Periodontal treatment to improve diabetic control in children and young people with type 1 or type 2 diabetes
NICE Guideline, No. 18
Evidence review on effectiveness of periodontal treatment to improve diabetic control in children and young people with type 1 or type 2 diabetes
1.1. Review question
In children and young people with type 1 or type 2 diabetes, what is the effectiveness of periodontal treatment to improve diabetic control?
1.1.1. Introduction
Diabetes mellitus represents an extremely significant health problem as it plays a pivotal role in the etiopathogenesis of long-term complications. Suboptimal diabetes control, typically quantified by increased glycated haemoglobin (HbA1c), is a recognised risk factor for periodontitis.
Periodontitis is the sixth most common complication of diabetes that can manifest either as gingivitis or periodontitis. Gingivitis is the most prevalent inflammatory periodontitis among children and young people with diabetes, which can be treated with simple non-surgical periodontal interventions such as debridement of root surfaces to remove bacterial plaque, biofilms, and mineralised plaque. Periodontal inflammation if left untreated or inadequately controlled, does not only progress to periodontitis, but results in increased systemic inflammatory burden, further worsening the glycaemic status and perpetual promotion of associated complications of diabetes. Establishing the effectiveness of periodontal treatment on diabetic control is important to help to reduce the harms associated with hyperglycaemia and diabetes complications.
The aim of this review is to assess the effectiveness of periodontal treatment in improving diabetic control in children and young people with type 1 or type 2 diabetes.
1.1.2. Summary of the protocol
Table 1
PICO table.
1.1.3. Methods and process
This evidence review was developed using the methods and process described in Developing NICE guidelines: the manual. Methods specific to this review question are described in the review protocol in appendix A and the methods document.
Randomised controlled trials (RCTs), systematic reviews of RCTs, prospective and retrospective cohort studies, non-randomised controlled trials, controlled before-and-after studies and before-and-after studies were considered.
No studies were found that matched the inclusion criteria for the review.
Declarations of interest were recorded according to NICE’s conflicts of interest policy.
1.1.4. Effectiveness evidence
1.1.4.1. Included studies
A systematic literature search was conducted for this review on effectiveness of periodontal treatment in improving diabetic control in children and young people with type 1 or type 2 diabetes.
The search after deduplication returned a total of 2070 results (see Appendix B for the literature search strategy). Based on title and abstract screening against the review protocol, 21 potential references were ordered and reviewed against the inclusion criteria for full text screening.
Of the 21 references screened as full texts, no studies met the inclusion criteria specified in the review protocol for this question (Appendix A). The clinical evidence study selection is presented as a diagram in Appendix D.
1.1.4.2. Excluded studies
See Appendix K for excluded studies and reasons for exclusion.
1.1.5. Summary of studies included in the effectiveness evidence
Studies that met the inclusion criteria specified in the review protocol were not identified.
1.1.6. Summary of the effectiveness evidence
Studies that met the inclusion criteria specified in the review protocol were not found.
1.1.7. Economic evidence
1.1.7.1. Included studies
No relevant health economic studies were included.
1.1.7.2. Excluded studies
No economic studies relating to this review question were identified.
See the health economic study selection flow chart presented in Appendix H.
1.1.8. Summary of included economic evidence
There are no existing studies for this review question.
1.1.9. Economic model
No original economic modelling was completed for this review question.
1.1.11. The committee’s discussion and interpretation of the evidence
1.1.11.1. The outcomes that matter most
Based on the evidence from the periodontal treatment in improving diabetic control in adults with type 1 and type 2 diabetes, the committee agreed that HbA1c, Clinical Attachment Level (CAL), and Probing Pocket Depth (PPD) are important outcomes to assess the link and further progression of diabetes and periodontitis. The committee members also agreed that by monitoring closely these indices, delay in the progression of diabetes complications and periodontitis later in life could be achieved. This would consequently result in improved Quality of Life (QoL) which was considered a secondary outcome.
Adverse effects were thought to be less important as periodontitis is not common among children and young people. In rare cases when required, conventional non-surgical techniques such as subgingival instrumentation / scaling and root planing cause only minor discomfort and tooth sensitivity that normally resolve after a few days.
1.1.11.2. The quality of the evidence
No studies were identified for the present evidence review.
The committee members agreed to extrapolate from the findings of the effectiveness of periodontal treatment in improving diabetic control in adults with type 1 and type 2 diabetes when compared to no active intervention or usual care. Two important factors influenced their decision. Firstly, the well documented biological link between diabetes and periodontitis and the pathogenesis of diabetic-related complications was considered. Namely, research shows that hyperglycaemia and resultant advanced glycation end-product formation exaggerate immuno-inflammatory response to the bacterial challenge which initiate periodontitis. As a result of persistent hyperglycaemia, these advanced glycation end products accumulate in the plasma and tissue cells, causing more rapid periodontal tissue destruction and premature loss of the teeth. Because the degree of diabetes control ranges widely in children and young people, the susceptibility to gingival and periodontal inflammation may vary. Consequently, although not all gingivitis proceeds into a destructive periodontitis, the committee members thought that prevention of gingival inflammation should be emphasised, particularly in children and young with poorly controlled diabetes.
