A Bermuda Triangle

Objective The early diagnosis of (pre)diabetes mellitus is essential for the prevention of diabetes complications. It has been suggested that gum disease (periodontitis) might be an early complication of diabetes and may be a useful risk indicator for diabetes screening. Therefore, a dental office could be a good location for screening for (pre)diabetes in periodontitis patients, using a validated hemoglobin A1c (HbA1c) dry spot analysis. Research Design and Methods A total of 313 individuals from a university dental clinic participated. From 126 mild/moderate periodontitis patients, 78 severe periodontitis patients and 109 subjects without periodontitis, HbA1c values were obtained by the analysis of dry blood spots. Differences in mean HbA1c values and the prevalence of (pre)diabetes between the groups were analyzed. Results The mild/moderate and severe periodontitis groups showed significantly higher HbA1c values (6.1% ± 1.4% [43 mmol/mol ± 15 mmol/mol] and 6.3% ± 1.3% [45 mmol/mol ± 15 mmol/mol], respectively) compared with the control group (5.7% ± 0.7% [39 mmol/mol ± 8 mmol/mol], p=0.003). In addition, according to the ADA guidelines for diagnosis, there was a significant overrepresentation of subjects with suspected diabetes (23% and 14%) and prediabetes (47% and 46%) in the severe periodontitis group and mild/moderate periodontitis groups, respectively, compared to the control group (10% and 37%, p=0.010). Notably, 18.1% of suspected new diabetes patients were found among subjects with severe periodontitis compared to 9.9% and 8.5% among subjects with mild/moderate periodontitis and controls, respectively (p=0.024). Conclusions The dental office, with particular focus on severe periodontitis patients, proved to be a suitable location for screening for (pre)diabetes; a considerable number of suspected new diabetes cases were identified. The early diagnosis and treatment of (pre)diabetes help to prevent more severe complications and benefit the treatment of periodontitis. 2 Periodontitis as a possible early sign of diabetes mellitus 27 INTRODUCTION Diabetes mellitus is a growing health problem and its prevalence is dramatically increasing (Lam and LeRoith, 2012). The prevalence of diabetes was estimated at 285 million adults worldwide in 2010 (Shaw et al., 2010), and this is expected to rise to 552 million by 2030 (Whiting et al., 2011). However, due to the absence of symptoms and/or disease-related knowledge, diabetes often goes undetected, and approximately one-third of people with diabetes are not aware of their status (Cowie et al., 2006, Kim et al., 2006). The early diagnosis and intervention of (pre)diabetes prevent the common microand macrovascular complications (Tian et al., 2014) and are cost-effective (Herman et al., 2005). Therefore, risk indicators for (pre)diabetes screening are needed and proposed (American Diabetes Association, 2015). In this respect, the onset of several oral pathologies might be indicative of metabolic dysregulation. Several studies demonstrate the association between diabetes and oral diseases. The most commonly observed chronic oral disease is periodontitis. Periodontitis is a common chronic multifactorial inflammatory disease of the supporting structures of the teeth (root cementum, gingiva, periodontal ligament and alveolar bone), initiated and sustained by an aberrant host immune response against resident bacterial biofilm on the teeth. It is a major cause of tooth loss (Pihlstrom et al., 2005). The severe form of this condition occurs in approximately 10-15% of the population, and the prevalence is twice as high in subjects >50 years of age (Burt et al., 2005, Eke et al., 2012b, Hugoson and Norderyd, 2008). Many studies have demonstrated that diabetes mellitus severely exacerbates the onset, progression and severity of periodontitis (Demmer et al., 2012, Lalla and Papapanou, 2011, Mealey and Rose, 2008, Taylor and Borgnakke, 2008). The prevalence of periodontitis in diabetes patients is estimated to be two or even three times higher than in an otherwise healthy population(Mealey et al., 2006). In addition, periodontitis is strongly associated with uncontrolled diabetes mellitus (Garcia et al., 2015, Eke et al., 2016). This is because diabetic subjects, particularly uncontrolled diabetic subjects, are more susceptible to infections and impaired wound healing (Muller et al., 2005); therefore, periodontitis is considered to be a complication of diabetes mellitus (Lalla and Papapanou, 2011, Löe, 1993, Preshaw et al., 2012). With this knowledge, it has been suggested that dentists could help screen for (pre)diabetes (Lalla et al., 2011, Strauss et al., 2010). The majority of dental practices are not equipped for blood biochemistry. The measurements of hemoglobin A1c (HbA1c) using dry blood spots may be a conservative way to screen for diabetes in patients with periodontitis. The aim of the present study was to determine HbA1c levels and affirm the presence of (pre)diabetes in subjects from a university dental clinic with and without periodontitis using the analysis of dry blood spots. Because periodontitis can be considered a