“…[T]he evidence supports the theory that there is a relationship between the 2 diseases, especially in patients with poorly controlled diabetes mellitus or hyperglycemia.” (The 2 diseases are periodontal disease and diabetes.)

Type 1 Diabetes Mellitus and Periodontal Diseases

“[I]t appears that Type 1 DM patients have an increased risk for developing periodontal disease with age, and that the severity of periodontal disease increases with the increased duration of diabetes. … Under similar conditions of plaque control, adult subjects with poorly controlled diabetes had lost more approximal attachment and bone than well-controlled diabetic subjects.”

Type 2 Diabetes Mellitus and Periodontal Diseases

“The increased risk of advancing bone loss was greatest among younger individuals. In addition, compared to non-diabetic controls, DM patients with poor glycemic control had a much greater risk of progressive bone loss (odds ratio = 11.4) than did well-controlled subjects (odds ratio = 2.2).”

American Diabetes Association Clinical Practice Recommendations 2000

These two documents can be accessed from the ADA web page at www.diabetes.org or in Diabetes Care volume 23 supplement 1.

Tests of Glycemia in Diabetes

“GHb, commonly referred to as glycated hemoglobin, glycohemoglobin, glycosylated hemoglobin, HbA1c, or HbA1, is a term used to describe a series of stable minor hemoglobin components formed slowly and nonenzymatically from hemoglobin and glucose. The rate of formation of GHb is directly proportional to the ambient glucose concentration. Since erythrocytes are freely permeable to glucose, the level of GHb in a blood sample provides a glycemic history of the previous 120 days, the average erythrocyte life span. GHb most accurately reflects the previous 2-3 months of glycemic control.”

“The American Diabetes Association recommends that the goal of therapy should be a GHb of <7% and that physicians should reevaluate the treatment regimen in patients with GHb values consistently >8%. Again, these specific GHb values apply only to assay methods that are certified as traceable to the DCCT reference method.”

Standards of Medical Care for Patients With Diabetes Mellitus

Type 1 Diabetes
“Setting individual patient glycemic targets should take into account the results of prospective randomized clinical trials, most notably the Diabetes Control and Complication Trial (DCCT). This trial conclusively demonstrated that in patients with type 1 diabetes the risk of development or progression of retinopathy, nephropathy, and neuropathy is reduced 50-75% by intensive treatment regimens when compared with conventional treatment regimens. These benefits were observed with an average HbA1c of 7.2% in intensively treated groups of patients compared with 9.0% in conventionally treated groups of patients. The reduction in risk of these complications correlated continuously with the reduction in HbA1c produced by intensive treatment. This relationship implies that near normalization of glycemic levels may prevent complications. The nondiabetic reference range for the HbA1c in the DCCT was 4.0-6.0. Because different assays can give varying glycated hemoglobin (GHb) values, it is important that laboratories only use assay methods that are certified as traceable to the DCCT HbA1c reference method. SMBG [Self Monitoring of Blood Glucose] targets in the DCCT were 70-120 mg/dl before meals and at bedtime and <180 mg/dl when measured 1.5-2.0 h postprandially. However, these goals were associated with a threefold increased risk of severe hypoglycemia. Therefore, it may be appropriate to increase these targets (e.g., 80-120mg/dl before meals and 100-140 mg/dl at bedtime) (Table 1, top). These targets should be further adjusted upward in patients with a history of recurrent severe or unrecognized hypoglycemia.

“Whole blood glucose values were provided for SMBG targets in the DCCT. Because laboratory methods measure plasma glucose, many blood glucose monitors approved for home use and some test strips now calibrate blood glucose readings to plasma values. Plasma glucose values are 10-15% higher than whole blood glucose values, and it is crucial that people with diabetes know whether their monitor and strips provide whole blood or plasma results. The preprandial and bedtime glucose values in the bottom of Table 1 have been modified to show plasma readings.

Type 2 Diabetes
“The largest and longest study of patients with type 2 diabetes, the United Kingdom Prospective Diabetes Study (UKPDS), conclusively demonstrated that improved blood glucose control in these patients reduces the risk of developing retinopathy and nephropathy and possibly reduces neuropathy. The overall microvascular complications rate was decreased by 25% in patient receiving intensive therapy versus conventional therapy. Epidemiological analysis of the UKPDS data showed a continuous relationship between the risk of microvascular complications and glycemia, such that for every percentage point decrease in HbA1c (e.g., 9 to 8%) there was a 35% reduction in the risk of microvascular complications.”

“When setting treatment goals for type 2 diabetes (Table 1), the same individual patient characteristics should be considered as for type 1 diabetes.”

Table 1 – Glycemic control for people with diabetes

RiskCalculator™

The RiskCalculator™ values for the diabetic are:

Conclusion and Recommendation

There is insufficient information to conclusively set a value for periodontal risk for the diabetic patient. Based on the available information I suggest that the RiskCalculator™ glucose values change to: