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Visiting rate of dental clinic by the recommendation based on theperiodontal screening tests for the patients with diabetes mellitus
Ayako Okada, DDS, PhD (1), Mitsutoshi Kato, MD, PhD (2), Noriko Kato, RD (2),Chiaki Nomura, DDS (3), Tomoyoshi Shirahashi, DDS, PhD (3), Mami Kotoh, DDS,PhD (4), Yoshihide Yabuki, DDS (4), Tomoaki Matsuyama, DDS (5), Hiroyuki
Hanamura, DDS (5), Naoko Takase, MS (6), Kuninobu Yokota, MD, PhD (7), YoshiakiNomura, DDS, PhD (1), and Nobuhiro Hanada, DDS, PhD (1)(1) Department of Translational Research, School of Dental Medicine, Tsurumi University, Yokohama,(2) Kato Clinic of Internal Medicine, Tokyo, (3) Katsushika-ku Dental Association, Tokyo, (4) Tokyo
Minato-ku Shiba Dental Association, Tokyo, (5) Kawasaki-shi Dental Association, Kawasaki, (6) Oral
Care Company, Sunstar Group, Osaka, and (7) Department of Internal Medicine, Jikei University
School of Medicine, Tokyo, Japan
Purpose: The aim of this study was to investigate the dental visit status of patients with diabetes mellitus whoneeded to treatment of periodontitis screened by immunological salivary hemoglobin detection test (PerioscreenSunstar) in the medical and dental clinic cooperation at community base.
Materials and Methods: The study population was patient with diabetes mellitus undergone periodontal
screening tests by a family doctor, who is diabetologist in the internal medicine. In total, 100 subjects wereselected. The dental visit status of the diabetes mellitus patients with positive results was investigated according
to correspondence between the medical and dental information including intraoral clinical examination: numberof remaining teeth, maximum value of the periodontal pocket and percent of bleeding on probing, and type ofperiodontal treatment.
Results: Fifty-seven patients were positive for Perioscreen Sunstar. Among the patients with positive results, 32
patients (56.1%) visited one of three partnership dental offices and all received periodontal treatment.
Twenty-six patients (45.6%) were finished their periodontal treatment within 6 months. For the patients who
finished dental treatment, parameters of periodontal diseases were improved.
Conclusion: About 60% patients with diabetes mellitus who regularly attend the medical clinic were positive for
periodontitis by Perioscreen Sunstar. Among them, about 60% patients attended for dental clinic by therecommendation by family doctor. These results may provide the basic information to medical and dental clinic
cooperation and community medical care networks.
(Asian Pac J Dent 2018; 18: 1-5.)
Key Words: diabetes mellitus, periodontal screening test, periodontitis

Introduction
Diabetes mellitus (DM) and chronic periodontitis are chronic inflammatory diseases that have been considered tobe biologically linked [1,2]. Cross-sectional and longitudinal studies identified that the risk of periodontitis isapproximately 3 to 4 times higher in people with diabetes than in non-diabetic subjects [3]. On the other hand,
periodontal disease can aggravate insulin resistance [4] affect glycemic control [5]. Periodontal treatment
improves glycemic control in type 2 DM [4]. By 2025, 300 million people are estimated to be afflicted withdiabetes worldwide, with a prevalence of 6.4% [6,7].
In Japan, Medical treatment low stipulate every prefecture to design their own health care planning. In thehealth care planning, 5 diseases were focused: cancer, cerebral stroke, acute myocardial infarction, DM, andmental disease. For these diseases, community cooperated clinical pathway plays an important role. Community
cooperated clinical pathway is a support system for the patients by sharing the information of the patients among
the medical specialist, family doctor and variety of job descripted medical staffs. It aims at to provide safety andhigh quality medical treatment, implementation of support by medical team, optimization of comprehensive
support, and saving medical resources.
As community cooperated clinical pathway is made by each community, variety of pathways are available.

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Some of the community cooperated clinical pathways for the DM, dentist or dental clinics are included in thepathway. However, most of the medical doctor cannot diagnose periodontal disease. Recommendation ofvisiting dental clinic by without screening or examination may not effective to promote the motivation ofpatients. And there is no data available for evaluation of medical and dental cooperation at the community base.
In this study, we provided the tool of screening periodontal disease for the medical doctor and recommended
for the patients with DM to visit the dental clinics based on the results of screening. We traced the patients forwith or without visiting dental clinics to evaluate the medical and dental clinic cooperation at community base.

