The Big Interview – Professor Ian Needleman
Ian Needleman is Professor of Restorative Dentistry and Evidence-based Healthcare at the University of College London (UCL) Eastman Dental Institute. He is also the president of the British Society of Periodontology and through his involvement with the organisation he is spearheading the annual Gum Health Awareness campaign which starts on Friday, May 12.
Here, he tells The Diabetes Times about the links between diabetes and gum disease and what they are doing to help increase awareness.
What’s the biggest challenge today in diabetes and oral care?
The biggest challenge is lack of awareness in how diabetes can affect gum disease and vice versa. I think that many of us in healthcare work in silos and may not be aware of the importance of other areas and how a multi-disciplinary approach might help.
In most people I know, with very few exceptions, their head is attached to the rest of their body. Inthe way we work across healthcare though, the head and the mouth particularly is seen to be completely disconnected from the rest of the body. Once you get away from the ridiculous idea that they are separate, you start to think that there must be a relationship between the two. It becomes clear that we need to work together to promote good health and well-being.
Gum disease is one of the lesser-known complications of diabetes, why do you think that is?
Very people know about it, whether they are healthcare professionals or patients. What we do know is that diabetes increases the risk of gum disease, called periodontitis, threefold. It’s a major risk factor. The issue surrounding gum disease is for people who have it, it’s an important impairment of their quality of life. It affects people’s eating ability, in later stages it can cause pain and tooth loss. It also has a really important psychosocial impact on self-confidence, socialisation and the person’s social mobility.
So gum disease hugely impacts people and diabetes increases the risk of the condition. But, we have increasing evidence that it also works in the other direction too. In other words, in those people who have periodontitis they are at an increased risk of diabetes. Depending on the severity of the gum disease, that increased risk seems to be between two and five times. So, again it’s quite a significant risk. We have similar data which shows there is a further association between gum disease and mortality rates in relation to cardiovascular issues in people with diabetes.
Why does diabetes increase the risk of gum disease?
A lot of research has been done but there is a lot of research to do. Gum disease is a complex chronic inflammatory disease. What we know about diabetes, particularly in periods where there is hyperglycemia, is that systemic inflammation will be raised.
The mechanisms which damage the tissues in the eye, the limbs and the cardiovascular system in people with diabetes are very similar to the mechanisms that are damaging to the mouth and can cause gum disease. In many ways, because of the similarity, it would be surprising if diabetes did not cause damage, particularly during hyperglycemia.
Are you surprised that oral healthcare is not included in the nine care processes which people with diabetes are screened for?
I think many of us within oral health find it very surprising. However, it’s not the only area where oral health is somewhat off the radar. That’s really what’s bringing about the public awareness campaign from the British Society of Periodontology and Diabetes.co.uk, because it’s an issue that’s important for individuals and it’s also important for public health. This public awareness campaign is also important for people who don’t yet have diabetes who may be developing a pre-diabetes state. It’s also important for other healthcare professionals to have an increased awareness so we can have conversations among all these different groups, the public, the patients, the professionals and also the policy makers so we can try to bring this lack of co-ordination together.
Can gum disease be treated?
Yes it can usually be treated successfully or even better, prevented from happening. There is also evidence to suggest that treatment of periodontitis, gum disease can improve diabetes control. I was a co-author of a Cochrane review which has shown there is evidence that by improving gum health it can reduce HbA1c levels by 0.29 per cent. As a periodontist and not a diabetes specialist, a 0.29 per cent reduction was quite hard for me to understand. But I am led to understand by experts in diabetes, that from a public health point of view that’s an important level and it could translate to something like a 10 per cent mortality reduction over a two to five year period, or is similar to introducing another hypoglycaemic medication. However, I would also say that more research is needed to clarify how to maximise the effect on diabetes health. So we’re relatively in early stages, but nevertheless I think that’s an important finding.
What are the links between HbA1c levels and gum disease?
That really goes back to the systemic inflammation. Gum disease is caused by bacteria and it’s those bacteria that causes inflammation. So we have a local inflammation in the gums which explains why one of the common signs of gum disease, is red gums. Perhaps what we’ve been slow to recognise is that inflammation, although visible in the gums, can create a systemic inflammatory response. So what we believe is that the systemic inflammatory response can also create insulin resistance and release of inflammatory mediators. Because of this connectedness it would be unsurprising if this inflammation within the gums didn’t create inflammation which could have an impact. To give you some sense of scale, that’s perhaps quite shocking. If you take someone with a moderate to severe level of periodontitis, if you looked at their gums, the inflamed surface would have thousands of micro ulcers hidden away on the edge of the gum. You don’t see them but when people try brushing their gums, they would certainly be able to feel their gums are sore. If you took the surface area of those micro ulcers and added them together, you would have one ulcer which was effectively the size of the palm of your hand. It would be very surprising if gum disease did not have an impact on general health and in particular – in this case – we’re talking about diabetes. Again, I would say, although a lot of research has been done, both diabetes and periodontitis, are incredibly complex diseases and there’s a lot more that needs to be done to give us a clearer idea.
