1. Foreword

NHS England produced the NHS Long Term Plan to set out a shared view of the challenges ahead and the choices about health and care services in the future; it applies to all services including dentistry.

The International Diabetes Federation and European Federation of Periodontology (EFP) have set out a clear roadmap for the co-morbid relationship between periodontitis and type 2 diabetes and their joined-up management. These recommendations were reinforced by the National Institute for Health and Care Excellence (NICE) guidance on management of Type-1 and Type-2 diabetes, where periodontitis is recognised as a complication of diabetes as well as a risk factor for diabetes complications (NG17, NG18, NG28), and by joint recommendations by the EFP and World Organisation of Colleges and Associations of Family Doctors.

This Clinical Standard will support the local implementation of pathways for patients to enable the benefits of timely and effective periodontal management on oral health and importantly general health to be realised and point to emerging pathways for oral healthcare professionals to risk assess for diabetes.

2. Executive summary

It is now clear that there is a bidirectional link between diabetes and periodontitis (severe gum disease) (Chapple, 2013). People with type 2 and type 1 diabetes (from here on, ‘diabetes’ which does not specify the type, will refer to both type 1 and type 2 diabetes) are at greater risk of developing periodontitis and people with periodontitis are at greater risk of developing type 2 diabetes and experiencing diabetes complications (Sanz et al, 2018). In addition, effective treatment of periodontitis in people with type 2 diabetes can improve glycaemic control to an extent that can reduce the need for an additional prescribed medication as well as reduce systemic complications that are associated with (hyper)-glycaemia and that can also reduce diabetes complications (D’Aiuto et al, 2018).

People with type 2 and type 1 diabetes need to access effective dental care and local pathways should be developed to support this. This will require local engagement between providers and commissioners of dental and diabetes services, and the commissioning of dental services from providers with the appropriate skills and competences to deliver the care required.

Emerging evidence from studies in primary dental care practices demonstrates the feasibility of a two-step model for early case detection of diabetes (Yonel et al, 2020). Using a validated questionnaire (Yonel et al, 2022) and point of care capillary HbA1c testing, 14.5% undiagnosed cases of non-diabetic hyperglycaemia (NDH) and/or diabetes in over 40-year-olds were detected (Yonel et al, 2023). Ongoing research aims to clearly define these risk assessment pathways and their cost-effectiveness.

This document assists commissioners with introducing new procurements for existing contracts in a planned way that considers local capacity and capability. In emphasising local resourcing, these standards do not place mandatory requirements on existing providers. The recommended changes outlined in this document relate to new procurements only and will involve redirection of an existing resource.

Planning of services should be underpinned by a needs assessment. In the context of this commissioning standard, an oral health needs assessment should be used to determine if current dental services for people with diabetes are adequate, given the context above. 

Commissioners will then need to work with their Local Dental Network and associated Managed Clinical Networks to redesign services where required, which may involve awareness raising, skill mix review and additional training and competence development. 

The views of people with diabetes who will be using the services must be sought at the outset and as information and services are developed (Yonel et all, 2018).

3. Introduction

This document sets out the Commissioning Standard for dental care for people with diabetes. The purpose of this standard is to ensure that people with diabetes can access effective oral healthcare services with the aim of improving their general and oral health (Sheiham et al, 2000), and that oral healthcare teams start to engage in risk assessment/early case detection of undiagnosed NDH/diabetes as practical and cost-effective protocols emerge and refer onwards for formal diagnosis and management (Herrera et all, 2023).

As national guidance, commissioners are required to implement the requirements contained within this document when procuring new periodontal services. The requirements to conform are also relevant for all current primary care providers. 

Commissioners need to work with existing providers and agree a timetable for adoption of these requirements. Commissioners should look to work towards addressing any unmet need and develop a plan to address this. There will also be a need for a local plan to raise awareness in the medical and dental professions and the public on the link between oral health and diabetes. 

4. Context

4.1 Diabetes

Diabetes is a life-long condition that is caused by problems with the levels of, or the response of the body’s cells to a hormone in the body called insulin. The lack of insulin or of cell responses to it, results in the level of sugar (glucose) in the blood becoming too high (NHS.uk). Most cases are classified as type 1 or type 2. Type 1 diabetes is an autoimmune condition characterized by immune destruction of the insulin producing cells in the pancreas, that results in absolute insulin deficiency. Type 2 diabetes accounts for almost 90% of cases (diabetes.org.uk), is associated with lifestyle factors such as being overweight or obese and is characterised by resistance to the action of insulin as well as relative insulin deficiency. Type 2 diabetes tends to occur in later life and around two thirds of cases can be prevented or delayed by maintaining a healthy weight, eating well and being physically active (diabetes.org.uk). Type 2 diabetes is more common in people of African, African-Caribbean and South Asian family origin. It can occur in all age groups and is increasingly being diagnosed in children (NICE.org.uk). Diabetes care is estimated to account for at least 5% of UK healthcare expenditure, and up to 10% of NHS expenditure (NICE.org.uk).

4.2 Periodontitis

Periodontitis (severe gum disease) is a preventable chronic inflammatory non-communicable disease linked to accumulation of plaque on the teeth and gums, and subsequent inflammatory-immune reactions that impact on other body systems. Once acquired it is a life-long condition, but it can be prevented by good oral hygiene and managing risk factors, for example, smoking or poorly controlled, or undiagnosed diabetes. It is treated by improving self-care and professional cleaning and debridement (West et al, 2021). Effective oral hygiene, short and long-term maintenance and review are important (Chapple et al, 2025).

4.3 The link between type 2 diabetes and periodontitis

There is high quality evidence (Sanz et al, 2017) that type 2 diabetes is a risk factor for periodontitis, so people with diabetes are more likely to have severe gum disease. There is evidence that in people with type 2 diabetes, intensive periodontal therapy involving scaling and subgingival professional mechanical plaque removal (PMPR) can reduce HbA1c (a marker of glycaemic control) at 3-4 months by between 0.27% and 1.03% (Sanz et al, 2017) and at 12-months following intensive periodontal treatment by 0.6% (D’Aiuto et al, 2028), which might mean the patient does not need a second diabetes medication. People with periodontitis have relatively higher levels of HbA1c, and so may be more likely to develop non-diabetic hyperglycaemia (NDH) and type 2 diabetes.

4.4 Implications of the link between diabetes and periodontitis

People with diabetes need to have support from the dental team to help prevent periodontitis, with early diagnosis and treatment of periodontitis, if it is already established. They need regular surveillance and review to maintain good gum health and spot any potential deterioration as early as possible. All people with periodontitis need to have this treated and then good gum health should be maintained, as above, to help to prevent development of type 2 diabetes. In both cases there is a need to raise awareness of this interrelationship, within the dental, medical and health professions, and with the public (David Herrera et all, 2023).

5. Current service provision

5.1 Diabetes services

NHS England’s commissioning has moved towards more place based, clinically-led commissioning, and shares or delegates commissioning of primary medical care services to ICBs. The diabetes pathway defines the core components of an optimal diabetes service for people with type 1 or type 2 diabetes, or at risk of developing type 2 diabetes and includes:

• risk detection
• diagnosis and initial assessment
• structured educational programmes
• annual personalised care planning
• service referral
• identification and management of admissions by inpatient diabetes teams

5.2 Dental services

Periodontal treatment is listed as a mandatory service. Currently all dentate adults (those with teeth), who visit a general dental practitioner for routine dental assessment, should expect an oral health needs assessment combining history taking and clinical examination, including screening for periodontitis. Should a patient subsequently be diagnosed with periodontitis they would receive care

according to their individual needs. A baseline detailed pocket chart is required for definitive diagnosis of periodontitis, except in BPE code 3 patients, when it is undertaken at Step 2 of care. The key components of periodontal treatment in primary dental care are set out in Delivering better oral health: an evidence-based toolkit for prevention (fourth edition, 2021) and in the BSP S3-level clinical treatment guideline (West et al, 2021). Implementation is via phased treatments.

5.3 Advanced periodontal care pathways

It is expected that general dental practitioners will be able to deliver Level 1 services to diagnose and manage patients with uncomplicated periodontitis (as detailed in Appendix 1). However, current provision and potential gaps in Level 2 periodontal services may need to be addressed.

6. Potential for integrated care pathways

The greatest impact can be achieved by ensuring that all patients with diabetes are sign-posted to a general dental practitioner for periodontal screening. Patients who are diagnosed with periodontitis will then be assessed for care complexity levels and managed accordingly (Appendix-1).

6.1 Patients attending General Dental Practice 

Currently all dentate patients, who present to a general dental practitioner for routine dental assessment, should expect an oral health needs assessment combining history taking and clinical examination, including screening for periodontitis. Should a patient subsequently be diagnosed with periodontitis they receive care according to their individual needs (West et al, 2021). Protocols and procedures for risk-driven early case detection of diabetes in dental practices are under evaluation and may develop as complimentary pathways in non-medical settings. The new clinical care pathway intends to complement current care by raising awareness with patients about the link between periodontitis and diabetes. 

6.2 Patients attending General Medical Practice

Patients attending their general medical practice are not routinely screened for type 2 diabetes, unless they are deemed “at risk”, or as part of the NHS Health Check. The new clinical care pathway intends to complement current care by raising awareness with patients about the link between periodontitis and diabetes, and signposting to general dental practice.

Figure 1: A flowchart detailing clinical care pathway for patients diagnosed with diabetes (from general medical practitioner to general dental practitioner, and appropriate triage – Level 1, 2, or 3).

6.3 Benefits of integrated care pathway

It is proposed that implementation of this standard would lead to the following impacts:

• greater awareness and access to effective periodontal services for patients.
• greater detection and effective treatment of periodontitis amongst people with diabetes.
• cost savings: an economic analysis showed that periodontal treatment is cost effective for people with type 2 diabetes, assuming improvements in HbA1c are maintained (NICE, 2022).

