Diabetes has been recognized as a risk factor for periodontitis for long. The risk of periodontitis has been increased 2-3 times in diabetic patients in poor control than individuals without [1]. Periodontitis may influence not only QOL/ADL of diabetic patients, but also various systemic conditions such as cardiovascular disease [2]. In the world, advanced periodontitis is said to be the 6^th most prevalence in all human diseases [3]. According to the National Health Service (NHS) of United Kingdom, advanced periodontitis has been observed in 8% of the adults [4].

The etiological aspect of diabetes and periodontitis are based on the chronic inflammation of oral gums [1,2]. Such patients with periodontitis are known to have elevated risk for impaired glucose variability and insulin resistance. Furthermore, there are mechanic links between them, including elevated values of interleukin (IL)-1-β, Tumor Necrosis Factor (TNF)-α, IL-6, receptor activator of nuclear factor-kappa B ligand/osteoprotegerin ratio, oxidative stress and so on [5,6].

From historical point of view, discussions have continued concerning diabetes and periodontal disease. The manifesto of EFP was formerly presented [5]. It was for medical and dental professionals, and it provided all healthcare professionals several necessary factors, including links, regular periodontal monitoring, mutual communication between medical and dental staffs, and particular collaboration for suspected diabetes cases.

Successively, the consensus report and guideline were presented [6]. It was both of the EFP and the American Academy of Periodontology (AAP) that recommended several steps for medical professionals and dental professionals. Those reports included links of both diseases, regular visit to dentist, periodontal assessment in the new case, liaising with physician in suspected diabetes. The strategy was impressive for the dentist to check potentially a chair-side HbA1c test. These processes were useful for prevention of the exacerbation of the both diseases in early stages [6].

Furthermore, British Society of Periodontology (BSP) has showed the consensus report concerning both diseases. Among them, there were some representative comments for medical professional. It included indicating the links of both diseases to diabetic patients, and advising them to receive the dental assessment in the dentistry [7]. BSP also showed other comments for dental professionals. They included prevalence of the links of both diseases, submission of the HbA1c values and mutual connections with diabetologist concerning detail information of diabetes in the usage of template letter each other [8].

For dental region, the standard guide was shown for adequate management of periodontology, which was from BSP. These points have been included, informing the links, asking HbA1c levels, continuing the relationship with the physician and so on [9]. The most recent proposal was the Consensus report and guidelines on periodontitis and diabetes [10,11]. It was presented on the joint conference by the International Diabetes Federation (IDF) and the European Federation of Periodontology (EFP). This guideline was published from both of Journal of Clinical Periodontology and Diabetes Research and Clinical Practice [11].

The content was for medical and dental professionals. There were comments for the medicals including i) Enquire the symptoms of periodontitis, ii) Inform patients the links, iii) Refer the patients for periodontal assessment, iv) Recommend regular visit to dentist and v) Collaboration with the dentistry. Furthermore, there were comments for the dentals including i) Inform patients the links, ii) Continue regular Periodontitis (PD) monitoring, iii) Enquire HbA1c values, iv) Cooperate physician to assess the risk of diabetes and pre-diabetes and v) Taking the advantage of validated screening questionnaire [10]. Thus, necessary information can be freely obtained through the EFP homepage [12].

As mentioned above, several crucial points have been found in standard guidelines. They include that i) They has been a bidirectional relationship between diabetes and periodontitis including advanced gum diseases, ii) There have been not enough actual communication between medical and dental professionals, iii) Patients with diabetes and periodontitis have been treated and controlled by both medical and dental departments, iv) The reduction of HbA1c value would bring effective treatment of periodontitis about 3-4 mmol/mol [13]. A conversion formula has been known about HbA1c, where IFCC value (mmol/mol)=10.93 × NGSP value (%)-23.52 (mmol/mol).

From clinical point of view, there have been some researches concerning diabetes and periodontitis. C-Reactive Protein (CRP) is a potential pro-inflammatory biomarker, and high sensitivity CRP was positively associated with periodontitis, smoking and obesity [14]. Chronic periodontitis would be influenced by the values of CRP, IL-6 and LK-10 [15].

In addition, Homeostasis Model Assessment for Insulin Resistance (HOMA-R) level significantly predicts periodontal inflammation [16]. From the data of 77 thousand patients with diabetes and periodontitis in 6 countries, the results showed that patients with periodontitis have higher ratio of developing pre-diabetes and diabetes, in which adjusted HR range was 1.19-1.33 [17].