The second decision-making factor was the clinical evidence base for the adult population with diabetes which had consistent and adequate volume of effectiveness to justify the recommendations for children and young people with diabetes aimed at prevention and delay of the onset of periodontitis.
Also, to support decision making, the committee referred to several other documents: care standard (the Commissioning Standard: Dental Care for People with Diabetes), guideline (the NICE’s Guideline on Oral health promotion: general dental practice (NG30)) and consensus papers (the European Federation of Periodontology (EFP) and the International Diabetes Federation (IDF) joint workshop).
The above evidence combined with the clinical knowledge and experience of the dental healthcare professionals co-opted to the committee was used as bases when drafting the recommendations for the effectiveness of periodontal treatment in children and young people with type 1 and type 2 diabetes.
The link to the effectiveness of periodontal treatment in adults with type 1 and type 2 diabetes review can be found here.
The committee did not suggest any recommendations for future research as periodontitis is a rare condition among children and young people.
1.1.11.3. Benefits and harms
Studies that met the inclusion criteria specified in the review protocol were not found and the committee members acknowledged the identified gap in evidence regarding children and young people diagnosed with type 1 and type 2 diabetes and periodontitis. They noted that the possible explanation for the lack of evidence lies in the fact that periodontitis rarely develops in children and young people. Periodontitis among children and young people consists mainly of gingivitis, the mildest form of periodontitis. Gingivitis is a reversible and non-destructive form of periodontitis which is characterised by plaque build-up, gingival redness, swelling, bleeding, and absence of periodontal attachment loss. However, if left untreated, it may progress to cause exposure of the roots, mobility, and premature loss of the teeth.
The committee members acknowledged that children and young people with diabetes are at increased risk of developing periodontitis and stated that this should be routinely discussed during diabetes consultations alongside eye disease and diabetes related foot problems. Regular oral health reviews to monitor plaque formation and gingival inflammation was suggested.
Based on the evidence in adults, the committee agreed that successful periodontal treatment can have a positive impact on metabolic control in people with type 1 and type 2 diabetes. Namely, the pooled effect of periodontal treatment when compared to no active intervention or usual care demonstrated that the treatment of periodontitis via subgingival instrumentation/scaling and root planing improved all primary outcomes (HbA1c, CAL and PPD) in the adult population. The committee considered this indirect beneficial effect and agreed that if left unattended, gingivitis in children and young people with type 1 and type 2 diabetes may progress to periodontitis which would further exacerbate diabetes outcomes.
Further extrapolating from the benefits of periodontal treatment evident in the adult diabetic population, the committee acknowledged that early detection and treatment of periodontitis has the potential to improve quality of life in some aspects of living with diabetes in adulthood. Due to the negligible side effects of subgingival instrumentation/ scaling and root planing, no specific adverse events regarding the management of gingivitis were highlighted.
Overall, it was agreed that the benefits outweigh the possible minor side effects, and the prevention and monitoring of periodontitis should be recommended to improve diabetic control in children and young people in the long term. As essential to the success of prevention and treatment of periodontitis, maintaining good oral health hygiene and early diagnosis was emphasised.
1.1.11.4. Cost effectiveness and resource use
The committee noted that no relevant published economic evaluations were identified, and no additional economic analysis was undertaken for the cost-effectiveness of periodontal treatment among children and young people with type 1 or type 2 diabetes. This is due to the fact that periodontitis is extremely rare in people under the age of 18. Therefore, the committee based the recommendations on the cost-effectiveness evidence of periodontal treatments among adults with diabetes, along with their clinical knowledge and experience, and existing NICE guidance. The new recommendations are mainly about preventive measures and should have a minimal cost impact to the NHS in terms of extra healthcare professionals’ time. This may be offset by better health outcomes by improving the care and quality of life of children and young people who may develop periodontitis when they reach adulthood.
1.1.11.5. Other factors the committee took into account
The committee agreed that maintaining gingival health to help prevent or manage periodontitis in children and young people with diabetes requires promoting and supporting positive oral health behaviours and regular dental prophylaxis. The provision of continuous educational support to improve self-care by maintaining effective oral health hygiene and managing lifestyle risk factors, such as smoking, diet and optimal diabetes control are essential to the success of prevention and management of periodontitis.
