EFP/IDF consensus on periodontitis and diabetes (2018): a two-way relationship, an HbA1c drop of 0.27 to 0.48% after periodontal therapy, and a screening job for the dental office

What it says#

The report is the consensus of a joint workshop held by the European Federation of Periodontology and the International Diabetes Federation in Madrid on February 19 and 20, 2017, chaired by Mariano Sanz and Antonio Ceriello, with 15 experts from Europe, the USA and South Asia. Funding came from the EFP in part through unrestricted educational grants from Sunstar. Its stated objective was to update the evidence on the bidirectional association between periodontitis and type 2 diabetes, last reviewed at the 2012 EFP/AAP workshop, and to provide recommendations for the multidisciplinary team caring for people with both diseases. It was published online in the Journal of Clinical Periodontology on December 26, 2017, in the February 2018 print issue, and in parallel in Diabetes Research and Clinical Practice.

On epidemiology it finds strong evidence that people with periodontitis have elevated risk for dysglycemia and insulin resistance. In people without diabetes, those with periodontitis have a higher HbA1c (weighted mean 5.64%, 95% CI 5.54 to 5.74%) than people with better periodontal health (5.31%, 95% CI 5.18 to 5.44%), a difference of 0.29% (95% CI 0.20 to 0.37%). In three cohort studies of people with type 2 diabetes (1252 participants), periodontitis was associated with poorer control, HbA1c 7.4% versus 7.0%, although four cross-sectional studies, one case-control study and one small cohort found no difference. Six studies from the USA, Japan and Taiwan with 77,716 participants consistently showed that periodontitis patients have a higher chance of developing pre-diabetes and diabetes (adjusted HR 1.29, 95% CI 1.11 to 1.46). For type 1 diabetes there is insufficient data, one clinical study, to answer the question. Across 13 studies and 34,149 subjects, periodontitis in people with diabetes was associated with retinopathy after adjustment (5 studies, OR 1.2 to 2.8), with more renal complications (3 studies), with neuropathic foot ulceration in one study (OR 6.6), with cardiovascular complications (HR 1.1 to 1.3) and with higher overall mortality (HR 3.5 to 4.5).

On mechanisms the report finds a moderate level of evidence: elevated pro-inflammatory mediators in poorly controlled diabetes (IL-1 beta, TNF-alpha, IL-6, the RANKL/OPG ratio, oxidative stress) within the gingival tissues play a role in the increased periodontal destruction, circulating mediators are elevated when both diseases are present, and successful periodontal treatment reduces circulating CRP and TNF-alpha in people with diabetes. It states there is currently no data supporting a causal relationship between the periodontal microbiome and the presence of diabetes.

On treatment its sentence is the one quoted above: in people with diabetes, periodontal therapy accompanied by effective home care is both safe and effective, and clinical parameters improve after standard non-surgical therapy even in people with poorly controlled diabetes. Since the 2013 systematic review at least 7 randomized trials with 912 patients from India, Malaysia and the USA have been published, and four meta-analyses from 2014 to 2017 give consistent evidence of a clinically meaningful reduction in HbA1c in type 2 diabetes of 0.27 to 0.48% at 3 to 4 months after periodontal therapy. There is insufficient data to show the effect is maintained at 6 months. The report notes that the reduction is similar in size to the HbA1c increase attributed to periodontitis, and similar to what is often achieved by adding a second medication to a pharmacological regimen. Adjunctive antibiotics do not enhance the HbA1c reduction beyond scaling and root planing alone, and no threshold of periodontal resolution has been identified as necessary to realize the HbA1c benefit.

