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

Duodecim, Finland's leading medical association, has published the book "The Healing Power of Medicine" (Lääketieteen Parantava Voima), which presents Finnish advancements in healthcare for disease prevention, easier diagnosis, and more effective treatment. The book also introduces Lumoral treatment, an antibacterial oral hygiene method recognized as one of Finland's significant breakthroughs in dentistry.

Edited by Emerita Professor Anne Pitkäranta, Professor Kaija-Leena Kolho, and Emeritus Professor Kimmo Kontula, the book emphasizes the importance of scientific research in society and its impact on healthcare outcomes. 

The book highlights the antibacterial Lumoral method, now available in 16 European countries. In the article "Light for Teeth" (Valoa hampaille), one of the developers of Lumoral, a specialist in heart and organ transplant surgery, Dr. Tommi Pätilä, discusses the method's origin and its potential to revolutionize oral health on both individual and societal levels.

"Dental and periodontal diseases are among the most common chronic infectious diseases worldwide. Chronic inflammation of the supporting tissues of the teeth, periodontitis, is considered a public health problem due to its prevalence as the sixth most common disease globally," Dr. Pätilä points out.

Lumoral is an antibacterial and light-activated oral hygiene method used as part of a regular oral hygiene routine, alongside brushing and interdental cleaning. Research shows that Lumoral treatment slows plaque formation and significantly reduces the number of bacteria in the mouth, which contribute to gum inflammation.

According to Dr. Pätilä, incorporating light-activated and antibacterial treatment into daily oral hygiene routines enhances the effectiveness of tooth cleaning, especially when traditional oral hygiene methods fall short.

"Lumoral treatment is suitable for everyone but is particularly beneficial for individuals with oral health issues. The method also freshens breath. Its antimicrobial effect targets harmful bacteria in the mouth while preserving the normal bacterial flora that maintains oral health," Dr. Pätilä explains.

Rapid Diagnosis - Effective Disease Management

Dr. Tommi Pätilä also contributes to another article in the book, "Finnish Oral Medicine Innovations Enable Rapid Diagnosis and Plaque Control for Gum Disease" (Suomalaiset suulääketieteelliset innovaatiot mahdollistavat iensairauden pikadiagnostiikan ja plakkikontrollin). The article discusses significant Finnish advancements, particularly in diagnosing and treating severe gum diseases. The article also emphasizes the connection between periodontitis and various systemic diseases. Therefore, early detection and treatment of the disease are crucial.

To expedite the diagnosis of periodontitis, researchers from the University of Helsinki and Helsinki University Hospital have developed chairside testing based on active matrix metalloproteinase-8 (aMMP-8) markers. The test complements the diagnosis of periodontitis and peri-implantitis and monitors treatment response and maintenance. It can be performed by a healthcare professional or independently by the patient at home, similar to COVID-19 antigen or traditional pregnancy tests.

Dr. Pätilä highlights that untreated periodontitis or peri-implantitis sustains and intensifies the body's low-grade systemic inflammation and is associated with several systemic diseases. Therefore, early diagnosis of gum diseases is essential. Rapid diagnosis also allows for the prompt initiation of effective treatment, halting or preventing disease progression. With the Lumoral method, patients can enhance their self-care at home.

"Low-grade inflammation is a condition where the body reacts to irritation by secreting mediators. Although the body's 'muted' inflammation is not a disease in itself, prolonged inflammation becomes harmful to health, especially in the aforementioned systemic diseases," Dr. Pätilä says.

Poor oral health incurs additional diseases for both individuals and society, emphasizes Professor Timo Sorsa, professor of oral and maxillofacial diseases at the University of Helsinki and developer of the aMMP-8 rapid test.

"Finnish dental and periodontal diagnostic and therapeutic inventions may significantly impact the detection, treatment, and prevention of the world's sixth most common disease, periodontitis/peri-implantitis. They also enable plaque and gum disease control," states an article in book.