The committee acknowledged that the terms used to refer to the non-surgical periodontal treatment such as scaling, polishing etc. are now historic terms and no longer used as per the new periodontal disease nomenclature. However, to increase acceptance among the target population, these terms have not been replaced according to the new terminology as these are still widely recognised by the public.
The committee wished to stress that although NHS dental services are free for all under 18 and for all under 19 and in fulltime education the increased risk and the needs of certain groups of children and young people with diabetes must be taken into account. The committee considered the needs of certain disadvantaged groups such as children and young people with physical disability, mental health related or learning disability. These groups may also have limitations with their dexterity which can cause difficulties in using interdental and interproximal brushes to maintain good oral hygiene and often do not engage during dental checks putting them into an increased risk of further progression towards periodontitis. Consideration for children and young people in secure settings was also given due to the limited access to interdental and/or interproximal brushes and other dental health care products for security reasons. In general, broader access to dental treatment and adequate personal oral hygiene products in combination with proactive engagement and enhanced educational support have the potential to reduce inequalities among disadvantaged groups.
Lastly, how the delivery of care for children and young people with diabetes is best integrated across healthcare settings was considered. Clear advice for the oral healthcare/ dental team, of what is expected of them regarding diabetes dental care of children and young people and clear pathways are necessary to enhance the quality of care across the continuum and improve service delivery. The committee members also discussed the uncertainty regarding the initial increase in referrals of children and young people with diabetes for oral health review following the publication of this guidelines, as this will potentially impact on the scarce NHS dental service. Current lack of access to NHS dentistry and gaps in periodontal services, the needs of the disadvantaged subpopulation and future provision of periodontal treatment was of a major concern, warranting a broader and more flexible access to dental/ oral care and services in general.
1.1.12. Recommendations supported by this evidence review
This review supports recommendations 1.2.1, 1.2.111 to 1.2.113, 1.3.1, and 1.3.41 to 1.3.43 of the Diabetes (type 1 and type 2) in children and young people: diagnosis and management guideline.
1.1.13. References – included studies
1.1.13.1. Effectiveness
References that met the inclusion criteria specified in the review protocol were not found.
1.1.13.2. Economic
No relevant studies have been included as part of the economic evidence review.
1.1.13.3. Other
No other studies were included in this review.
Appendices
Appendix A. Review protocols
Appendix B. Methods
Priority screening
The review undertaken for this guideline made use of the priority screening functionality with the EPPI-reviewer systematic reviewing software. This uses a machine learning algorithm (specifically, an SGD classifier) to take information on features (1, 2 and 3 word blocks) in the titles and abstract of papers marked as being ‘includes’ or ‘excludes’ during the title and abstract screening process, and re-orders the remaining records from most likely to least likely to be an include, based on that algorithm. This re-ordering of the remaining records occurs every time 25 additional records have been screened. As the number of records for screening was relatively small (2070 articles), a stopping criterion was not used when conducting screening. Therefore, all records were screened. Twenty-one potential studies were assessed at full-text stage.
Evidence of effectiveness of interventions
Evidence that met the inclusion criteria specified in the review protocol was not found.
Appendix C. Literature search strategies
Evidence review on effectiveness of periodontal treatment in improving diabetic control in children and young people with type 1 or type 2 diabetes.
Clinical literature search strategy
The search of the following databases was conducted on 8th November 2021: Medline, Medline In Process, Medline E-pub Ahead of print, PsycINFO, Embase (all via the Ovid platform), Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews (both via the both via the Wiley platform) and the Database of Abstracts of Reviews of Effect (via the CRD platform)
Intervention and population terms
Download PDF (280K)
Appendix D. Effectiveness evidence study selection
PRISMA diagram (PDF, 142K)
Appendix E. Effectiveness evidence
Evidence that met the inclusion criteria specified in the review protocol was not found.
Appendix F. Forest plots
Evidence that met the inclusion criteria specified in the review protocol was not found, hence no data was available to generate forest plots.
Appendix G. GRADE tables
Studies that met the inclusion criteria specified in the review protocol were not found.
Appendix H. Economic evidence study selection
Download PDF (140K)
Appendix I. Economic evidence tables
There are no included studies in this review question.
Appendix J. Health economic model
There is no original modelling in this review question.
Appendix K. Excluded studies
Download PDF (150K)
Final version
Evidence reviews underpinning recommendations 1.2.1, 1.2.130 to 1.2.132, 1.3.1, and 1.3.58 to 1.3.60 and research recommendations in the NICE guideline
These evidence reviews were developed by the NICE Guideline Development Team
Disclaimer The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.
Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.
NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the Welsh Government, Scottish Government, and Northern Ireland Executive. All NICE guidance is subject to regular review and may be updated or withdrawn.