Citation: Sandhu HS and Hosein YK. Relationship between Type 2 Diabetes and Periodontitis: Recommendation for Diabetes Screening In Specialty

Abstract

Type 2 diabetes has reached epidemic proportions globally. Medical care for the complications of diabetes costs billions of dollars and it is estimated that, by 2030, these complications will be a leading cause of mortality. The undiagnosed prediabetic population is an even bigger concern. There are strong links between type 2 diabetes and periodontitis. As such, dental practices have a unique opportunity to implement prediabetes screening tests. These include the CDC Prediabetes Screening Test questionnaire, as well as new technology available to conduct reliable chairside tests of glycated haemoglobin (HbA1c). We recommend the implementation of such a program in dental clinics to identify individuals at risk for prediabetes, and present one example of a case in which a prediabetic individual was identified by a periodontist. Practice-based research networks could pool data from such programs to evaluate the concept and, based on the outcomes, recommend appropriate changes in health policy.

Full text

Citation: Sandhu HS and Hosein YK. Relationship between Type 2 Diabetes and Periodontitis: Recommendation
for Diabetes Screening In Specialty Periodontal Practices. J Dent & Oral Disord. 2016; 2(1): 1005.
J Dent & Oral Disord - Volume 2 Issue 1 - 2016
Submit your Manuscript | www.austinpublishinggroup.com
Sandhu et al. © All rights are reserved
Journal of Dentistry & Oral Disorders
Open Access
Abstract
Type 2 diabetes has reached epidemic proportions globally. Medical care
for the complications of diabetes costs billions of dollars and it is estimated
that, by 2030, these complications will be a leading cause of mortality. The
undiagnosed prediabetic population is an even bigger concern. There are strong
links between type 2 diabetes and periodontitis. As such, dental practices have
a unique opportunity to implement prediabetes screening tests. These include
the CDC Prediabetes Screening Test questionnaire, as well as new technology
available to conduct reliable chairside tests of glycated haemoglobin (HbA1c).
We recommend the implementation of such a program in dental clinics to
identify individuals at risk for prediabetes, and present one example of a case
in which a prediabetic individual was identied by a periodontist. Practice-based
research networks could pool data from such programs to evaluate the concept
and, based on the outcomes, recommend appropriate changes in health policy.
Keywords: Type2 diabetes; Periodontitis; Risk prevention; Prediabetes;
HbA1c testing; CDC prediabetes screening test
destruction and, if le untreated, periodontitis results in tooth loss
[10,20]. Glycated haemoglobin (commonly known as HbA1c or A1c)
levels of nine percent are considered indicative of uncontrolled blood
glucose, and elevated HbA1c is one of two signicant risk factors
(the other being heavy tobacco smoking) for severe periodontitis
[10,20]. Family dentists refer patients with moderate to advanced
periodontitis to periodontal specialists. e majority of patients with
periodontitis are unaware of their higher than normal risk of elevated
blood glucose levels.
Despite the association between periodontitis and uncontrolled
blood glucose, dental practitioners do not routinely screen periodontal
patients for diabetes. However, Strauss et al. has estimated that 93.4
percent of patients with periodontitis should qualify for diabetes
screening [6]. In addition, the American and Canadian Diabetes
Associations recommend screening of all patients ≥ 45 years of
age, with BMI ≥ 25kg/m2, and one or more risk factors for diabetes
[21,22]. e Dental Practice-Based Research Network has looked
at the feasibility of random glucose testing in the general patient
population [23]. In a Michigan study, a high burden of dysglycemia
was found in a general dental practice patient population [24]. e
authors of this study recommended chairside blood glucose testing
to identify prediabetic patients. is concept of chairside testing of
blood glucose levels for the diagnosis of prediabetes is not unique to
the Michigan study, since it has been previously described [25,26].
