EFP Perio Talks: Lior Shapira explains latest evidence on perio-diabetes links and importance of periodontist's role

“I want to emphasise the need for diagnosing diabetes in the dental chair: this is very, very important.”

This was a key message from EFP president-elect Lior Shapira in the second EFP Perio Talks session on Instagram, which focused on the latest evidence on the bidirectional link between periodontitis and diabetes.

Prof Shapira emphasised the role that periodontists and dentists can play beyond oral health in helping to diagnose diabetes and the need to collaborate with physicians in treating patients with both diseases.

“The problem with diabetes is that about 30% of people with diabetes are not diagnosed,” explained the professor of periodontology at the Hebrew-University-Hadassah Faculty of Dental Medicine in Jerusalem, Israel. “The dental chair and the periodontal chair are maybe one of the most common places they go for treatment. Our role as periodontists and dentists is to help the patient identify if they have diabetes or not.”

When a periodontist or dentist sees a patient with bleeding gums, “we need to check carefully and see maybe they have something else, maybe it’s not just bugs and inflammation in the oral cavity, maybe they have something systemic affecting it.”

If diabetes is suspected, the dentist or periodontist should “ask for glucose levels, ask for glycated haemoglobin (HbA1c) levels, send them to the physician, try to connect with the physician. If you see people that are overweight who are more prone to diabetes, you should talk to them about reducing their weight.”

Change in attitude

Prof Shapira highlighted how the attitude of physicians has changed as more evidence about the bidirectional link between periodontitis and diabetes has emerged. “When we talked with physicians 15 years ago, they were laughing and saying this is nonsense. But today we approach all the important organisations and we did the Perio-Diabetes Workshop with the International Diabetes Federation (IDF) and they welcomed us immediately and they know that we can contribute to the treatment of patients with diabetes.”

He highlighted the findings of this February 2017 workshop, which performed systematic reviews of the latest research and provided the material for the EFP’s Perio & Diabetes campaign, including recommendations for patients, physicians, periodontists, and dentists.

For this second EFP Perio Talks live session on Instagram, Prof Shapira was interviewed by Reena Wadia (a UK periodontist and member of the EFP communications team). She asked him about the strength of evidence on the bidirectional link between periodontitis and diabetes, particularly on how periodontal treatment can have a positive effect on diabetes.

“We have correlation studies, association studies, and intervention studies that show that if you treat and control the diabetes in a very efficient way you can reduce the severity of periodontal disease and your periodontal treatment can be more effective. And if you treat periodontal disease it is easier to control diabetes: you can reduce the HbA1c – which is the marker of diabetes – by 0.3-1%, which is equivalent to a second antidiabetic medication.”

He added that recent studies had also shown that treating pre-diabetes can reverse the state to a non-diabetic stage. “We know more about the mechanism, more about the treatment, and we know that if we reduce the inflammation in the oral cavity, we have a tremendous effect on the diabetic status.”

Research and treatment

Asked by Dr Wadia about areas for further research, Prof Shapira responded that more intervention studies and good randomised controlled trials were needed as well as more work on the connection between periodontal disease and Type-1 diabetes, as research has so far focused mainly on Type-2 diabetes.

“Today we have recent data that young people with Type-1 diabetes have more severe inflammation and more severe periodontitis compared to their age-range controls,” he observed. “The information we have about type-1 diabetes is limited, but it is emerging now and we will know more in the coming years.”

On treatment for periodontal patients with diabetes, Shapira said that “maybe we need to be more aggressive in our treatment with people with uncontrolled diabetes, as it’s hard to control their diabetic status and it’s hard to control their periodontal status.”

He pointed to a recent study by Hatice Hasturk and Thomas van Dyke on the treatment of subjects with poorly-controlled diabetes and severe periodontitis using a “total elimination of inflammation” approach (non-surgical treatment, extraction of hopeless teeth, surgery, and antibiotics).

 “If the first stage of non-surgical therapy is not as successful as we expected and there is still a problem controlling both the diabetes and the periodontal disease, we need to consider surgery and the use of antibiotics to treat those non-responsive patient,” Prof Shapira said. “The paradigm that periodontal surgery should be avoided in people with diabetes should be revisited”.

In conclusion, explaining the importance of the work of periodontists in tackling diabetes, he said: “We need to be not dentists but the doctors of the mouth, like any other profession in medicine. If we do this, we will give our patient a much better service. And if you do this, you will find every month one patient with undiagnosed diabetes, prediabetes or diabetes that needs treatment and maybe you save his or her life.”

Note: Lior Shapira’s comments have been edited for clarity and concision.

VIEW LIOR SHAPIRA’S EFP PERIO TALK