OPINION
Diabetes mellitus and periodontal disease:
the profession’s choices
Chris Turner1
Key points
Suggests development towards joint care with
doctors for patients with diabetes.
Abstract
This paper reviews why doctors rarely refer their diabetic patients for a dental opinion and suggests strategies to
teach them the importance of controlling periodontal disease as part of a system of joint care. A pro forma to share
results and define diabetic risks for doctors, dentists and patients has been developed. Periodontal risks could be
better defined if the community periodontal index of treatment needs score of 2 for calculus is divided into 2 for
supra-gingival and 2* for sub-gingival types.
There is now overwhelming scientific evidence
that diabetes mellitus and periodontal
disease have a biological link1 and a two-way
relationship,2 although the mechanism remains
unclear. People with diabetes have a 3–4 times
greater risk of developing periodontal disease
than people who don’t, rising to ten times for
smokers.3
Dentists have been taught about these links,
first described in 1928,4 but doctors have not;
not least in the UK, as a question about dental
status has been omitted from the National
Institute for Health and Care Excellence
(NICE) annual diabetic systems checks and
the Department of Health and Social Security’s
own website until June 2022. It is clear that
treatment for periodontal disease improves
glycaemic control,5 may lead to a reduction in
diabetic medications and reduces the severity
of the known medical complications.5
While this should be helpful for those people
with diabetes who do access dental care, there
is at least half of the UK population who do
not. How are they going to find out about a
possible health benefit of dental care?
It follows that there is a need to inform
doctors and for they and dentists to work
1
Retired, Bath, UK.
Correspondence to: Chris Turner
Email address: info@spacemark-d.com
Submitted 10 June 2022
Accepted 7 July 2022
https://doi.org/10.1038/s41415-022-5029-5
BRITISH DENTAL JOURNAL | VOLUME 233 NO. 7 | October 14 2022 537
Aims to educate doctors about diabetic
periodontopathy.
together.6,7 Doctors cannot do it themselves
because they do not know. That educational
lead should come from dentists as follows:
• For those people with diabetes who do
have dental care, send a copy of the Basic
Periodontal Examination scores with
an explanation about what they mean
either directly to your patient’s general
practitioner (GP) or via the patient
themselves.7 The highest overall score
from the sextants is the risk factor. Ask in
return for the HbA1c glycated haemoglobin
scores. These two scores have been classified
using a traffic light (red, amber and green)
system to simplify identifying the level of
risk (Appendix 1)
• Dental postgraduate tutors should contact
their medical counterparts and find a
lecturer who can talk to doctors about this
important omission in their professional
training and knowledge
• Deans of dental schools should contact
the deans of medical schools about adding
this to the curriculum and find a lecturer
who can talk to medical students about this
important omission in their professional
training and knowledge
• NICE have been asked to add dental
questions8 as the sixth complication9 to
doctors’ annual diabetic health checks for
five other conditions. Now, doctors should
advise their patients living with diabetes
that they are at greater risk of developing
periodontitis and that periodontal
Proposes to add a second star to community
periodontal index of treatment needs scores.
treatment may improve glycaemic control.
However, dentists have not been informed
of this change in medical practice.
There is a compelling argument for a paradigm
shift in the care of people with diabetes
for both doctors and dentists and a need to
identify those patients who are at greatest risk.
This should be straightforward for patients
attending for dental care if the proposed pro
forma (Appendix 1) is trialled.
For those patients that doctors identify in the
highest-risk groups that are not receiving dental
care, where should they be referred for a dental
screening and opinion when dentists have either
left, or are planning to leave, the NHS and there
is already insufficient capacity to cope? In the
short term, this could include referrals for
hospital consultants to dental departments, or
for GPs, a referral to an expanded community
dental service. A more radical solution to free
up professional time could be to limit NHS
dental checks to yearly rather than six-monthly.
In the medium to long term, more dentists and
hygienists should be recruited and trained. With
these limitations, it follows that identification
of people with diabetes in the highest-risk
categories should have priority.
A secondary and equally important issue
concerns the Basic Periodontal Examination
scores and whether or not the existing categories
are sufficiently robust as predictors of the above
periodontal risks. Since its introduction nearly
40 years ago, the community periodontal index
 OPINION

of treatment needs (CPITN) has become a

worldwide standard method of screening for
periodontal disease.10
As it stands, the score of 2 for calculus covers
both supra- and sub-gingival types. Using the
above classification, a patient with diabetes with
minimal levels of supra-gingival calculus and
otherwise excellent levels of plaque control, no
bleeding on probing, or pockets greater than
3 mm, would score 2 and be placed in the amber,
medium-risk group; an incorrect assessment of
their real risk level.11
There is general agreement that sub-gingival
calculus is more deleterious than supra-
gingival calculus. With this in mind, the time
has come to re-evaluate the score of 2.
In the early development of the CPITN
system, it was recognised that the score of 4
for pockets greater than 5.5  mm depth was
too imprecise and 4* was created for pockets
greater than 8.5 mm. A similar argument about
imprecision can be made for the score of 2. By
adding a star to this group, making 2 = supra-
gingival calculus and 2* = sub-gingival calculus,
it may be possible to improve the prognostic
value of these scores, with 0, 1 and 2 as green
(low risk) and 2* and 3 as amber (the medium-
risk category).
The World Health Organisation is invited to
make these changes to the score of 2.
I am reminded of James Lind’s 1770 dictum
to the Board of Admiralty about the benefits of
fresh fruit to combat scurvy aboard warships
that took 40 years to be implemented. I suggest
that the dental profession should commit to
implementing the changes I have proposed
by 2028, the centenary of Williams’ paper,
‘Diabetic periodontoclasia’.4 Appendix 1 Proposed pro forma
To quote James Lind, ‘the province has
been mine to deliver precepts: the power of
3. Battancs E, Gheorghita D, Nyiraty et al. Periodontal collaborative care – A systematic review of the
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2715–2728. review. Geriatr Med J 2021.
References 4. Williams J. Diabetic Periodontoclasia. J Amer Dent Assoc 8. UK Parliament. Hansard 16 March 2022. 2022.
1. Bullon P, Newman H N, Battino M. Obesity, diabetes 1928; 15: 523–529. Available at https://hansard.parliament.uk/
mellitus, atherosclerosis and chronic periodontitis: a 5. Genco R J, Graziani F, Hasturk H. Effects of periodontal commons/2022-03-16 (accessed September 2022).
shared pathology via oxidative stress and mitochondrial disease on glycaemic control, complications, and incidence 9. Löe H. Periodontal disease. The sixth complication of
dysfunction? Periodontol 2000 2014; 64: 139–153. of diabetes mellitus. Periodontol 2000 2020; 83: 59–65. diabetes mellitus. Diabetes Care 1993; 16: 329–334.
2. Grossi S G, Genco R J. Periodontal disease and diabetes 6. Siddiqi J, Zafar S, Sharma A, Quaranta A. Diabetes 10. Barmes D. CPITN – a WHO initiative. Int Dent J 1994;
mellitus: a two-way relationship. Ann Periodontol 1998; mellitus and periodontal disease. The call for 44: 523–525.
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