The Centers for Disease Control and Prevention (CDC) estimate that 34.2 million Americans have diabetes, of which 7.3 million (21.4%) are undiagnosed. A further 88 million adults are believed to have pre-diabetes, but only 15.3% report having been diagnosed by a healthcare professional. Given the bidirectional relationship between diabetes and periodontitis, and the high prevalence of diabetes and pre-diabetes, we discuss how dental students can support the early detection of diabetes to improve both oral and systemic health.
The oral-systemic connection
Research has shown a strong bidirectional relationship between diabetes and periodontitis, so much so that periodontal disease is often referred to as “the sixth complication of diabetes”. A meta-analysis published in Acta Diabetologica found that diabetes can increase the risk of periodontitis and its progression by up to 86%, while another study published in Diabetologia noted a three-fold increase in risk for periodontitis for patients with diabetes compared to other patients. The more poorly controlled the patient’s blood glucose levels is, the higher their risk.
Not only does diabetes increase the risk of periodontitis, but periodontitis in turn is known to elevate blood glucose levels and negatively affect glycemic control. A 2017 article in the Journal of Clinical Periodontology cites growing evidence that periodontal inflammation contributes to the onset and persistence of hyperglycemia.
This bidirectional relationship means that periodontitis and diabetes can reinforce each other in a continuous cycle. It is not enough to simply treat the oral disease; we must consider the whole patient. As dental students, you can achieve this by ensuring you are equipped to spot the early signs of diabetes and provide timely intervention.
Oral examinations and screening for diabetes
Oral manifestations of diabetes can often be detected before the patient experiences other signs and symptoms. The American Dental Association (ADA) recommends checking for the following:
- Xerostomia (dry mouth)
- Burning sensation in the mouth
- Frequent and/or severe infections
- Secondary infections, for example candidiasis
- Impaired or delayed wound healing
- Enlargement of the parotid salivary glands.
Research indicates that adding point-of-care testing to your screening process can help to increase successful detection of undiagnosed diabetes or pre-diabetes. In a 2011 study, Dr. Evie Lalla et al. identified a cohort of dental patients with no prior diagnosis of pre-diabetes or diabetes. In patients with at least one risk factor for diabetes, the following criteria were used to predict undiagnosed diabetes or pre-diabetes, with a success rate of 73%:
- The presence of 26% deep pockets; or
- 4 missing teeth.
When a point-of-care HbA1c test was added to measure the average blood glucose of the patient over the preceding three months, the success rate increased to 92%. A later study by Lalla et al. confirmed the validity of this prediction model.
In a 2019 study published in Diagnostics, researchers found evidence that combining an HbA1c test with an active matrix metalloproteinase 8 (aMMP-8) test could also be a valuable indicator of undiagnosed diabetes.
Both the aMMP-8 and HbA1c tests can be conducted chairside, with results in just a few minutes. Note that you may require a CLIA Certificate of Waiver to administer finger-prick blood tests. Combined with a thorough periodontal assessment, they represent an effective and convenient way to help identify high-risk patients and refer them to a physician for formal diagnosis and care.
Supporting patients with diabetes
Once diabetes is diagnosed, you can further support your patients with oral care advice and recommendations. They may benefit from an antibacterial toothpaste, like Colgate® Total SF™, to help prevent periodontal disease, or a prescription-strength fluoride toothpaste like PreviDent® 5000 ppm Booster Plus to provide extra protection against dental caries. You can also direct them to resources like the American Diabetes Association, which offers detailed support on the medication, diet and lifestyle changes associated with a diagnosis of diabetes. If left to progress unchecked, both diabetes and periodontal disease can have a serious impact on our patients’ oral and systemic health and their long-term quality of life. With vigilant screening and the use of simple, convenient tests like the HBA1c and aMMP-8, you can spot the early warning signs and help your patient live a longer, healthier life free of serious complications.