Periodontitis and diabetes are two prevalent diseases with a strong bidirectional relationship between them. Poorly managed diabetes promotes the progression of periodontitis and complicates its treatment. Conversely, active periodontitis adversely affects diabetes management and treatment.

In honor of World Health Day, Tommi Pätilä, a heart and transplant surgeon at HUS New Children's Hospital, in Finland, and Timo Sorsa, a professor of oral and maxillofacial diseases at the University of Helsinki, reflect on the connection between these two prevalent diseases from the perspective of oral health.

Diabetes and gum inflammation are two significant global health issues that require immediate attention. About half of the world's population suffers from gum inflammation, while nearly half a billion people have diabetes.

In Finland alone, there are approximately 500,000 diabetics, with about 50,000 suffering from type 1 diabetes and around 400,000 from type 2 diabetes. Additionally, it is estimated that there are up to 100,000 undiagnosed type 2 diabetics in Finland.

Understanding the Close Connection

Periodontitis is a disease of the tooth-supporting tissues that progresses from gum inflammation and can ultimately lead to tooth loss. Symptoms of the disease include red, swollen, and bleeding gums, gum recession, formation of gum pockets, loosening of teeth, bad breath, and possible swallowing and chewing problems.

Periodontitis is associated with many risk factors, such as smoking, genetic factors, and systemic diseases like diabetes.

The symptoms of the disease can vary from mild to severe and often require evaluation and treatment by a dentist or dental hygienist. Early detection and treatment are crucial for managing periodontitis.

Diabetic patients have an increased risk of developing periodontitis, and conversely, periodontitis has a negative impact on diabetes treatment and management. High blood sugar levels increase inflammation in the mouth and hinder the healing of periodontitis. The combined effect of these two diseases is also reflected in systemic inflammatory markers and blood sugar levels.

Traditional diagnostic methods are not always sufficient to identify the risk of periodontitis and diabetes. Therefore, new biomarker-based rapid tests have been developed to help identify the risk of these diseases at an early stage.

Oral Health Status Revealed in Minutes

The aMMP-8 rapid test developed in Finland is based on measuring the concentration of active matrix metalloproteinase 8 (aMMP-8) in mouthwash. Studies have shown that elevated levels of aMMP-8 may indicate both periodontitis and diabetes.

The aMMP-8 rapid test can be performed at the dentist's office, and the results are obtained immediately. This allows for early intervention in the development of periodontitis and assessment of the risk of diabetes. Additionally, the test provides patients with important information about their oral health and the risk of diabetes, which encourages better self-care and adherence to healthy lifestyles.

"The test allows for the detection of signs of periodontitis even before symptoms occur, which provides an opportunity for early treatment and prevention of complications," says Professor Timo Sorsa of the University of Helsinki's Department of Oral and Maxillofacial Diseases.

The test has proven to be useful in screening patients with type I, type II, and gestational diabetes.

Oral Health: A Crucial Factor for Diabetics

Diabetic patients with periodontitis require special attention, reminds pediatric heart and transplant surgeon Tommi Pätilä. Pätilä is also one of the developers of the Lumoral innovation, which enhances mechanical oral hygiene.

"It is especially important for diabetics to invest in regular oral hygiene and dental visits. This not only improves patients' quality of life but also reduces the risk of long-term complications," says Pätilä.

According to Pätilä, adjunctive therapies can be combined with at-home oral hygiene management, such as low-dose doxycycline acting as an aMMP-8 inhibitor and light-activated mouthwashes with anti-inflammatory effects.

"Antibacterial Lumoral treatment effectively removes harmful plaque bacteria from tooth surfaces and gum lines. Home-administered Lumoral treatment has been shown to be significantly more effective and better tolerated than chlorhexidine-based mouthwashes commonly used today," Pätilä explains.

Pätilä emphasizes that antibacterial treatment complements mechanical tooth cleaning and does not replace the need for brushing and cleaning between teeth. Why is additional treatment needed to enhance mechanical oral cleaning?

"Research shows that brushing only removes 65% of plaque. Residual plaque remains in the mouth even after the most effective brushing. Lumoral helps remove this residual plaque. Regular Lumoral treatment ensures that tooth surfaces are thoroughly clean. Diabetics, in particular, benefit from this removal of residual plaque," says Pätilä.

According to studies, regular adjunctive antibacterial treatment alongside traditional non-surgical standard treatment reduces inflammation in gum tissues and improves oral hygiene and healing of deep pockets in chronic periodontitis compared to conventional treatment.