In relation to diabetes and periodontitis, authors and colleagues have continued clinical practice and research [18]. Among them, we have clarified the efficacy of Low Carbohydrate Diet (LCD) and comparison with Calorie Restriction (CR) [19]. Furthermore, we had treated diabetic patients with various complications, including macroangiopathy, microangiopathy, periodontitis and so on. Through our clinical experiences, treating periodontitis would be crucial for better diabetic control [20]. Periodontitis exacerbates chronic inflammation of gums and supporting tissues of teeth such as alveolar jaw bone [1]. Persisting inflammatory condition develops progressive tissue damage and teeth loss [1,21]. Periodontitis may lead to cardiovascular diseases and metabolic syndrome with persistence positive results of CRP [1,21].

From the pathophysiological point of view, the aggravating mechanisms with diabetes and periodontitis have not been completely understood. However, it is the glycemic control condition that can decide the key for developing the risk [19]. As the glucose control becomes worse, the risk of periodontitis would be increased [22]. In contrast, as the periodontitis becomes worse, the glucose control would be aggravated [23]. From the statistical data of meta-analyses and Cochrane reviews, HbA1c value showed the reduction of 3-4 mmol/mol after receiving successful periodontal treatment after the treatment for several months [13,24].

For actual clinical practice in various situations, there have been rather difficulties about smooth collaborative relationship between medical and dental departments [25]. However, some improvement has been found between them because of better mutual relationship by the usage of common guideline [19]. The reasons seem to be from the following factors: i) The research of the relationship between HbA1c and periodontitis has known, ii) Useful and relevant guidelines have been introduced, iii) Clinicians can introduce and treat such patients together, by usage of mutual referral letters, iv) The necessity of combined treatments in both clinics have been known widely including primary care physicians and v) Patients also came to know the beneficial collaborative therapies in medical and dental clinic [10].

In summary, recent trend about diabetes and periodontitis has been discussed. Several important points are to be emphasized. They are i) Diabetes and periodontitis have mutually bidirectional influence, ii) Effective treatment of periodontitis can bring reduction in HbA1c up to 3-4 mmol/mol, and iii) The joint management of dentist and physician would be recommended. This article would be expected to become a reference for beneficial treatment and management in the clinical practice.