However, it is reported that less than 10 percent of dental practices
routinely screen patients for diabetes and more than 98 percent do
not have blood glucose monitors available on site [23]. Considering
the close association of elevated blood glucose levels and the severity
of periodontitis, periodontists and other dental practitioners are
uniquely positioned to monitor blood glucose levels or other
Introduction
Diabetes is a progressive chronic disease with multifactorial
pathophysiological abnormalities, resulting in sustained
hyperglycemia. It greatly increases the risk of micro and macro
vascular diseases and, when le uncontrolled, is a major cause of
mortality [1]. Globally, it has acquired epidemic proportions with
4.6 million deaths annually attributable to diabetes, and the number
of people with diabetes is predicted to rise from over 366 million in
2011 to 552 million by 2030, or one adult in ten [2]. Based on reports
published by the Canadian Diabetes Association (CDA) and Centers
for Disease Control and Prevention (CDC), 8.9 to 9.3 percent of the
general population in Canada and the US have been diagnosed with
diabetes [3,4] and there is an even larger number with undiagnosed
prediabetes [3-5]. ese people are at high risk of becoming diabetic.
However, early diagnosis and modication of life style can prevent
progression of the disease and the resulting serious complications. A
large number of individuals with diabetes or prediabetes are unaware
of their condition and have never been tested for elevated blood
glucose levels [6].
In the US and Canada, approximately 70 percent of the population
visit their dentist at least once a year [7,8]. As such, the US Department
of Health and Human Services promotes the active participation of
dentists in monitoring and preventing diseases like diabetes [9]. is
can be done through the identication of dental conditions associated
with the disease. For example, within the clinical literature, there is
a plethora of evidence on the association of elevated blood sugar
levels and the severity of periodontitis [10-18]. Periodontitis is an
inammatory condition of the supporting structures of teeth caused
by polymicrobial biolms, containing predominately gram negative
anaerobic bacteria [19]. Host immune response plays a role in tissue
Mini Review
Relationship between Type 2 Diabetes and Periodontitis:
Recommendation for Diabetes Screening In Specialty
Periodontal Practices
Sandhu HS1* and Hosein YK2
1Division of Periodontics, Schulich School of Medicine &
Dentistry, Western University, Canada
2Division of Orthodontics, Schulich School of Medicine
& Dentistry, and Bone and Joint Institute, Western
University, Canada
*Corresponding author: Harinder S Sandhu, Division
of Periodontics, Schulich School of Medicine & Dentistry,
Western University, Ontario, Canada
Received: December 23, 2015; Accepted: January 22,
2016; Published: January 25, 2016

J Dent & Oral Disord 2(1): id1005 (2016) - Page - 02
Sandhu HS Austin Publishing Group
Submit your Manuscript | www.austinpublishinggroup.com
biomarkers to detect undiagnosed diabetic and prediabetic patients.
It is now realized that random glucose testing does not provide
a reliable indicator of a sustained hyperglycemic condition [27].
On the other hand, the HbA1c test reects a two- to three-month
history of blood glucose levels. Although other intensive testing may
be required to arrive at a denitive diagnosis and treatment regimen,
the HbA1c test presents a practical chairside screening opportunity
[28]. e HbA1c test result is reported as a percentage. e higher
a person’s blood glucose levels, the more hemoglobin they will have
with sugar attached, resulting in a higher HbA1c percentage. A
normal HbA1c level is below 5.7 percent, while HbA1c of 5.7 to 6.4
percent indicates prediabetes. HbA1c above 6.0 percent is considered
high risk of developing diabetes, and a level of 6.5 percent or above
means a person has diabetes [27]. PTS Diagnostics (Indianapolis
IN, USA; Roxon Medi-Tech, Etobicoke, ON, Canada) markets
the“A1CNow®+Multi-test A1C System” [29]. is instrument can
provide results of the HbA1ctest within ve minutes. is point-
of-care test would allow dental practitioners to conveniently screen
patients for prediabetes and diabetes, and provide information that
will help direct them to pertinent resources for further investigation.
ere is a complex relationship between diabetes and periodontitis
[30]. Diabetes is well established as a risk factor for periodontitis.