How are you involved in Gum Health Awareness Day?
Gum Health Awareness Day, May 12th is an initiative of the British Society of Periodontology and I have the huge privilege of being President this year. We ran our first awareness campaign last year, which was very successful and we reached about 4.6 million people via social media, which was great. This year we’ve decided to focus on the impact of diabetes on gum health and the lack of awareness about how diabetes can greatly increase the risk of gum disease. To help develop this campaign we are delighted to work closely with diabetes.co.uk.
The campaign with diabetes.co.uk involved running a survey which we are using to publicise Gum Health Awareness Day on May 12th. The campaign is then going on for three months following that.
We wanted to try and get some clarity. We sensed that there’s a lack of awareness about the related conditions, and one of the key things is we wanted to try and find out if that’s true. The results showed that out of more than 700 people who were surveyed, only half said they had received advice that diabetes could worsen gum health and vice versa. Mostly, this was provided by dentists with few receiving information from their doctor or pharmacist. What’s also being produced is a series of videos about the condition and infographics and this will also link into materials we have already produced. The British Society of Periodontology is working closely with the European Federation of Periodontology, as May 12th is also European Gum Health Awareness Day. Although we are focused on a UK campaign, you can see that we’re also trying to spread the message across Europe. It’s important that we keep the message going. As dentists, we should be more confident about talking to other healthcare professionals. Another of my research areas is oral health and performance in elite sport and when I speak to experts in sport and exercise medicine, I see there are few barriers to collaboration. So, our healthcare colleagues outside of dentistry are interested and we have to find better ways to communicate and work together.
What are the signs of gum disease?
First thing to say is, often in the early stages, gum disease causes no pain and therefore can easily be missed. One of the most common signs we see is bleeding when cleaning around teeth or gums or when eating. That’s nearly always a sign of gum disease. Other signs that people might notice are teeth which are becoming loose, starting to move around and change position, halitosis, and if gums start to recede or shrink. Receding gums are not a sign of old age.
What would you like to see change?
The most important thing is that people who have a diagnosis of diabetes, in addition to the other potential complications, are advised that gum disease is another complication and advised to see their dentist. What we know from behaviour change is it’s not enough to tell somebody they are at risk of a complication, it’s important that there’s an action there. And that action should be to go and see your dental professional. We would also like to see national official bodies start offering guidance and advice to people with diabetes so oral health becomes part of the annual diabetes screenings.
What does the future hold for diabetes-related gum disease research?
One of the key things is to identify which aspects of treatment of gum disease have the biggest effect on improving diabetes control. Treatment of gum disease is remarkably successful for most people and even in later stages of gum disease the condition can be slowed down so that people can keep their teeth for much longer than they otherwise would do – the earlier the better. Treatment involves self-care and professional care. The self-care involves very careful, daily removal of plaque and bacteria by toothbrushing and cleaning between the teeth with interdental brushes. Also it involves attending regular check-ups because as it’s a chronic disease, there’s always the potential for relapse and recurrence. Those are the elements of self-care that are really important. Professional care is equally important and that involves instruction by the dentist on how to do the self-care really effectively because what we know is that most people, who have not had instruction on how to carry out good plaque control, do not do it affectively.
Antiseptic and other medications are not required as an ongoing measure but they can be useful during initial stages, particularly if the gum inflammation is acute and uncomfortable and sore to clean. The reason for that is because dental plaque is a biofilm. Therefore, chemicals are less effective against biofilms and also what we’re starting to understand in the mouth is that we want to nurture a healthy microflora just as we do in the gut. Professional treatment involves treating the gum pockets that open up as a result of gum disease. The pocket is the space between the gum and the tooth and that space isn’t visible to most patients but it harbours several million bacteria around each tooth. After a few weeks the bacteria will also produce hardened plaque, which is also known as tartar. That needs to be thoroughly cleaned out, which is often called deep-cleaning or scaling. A few weeks after finishing that, gum health is re-assessed and a decision will be made to see whether the gum disease is under control. For some patients, minor surgery is needed to treat deep pockets that are not responding to treatment. Then the next phase would be on-going supportive maintenance, every three to six months and is a life-long commitment.