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

In the field of dental care, changes are constant as fresh ideas shape the industry. A recent collaboration agreement between Finland’s Koite Health Ltd and Trading Co., Ltd. from Thailand is set to revolutionize dental care standards by introducing innovative light-activated technology to the country.

Founded in 2017, Innodent has been at the forefront of delivering cutting-edge dental solutions to Thailand's healthcare sector. Driven by a commitment to leverage the latest advancements in high-tech solutions, the company aims to provide the most innovative technologies to the dental industry. This strategic vision led to a partnership with Koite Health, and the introduction of Lumoral, a Finnish med-tech innovation, to the dental market in Thailand.

– The introduction of Lumoral to Innodent's product portfolio was the result of a personal recommendation from Dr. Hildebrand, a renowned maxillofacial surgeon from Berlin. Dr. Hildebrand's successful clinical experiences with Lumoral convinced the team at Innodent to explore this revolutionary technology further, explains Thomas Constantin, CEO and owner of Innodent Trading Co., Ltd.

Lumoral: an innovative personal healthcare device

So, what exactly is Lumoral, and how does it work? Mr. Constantin reminds that the close link between oral bacteria and overall health and well-being is an important factor that sparked interest in the Finnish oral health-enhancing innovation in the first place.

– Oral bacteria can cause dental caries and bad breath but there can also be more severe secondary effects such as cardiovascular diseases, dementia, psoriasis and many more. Overall health starts with a healthy mouth. It is therefore important to regularly clean the mouth thoroughly.

Lumoral is an innovative personal healthcare device designed to remove 99.9% of harmful oral bacteria while preserving the healthy mouth flora. Traditional oral hygiene methods can only remove approximately 60% of bacteria, leaving behind a significant risk of oral health issues, Thomas explains.

Lumoral's advanced technology utilizes color molecules in its Lumorinse mouth rinse, which adhere to harmful oral bacteria attached to teeth surfaces and gum tissue in the mouth. Subsequently, the light emitted by the mouthpiece reacts with the green sensitizer, effectively breaking down the cell membrane of bacteria and destroying them both from inside and outside. This method ensures the eradication of harmful bacteria without the risk of resistance development.

Long-term benefits for implant patients

The addition of Lumoral to Innodent's product portfolio aligns with the company’s focus on dental implantology, with a specialization in ceramic implants. While the industry predominantly utilizes titanium implants, scientific evidence suggests a significant risk of peri-implantitis, an inflammation of the tissues surrounding these metal implants, over time.

– Lumoral presents a solution to mitigate this risk, offering long-term benefits for implant patients, Constantin says.

Furthermore, Lumoral's versatility extends beyond implant care, offering benefits for individuals with various oral health concerns, including chronic bad breath, gum disease, and orthodontic patients wearing braces or clear aligners.

– This accessibility makes Lumoral an invaluable addition to Innodent's offerings, catering to a diverse range of dental needs in Thailand.

– The great advantage of Lumoral however, is that everyone benefits from removing harmful oral bacteria. Whether you are wearing braces or clear aligners, suffer from chronic bad breath, gum disease or simply want to have a perfectly clean and healthy mouth, Lumoral is your solution.

Promising prospects for both companies

The collaboration between Koite Health and Innodent holds promising prospects for both companies and dental patients in Thailand. Mr. Constantin says that for Innodent, this partnership marks a significant expansion into the business-to-consumer (B2C) market, enabling the company to reach individual consumers through online channels like their dedicated webshop.

– This shift opens new avenues for marketing and sales, enhancing accessibility to innovative dental solutions for patients across the country. Ultimately, the collaboration aims to raise awareness about oral health and its crucial role in overall well-being among the Thai population.

– By introducing Lumoral's advanced technology to the market, Koite Health and Innodent are paving the way for a new era of dental care in Thailand, one that prioritizes prevention, innovation, and improved patient outcomes.

World Oral Health Day is celebrated annually on March 20th. This year's theme - A Happy Mouth… A Happy Body  - emphasizes the connection between a healthy mouth and overall health.

Dental and oral bacteria are linked to many chronic diseases in the body. Thorough brushing and regular dental visits can also prevent strokes (1).

According to statistics from the World Stroke Organization (WSO), over 13 million people suffer from strokes each year, and one in four people will have a stroke in their lifetime. Surprisingly, up to 90% of these cases could be prevented by making lifestyle changes such as adopting a healthier diet, increasing regular exercise, quitting smoking, and even improving regular oral hygiene.

Medical Licentiate Olli Patrakka examined the significance of oral bacteria, especially viridans group streptococci, in the development of strokes in his recent doctoral dissertation in forensic medicine at the University of Tampere. Although these bacteria are normal mouth microbes, they can cause serious illnesses such as heart valve inflammation when they enter the bloodstream. For example, they can enter the bloodstream through inflamed gums while brushing teeth.

- These bacteria attach to the tooth's surface in the mouth and initiate the process, leading to the formation of dental plaque. We hypothesize that a similar phenomenon occurs when bacteria that enter the bloodstream during, for example, dental procedures or dental infections travel into the walls of the arteries. This may accelerate the development of both strokes and atherosclerosis, explains Patrakka.

Poor oral hygiene is a risk factor for strokes

According to Patrakka, dental bacteria can be found in the blood clots of stroke patients in about four out of five cases. A similar result has yet to be reported.

Blood clots from stroke patients treated in Tampere were collected for the study during acute care. In addition, samples from patients suffering from symptomatic carotid artery stenosis were used as tissues for endarterectomy.

Epidemiological studies have shown that poor oral hygiene is an independent risk factor for strokes.

