Incorporating Oral Health as Part of Routine Diabetes Care in Ireland

J Ahern 1,3,4, OP Hamnvik 2, J Barrow 3, J Nunn 4

1 Oral and Maxillofacial Pathology, St. James’s Hospital, Dublin 8, Ireland
2 Division of Endocrinology, Diabetes and Hypertension, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
3 Initiative for Integration of Oral Health and Medicine, Harvard School of Dental Medicine, Boston, MA, USA
4 School of Dental Science, Trinity College Dublin, Dublin 2, Ireland

Abstract

Diabetes mellitus is a common disorder of glucose metabolism that is increasingly prevalent in the Irish population. It is associated with a range of complications leading to substantial morbidity and mortality. A less well-recognized complication of diabetes is periodontal disease. This is a chronic inflammatory disease affecting the periodontium, the specialized group of tissues that surround and support the teeth, including the gingiva (gums) and alveolar bone. Periodontal disease affects patients with diabetes with a greater prevalence and incidence than non-diabetic patients, and can itself exert negative effects on glucose control in people with diabetes. The National Clinical Programme for Diabetes in Ireland aims to reduce the morbidity and mortality associated with diabetes, which includes the development and dissemination of guidelines supporting integrated care. Based on the bidirectional relationship between diabetes mellitus and periodontal disease, we recommend that an oral health evaluation, as well as any necessary onward referral, be incorporated into the Irish recommendations for routine diabetes care, as part of the National Clinical Programme.

Introduction
The presence of a bidirectional relationship between oral and systemic health has been well described, highlighting a need to consider oral health in the management of chronic diseases1. A particularly common chronic disease that affects oral health is diabetes mellitus2. In Ireland, there are approximately 190,000 people living with diabetes, 90% of whom have type 2 diabetes; the prevalence in adults aged 50 years and over is 8.5% and is increasing3,4. In 2016, a set of guidelines was released in Ireland, entitled a “Practical guide to integrated type 2 diabetes care”. These guidelines, which were supported by the Health Service Executive (HSE), aimed to present a model of integrated diabetes care, and were developed in conjunction with the National Clinical Programme Diabetes Working Group5. These guidelines did not address the oral health needs of patients with diabetes. However, the interrelationship between diabetes and periodontal disease, and their ability to negatively affect each other, emphasizes the need for guidelines such as the aforementioned, to support and encourage collaboration between medical and dental professionals to ensure optimal co-management of diabetic patients2, 6-8.

Oral health considerations for the diabetic patient
Hyperglycaemia in diabetes is strongly associated with the development of oral complications, including periodontal disease, xerostomia, oral candidiasis and neurosensory disorders such as burning mouth syndrome9. Periodontal disease, which is a bacterially induced, chronic inflammatory disorder, which affects the supporting structures of the teeth, including the gingiva (gums) and alveolar bone, is a particularly significant oral complication of diabetes mellitus6. It begins as an inflammatory process of the gums and can, if unchecked, progress to involve the supporting structures, including periodontal ligaments and alveolar bone around the teeth eventually leading to tooth loss. The resultant periodontal pocket, that forms around the tooth after loss of supporting structures, presents the ideal environment for the growth of mostly anaerobic microorganisms, and a nidus from which their toxins can spread systemically, while also causing local tissue destruction and alveolar bone loss7.

Typical signs and symptoms of periodontal disease include gingival bleeding, gingival erythema, halitosis, tooth mobility, gingival suppuration and resultant tooth loss7. The loss of intra-oral hard and soft tissues negatively impacts on masticatory function, thus compromising nutrition as well as affecting both speech and appearance. Tooth loss also increases the functional stress on the remaining dentition, and patients may often require an oral prosthesis, such as a denture, to aid function. Meta-analyses have shown diabetic patients to have an increased susceptibility to the development of periodontal disease 10-11. In addition to increasing the risk of developing periodontal disease, diabetes can also contribute to the periodontal disease process. Patients with poorly controlled diabetes are three times more likely to develop periodontal disease at the severe end of the spectrum when compared with non-diabetics12-13.

Importantly, in addition, periodontal disease has been shown to influence diabetic control. Severe active periodontal disease adversely affects blood glucose levels in patients with diabetes. Randomized controlled trials have consistently demonstrated that mechanical periodontal therapy is associated with a reduction in the haemoglobin A1c by 0.4 percentage points at three months, a clinical impact equivalent to adding an additional medication to a patient’s pharmacological regime2.