Materials and Methods
Study population
Study population consisted of the one hundred patients who attended at the Kato Clinic from November 1, 2017
to November 24, 2017. The patients were diagnosed as DM by the criteria of Classification and Diagnostic
Criteria of DM [8]. Kato clinic specialized in internal medicine especially DM and is located north-east area ofTokyo. Patients with DM attended Kato clinic every month.
Clinical parameters of DM
Serum levels of HbA1c was measured by latex coagulating method.
Screening of periodontal disease
The patients rinsed with 3 mL distilled water for 10 s and expectorated into a 50 mL paper cup. The tail ofimmunological salivary hemoglobin detection test (Perioscreen Sunstar, Sunstar, Osaka, Japan) strip was placed
into the cup and the color change was scored after 5 minutes. The color change due to the binding of humanhemoglobin to its polyclonal antibody was evaluated [9,10]. The strip color was compared against themanufacturer’s reference and assigned a score by two nurses simultaneously.
Medical and dental clinic cooperation
The patients with positive results of periodontal disease were given a letter of introduction to the dental clinic.
The unification form of the data sheet of oral conditions and postage printed envelope to the medical clinic wasenclosed with the letter of introduction. In the data sheet, number of remaining teeth, plaque control record(PCR), maximum value of the periodontal pocket, percent of bleeding on probing (BOP %) were recorded.
Statistical analysis
For the calculation of p-values by chi-square tests, Paired t-tests, Kruskal Wallis tests, Mann Whitney’s U tests,
or Wilcoxon signed-rank tests were performed by SPSS ver 24.0 (IBM, Tokyo, Japan).
EthicsInformed consents were obtained from patients with DM prior to the Perioscreen Sunstar. This study wasapproved by the Ethics Committee of Tsurumi University School of Dental Medicine (No. 1414) and conductedin accordance with the Declaration of Helsinki.

Results
Among the one hundred patients with DM, 40 patients were more than 5 µg/mL, 17 subjects were 2 to 5 µg/mL
and 43 were negative. For 57 subjects with more than 2 µg/mL were evaluated as positive for the Perioscreen
Sunstar and recommended to visit the dental clinics. The results described above are shown in the diagram (Fig.
1). The characteristics of the patients with DM divided by results of Perioscreen Sunstar and compliance for the2Okada et al.

Asian Pac J Dent 2018; 18: 1-5

visit of dental clinics. As shown in Table 1, statistically significant differences were not observed by the resultsof Perioscreen Sunstar in age, gender, BMI, HbA1c. And by the compliance of dental visit, statisticallysignificant differences were not observed in age, gender, BMI and HbA1c (Table 2).

Fig. 1
Diagram of the compliance of visit to dental clinic
Fifty-seven patients with DM were positive forPerioscreen Sunstar. Among the 57 patientspositive for Perioscreen Sunstar, 32 patients(56.1%) visited dental clinics by therecommendation of physician.
Table 1 Characteristics of the patients participated in this study divided by the results of Perioscreen Sunstar
Perioscreen Sunstar
Positive
5 µg (n = 40)
2-5 µg (n = 17)Age61.0 +/− 11.5
63.2 +/− 10.9
65.5 +/− 11.0
Male/Female
28/15
24/16
4/13
BMI
25.6 +/− 4.1
25.2 +/− 5.4
24.5 +/− 3.8
HbA1c Baseline
6.9 +/− 0.7
7.1 +/− 0.7
7.2 +/− 0.8
HbA1c After 1 year
7.1 +/− 0.9
7.2 +/− 0.8
7.0 +/− 0.8
The p-values were calculated by chi-square tests or Kruskal Wallis tests.

p-value

Negative (n = 43)

Total (n = 57)
64.8 +/− 10.9
28/29
24.7 +/− 4.3
7.1 +/− 0.8
7.1 +/− 0.8

0.128
0.528
0.487
0.232
0.652

Table 2 Characteristics of the patients divided by the compliance for visiting dental office
Visited dental office (n = 32)
Refused to visit dental office (n = 25)
Age66.4 +/− 8.6
63.0 +/− 13.5Male/Female
20/128/17
BMI
24.1 +/− 3.2
25.7 +/− 5.6
HbA1c Baseline
7.1 +/− 0.7
7.1 +/− 0.8
HbA1c After 1 year
7.1 +/− 0.8
7.1 +/− 0.8
Perioscreen Sunstar 2-5 µg
126Perioscreen Sunstar ˃5 µg
2019The p-values were calculated by chi-square tests or Mann Whitney’s U tests.