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"The Healing Power of Medicine - 100 Stories from Cells to Applications," edited by Emerita Professor Anne Pitkäranta, Professor Kaija-Leena Kolho, and Emeritus Professor Kimmo Kontula, 1st edition 2024, 365 pages, paperback

"The Healing Power of Medicine," edited by Emerita Professor Anne Pitkäranta (right), Professor Kaija-Leena Kolho, and Emeritus Professor Kimmo Kontula, is a testament to the importance of research in society. Vilja Harala (Duodecim)

Oral mucositis, an inflammation of the oral mucosa, often occurs in association with cancer treatments, particularly radiation and chemotherapy. It manifests as severe pain, redness, and swelling in the patient's mouth, potentially impacting the success of cancer therapy. To date, no existing medication has effectively prevented the development of mucositis. Recent research suggests that antibacterial dual light therapy may be an effective method to manage the symptoms of this condition.

Traditional approaches to treating oral mucositis include preventive measures such as maintaining good oral hygiene and using ice therapy during chemotherapy. If bacterial infection is present, the use of antibiotics may be considered by the physician. Corticosteroids are also a treatment option to alleviate pain and the inflammatory response associated with mucositis. However, corticosteroid use poses risks, as it can suppress the immune system, making cancer patients more susceptible to infections.

Ongoing research explores novel methods for preventing and treating oral mucositis. Mitochondria-stimulating red light therapy has proven to be very effective in treating oral mucositis, particularly as a preventive measure. Although light therapy is estimated to be the most effective treatment modality, its widespread implementation faces challenges such as availability and practical issues.

The latest studies investigate antibacterial treatments to preventively address oral mucosal ulcers originating from mucositis, aiming to mitigate the adverse effects of aggressive cancer treatments.

In the bachelor's thesis from the Faculty of Medicine at the University of Helsinki titled "Oral Mucositis – Antibacterial Dual Light in the Treatment of Oral Mucositis," medical student Jessica Hentilä explores the effects of antibacterial photodynamic therapy (aPDT) and antibacterial blue light (aBL) on mucositis ulcers as local treatments.

Hentilä's research evaluates the efficacy of dual light therapy against Streptococcus Oralis – a common bacterium in the oral microbiome. The study indicates that antibacterial dual light, a combination of aPDT and aBL, not only effectively targets streptococcal infections found in mucositis-induced ulcers but provides red light therapy simultaneously.

According to Dr. Tommi Pätilä, the thesis advisor of Hentilä’s project and specialist in pediatric heart and organ transplantation surgery, the reduction of oral bacterial load in the mouth promotes mucosal wound healing, concurrently reducing the risk of local and systemic infection complications common in cancer patients. This is an important addition to the conventionally applied red light therapy.

Oral Health Improves Quality of Life

Oral mucositis is a prevalent side effect in cancer patients undergoing chemotherapy, radiation therapy, or combined chemo-radiation therapy. Its pathophysiology stems from the ability of cancer treatments to inhibit rapidly dividing cells, present not only in cancer tissues but also in the oral mucosa.

Clinically, oral mucositis induces an inflammatory reaction in the oral mucosa, leading to swelling, redness, and painful ulcers. These mucosal variations create an entry point for oral bacteria, exacerbating mucositis-related inflammation or potentially spreading to other parts of the body, explains Dr. Matti Mauramo, a dentist and specialist in pathology.

Mauramo emphasizes that maintaining good oral hygiene is crucial for overall well-being. For cancer patients, oral health preservation is especially vital, as a clean mouth reduces the inflammatory burden caused by bacteria, worsening mucositis. Cancer patients must maintain good chewing ability and a diverse, high-calorie diet during intensive cancer treatments to avoid malnutrition and the development of a general weakness known as cachexia.

Professor Tuomas Waltimo from the University of Basel notes that while mucositis can occur in any part of the digestive tract, its manifestation on the oral mucosa poses specific challenges for cancer patients. Severe cases may hinder oral nutrition intake, leading to premature discontinuation of cancer treatments and compromising overall prognosis.