Antibacterial treatment has also been shown to prevent and improve inflammation of peri-implant tissues. The treatment is suitable for everyone, but light-activated antibacterial treatment is seen as most effective for patients who require enhanced oral hygiene.

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World Health Day, launched by the World Health Organization (WHO), is celebrated globally on April 7th to increase awareness of health issues. This year, the timely theme "My health, my right" emphasizes the importance of health equity.

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References:

Trujillo K, Räisänen IT, Sorsa T, Pätilä T. Repeated daily use of dual-light antibacterial photodynamic therapy in periodontal disease—a case report. Dent J (Basel). 2022;10(9):163. doi:10.3390/dj10090163

Pakarinen S, Saarela RKT, Välimaa H, et al. Home-applied dual-light photodynamic therapy in the treatment of stable chronic periodontitis (HOPE-CP)—three-month interim results. Dent J (Basel). 2022;10(11):206. doi:10.3390/dj10110206

Gholami L, Shahabi S, Jazaeri M, Hadilou M, Fekrazad R. Clinical applications of antimicrobial photodynamic therapy in dentistry. Front Microbiol. 2023;13:1020995. doi:10.3389/fmicb.2022.1020995

Lähteenmäki H, Pätilä T, Räisänen I, Kankuri E, Tervahartiala T, Sorsa T. Repeated Home-Applied Dual-Light Antibacterial Photodynamic Therapy Can Reduce Plaque Burden, Inflammation, and aMMP-8 in Peri-Implant Disease – A Pilot Study. Curr Issues Mol Biol 2022; 44: 1273–1283. doi: 10.3390/cimb44030085

According to a report commissioned by the European Federation of Periodontology (EFP), 4.9 percent of global healthcare expenditure is allocated to treat preventable oral diseases such as gum inflammation, cavities, and tooth loss. A preventive approach to oral disease management can bring significant savings to societies, especially when interventions are targeted at economically vulnerable populations.

The "Time to put your money where your mouth is: addressing inequalities in oral health" report by the Economist Impact reveals that the combined prevalence of cavities and severe gum inflammation, periodontitis, has already exceeded the combined global prevalence of non-communicable diseases (NCDs) like mental health disorders, cardiovascular diseases, diabetes, chronic respiratory diseases, and cancers.

Preventive oral care saves money

The report introduces a new cost calculation model for oral disease prevention and treatment, estimating that preventable oral diseases consume approximately $357 billion annually from global healthcare budgets.

Preventable oral diseases affect too many people worldwide. Tooth decay affects over two billion individuals globally, while severe gum inflammation impacts over one billion people. Hence, the EFP report underscores the urgent need to improve global oral health.

Reducing risk factors threatening oral health, such as sugary diets, tobacco, and alcohol consumption, is recommended not only to reduce oral diseases but also to improve overall health and prevent non-communicable diseases.

The scientific evidence linking oral infections to overall health is growing continuously, emphasizing the importance of utilizing this knowledge more extensively among healthcare professionals.

For instance, a recent doctoral thesis from the University of Turku reveals that poor oral hygiene increases the risk of severe head and neck infections requiring hospitalization. The study's findings suggest that investments in oral health and dental care can reduce infection-related costs, complications, and even mortality.

The EFP emphasizes the clear link between oral and overall health, stressing the importance of prioritizing oral health in healthcare budgets and policies.

The report also introduces a framework detailing the progression of cavities from healthy teeth to severely decayed teeth, presenting preventive measures such as maintaining oral hygiene with fluoride toothpaste and implementing local fluoride treatments to prevent or slow down cavity development.

Lumoral: Support for Mechanical Brushing

Efficient oral self-care is crucial for preventing and treating cavities and gum diseases. However, as people age, maintaining oral hygiene can become challenging due to declining vision, memory, or motor skills.

The Lumoral method serves as a targeted solution against microscopic plaque in the mouth, enhancing the effectiveness of mechanical tooth brushing and interdental cleaning. Lumoral treatment eliminates Streptococcus mutans bacteria responsible for tooth decay and gingivitis bacteria.

Endorsed by dentists and the Dental Hygienists' Association in Finland, Lumoral is suitable for maintaining oral health, as well as treating and preventing oral diseases at home. Lumoral slows plaque formation and significantly reduces the amount of bacteria causing periodontitis on tooth surfaces and along the gum line.

