This research was undertaken to explore the knowledge of both people with diabetes and healthcare professionals who manage people with diabetes regarding the links between periodontitis and diabetes. Interviews were conducted with a broad range of key stakeholders in a diabetes patient care pathway and even though the numbers within each relevant group were relatively small, a consistent message appeared across the groups. Despite the fact that there is a substantial body of research evidence linking these two diseases (including a Cochrane systematic review),12
this information does not seem to have impacted on these healthcare professionals, including those who specialise in managing the care of people with diabetes. The World Health Organisation has identified that oral health is integral to general health and is essential for general well-being.17
Furthermore, periodontal disease is highly prevalent8
and impacts on many aspects of daily living, affecting confidence, social interactions and food choices.18
The patients with diabetes whom we interviewed expressed a desire to be informed about their increased susceptibility to periodontitis and the potential benefits in terms of improvements in glycaemic control (reductions in HbA1c) that might occur following the treatment of periodontal disease. The healthcare professionals’ accounts suggested that they were relatively inactive, however, when questioned about their role in this area of diabetes management.
Healthcare professionals’ knowledge about the links between diabetes and periodontitis was found to be relatively minimal in this study population. Further research is necessary to identify how these findings apply more broadly; for example, a questionnaire survey could target healthcare professionals across a range of disciplines and at various geographical locations. Although the benefits of screening for, and treating, periodontitis in patients with diabetes were recognised, a number of barriers were identified that would need to be addressed before patients would benefit from the evidence-base. Clearly, awareness of the current evidence-base could be raised in a range of settings, including undergraduate, postgraduate and continuing medical education. As clinical routines are based on a mixture of education, evidence, experience and habit, improving the awareness of healthcare professionals of the bidirectional relationship between periodontitis and diabetes alone,7
will not necessarily translate to patient benefit. The inclusion of the oral complications of diabetes into local care pathways, electronic templates and national diabetes guidelines could also help. However, protocols and guidelines, although an excellent way to implement new clinical interventions, are not the only way to influence the practice of healthcare professionals.19
The role of key opinion leaders, commercially supported local networking events and peer-led discussion forums such as lunchtime practice seminars, were also highlighted by the interviewees as being potentially effective ways to raise general awareness of the links between periodontitis and diabetes, and the current evidence-base such as the Cochrane review.
Any implementation of change needs to be situated with the context of both public and professional cultures in relation to oral health. The last Adult Dental Health Survey (2009) stated that the most frequent reasons for dental non-attendance are that patients cannot find an NHS dentist (or their dentist has just changed from providing NHS care to private care only), they cannot afford to go, or they are afraid to go to the dentist.9
In the UK, the relationship between a patient and their dentist is different from the relationship with their doctor, because even when receiving NHS dental treatment, there is a financial element involved with virtually every appointment (unless the patient is in receipt of certain benefits).20
As yet, we have relatively little knowledge of how people with diabetes seek oral healthcare and how this could impact on promoting oral health screening. In this research, we have also documented some of the divisions that exist between the medical and dental professions, specifically related to the links between periodontitis and diabetes. These divisions are not new; they have existed since the medical and dental professions first emerged as independently regulated professions which, in the case of Britain, was in the early to mid-20th century.21
From the outset, the distinction was made that dental health was the jurisdiction of dentists and quite separate, although closely related, to general health. This state of affairs has existed with little dispute from either professions for many years. Clearly, this tension has the potential to impact on any intervention introduced to promote interprofessional collaboration.
As the prevalence of diabetes is growing, so is the cost of treating it. During 2010/2011, the direct cost to the NHS for treating diabetes was £9.8 billion (the indirect cost being £13.9 billion).23
In total, 80% of the direct costs were reported to go towards treating the complications of the disease, many of which are preventable. Diabetes UK reports that the economic burden to the NHS, for both direct and indirect costs of diabetes is estimated to rise to £16.8 billion by 2035/2036, which equates to a predicted 17% of the total health resource expenditure for the NHS.23
Diabetes is a major risk factor for periodontitis4
and periodontitis appears to impair glycaemic control in people with diabetes.24
Furthermore, periodontal treatment results in improvements in glycaemic control, which although modest (HbA1c reductions of approximately 0.4%), could be clinically relevant, and are similar to reductions achieved by some oral therapies such as the gliptins. Interprofessional collaboration in the form of education and practice may enhance the management of chronic diseases, such as diabetes, through the management of their common risk factors, underlying social determinants and their common biological pathways.25
Interprofessional collaboration already exists for management of certain complications of diabetes, such as the established screening programmes to assess for retinopathy.
Clearly, the value placed on screening programmes will be linked to the morbidity associated with the complication that is being assessed. Given that patients and most healthcare providers in our sample appeared to be relatively uninformed about the links between diabetes and periodontitis, assessing oral health may be regarded as having a lower priority than assessing retinal health, for example. On the other hand, periodontitis has a major impact on quality of life,18
and the early loss of teeth can be a very distressing outcome for any patient. Therefore, diabetes care teams could inform patients with diabetes about their increased risk for periodontitis, and of the importance of obtaining dental care, as proposed in the suggested brief oral health intervention (in box 4
). The validity of such an approach would need to be tested in future research. It may also be worthwhile investigating the use of leaflets or posters to provide more information for patients, and ultimately, the inclusion of a dental hygienist into diabetes care teams to undertake oral health assessments could benefit patients and enhance interprofessional working.
Box 4. Suggested brief oral health intervention for diabetes care providers to implement with their patients with diabetes
- ASK if the patient attends the dentist.
- INFORM them of their increased susceptibility to periodontitis. If the patient has periodontitis, inform them about the potential benefits of getting their periodontitis treated; in the form of improved glycaemic control (reductions in HbA1c).
- ADVISE them to seek professional dental assessment and regular oral screening.
The small sample numbers in this study is a limitation, although statistical representation is rarely sought in qualitative research.26
By focusing on how knowledge was distributed across a range of different stakeholders we only recruited a small number of people within each category, so we were unable to further document the diversity of knowledge within specific groups. In relation to patients, there is a clear need for further in-depth research involving a broad range of patients, with both type 1 and type 2 diabetes, to explore their experiences of oral health in the context of their diabetes. This was an exploratory study in a very under-researched area in which we sought to scope the variance in the phenomenon, while accepting the potential for bias in this relatively small sample. Despite these limitations, the same key issues consistently emerged across the sample, and we feel they offer a useful direction for further research.