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

The link between oral and general health is widely understood, but is this reflected in Finland's health care system and people's oral health? To mark World Health Day, Jukka Meurman, Professor Emeritus of Oral Infectious Diseases, and Tommi Pätilä, cardiac and transplant surgeon at the New Children's Hospital of HUS, reflect on the issue from the perspective of oral health.

World Health Day, launched by the World Health Organisation (WHO), is celebrated worldwide on April 7 to raise awareness of various health concerns. This year's theme – Health for All – focuses on health equity. In other words, the state in which everyone has a fair and just opportunity to attain their highest level of health. 

What about health equity in Finland? Does everyone have equal opportunities to attain their highest level of health in Finland, a country ranked the world's happiest for the sixth year in a row in 2023?

Health inequality is a national challenge also in Finland. Also, in terms of oral health equity. Although the health of Finns has improved considerably over the last decades, according to indicators such as morbidity, work capacity, and mortality, poverty and exclusion are also reflected in Finns' teeth and oral health.

Poor socio-economic status and low education and income levels have a negative impact on oral health. The Finnish Dental Society Apollonia has warned that there is still a lack of comprehensive and adequate oral health care services for the adult population. The poor oral health situation in Finland is also reflected in children.

According to Professor Jukka Meurman, the lack of resources for public oral health care is also directly reflected in the quality of oral health care for people with physical disabilities and, thus, in the prevalence of oral diseases. There is also an urgent need for more staff trained in oral health care for people with disabilities.

Cross-border cooperation for more efficient use of health resources

Oral health is directly linked to a person's overall health and well-being. However, oral health problems are challenging because they are often asymptomatic and may go unnoticed. Undetected chronic oral infections such as caries and periodontitis can contribute to the development of serious diseases such as cardiovascular disease, diabetes, and cancer and, for example, increase the risk of premature birth in expectant mothers (1). 

- Although the link between oral health and general health has been discussed since ancient times, much remains to be done, especially among the public. The issue is becoming well understood in the medical profession, but there is still a need to add dental education to medical curricula and vice versa, says Meurman.

According to the WHO, periodontal disease is estimated to affect around 19% of the world's adult population. This means more than one billion cases worldwide.

In Finland, it is estimated that up to two out of three people over 30 suffer from periodontitis. The disease is even more common in people with diabetes. If left untreated, persistent gum disease can put people at risk of tooth loss - but it is also linked to severe heart events. 

According to a study, the first heart attack is 30% more common in people with periodontal disease than in healthy people of the same age (2).

According to Meurman, many doctors in Finland check the oral health status of their patients in their practices and refer them for further treatment if necessary. Diabetes, for example, is a good example of a disease where the importance of latent inflammation is already widely understood.

Meurman further believes that cooperation between doctors and oral health professionals in Finland should be significantly increased, even during basic training. This would make sharing the workload and managing the health workforce easier. Finland should also consider offering new training programs to ease the shortage of resources in the dental healthcare sector.

- While current dental training takes 5-6 years, an "oral health therapist" training course would only take about 2.5 years, Meurman suggests.

The ideal situation would be for dental training to be similar to specialist training in, say, ophthalmology. Moreover, many practical dental procedures could be carried out by specialists with a university of applied sciences degree.

Meurman admits that such a situation has not yet been fully achieved anywhere in the world. However, in countries such as Singapore and New Zealand, professionals receiving Oral Health Therapist training have, for many years, already eased the workload of dentists. Oral Health Therapists examine dental decay and gum disease and provide routine dental treatments such as teeth cleaning, polishing, teeth extraction and treatment for patients under the prescription of dentists.

Preventive oral care brings benefits to individuals and society

Tommi Pätilä, a cardiac and transplant surgeon at the New Children's Hospital at HUS, believes that oral health is not sufficiently taken into account for patients coming to specialized care. The problem is the frequent lack of time. In specialized care, it is easy to think that a dentist can examine the patient's mouth in due course.

Oral health should always be considered at the basic examination stage for hospital patients. The information should be regularly recorded in the medical records – just like blood pressure values are routinely monitored, says Pätilä. 

More resources for oral health care would be necessary for Finland. It would also be economically worthwhile for society, as it would help prevent the onset of many general diseases.

According to Meurman, preventive health care, including using the antibacterial Lumoral method to improve oral hygiene, will quickly pay for itself.

Pätilä stresses that investing in oral health care and prevention would reduce the development of chronic diseases and the exacerbation of those that have already developed. This would be particularly important for people with cardiovascular disease, diabetes, and rheumatic diseases.

- Preventive oral health care brings significant savings to society. This applies not only to dental care but to the entire healthcare system. Lumoral supports regular mechanical dental hygiene and helps to achieve gum health and prevent inflammation when regular dental hygiene is not enough, says Pätilä.

References:

1) Jacobsson B, Kacerovsky M, Menon R, Musilova I, Radochova V, Slezak R, Stepan M, Vescicik P (2019) ‘Association between periodontal disease and preterm prebalor rupture of membranes'. Journal of Clinical Periodontology.

2) Rydén L, Buhlin K, Ekstrand E, de Faire U, Gustafsson A, Holmer J, Kjellström B, Lindahl B, Norhammar A, Nygren Å, Näsman P, Rathnayake N, Svenungsson E, Klinge B: Periodontitis Increases the Risk of a First Myocardial Infarction. A Report From the PAROKRANK Study. 13.1.2016 Circulation. 2016;133:576–583