Conversely, periodontal inammation may exacerbate diabetes and
its complications. However, with regard to periodontal therapy, there
is only weak evidence that non-surgical treatment and reduction of
inammation in diabetic patients results in moderate reduction of
blood glucose [31]. More randomized controlled trials are required
to validate this.
e CDC has provided a screening tool, which allows
nurses, podiatrists, and dentists to collaborate with their medical
colleagues in identifying individuals at high-risk of prediabetes
(Table 1) [32]. e CDC screening test is a simple and quick self-
assessment questionnaire that patients can use to determine their
risk of prediabetes. A score of nine or higher indicates a high risk
for prediabetes. In the 2007-2008 National Health and Nutrition
Examination Survey [33], the CDC screening test correctly identied
27 to 50% of U.S. adults (aged 18 years and older) with a score of 9
or higher as true cases of prediabetes. is identication was based
on HbA1c, fasting blood glucose, or two-hour oral glucose tolerance
conrmatory diagnostic tests [5]. Despite urging by the CDC for
collaboration in identifying individuals at high-risk for developing
diabetes, there still remains a gap in communication among health
care providers. is lack of communication results in large numbers
of individuals with undetected prediabetes, many of whom may
eventually progress to more serious disease [4]. One example of
identication of a prediabetic case in a periodontal practice is
described in Figure 1.
e nancial burden of medical care for diabetic patients is
enormous. Cost of care for complications of diabetes is in the
hundreds of billions of dollars worldwide [2]. In Canada, it is
estimated that the prevalence and direct costs for diabetes care will go
up by more than 40 percent over the next ten years [3]. Similar data
are also available for the United States of America [34]. Considering
the detrimental impact of diabetes on individual patients and the
healthcare system, as well as the association between periodontitis
and blood glucose levels, it is recommended that all periodontal and
general dental practices implement risk assessment questionnaires,
as well as chairside HbA1ctests. Diabetes screening done in dental
oces will benet the patient and healthcare system with early
Table 1: CDC Prediabetes Screening Test [32].
Prediabetes means your blood glucose (sugar) is higher than normal, but not yet
diabetes. Diabetes is a serious disease, which can cause heart attack, stroke,
blindness, kidney failure, or loss of toes, feet or legs. Type 2 diabetes can be
delayed or prevented in people with prediabetes, however, through effective
lifestyle programs. Take the rst step. Find out your risk for prediabetes.
Take the Test — Know Your Score!
Answer these seven simple questions. For each “Yes” answer, add the number
of points listed. All “No” answers are 0 points.
Yes No
Are you a woman who has had a baby weighing more than 9 pounds
at birth? 1 0
Do you have a sister or brother with diabetes? 1 0
Do you have a parent with diabetes? 1 0
Find your height on the chart. Do you weigh as much as or more than
the weight listed for your height? (See chart below) 5 0
Are you younger than 65 years of age and get little or no exercise in
a typical day? 5 0
Are you between 45 and 64 years of age? 5 0
Are you 65 years of age or older? 9 0
Total points for all “yes” responses: _____
CDC Diabetes Prevention Recognition At-Risk Weight Chart
Height Weight
(Pounds) Height Weight
(Pounds)
4’10” 129 5’7” 172
4’11” 133 5’8” 177
5’0” 138 5’9” 182
5’1” 143 5’10” 188
5’2” 147 5’11” 193
5’3” 152 6’0” 199
5’4” 157 6’1” 204
5’5” 162 6’2” 210
5’6” 167 6’3” 216
6’4” 221
Figure 1: Example of a prediabetic case detected during periodontal
examination.
A mildly overweight, 48-year-old Caucasian male with a history of hypertension
was referred to a specialty periodontal clinic for increase in pocket depths.
(A) Clinical examination showed generalized redness of gingival unit, deep
periodontal pockets, furcation invasion on maxillary molars, bleeding score of
over fty percent and inamed interdental papilla. There were many areas of
moderate to advanced loss of attachment. (B) Two-dimensional radiographic
assessment showedonly moderate bone loss in some areas. The patient
was never tested for blood glucose level and was not aware that he may
be a prediabetic. A CDC prediabetes screening questionnaire was used and
HbA1ctest was conducted. CDC Prediabetes Screening Test score was 15
and HbA1cwas 5.9 percent.