Incorporating oral health into overall diabetic care
The American Diabetes Association’s “Standards of Medical Care in Diabetes” recommends referral of a patient to a dental professional for a comprehensive oral health examination, as part of the initial management of a diabetic patient14. By contrast, the HSE supported “Practical guide to integrated type 2 diabetes care” does not address the oral health needs of patients with diabetes (other than mentioning dry mouth as a possible new symptom of diabetes) and specifically omits mention of visiting a dental professional as part of overall diabetic care5. This Irish guideline supports an integrated model of care for patients with type 2 diabetes, which involves the patient, the General Practitioner (GP), the practice nurse, the diabetologist, the clinical nurse specialist in diabetes, the dietitian, the ophthalmologist and the podiatrist5. There is a compelling argument, as outlined in the foregoing, for including dental professionals as part of this integrated model of care6-8.

The GP and the practice nurse are key to the success of Integrated Care5. However, engaging with dental professionals and incorporating oral health as part of overall diabetes care can reduce the morbidity and mortality associated with diabetes-related oral health complications, and may also, by controlling a patient’s periodontal disease, actually improve diabetic control2, 6-7. In addition to the management of oral disease, dental professionals are well positioned to evaluate risk factors and intra-oral signs and/or symptoms indicative of poor metabolic control in patients who have been diagnosed with diabetes, for example xerostomia and oral candidiasis6. Dental professionals are experienced in motivating behavioural change in their patients, and these skills may be used to support their medical colleagues to achieve a common goal such as smoking cessation or diet modification, in order to improve the overall health of diabetic patients7. Many patients visit their dentist or their dental hygienist more regularly than their medical doctors; thus, providing dental professionals with the opportunity to support their medical colleagues in the detection of undiagnosed diabetes, by facilitating the onward referral of patients who present with poorly controlled periodontal disease or any other signs or symptoms suggestive of hyperglycaemia to their GP for assessment7.

There is a significant body of evidence to suggest that diabetes and periodontal disease are interrelated and may negatively affect each another if management is neglected. It is important, therefore, to improve patient awareness of the link between these two diseases, and to advocate for increased collaboration between medical and dental professionals in their co-management2, 6. In 2016, the Centers for Disease Control and Prevention in the United States awarded funding to six state departments of health to support the integration of state chronic disease programs and state oral health programs. With respect to diabetic care, the aim is to develop an enhanced model of care in which oral health and other primary care providers collaborate to deliver integrated, patient-centered diabetes prevention and management.

Opportunities for integrated care
Members of the primary care medical team should inform patients that the risk of periodontal disease is increased by diabetes, and that achieving proper glycaemic control in the presence of active periodontal disease may be more difficult, therefore increasing the risk of diabetic complications2, 6. GPs and/or practice nurses should encourage good oral health practices by asking simple questions such as “Do you have a dentist/dental hygienist?” or “When was your last dental visit?” By bringing the topic of oral health into the GP surgery, members of the primary care medical team can play an important role in the promotion of oral health, the prevention of periodontal disease and the improvement in overall diabetic health6. The primary care medical team is in a unique position to ensure that each patient with diabetes has engaged with a dental professional13, which in Ireland is accessible privately or through state subsidized schemes such as the Dental Treatment Benefit Scheme or the Dental Treatment Services Scheme. In order to develop these opportunities for integrated care, there would need to be a greater emphasis placed on oral health during GP training, and the training of other members of the primary care team2, 15.

Conclusion
Patients with diabetes are at higher risk of oral health complications, and these complications carry substantial morbidity. In addition, uncontrolled active periodontal disease can worsen glucose control. Based on this, the American Diabetes Association’s guidelines recommend a comprehensive oral health examination by a dental professional as part of diabetes management. In Ireland, this recommendation was not included in the HSE supported guidelines, entitled a “Practical Guide to Integrated Type 2 Diabetes Care”. However, based on the interrelationship between diabetes and oral health, there is a compelling case to be made for routine oral health assessment by a dental professional to be incorporated into Irish guidelines. Simple questioning of the patient about recent dental visits and encouraging engagement with a dental professional as part of their overall disease management is a simple, rapid and effective way of incorporating oral health into comprehensive diabetes care.

Correspondence:
Dr. John Ahern, Oral & Maxillofacial Pathology, St. James's Hospital, Dublin 8, Ireland.
Email: joahern@stjames.ie

Conflict of Interest
There is no conflict of interest declared from any of the authors named in this article.

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