The guidelines for oral health professionals follow. People with diabetes should be told they have an increased risk of gingivitis and periodontitis, that periodontitis may make glycemic control harder to achieve, and that they are at higher risk of eye, kidney and cardiovascular complications. The dental team should collect a careful diabetes history (type, duration, complications, therapy and concomitant drugs), ask how well controlled the diabetes is and when glucose was last checked, and request the last HbA1c result. Every patient with any form of diabetes should receive a thorough oral examination including a comprehensive periodontal evaluation, with a full-mouth pocket chart and bleeding scores if indicated by screening; if no periodontitis is found, a preventive regime with regular monitoring; if periodontitis is diagnosed, management without delay; and non-surgical periodontal therapy irrespective of the level of control, because it may help glycemic control. Surgical periodontal and implant therapy is not indicated in patients without acceptable diabetes control; in well-controlled patients the results equal those in patients without diabetes, with attention to post-operative infection risk in poorly controlled patients and to the timing of procedures in patients on insulin or sulfonylureas. Patients with extensive tooth loss should be encouraged to pursue rehabilitation for proper nutrition, other oral complications (dry mouth, burning mouth, candida, caries) should be evaluated, children with diabetes should have an annual oral screening, and patients with risk factors for type 2 diabetes but no diagnosis should be informed of their risk and referred to a physician for testing, with screening by a validated questionnaire such as FINDRISC or by the American Diabetes Association criteria, and direct referral if symptomatic.

The guidelines for physicians mirror them: oral health education for all patients with diabetes, a warning about periodontal risk and its effect on control and complications, asking about signs of periodontitis (bleeding gums, loose teeth, spacing, malodor, abscesses) at diabetes visits, referral for a periodontal examination for everyone newly diagnosed with annual periodontal review thereafter, annual oral screening for children, and liaison with the dentist before oral surgery to avoid hypoglycemia. The report notes these guidelines also apply to people with pre-diabetes and the metabolic syndrome. Patient guidelines for the physician's office and the dental office list the warning signs and the home-care routine, twice-daily brushing for at least two minutes and daily interdental cleaning.

Who it applies to#

Every patient with type 2 diabetes, pre-diabetes or the metabolic syndrome who sits in a dental chair, every child or adolescent with diabetes, and the undiagnosed patient with risk factors, whom the report wants the dental team to identify and refer. The physician guidelines make the dentist part of diabetes care: a new diagnosis is supposed to come with a periodontal referral, and an annual periodontal review after that.

The report is explicit about where its evidence stops. Type 1 diabetes has insufficient data on both the association with control and the effect of therapy on HbA1c, and the report says the biological plausibility there is unclear. Gestational diabetes has insufficient data on control and no studies on incidence. The HbA1c benefit is demonstrated at 3 to 4 months, not at 6, and it comes from non-surgical therapy with home care, not from antibiotics or adjuncts.

What changed#

The prior consensus came from the 2012 joint EFP/AAP workshop (Chapple and Genco 2013), which found severe periodontitis associated with higher HbA1c in people with and without diabetes and a mean HbA1c reduction of 0.36% (95% CI 0.19 to 0.54) at three months after periodontal treatment in the accompanying systematic review. The 2018 report updates each of the three domains, epidemiology, mechanisms and intervention, with the studies published since, and states that its guidelines are modified from the 2012 set.

The additions a practice notices: the incident-diabetes risk is now quantified (HR 1.29 across 77,716 participants), the complication data are laid out organ by organ, at least 7 new randomized trials with 912 patients sit behind an HbA1c range of 0.27 to 0.48%, the negative finding on adjunctive antibiotics is explicit, and the dental screening guideline now names its tools, a validated questionnaire such as FINDRISC or the American Diabetes Association criteria, with the questionnaire reproduced as an appendix.

Where the source is#

The consensus report is Sanz and colleagues, Journal of Clinical Periodontology 2018, volume 45, issue 2, pages 138-149, DOI 10.1111/jcpe.12808; the link under the title opens the Wiley article page. The same report was published in Diabetes Research and Clinical Practice, volume 137, pages 231-241. When this entry was written the Wiley page refused automated access; the report was read in full from the peer-reviewed author version deposited in the University of Birmingham research portal, which carries the publisher's rights statement and is free to download for private study, and the abstracts were checked against both PubMed records. The EFP's news item of February 25, 2017 supplied the workshop dates and organizers. Quote the published version when citing.