J Dent & Oral Disord 2(1): id1005 (2016) - Page - 03
Sandhu HS Austin Publishing Group
Submit your Manuscript | www.austinpublishinggroup.com
diagnosis and eective management of the disease. In addition,
appropriate screening and subsequent diagnosis will provide proof of
concept regarding the link between periodontitis and type 2 diabetes.
Data from such screening programs can also inform healthcare
policy makers of the importance of oral health care professionals in
identifying life-threatening diseases. As well, delivery of appropriate
oral health care to diabetic patients is an urgent concern, since a
recent Canadian report described serious gaps, with only 51 percent
of identied diabetics having dental insurance and access to proper
dental care [3].
Concluding Remarks
In view of the above discussion, we make following
recommendations:
1. All periodontal patients (not already being managed for
prediabetes or diabetes) should be asked to complete the
CDC questionnaire.
2. Patients with scores of nine or higher on the CDC
questionnaire should be oered a chairside HbA1c test.
3. Once sucient pilot data have been collected and
analyzed, policy makers and third party medical and
dental insurance companies should be informed of the
ndings.
Benets of performing such assessments in clinical practice
include:
1. Identied prediabetic patients can be referred for
preventive counseling to avoid serious complications and
reduce healthcare costs.
2. e impact of periodontal treatment on glycemic control
can be assessed in randomized controlled studies.
Acknowledgment
Dr. Hosein is supported in part by a Transdisciplinary Bone &
Joint Training Award from the Collaborative Training Program in
Musculoskeletal Health Research at Western University. We thank
the Centers for Disease Control and Prevention (CDC, Atlanta GA)
for permission to reproduce their prediabetes screening test, and
Dr. S. J. Dixon (Western University) for helpful comments on the
manuscript.
References
1. American Diabetes Association. Diagnosis and classication of Diabetes
Mellitus. Diabetes Care. 2010; 33: 62-69.
2. International Diabetes Federation. Global Diabetes Plan at a Glance, 2011-
2021.
3. Canadian Diabetes Association. Report on Diabetes - Driving Change. 2015.
4. National Center for Chronic Disease Prevention and Health Promotion.
National Diabetes Statistics Report, 2014.
5. Centers for Disease Control and Prevention. Diabetes Prevention Recognition
Program. 2015.
6. Strauss SM, Russell S, Wheeler A, Norman R, Borrell LN, Rindskopf D. The
dental ofce visit as a potential opportunity for diabetes screening: an analysis
using NHANES 2003-2004 data. J Public Health Dent. 2010; 70: 156-162.
7. Baldota KK, Leake JL. A macroeconomic review of dentistry in Canada in the
1990s. J Can Dent Assoc. 2004; 70: 604-609.
8. Health, United States, 2014: With Special Feature on Adults Aged 55-64.
National Center for Health Statistics. 2015; 1232.
9. A National Call to Action to Promote Oral Health. U.S. Department of Health
and Human Services. 2003.
10. Demmer RT, Squillaro A, Papapanou PN, Rosenbaum M, Friedewald WT,
Jacobs DR, et al. Periodontal infection, systemic inammation, and insulin
resistance: results from the continuous National Health and Nutrition
Examination Survey (NHANES) 1999-2004. Diabetes Care. 2012; 35: 2235-
2242.
11. Taylor JJ, Preshaw PM, Lalla E. A review of the evidence for pathogenic
mechanisms that may link periodontitis and diabetes. J Clin Periodontol.
2013; 40: 113-134.
12. Albert DA, Ward A, Allweiss P, Graves DT, Knowler WC, Kunzel C, et al.
Diabetes and oral disease: implications for health professionals. Ann N Y
Acad Sci. 2012; 1255: 1-15.
13. Lalla E, Papapanou PN. Diabetes mellitus and periodontitis: a tale of two
common interrelated diseases. Nat Rev Endocrinol. Nature Publishing
Group. 2011; 7: 738-748.
14. Mealey BL. Periodontal disease and diabetes. A two-way street. J Am Dent
Assoc. 2006; 137: 26-31.
15. Jepsen S, Stadlinger B, Terheyden H, Sanz M. Guest Editorial Science
transfer: Oral Health and General Health - the Links between Periodontitis,
Atherosclerosis, and Diabetes. J Clin Periodontol. 2015.