References

1. 1. Preshaw PM, Alba AL, Herrera D, Jepsen S, Konstantinidis A, et al. Periodontitis and diabetes: A two-way relationship (2012) Diabetologia 55: 21-31. https://doi.org/10.1007/s00125-011-2342-y
   2. Montebugnoli L, Servidio D, Miaton RA, Prati C, Tricoci P, et al. Periodontal health improves systemic inflammatory and heaemostatic status in subjects with coronary heart disease (2005) J Clin Periodontol 32: 188-192. https://doi.org/10.1111/j.1600-051x.2005.00641.x
   3. Kassebaum NJ, Bernabé E, Dahiya M, Bhandari B, Murray CJL, et al. Global burden of severe periodontitis in 1990-2010: a systematic review and meta-regression (2014) J Dent Res 93:1045-1053. https://doi.org/10.1177/0022034514552491
   4. White D, Pitts N, Steele JG, K. Sadler and Chadwick BL. Disease and related disorders - A report from the Adult Dental Health Survey 2009 (2011) NHS Information Centre for Health and Social Care, United Kingdom.
   5. European Federation of Periodontology (EFP) (2012) EFP Manifesto.
   6. Chapple ILC and Genco R. Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases (2013) J Clin Periodontol 40: S106-S112.
   7. British Society of Periodontology Diabetes and Periodontitis Campaign (2017).
   8. Department of Health Delivering Better Oral Health: An Evidence-based Toolkit for Prevention (2017) Public Health England, United Kingdom.
   9. British Society of Periodontology. Good Practitioners Guide to Periodontology (2016).
   10. Bissett SM, Presseau J, Rapley T and Preshaw PM. Uptake of best practice recommendations in the management of patients with diabetes and periodontitis: a cross-sectional survey of dental clinicians (2019) BDJ 226: 131-137. https://doi.org/10.1038/sj.bdj.2019.48
   11. Sanz M, Ceriello A, Buysschaert M, Chapple I, Demmer RT, et al. Scientific evidence on the links between periodontal diseases and diabetes: consensus report and guidelines of the Joint EFP/IDF Workshop on Periodontal Diseases and Diabetes (2018) J Clin Periodontol 45: 138-149. https://doi.org/10.1111/jcpe.12808
   12. EFP Outreach Project on Periodontitis and Diabetes(2018) European Federation of Periodontology (EFP)
   13. Simpson TC, Weldon JC, Worthington HV and Needleman I. Treatment of periodontal disease for glycemic control in people with diabetes mellitus (2015) Cochrane Database Syst Rev 1-142 https://doi.org/10.1002/14651858.CD004714.pub3
   14. Pitchika V, Thiering E, Metz I, Rothmaier K, Willenberg A, et al. Gingivitis and lifestyle influences on high-sensitivity C-reactive protein and interleukin 6 in adolescents (2017) J Cli Periodontol 44: 372-381. https://doi.org/10.1111/jcpe.12690
   15. Aziz AS, Kalekar MG, Suryakar AN, Kale R, Benjamin T, et al. Pre and post-treatment effectiveness of srp on levels of IL-6, IL-10, and CRP in chronic periodontitis patients with and without diabetes (2018) Am J Biochem 8: 1-6. https://doi.org/10.1111/jcpe.12690
   16. Andriankaja OM, Muñoz-Torres FJ, Vivaldi-Oliver J, Leroux BG, Campos M, et al. Insulin resistance predicts the risk of gingival/periodontal inflammation (2018) J Periodontol 89: 549-557. https://doi.org/10.1002/jper.17-0384
   17. Graziani P, Gennal S, Solini A and Petrini M. 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 (2017) J Cli Periodontol 45: 167-187. https://doi.org/10.1111/jcpe.12837
   18. Bando H, Ebe K, Muneta T, Bando M and Yonei Y. Difference of Glucose variability between Low Carbohydrate Diet (LCD) and Calorie Restriction (CR) (2018) Asp Biomed Clin Case Rep 2: 4-15. https://doi.org/10.36502/2019/asjbccr.6142
   19. Ebe K, Bando H, Muneta T, Bando M and Yonei Y. Remarkable improvement of glucose variability by Sodium-Glucose Cotransporter 2 (SGLT2) inhibitors using continuous glucose monitoring (CGM) (2019) Diabetes Case Rep 4: 1. https://doi.org/10.4172/2572-5629.1000124
   20. Bando H. Diabetes Mellitus (DM) and Periodontal Disease (PD) with Mutual Vicious Cycle (2018) Int J Res Studies Med Health Sci 3: 37-39.  https://repo.lib.tokushima-u.ac.jp/113828
   21. O’Dowd LK, Durham J, McCracken GI and Preshaw PM. Patients’ experiences of the impact of periodontal disease (2010) J Clin Periodontol 37: 334-339. https://doi.org/10.1111/j.1600-051x.2010.01545.x
   22. Pihlstrom BL, Michalowicz BS and Johnson NW. Periodontal diseases (2005) Lancet 366: 1809-1820. https://doi.org/10.1016/s0140-6736(05)67728-8
   23. Simpson TC, Needleman I, Wild SH, Moles DR and Mills EJ. Treatment of periodontal disease for glycemic control in people with diabetes (2010) Aust Dent J 55: 472-474. https://doi.org/10.1111/j.1834-7819.2010.01273.x
   24. Madianos P and Koromantzos P. An update of the evidence on the potential impact of periodontal therapy on diabetes outcomes (2018) J Clin Periodontol 45:188-195. https://doi.org/10.1111/jcpe.12836
   25. Holzinger F, Dahlendorf L and Heintze C. ‘Parallel universes’? The interface between GPs and dentists in primary care: a qualitative study (2016) Fam Pract 33: 557-561. https://doi.org/10.1093/fampra/cmw058



^*Corresponding author

Hiroshi Bando, Medical Research/Tokushima University, Nakashowa 1-61, Tokushima 770-0943, Japan, Tel: +81-90-3187-2485, E-mail: pianomed@bronze.ocn.ne.jp

Citation

Sakamoto D and Bando H. Recent trend from the clinical point of view for periodontitis and diabetes mellitus (2020) Dental Res Manag 4: 8-10.

Keywords

Periodontitis, Diabetes mellitus, European federation of periodontology, International diabetes federation, British society of periodontology.