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Control of diabetes

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Control of diabetes

Good long-term control of blood sugar levels is important in the management of both type 1 and type 2 diabetes and in preventing complications associated with the disease, including retinopathy, coronary heart disease and renal failure. Sub-optimally controlled diabetes is a known risk factor for periodontitis and also impairs the response to periodontal treatment. While well-controlled diabetes is not a risk factor, the Delivering Better Oral Health (DBOH) toolkit7 notes that many people oscillate between different levels of control and states that an increased risk of periodontal diseases should be assumed for anyone who has diabetes. 

There is low certainty evidence that sub-optimally controlled diabetes substantially increases the risk of progression of periodontitis20 and moderate certainty evidence that diabetes control improves periodontal health.36 DBOH also notes that many patients with diabetes are unaware of the link between diabetes and periodontal health.49 Accordingly, both the DBOH and the BSP implementation of European S3 – level evidence-based treatment guidelines for stage I-III periodontitis in UK clinical practice (BSP-S3)6 guidelines recommend that patients with diabetes should be informed of their increased risk of periodontal disease and the ways in which this can be mitigated. 

As well as regular testing by patients, blood glucose levels should be assessed by the patient’s medical team.22, 23 Testing to determine the level of glycated haemoglobin (HbA1c) gives an indication of the average blood glucose level in the previous 8-to-12-week period. HbA1c levels of between 48 and 58 mmol/mol (6.5-7.5%) indicate that the patient has good control of their condition, with levels greater than 58 mmol/mol (7.5%) associated with an increased risk of diabetes-related complications. 

The National Institute of Health and Care Excellence (NICE) guidelines on management of type 1 diabetes (NG17)22 and type 2 diabetes (NG28)23 in adults were amended in 2022 to include updated recommendations on periodontitis. These recommendations address concerns that people with diabetes are often unaware of their risk of periodontal disease and may not be having regular oral health reviews. The guidelines recommend that adults with diabetes:

  • have regular oral health reviews;
  • are informed that they are at higher risk of periodontitis; 
  • are advised that if they do develop periodontitis, managing it can improve their blood glucose control and can reduce their risk of hyperglycaemia; 
  • are offered dental appointments to manage and treat their periodontal disease.

Ensure that you have an up-to-date medical history for all patients.

  • If a patient states that they have diabetes, ask the patient if it is Type 1 or Type 2 and how their diabetes is controlled (e.g. by diet, medication or insulin).
  • If a patient presents with periodontitis or recurrent periodontal abscesses and you suspect undiagnosed diabetes (e.g. if the patient is overweight/obese or there is a family history of diabetes), advise the patient to use the Diabetes UK screening tool and to seek advice from their medical team.

Ask patients who have diabetes:

  • “Is your diabetes well-controlled?”;
  • “What was your last HbA1c reading? When was it measured?” 
    (If patients are unsure about their HbA1c levels, encourage them to contact their medical team to obtain this information);
  • “How often does your doctor check your diabetes control?”;
  • “Do you have any of the complications of diabetes?”.

Record this information in the case records.

Explain to patients who have diabetes that sub-optimally controlled blood sugar levels increase the risk of developing periodontal disease or worsening existing periodontal disease.

Explain to patients with diabetes what periodontal diseases are and what causes them in general terms.

Ensure that patients with diabetes understand the need for effective oral hygiene. Provide oral hygiene instruction where required.

For patients who have both a diagnosis of periodontitis and diabetes, explain that treatment of their periodontal disease is likely to improve control of their diabetes. Encourage these patients to inform their medical team of their periodontitis diagnosis.

Encourage patients with diabetes to attend for regular dental checks, and treatment where required.

Information for non-dental healthcare professionals on the links between periodontal disease and systemic health conditions is provided in Supporting tools.