World Diabetes Day – Sunstar and diabetes research

November 14, 2020

Today – the 14^th of November – is World Diabetes Day. What better way to mark the occasion than by sharing some updates about recent and future research initiatives we are supporting.

DiabetRisk study in partnership with the Spanish Society of Periodontology

Those familiar with diabetes mellitus know that its associated complications are exceptionally devastating. Most of these complications are mainly the result of high levels of glucose in the blood (hyperglycemia). We know that screening for hyperglycemia can spur on early diagnosis of diabetes, which is essential if we want to prevent these complications from happening. Previous research already suggested that the dental office could be a suitable setting to screen for subjects at risk for diabetes1,2,3.

To continue this path, SUNSTAR partnered up with the Spanish Society of Periodontology to initiate the “DiabetRisk” project. The objective of this study was to evaluate the efficacy of different screening protocols for undiagnosed hyperglycemia in the dental office. And now we have an exclusive insight into the first preliminary results.

For this project, SEPA had access to a group of 41 centers, including both private practices and university clinics, that are part of their “Research Network of Dental Clinics”. At these centers, participants completed a questionnaire (FINDRISC) which includes risk factors such as age, consumption of fruits and vegetables, physical exercise, family history of diabetes mellitus, etc. The outcome of this questionnaire provides a risk estimate for developing diabetes. The participants also received a periodontal exam. Patients with a moderate risk to develop diabetes, according to the FINDRISC questionnaire, received a point-of-care HbA1c test, which provides an estimation of the three-month average blood glucose levels. As a final step, patients with HbA1c values above normal (≥5.7%) were eventually referred to their physician for confirmatory diagnosis.

Early diabetes detection at the dental office

Together, the 41 centers included a total of 1143 patients. Out of those patients, 97 individuals (8.5%) were diagnosed with previously unknown diabetes (n=28, 2.5%) or prediabetes (n=69, 6.0%). Compared to patients with good metabolic health or prediabetes, patients with diabetes had a worse periodontal condition. Likewise, patients with poor periodontal health were more likely to present pre-diabetes or diabetes.

These results demonstrate that a screening protocol that combines the FINDRISC questionnaire and a point-of-care HbA1c test is a feasible and efficient approach to identify subjects with undiagnosed diabetes or prediabetes in the dental office. This could make an important difference for many patients. For example, for patients identified with prediabetes, early detection means they still can implement measures that prevent or delay progression to overt diabetes mellitus. And early diagnosis of diabetes means those patients might have an opportunity to prevent the development of complications.

The dental setting offers a unique opportunity to identify a considerable number of previously unknown diabetes and prediabetes cases. The fact that most people visit the dentist on a regular basis – once or twice a year – increases this potential even further. In that case, the dental professional could act as a “gatekeeper” who is the first person to identify a potential problem. Subsequent referral to a physician for confirmatory diagnosis supports the concept of an interdisciplinary, holistic approach of chronic conditions such as diabetes.

Collaboration with the Pisa University

As demonstrated in the DiabetRisk study, patients with diabetes mellitus suffer from periodontal disease more often, and in many cases, the disease progression is also more severe. Vice versa, research from the past decades shows that periodontal disease can also negatively influence the diabetic state4. In a 2018 consensus report by the European Federation of Periodontology (EFP) and the International Diabetes Federation (IDF), which was supported by SUNSTAR, it was concluded that patients who suffer from diabetes and periodontal disease have an increased risk or hyperglycemia, compared to periodontally healthy people5.

It is generally accepted that inflammatory disturbances play a crucial role in the bi-directional relationship between periodontal disease and diabetes5,6. Previous research indicates that successful treatment of periodontal disease in patients with diabetes can have beneficial effects on these inflammatory disturbances, both locally and systemic7. However, dental professionals such as periodontists have several different periodontal treatment modalities at their disposal. There is no data available whether these different treatment modalities are equally effective in lowering inflammation in patients with diabetes. It could very well be that patients with diabetes respond differently to the different types of periodontal treatment.

Therefore, the objective of this study at the University of Pisa is to compare the effect of different periodontal treatment modalities in terms of inflammatory responses in patients presenting co-morbidities, among which type 2 diabetes mellitus. Dr. Massignani explains: “One of the links in need of deeper understanding in the bi-directional relationship between diabetes and periodontal disease is the efficacy of different treatment modalities. We are confident this study will result in a robust clinical indication on how to periodontally treat patients with diabetes, providing support for the dental care community.”

1. Lalla E, Kunzel C, Burkett S, Cheng B, Lamster IB. Identification of unrecognized diabetes and pre-diabetes in a dental setting. Journal of dental research. 2011 Jul;90(7):855-60.
2. Genco RJ, Schifferle RE, Dunford RG, Falkner KL, Hsu WC, Balukjian J. Screening for diabetes mellitus in dental practices: a field trial. The Journal of the American Dental Association. 2014 Jan 1;145(1):57-64.
3. Teeuw WJ, Kosho MX, Poland DC, Gerdes VE, Loos BG. Periodontitis as a possible early sign of diabetes mellitus. BM Open Diabetes Research and Care. 2017 Jan 1;5(1).
4. Graziani F, Gennai S, Solini A, Petrini M. A systematic review and meta‐analysis of epidemiologic observational evidence on the effect of periodontitis on diabetes An update of the EFP‐AAP review. Journal of Clinical Periodontology. 2018 Feb;45(2):167-87.
5. Sanz M, Ceriello A, Buysschaert M, Chapple I, Demmer RT, Graziani F, Herrera D, Jepsen S, Lione L, Madianos P, Mathur M. Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the International Diabetes Federation and the European Federation of Periodontology. Diabetes Research and Clinical Practice. 2018 Mar 1;137:231-41.
6. Verhulst MJ, Loos BG, Gerdes VE, Teeuw WJ. Evaluating all potential oral complications of diabetes mellitus. Frontiers in endocrinology. 2019 Feb 18;10:56.
7. Polak D, Shapira L. An update on the evidence for pathogenic mechanisms that may link periodontitis and diabetes. Journal of Clinical Periodontology. 2018 Feb;45(2):150-66.

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