p-value
0.407
0.266
0.368
0.843
0.887
0.304

Table 3 Transition of the clinical parameters after dental treatment
Mean values +/− SD Median values (25%; 75% percentiles)
p-valueBeforetreatment
22.15+/−
6.47
24.5(21.0;26.0)
Number of0.066
remaining teeth
After treatment
21.85 +/− 6.64
24.5 (21.0; 26.0)
Before treatment
57.1 +/− 12.21
52.23 (48.50; 67.0)
PCR (%)<0.001After treatment
31.29 +/− 14.62
30.4 (16.0; 44.45)
Before treatment
4.95 +/− 2.13
4.75 (3.50; 6.0)
Maximum value of
0.012
pocket depth (mm)After treatment
3.98 +/− 1.44
4 (3.0; 5.0)
Before treatment
27.92 +/− 22.63
20 (9.00; 50.0)
BOP (%)<0.001After treatment
9.01 +/− 5.0
5 (0; 10.3)
Before treatment
7.2 +/− 0.8
7.2 (7.0; 7.4)
HbA1c
0.987
After treatment
7.2 +/− 0.9
7.2 (7.0; 7.4)
Among the 32 patients who visited dental clinics, 26 were finished their periodontal treatment within 6 months. Clinicalparameters of periodontal disease and DM were compared. Statistical difference between before and after treatment,
calculated by the Wilcoxon signed rank tests

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All of the patients visited the dental clinics needed to treatment of periodontal disease. Intraoral clinicalexamination data are shown in the Table 3. Periodontal treatment showed significant reductions (p < 0.001) ofPCR, maximum value of periodontal pocket and BOP.

Discussion
In this study about 60% of patients with DM were positive for the Perioscreen Sunstar. By the National Surveyof Dental Diseases in Japan [11], subjects with bleeding by probing is 52.0 to 59.3% for the age 40 to 74. Thesenumbers were almost corresponded to our results.
In Japan three kind of periodontal screening tests are now available [9,12-15]. These tests were approved by
Pharmaceutical Affairs Law as extracorporeal diagnostic agents. In these three tests, only Perioscreen Sunstar isa paper chromatography and the result of the test is obtained after 5 minutes [10]. Even though Perioscreen
Sunstar is a simple and cost effective method, experienced examiner is necessary for the evaluation. And
treatment of infective medical waste is necessary. Other two tests need to send saliva samples to the medical
examination company and results are obtained by the numerical values. However, it takes at least 5 days. Thereare several merits and demerits are existed. In this study, we applied the Perioscreen Sunstar, because in theclinic, there are experienced examiner and patients need not to visit the clinic for only obtain the results ofperiodontal screening tests.
And the results of oral examinations by dentists demonstrated that PCR 57.1 +/− 12.21%, maximum value ofperiodontal pocket 4.95 +/− 2.13 mm and BOP % 27.92 +/− 22.63%. These cases were not moderate serious.
The patients with DM were appropriately controlled by the treatment and health instruction. In fact, the levels ofHbA1c were stable. It is well known that periodontal conditions are aggravated by the DM. Therefore,periodontal conditions of patients with DM were not so clear by complication of diabetes.
In this study, about 60% of patients with DM visited to three dental clinics. As far as we aware, only one data
available for the visiting rate by post periodontal screening [16]. By the event style, subjects who answered tointended to visit dental clinic were more than 60% based on the results of periodontal screening test. However,this survey conducted by the questionnaire of posted mail style and recovery rate were around 20%. Whensimply compare the recommendation by periodontal screening tests, recommendation by the family doctor withscreening tests were more effective to promote the visiting dental clinics.
In summary, the results that about 60% of patient with DM needed the periodontal treatment and then they
did not visit dental clinics. And 60% of the patients who needed to periodontal treatment began to visit the dental
clinic by the recommendation of their family doctor with the results of periodontal screening.
Even by the recommendation for visiting dental clinic by the family doctor, patients without subjective
symptom usually do not visit dental clinic. This tendency may be applicable for the medical check-ups. Even by
the simple screening tests, dental examination may facilitate visiting dental clinic. And results of this report may
provide the basic information for medical and dental clinic cooperation and community medical care networks.
Acknowledgments
We would like to express our gratitude to Dr. Kazuyuki Ookubo, Dr. Noboru Harada, Koichi Ogasawara, and Dr. Hideki Komiya,
Katsushika-ku Dental Association, Tokyo, Japan, for their contribution in obtaining intraoral clinical examination data.

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Correspondence to:Dr. Yoshiaki Nomura
Department of Translational Research, School of Dental Medicine, Tsurumi University2-1-3, Tsurumi, Tsurumi-ku, Yokohama 230-8501, Japan
Fax: +81-45-573-2473 E-mail: nomura-y@tsurumi-u.ac.jp
Accepted January 9, 2018.
Copyright ©2018 by the Asian Pacific Journal of Dentistry.
Online ISSN 2185-3487, Print ISSN 2185-3479

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