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As evidence of a causal link between periodontal disease and diabetes strengthens, Vernon Baxter asks: Is the dental industry ready to take a prominent role in tackling the disease, or is it happy to just pay lip service?
At a recent event at the New York Academy of Sciences, leaders in epidemiology, clinical research, and public policy were asked to rate their perceptions of the connection between periodontal disease and specific systemic diseases.
The proposition of a correlation between oral health and systemic health is hardly breaking news in the medical community, but an example from the results perhaps illustrates a recent shift in attitudes.
An overwhelming number of the audience (74%) were 100% certain that periodontal disease is linked to pregnancy problems. At the time of the event, all interventional trials showed that intensive treatment of periodontal disease had no effect on pregnancy outcome.
The willingness of the audience to believe in a link is indicative of periodontal disease's status as one the pre-eminent ‘cross-over' topics for academics in dentistry and medicine. At the forefront of these studies is the relationship between diabetes and periodontal disease.
This was evidenced by the first ever symposium presented by dentists to diabetes experts at the American Diabetes Association's Annual Scientific Sessions on June 6 2008. Diabetes is one of the biggest disease burdens in the developed world and.
The prevalence of type 2 diabetes in the Middle East is staggering; after the tiny island of Nauru, the United Arab Emirates is estimated to have the highest prevalence in the world.
The question now being asked by a number of academics is whether or not dentists can, or should, take a prominent role in the fight against diabetes.
Whose disease is it anyway?
Dr Ryan Demmer, as associate research scientist at Columbia University's Department of Epidemiology, was recently lead author on a study reviewing the link between oral health and diabetes. The findings raised the potentially industry-changing question of whether or not periodontal disease could actually have a causal relationship with diabetes.
"Up until this paper no-one had ever taken a large group of people without type 2 diabetes at base-line, looked at their periodontal health status and followed them forward in time to see if the people with perio develop diabetes at a higher rate," he claims.
"We [assumed] if periodontal disease was predominantly a result of diabetes, you really wouldn't see an association among non-diabetics. In fact, what we saw was that people with perio infections were at quite an elevated risk for type 2 diabetes - so it added a new twist to the science, which has always seen the infection as a consequence of diabetes."
The evidence, admits Demmer, is still patchy, but he believes the implications of his study are too important to ignore. If the theory that periodontal disease could trigger type 2 diabetes, is proven correct, then it could fundamentally alter dentistry's relationship with general health.
Rather than be encouraged to work together with the medical industry, dentists might be forced to offer diabetic screens to at-risk patients, as their physician colleagues do.
It might be an added burden for clinics but from a public health perspective it would make perfect sense.
"We have statistics to show that, right now, more people see their dentists than their primary care physicians because of factors such as aesthetic concerns," states Dr Anthony Vernillo of New York University's College of Dentistry. "This really provides dentists an unprecedented opportunity to help patients with diabetes."
Vernillo, who has specialised in the oral and systemic effects of diabetes mellitus, considers this line of research of growing importance to dentistry. However, there are others in the field that would rather not debate the prospect of periodontal care becoming a cornerstone of diabetes treatment.
"I'm not a dentist but my experience of working with dentists in this field is that there are a lot of dentists that are very excited about this - they think it is very interesting and it is very plausible," Dr Demmer remarks.
"However there are certainly a reasonable number of dentists who are reluctant to allow the hypothesis to gain any traction. They simply don't believe it and they don't think it is necessarily relevant in any way to dentistry."
The crux of the issue for opponents is that poor oral health, and periodontal disease in particular, is normally a sign of poor overall health. If doctors are failing to advise patients on risk factors such as a poor diet or obesity, why should it fall to dentists to perform what has traditionally been the task of a physician? Demmer admits that it is still too early to argue for the introduction of mandatory protocols for dental screening, but does believe that the topic warrants further investigation.
"It is really difficult to say at this point of time what should be done and I personally wouldn't lobby for anything - it still very unclear," he concedes.
"You certainly won't want to recommend that dentists should say that you should get this treated because it will help prevent diabetes - that would be inappropriate. Besides, there are a number of reasons why you should treat your periodontal disease anyway."
Food for thought
Regardless of the clinical debate, dental practices could and should be doing more to assist diabetic patients, argues Dr Vernillo. In the Middle East, practices are considered forward-thinking if they employ a dental hygienist. If Vernillo had his way, the dental team would include a nutritionist trained in diabetic advice as standard practice.
"Most dentists are generally doing great work with patients. I just think that more dentists should perform a role where they refer patients to a nutritionist," he says.
"Eating properly is just as important a part of the medical management of diabetes as what a dentist or a physician does and I would like to see more dentists embracing that and even having a nutritionist there in the office."