16. Apoorva SM, Sridhar N, Suchetha A. Prevalence and severity of periodontal
disease in type 2 diabetes mellitus (non-insulin-dependent diabetes mellitus)
patients in Bangalore city: An epidemiological study. J Indian Soc Periodontol.
2013; 17: 25-29.
17. Llambés F, Arias-Herrera S, Caffesse R. Relationship between diabetes and
periodontal infection. World J. Diabetes. 2015; 6: 927-935.
18. Chapple IL, Genco R. Diabetes and periodontal diseases: consensus report
of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J
Clin Periodontol. 2013; 40: 106-112.
19. American Academy of Periodontology Task Force Report on the update to the
1999 Classication of Periodontal Diseases and Conditions. J Periodontol.
2015; 86: 835-838.
20. Garcia D, Tarima S, Okunseri C. Periodontitis and glycemic control in
diabetes: NHANES 2009 to 2012. J Periodontol. 2015; 86: 499-506.
21. Rising diabetes rates, gaps in care and stigma addressed in new report from
CDA. Canadian Diabetes Association. 2015.
22. Standards of medical care in diabetes--2014. American Diabetes Association.
Diabetes Care. 2014; 37: 14-80.
23. Barasch A, Safford MM, Qvist V, Palmore R, Gesko D, Gilbert GH. Random
blood glucose testing in dental practice: a community-based feasibility study
from The Dental Practice-Based Research Network. J Am Dent Assoc. 2012;
143: 262-269.
24. Herman WH, Taylor GW, Jacobson JJ, Burke R, Brown MB. Screening for
prediabetes and type 2 diabetes in dental ofces. J Public Health Dent. 2015;
75: 175-182.
25. Beikler T, Kuczek A, Petersilka G, Flemmig TF. In-dental-ofce screening for
diabetes mellitus using gingival crevicular blood. J Clin Periodontol. 2002;
29: 216-218.
26. Greenberg BL, Glick M, Frantsve-Hawley J, Kantor ML. Dentists’ attitudes
toward chairside screening for medical conditions. J Am Dent Assoc. 2010;
141: 52-62.
27. Diagnosis of Diabetes and Prediabetes. National Institute of Diabetes and
Digestive and Kidney Diseases. 2014.
28. Sacks DB. A1C versus glucose testing: a comparison. Diabetes Care. 2011;
34: 518-523.

J Dent & Oral Disord 2(1): id1005 (2016) - Page - 04
Sandhu HS Austin Publishing Group
Submit your Manuscript | www.austinpublishinggroup.com
29. Knaebel J, Irvin BR, Xie CZ. Accuracy and Clinical Utility of a Point-of-Care
HbA 1c, Testing Device. Postgrad Med. 2013; 125: 91-98.
30. Chee B, Park B, Bartold MP. Periodontitis and type II diabetes: a two-way
relationship. Int J Evid Based. Healthc. 2013; 11: 317-329.
31. Li Q, Hao S, Fang J, Xie J, Kong XH, Yang JX. Effect of non-surgical
periodontal treatment on glycemic control of patients with diabetes: a meta-
analysis of randomized controlled trials. Trials. 2015; 16: 291.
32. CDC Prediabetes Screening Test. National Diabetes Prevention Program.
33. United States Department of Health and Human Services. Centers for
Disease Control and Prevention. National Health and Nutrition Examination
Survey (NHANES), 2007-2008. Inter-university Consortium for Political and
Social Research (ICPSR).
34. American Diabetes Association. Economic costs of diabetes in the U.S. in
2012. Diabetes Care. 2013; 36: 1033–1046.
Citation: Sandhu HS and Hosein YK. Relationship between Type 2 Diabetes and Periodontitis: Recommendation
for Diabetes Screening In Specialty Periodontal Practices. J Dent & Oral Disord. 2016; 2(1): 1005.
J Dent & Oral Disord - Volume 2 Issue 1 - 2016
Submit your Manuscript | www.austinpublishinggroup.com
Sandhu et al. © All rights are reserved