Diabetes screening in dental offices

In April 2013, a report was published from a workshop involving the American Academy of Periodontology and its European counterpart, the European Federation of Periodontology, on periodontitis and systemic diseases.¹ The authors stated, "Over the last 20 years, consistent and robust evidence has emerged that severe periodontitis adversely affects glycaemic control in diabetes and glycaemia in nondiabetes subjects. In diabetes patients, there is a direct and dose-dependent relationship between periodontitis severity and diabetes complications. Emerging evidence supports an increased risk for diabetes onset in patients with severe periodontitis.. ... Randomized controlled trials (RCTs) consistently demonstrate that mechanical periodontal therapy associates with approximately a 0.4% reduction in HbA1C at three months, a clinical impact equivalent to adding a second drug to a pharmacological regime for diabetes." The authors concluded that larger studies need to be conducted.

A 2015 study² demonstrated significant improvement in clinical parameters of periodontal disease and glycemic control six months after nonsurgical periodontal treatment was provided. What makes this study different is that antibiotics were not used adjunctively during the treatment. The authors' rationale for providing treatment without locally applied or systemic antibiotics was to eliminate this as a variable. They point out that antibiotics, particularly systemic, can lead to controversial results regarding A1c levels, because they may affect other sources of infection in the body. If antibiotics were used, A1c improvement could not be solely attributed to reduction in the infectious and inflammatory burden from periodontal disease. The authors also stated in the introduction: "Chronic periodontal disease (CPD) and type 2 diabetes mellitus (T2DM) share common pathogenic pathways involving the cytokine network, resulting in increased susceptibility to both diseases, leading to increased inflammatory destruction, insulin resistance, and poor glycemic control."

Generalizations about the relationship between periodontal disease and diabetes cannot be drawn from two pieces of research. However, both articles make important statements about the current state of knowledge going back a number of years. The AAP/EFP workshop report had two authors and 22 collaborators. Their statement about the reduction in A1c from scaling and root planing being equivalent to adding a second oral diabetes medication speaks volumes. As important is their statement that there is a dose-dependent relationship between periodontitis and diabetes complications. That is a very bold statement. The 2015 research cited above also speaks volumes with their assumption that periodontal disease and diabetes share common pathogenic pathways. When authors of such prominence are indicating that the bidirectional relationship between periodontal disease and diabetes no longer needs proving, clinicians can take that to their patients and act on it to improve outcomes.

Another very recent development involves the action by the New Jersey State Board of Dentistry. In June, the board ruled that dentists in New Jersey can now screen at-risk patients for diabetes. The board stated that such in-office screening is within the scope of licensure in the state, but that this testing is not to be presumed to be the standard of care. This latter statement can be interpreted to mean that the screening needs to be followed by referral to a physician for definitive diagnosis. The HbA1c screening can be performed as a finger prick and analyzed in the dental office. Furthermore, an insurance carrier is launching a pilot program to enable providers to implement A1c screening. Patients generally visit their dental provider more frequently than their physician. The impact of diabetes screening and referral of patients with positive test results to their physician for management will be felt immediately for the individual and the health-care system as well. Early diagnosis is critical to the lifespan and healthspan of individuals with diabetes. Overall health-care savings should be very significant especially in view of the seriousness of the rapidly expanding number of diabetic and prediabetic individuals in the US.

These studies, among many others, and the decision by a state dental board reveal the acceptance by the dental profession of the interconnected relationship between periodontal disease and diabetes.

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