Existing studies support Lumoral's efficacy, showing that while even the most effective electric toothbrushes remove only about 65% of harmful bacteria from teeth, Lumoral eliminates over 99% of biofilm bacteria.

Sources:

1. Pakarinen S, Saarela RKT, Välimaa H, et al. Home-applied dual-light photodynamic therapy in the treatment of stable chronic periodontitis (HOPE-CP)—three-month interim results. Dent J (Basel). 2022;10(11):206. doi:10.3390/dj10110206
2. https://www.suuhygienistiliitto.fi/suomen-suuhygienistiliitto-suosittelee-lumoralia/
3. Aggarwal N, Gupta S, Grover R, Sadana G, Bansal K. Plaque removal efficacy of different toothbrushes: a comparative study. Int J Clin Pediatr Dent. 2019;12(5):385-390. doi:10.5005/jp-journals-10005-1669 
4. https://www.efp.org/publications/special-publications/the-burden-of-caries-and-periodontitis/

Maintaining good oral hygiene and oral health is paramount for overall well-being. When it comes to older individuals, proper dental care goes beyond just addressing oral issues; it also plays a critical role in managing underlying health conditions.

Periodontal disease (periodontitis) affects up to two thirds of people over 65. The condition is even more common in people with diabetes.

- Clean mouths, teeth and dentures are a priority in the oral care of older people, as they prevent both decay and various types of oral infections. Inflammation of the gums is thought to be linked to the risk of heart attack, among other things, says Tommi Pätilä, a cardiac and organ transplant surgeon at the New Children's Hospital in Helsinki.

Oral health is known to predispose to more than 200 chronic diseases, including lung disease and rheumatic diseases. According to researchers, severe gum disease, periodontitis, can increase the risk of developing even dementia or milder form of memory loss. The results of a study published in the Journal of the American Geriatrics Society show that the risk was about a fifth higher if a patient had poor dental health.

- Simple measures, such as regular brushing and cleaning of gaps between teeth and regular dental check-ups, can help prevent the onset of gum disease while minimising the risk of oral bacteria or their structures entering the bloodstream and spreading to other parts of the body, says Pätilä.

A healthy mouth is a prerequisite for well-being

Looking after your teeth and oral health is particularly important if you have an underlying disease such as diabetes or cardiovascular disease. Preventing and treating oral infections is also necessary before surgery, Pätilä points out.

For instance, prior to prosthetic joint or flap surgery, it is imperative for a dentist to confirm the absence of asymptomatic infections within the oral cavity. Such infections could potentially serve as entry points for bacteria into the surgical site, leading to post-operative complications.

Thorough oral hygiene is the basis for the prevention and treatment of gum diseases such as periodontitis. However, effective mechanical tooth brushing and extractions are not always enough.

As we get older, oral hygiene can also become more difficult to maintain as vision, memory or hand motor skills deteriorate. Finnish researchers have developed Lumoral, a method that acts as a precision weapon against microscopic plaque in the mouth. Lumoral kills both Streptococcus mutans, the bacteria that cause tooth decay, and gingivitis bacteria.

- Lumoral retards plaque formation and significantly reduces problem-causing bacteria in the mouth. Notably, older people align well into the product's user profile, as thorough oral hygiene is so important in this age group, says Pätilä.

Tested in the treatment of peri-implantitis

Lumoral is a Finnish innovation for maintaining oral health and treating and preventing oral diseases at home. It is recommended by many dentists and the Finnish Association of Oral Hygienists.

- The device is intended primarily for people whose conventional oral hygiene does not produce desirable results. This is often the case, for example, with patients suffering from chronic periodontitis.

Lumoral has also been tested in the treatment of peri-implantitis.  Peri-implantitis is characterised by inflammation of the soft and hard tissues around the implant. It affects both the mucosa and the bone supporting the implant, leading to the gradual destruction of the skeletal structure holding the implant in place.

The pilot study involved patients diagnosed with peri-implantitis or a milder form of it. Lumoral was used by the patients as part of their dental self-care routine.

The amount of plaque and gingival bleeding around the inflamed implant was significantly reduced compared to baseline, the study found. In four out of seven patients, the inflammatory markers in the implant pocket fell to normal levels.

According to the researchers, the pilot study shows that regular, repeated antibacterial Lumoral treatment can prevent and cure inflammation of the tissue around dental implants, while promoting overall oral health.