- The results of my study suggest that the connection could be explicitly explained through the inflammatory reaction caused by dental bacteria in atherosclerotic plaques.

The findings of the dissertation are significant as they open up new opportunities to develop the treatment of stroke patients.

Patrakka estimates that the development of a vaccine may also be possible.

So, what practical implications can findings like these have on treating stroke patients and healthcare practices?

Although further research is needed to determine causality, the study supports the view that oral health must be taken care of, especially in those at risk of strokes.

According to Patrakka, the inflammation caused by streptococcal bacteria in the mouth should always be considered in stroke prevention as part of regular dental care. Additionally, it is essential to investigate the potential benefits of timely antimicrobial treatment or bacterial vaccines in the future.

Periodontitis is the root cause of many ailments

Studies show dental plaque bacteria are responsible for about 95 per cent of oral diseases. One of the most common oral diseases is periodontitis, a severe gum disease caused by dental plaque. Early signs of this disease include red gums, gum bleeding, and bad breath.

In patients with periodontitis, the fibres that attach the tooth to the gum are destroyed, forming a periodontal pocket between the gum and the tooth. This pocket may expand around the entire tooth. If the infection is not treated promptly and oral hygiene is not improved, it can progress to destroy more extensively the supporting tissues of the teeth and, ultimately, the jawbone.

Thorough oral hygiene is crucial for the prevention and treatment of oral infections. According to the Finnish Institute for Health and Welfare (THL), more and more people in Finland brush their teeth at least twice a day, but there are still deficiencies in self-care. While about 80% of women brush their teeth at least twice a day, the corresponding figure for men is 53%.

Deficiencies in oral hygiene are directly reflected in the statistics of oral infectious diseases. For example, gum diseases are worryingly common in the age group of 30-44, both in women (43%) and men (57%).

Thorough mechanical brushing of teeth and cleaning of the interdental spaces are crucial because even asymptomatic oral inflammations can affect the body's overall health.

- According to statistics, individuals with healthy mouths live longer. Every missing tooth reduces life expectancy. This is talked about far too little, says Tommi Pätilä, a heart and transplant surgeon at HUS New Children's Hospital in Helsinki, Finland.

Pätilä is also one of the developers of the antibacterial Lumoral method. Lumoral is a medical device designed to improve oral hygiene and oral health. The antibacterial oral care method is especially suitable for patients with difficult-to-treat gum diseases such as periodontitis who do not get adequate results from traditional oral hygiene methods such as brushing teeth and cleaning interdental spaces.

The importance of interdisciplinary collaboration

According to Pätilä, collaboration between doctors and dentists is essential and needs to be increased in Finland. Many doctors in Finland already check the oral health status of their patients at their clinics and guide them to further treatment as needed. Diabetes is an excellent example of a disease where the importance of hidden inflammations is generally understood. However, more collaboration is required to expedite many diagnoses and even prevent general diseases.

- The recent medical dissertation at the University of Tampere is significant as it addresses oral health as part of overall body health, says Pätilä.

Olli Patrakka's interest in oral bacteria arose as part of his duties as a pathologist. Has the interest of young doctors in the impact of dental infections on general health increased?

- It hasn't increased, but it should. In the basic medical training I received about five years ago, there was also no discussion of the impact of dental infections on general health. Of course, the topic is still relatively new, but hopefully, awareness and scientific evidence will gradually increase over the years.

Patrakka emphasizes that a general practitioner should know when a dental problem requires a referral to a dentist. This would expedite the treatment of oral infections and potentially support the achievement of balance in the treatment of many general diseases.

- My research contributes to the evidence that the impact of oral health on general health is significant. The blood vessels of the tooth pulp are directly connected to the systemic circulation. Thus bacteria and their metabolites can circulate directly into our bodies if the teeth are not in good condition.

Olli Patrakka. Image: Hanna-Sofia Luoto

References:

Sen S, Giamberardino LD, Moss K, Morelli T, Rosamond WD, Gottesman RF, Beck J, Offenbacher S. Periodontal Disease, Regular Dental Care Use, and Incident Ischemic Stroke. Stroke. 2018 Feb;49(2):355-362. doi: 10.1161/STROKEAHA.117.018990. Epub 2018 Jan 15. PMID: 29335336; PMCID: PMC5780242.

https://trepo.tuni.fi/bitstream/handle/10024/154588/978-952-03-3315-7.pdf?sequence=2&isAllowed=y

Pakarinen S, Saarela RKT, Välimaa H, Heikkinen AM, Kankuri E, Noponen M, Alapulli H, Tervahartiala T, Räisänen IT, Sorsa T, et al. Home-Applied Dual-Light Photodynamic Therapy in the Treatment of Stable Chronic Periodontitis (HOPE-CP)—Three-Month Interim Results. Dentistry Journal. 2022; 10(11):206. https://doi.org/10.3390/dj10110206

Nikinmaa S, Alapulli H, Auvinen P, Vaara M, Rantala J, et al. (2020) Dual-light photodynamic therapy administered daily provides a sustained antibacterial effect on biofilm and prevents Streptococcus mutans adaptation. PLOS ONE 15(5): e0232775. https://doi.org/10.1371/journal.pone.0232775

Nikinmaa S, Moilanen N, Sorsa T, Rantala J, Alapulli H, Kotiranta A, Auvinen P, Kankuri E, Meurman JH, Pätilä T. Indocyanine Green-Assisted and LED-Light-Activated Antibacterial Photodynamic Therapy Reduces Dental Plaque. Dentistry Journal. 2021; 9(5):52. https://doi.org/10.3390/dj9050052