teeuw noted, "the dental clinic might be a suitable location" for screening, but there will be a "cost issue to screen everyone," so it would be better to be able to identify those at highest risk. "So, to make screening more effective, we were looking at oral complications of diabetes [in our study], and one of them turned out to be severe periodontitis."

"The first signs of periodontitis are often without any complications or pain, and due to the fact that diabetes patients, in the beginning, are very susceptible to infections and impaired wound healing, we thought that periodontitis might be one of the early signs of an underlying illness like diabetes," he explained.

So a screening program for diabetes targeted at individuals with severe periodontitis using an HbA1c finger-stick test would be easier to roll out, but cost may still be an issue.

One way around this would be simply for dentists to refer the patient to their primary-care physician.

And if the finger-stick analysis is not available, "you at least think about an underlying pathology like diabetes and you refer your patient to the general practitioner for diagnosis." He added it is important to highlight that "as dentists, we are not equipped to do the diagnosis. We can only screen."

Screening could also help dentists, Dr Teeuw noted, adding it is useful to know if a patient has diabetes, as it can be "very difficult" to treat periodontitis in patients with poorly controlled diabetes.

Almost One in Five Severe Periodontitis Patients Had Suspected Diabetes

For the current study, Dr Teeuw and colleagues recruited 313 participants: 109 healthy controls, 126 with mild/moderate periodontitis, and 78 with severe periodontitis, with an average age of 48.4 years, 51.1 years, and 50.5 years, respectively.

Patients with severe periodontitis were significantly more likely to be men than participants in the other groups, and there were significantly more current smokers and patients with a higher mean BMI in the severe-periodontitis group than healthy controls.

Researchers measured HbA1c using dry capillary blood spots collected on Whatman paper from a finger stick sent to a laboratory for analysis. The process had previously been shown to have a high correlation with standard blood analyses.

"The finger-stick test we developed is very precise, so it is as easy as a finger-stick analysis but has the accuracy of a lab test," explained Dr Teeuw.

HbA1c significantly increased with increasing severity of periodontitis, from 5.7% among controls, to 6.1% in the mild/moderate periodontitis group, and 6.3% in the severe periodontitis group (P = .003).

Using the American Diabetes Association guidelines, the team found there were significantly more individuals with suspected diabetes and prediabetes in the severe-periodontitis group (23.1% and 47.4%, respectively) and mild/moderate-periodontitis group (13.5% and 46.0%, respectively) than in the control group (10.1% and 36.7%, respectively) (P = .010).

Researchers also determined that the proportion of patients with suspected diabetes, defined as those without a history of diabetes but an HbA1c of 6.5% or higher. The analysis revealed there were significantly more cases of suspected diabetes among patients with severe periodontitis (18.1%) compared with those with mild/moderate periodontitis (9.9%) and healthy controls (8.5%) (P = .024).

"The early diagnosis and intervention of (pre)diabetes prevent the common microvascular and macrovascular complications and are cost-effective. In addition, it can be suggested that the early diagnosis and treatment of (pre)diabetes may also benefit the treatment of periodontitis," the team writes.

They therefore conclude: "A dental office that treats patients with severe periodontitis is a suitable location for screening for (pre)diabetes; a considerable number of suspected new diabetes cases were identified and indicated that periodontitis is an early sign of diabetes mellitus."

This research was supported in part by a grant from the University of Amsterdam. The authors  have reported no relevant financial relationships.

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BMJ Open Diabetes Res Care. 2017;5:e000326. Full text

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