Waltimo, currently practicing as a private dentist at a Finnish clinic providing specialized dental care for patients undergoing cancer treatments, acknowledges the improvement in managing the side effects of cancer treatments compared to the early 2000s. Throughout his two-decade-long career as a researcher, Waltimo closely observed the development of cancer treatment pathways, particularly the increasing understanding of the role of oral infections in treatment outcomes.

In the early 2000s, according to Waltimo, the importance of oral health in the context of general healthcare was not systematically recognized as it is today in many European countries. However, the situation has improved, with dental care becoming a standard practice before initiating stem cell transplantation treatments in countries like Switzerland.

Simultaneously, patients’ prognoses have improved, and, most importantly, the quality of life for many patients has improved as the management and prevention of side effects of cancer treatments have become more efficient.

A Healthy Mouth Guards Against Serious Infections

Professor Waltimo highlights that alongside mucosal inflammation, cancer treatments often induce dry mouth, exposing cancer patients to various other oral diseases as well, such as tooth decay, gingivitis, and challenging periodontal and peri-implant diseases.

Oral infections are detrimental to overall health, causing a low-grade inflammatory state and potentially affecting the entire body. Oral infections are particularly harmful to cancer patients due to an increased risk of bacteremia – a bacterial infection that occurs when bacteria entering the bloodstream trigger the body's defense reaction. In severe cases, bacteremia can lead to life-threatening sepsis.

Waltimo emphasizes that good oral care can prevent infection complications, which cancer patients are more susceptible to, given their increased risk of diseases. Maintaining oral health is crucial for cancer patients, as the mouth is the primary source of routine bacterial seeding in the body. Mucous membranes, teeth, and gums must be kept in impeccable condition through daily effective oral hygiene.

According to Dr. Matti Mauramo, Lumoral's antibacterial treatment can influence the inflammatory process and induce an anti-inflammatory effect. Additionally, antibacterial dual light therapy can complement traditional bactericidal treatments.

Professor Tuomas Waltimo suggests that Lumoral's antibacterial dual light therapy could potentially serve as a preventive measure to support the oral health of cancer patients before the initiation of cancer treatments.

Preliminary observations suggest that Lumoral's antibacterial dual light therapy might be an important tool in the armory for oral mucositis treatment. Confirmation studies shall be set up to further investigate the effectiveness of the novel approach. A new doctoral dissertation study will commence at the University of Helsinki in spring to delve into this topic, adds Tuomas Waltimo.

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World Cancer Day is observed on February 4th every year. It is a day dedicated to raising awareness about cancer, promoting its prevention, detection, and treatment, as well as advocating for improved access to cancer care for all people globally. The day also serves as a reminder of the importance of early detection and education about cancer risk factors.

Sources:

Brown TJ, Gupta A. Management of Cancer Therapy-Associated Oral Mucositis. JCO Oncol Pract. 2020 Mar;16(3):103-109. doi: 10.1200/JOP.19.00652. Epub 2020 Feb 3. PMID: 32048926.

Al-Rudayni AHM, Gopinath D, Maharajan MK, Veettil SK, Menon RK. Efficacy of Oral Cryotherapy in the Prevention of Oral Mucositis Associated with Cancer Chemotherapy: Systematic Review with Meta-Analysis and Trial Sequential Analysis. Curr Oncol. 2021 Jul 29;28(4):2852-2867. doi: 10.3390/curroncol28040250. PMID: 34436016; PMCID: PMC8395421.

Hentilä, Jessica. "Oral Mucositis – Antibacterial Dual Light in the Treatment of Oral Mucositis." Bachelor of Medicine, University of Helsinki, Faculty of Medicine, October 22, 2023.

Gholami L, Shahabi S, Jazaeri M, Hadilou M, Fekrazad R. Clinical applications of antimicrobial photodynamic therapy in dentistry. Front Microbiol. 2023 Jan 5;13:1020995. doi: 10.3389/fmicb.2022.1020995. PMID: 36687594; PMCID: PMC9850114.