7. Setting up service

Local Dental Networks in conjunction with commissioners will need to agree a timeframe for this piece of work, taking account of other local priorities, but being mindful of the potential savings to the NHS and improvement in quality of life for people with diabetes. Once the timeframe is agreed, the local staffing resources can be identified to support the service as this will need building into workplans for commissioners, Local Dental Network and the Restorative Managed Clinical Network chairs, and members and Consultants in Dental Public Health. 

The service will include several workstreams, some of which can run concurrently. Early establishment of a service delivery board is recommended to oversee the process.

Identified workstreams are:

• needs assessment
• communication and awareness raising
• training and development of dental teams
• development of local care pathway for people with diabetes that includes an oral health assessment
• procurement of periodontal level 2 complexity services
• potential development of risk-driven early case detection of diabetes/NDH in dental settings, for onward referral for formal diagnosis and management

7.1 Needs assessment

Planning oral healthcare services should be underpinned by a needs assessment. In the context of this commissioning standard, an oral health needs assessment (OHNA) should be used to determine if current dental care for people with diabetes is meeting local oral health needs. Appendix 1 Clinical guide to dentistry outlines needs assessment.

7.2 Communication and awareness raising

The bidirectional link between diabetes and periodontitis is not currently well known and so it is vital that this is communicated at National level and reinforced locally. The EFP/BSP have developed a suite of resources that could be used for such purpose at Appendix 2. Local Dental Networks will have developed communication links with local dental practices and so these should be used to raise awareness amongst dental teams first. This could be linked to training and development activity, for example, ensuring all clinical team members have up to date knowledge skills and competences in line with Delivering Better Oral Health and the BSP S3-level clinical guideline (West et al, 2021).

Once dental practices are engaged they should undertake in-practice audits of the number of patients with diabetes they currently see and ensure these patients are offered regular periodontal surveillance and support. Oral healthcare professionals should look to engage in risk assessment of their periodontitis patients for NDH/diabetes and be aware of emerging tools to support such assessments.

Communication with GPs and diabetes teams should follow and be undertaken in conjunction with local Diabetes Clinical Networks. These Networks can also assist with communication to people with diabetes and their healthcare professionals. It is essential that the importance of good periodontal, or gum health, is incorporated into the suite of self-care measures that people with diabetes already employ.

7.3 Training and development of dental teams

This should be undertaken in conjunction with the awareness raising discussed above, and the local Restorative MCN, should be involved in designing training, and development. The value of the whole dental team should be stressed, as training should include patient education and motivation, as well as clinical periodontal assessment and treatment.

Emphasis should be placed on effective treatment of the practice’s current patient base with diabetes, or the potential to develop diabetes. Once this is established, the practice will be able to move on to look after patients directed from the care pathway. The MCN should involve practices in design of short-term and longer-term clinical audits of the effectiveness of patient motivation on self-care and effectiveness of periodontal treatment on periodontal (gum) health. 

7.4 Development of local care pathway for people with diabetes that includes an oral health assessment

Once the OHNA has been completed and the local dental practices have been engaged in appropriate training and development, the pathway described above can be tailored for local needs and local practices. The key point is that patients with diabetes who do not currently regularly visit a dentist, should be able to quickly and easily find a practice to look after them, in line with NICE guidance and the EFP-WONCA recommendations. This might require a local prioritisation plan for people signposted from the diabetes care pathway. Consideration should be given to use of flexible commissioning to incentivise practices to develop services for people with diabetes.

7.5 Potential procurement of periodontal level 2 complexity services

It is expected that all general dental providers will deliver level 1 services to diagnose and manage patients with uncomplicated periodontitis (levels of complexity can be found in Appendix 1). The OHNA may have identified potential gaps in provision of level 2 periodontal services which may need to be addressed. Given that 12-month improvements in HbA1c of 0.6% arose following intensive periodontal treatment (D’Aiuto et al, 2018) the MCN should design a clear referral pathway for people with diabetes who require treatment of level 2 complexity. The in-practice audits described above could provide a method to quantify the volume of level 2 services, so that commissioners can plan the procurement required. A hub and spoke model is recommended so that the providers of level 2 complexity care can support a number of general dental practitioners and help them to develop more advanced competences where appropriate.

8. Local implementation example

London region is a case study for early adoption and piloting of the clinical standard, and as such have formed an Implementation Group for Diabetes and Oral Health Commissioning Standard in London:

• To establish a better knowledge of the bidirectional link between diabetes and periodontitis with GMPs and GDPs
• to improve the flow of patients with diabetes and/or periodontitis between medical and dental clinical care pathways, leading to improved oral and general health outcomes

Through the following roles:

• to lobby appropriate support, use local knowledge and networks to enable the aims stated above.
• to consider contractual levels and/or initiatives to enable a culture shift for collaboration between the medical and dental professions.

Figure 2:  An overview of the proposed engagement process for use when implementing the care pathway locally.

Appendix 1: Complexity criteria for Periodontal Services

Appendix 2: Resources

This suite of resources was developed by European Federation of Periodontology (EFP) and British Society of Periodontology (BSP).

• EFP’s infographic material
• BSP’s infographic material

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