Advise adults with type 2 diabetes at their annual review that:
they are at higher risk of periodontitis
if they get periodontitis, managing it can improve their blood glucose control and can reduce their risk of hyperglycaemia. [2022]
Advise adults with type 2 diabetes to have regular oral health reviews (their oral healthcare or dental team will tell them how often, in line with NICE's guideline on dental checks: intervals between oral health reviews). [2022]
For guidance for oral healthcare and dental teams on how to provide oral health advice, see NICE's guideline on oral health promotion. [2022]
For adults with type 2 diabetes who have been diagnosed with periodontitis by an oral healthcare or dental team, offer dental appointments to manage and treat their periodontitis (at a frequency based on their oral health needs). [2022]
The evidence showed that people with diabetes are at increased risk of periodontitis, and that non-surgical periodontal treatment can improve diabetes control. However, in the committee's experience, people with diabetes are often unaware of this and may not be having regular oral health reviews. To address this, the committee recommended routinely discussing the risk of periodontitis at annual reviews, alongside eye disease and foot problems.
The evidence also showed that periodontal treatment is cost effective for people with type 2 diabetes, assuming improvements in HbA1c are maintained. This was tested with health economic modelling in a range of different scenarios. There were some scenarios where periodontal treatment was not cost effective, but the committee did not think these scenarios reflected real-world practice.
Full details of the evidence and the committee's discussion are in evidence review D: periodontitis.
For oral healthcare professionals, the long-term impact of the recommendations is uncertain. The recommendations specify that people should follow existing NICE guidelines on oral health. However, the recommendations may also increase awareness of periodontitis, leading to a possible short-term increase in the number of oral health reviews. Any increase in the number of oral health reviews will potentially impact on services, as NHS dental services already have capacity issues.
A short-term increase in the number of oral health reviews will also lead to a short-term increase in costs. However, there is likely to be a larger long-term reduction in costs from the improvement to oral health and diabetes control.
Oral healthcare and dental teams will need clear advice on what they need to do for people with diabetes. They will need clear care pathways to improve quality of care and service delivery, in line with the NHS England commissioning standard on dental care for people with diabetes.
Many people do not have regular oral health reviews, even if they are eligible for free NHS dental care. People are eligible for free dental care if they are:
pregnant
mothers with babies under 1 year old
on low income benefits, or under 20 and dependent on someone who is receiving low income benefits
having treatment in an NHS hospital by the hospital dentist.
The recommendations may encourage more people with diabetes to have regular oral health reviews. Combined with proactive engagement and enhanced support for people with diabetes, this may broaden access to dental and oral healthcare and help to reduce oral health inequalities.
Think about a diagnosis of gastroparesis in adults with type 2 diabetes who have erratic blood glucose control or unexplained gastric bloating or vomiting, taking into account possible alternative diagnoses. [2009, amended 2015]
For adults with type 2 diabetes who have vomiting caused by gastroparesis, explain that:
there is no strong evidence that any available antiemetic therapy is effective
some people have had benefit with domperidone, erythromycin or metoclopramide
the strongest evidence for effectiveness is for domperidone, but prescribers must take into account its safety profile, in particular its cardiac risk and potential interactions with other medicines. [2015]
In February 2026, the use of erythromycin was off label. See NICE's information on prescribing medicines.
To treat vomiting caused by gastroparesis in adults with type 2 diabetes:
consider alternating the use of erythromycin and metoclopramide
consider domperidone only in exceptional circumstances (if domperidone is the only effective treatment) and in accordance with MHRA guidance on domperidone. [2015]
In February 2026, the use of erythromycin was off label. See NICE's information on prescribing medicines.
If gastroparesis is suspected, consider referring adults with type 2 diabetes to specialist services if:
the differential diagnosis is in doubt or
the person has persistent or severe vomiting. [2009]
For guidance on managing painful diabetic peripheral neuropathy in adults with type 2 diabetes, see NICE's guideline on neuropathic pain in adults. [2015]
Think about the possibility of contributory sympathetic nervous system damage in adults with type 2 diabetes who lose the warning signs of hypoglycaemia. [2009, amended 2015]
Think about the possibility of autonomic neuropathy affecting the gut in adults with type 2 diabetes who have unexplained diarrhoea that happens particularly at night. [2009, amended 2015]
For adults with type 2 diabetes and autonomic neuropathy who are taking tricyclic antidepressants and antihypertensive medicines, be aware of the increased likelihood of side effects such as orthostatic hypotension. For guidance on safe prescribing of antidepressants and managing withdrawal, see NICE's guideline on medicines associated with dependence or withdrawal symptoms. [2009]
For adults with type 2 diabetes who have unexplained bladder‑emptying problems, investigate the possibility of autonomic neuropathy affecting the bladder. [2009]
In managing autonomic neuropathy symptoms, include specific interventions indicated by the manifestations (for example, for abnormal sweating or nocturnal diarrhoea). [2009]
For guidance on preventing and managing foot problems in adults with type 2 diabetes, see NICE's guideline on diabetic foot problems. [2015]
As part of the type 2 diabetes annual review, offer to discuss erectile dysfunction (if relevant). [2015]
Assess, educate and support people with type 2 diabetes who have problematic erectile dysfunction, addressing contributory factors such as cardiovascular disease as well as possible treatment options. [2015]
Consider a phosphodiesterase‑5 inhibitor to treat problematic erectile dysfunction in people with type 2 diabetes. Initially choose the medicine with the lowest acquisition cost and take into account any contraindications. [2015]
After discussion, refer people with type 2 diabetes to a service offering other medical, surgical or psychological management of erectile dysfunction if treatment (including a phosphodiesterase‑5 inhibitor, as appropriate) has been unsuccessful. [2015]
When adults are diagnosed with type 2 diabetes, refer them immediately to the local eye screening service. [2009, amended 2020]
Encourage adults to attend eye screening, and explain that it will help them to keep their eyes healthy and help to prevent problems with their vision. Explain that the screening service is effective at identifying problems so that they can be treated early. [2009]
Arrange emergency review by an ophthalmologist for:
sudden loss of vision
rubeosis iridis
pre-retinal or vitreous haemorrhage
retinal detachment. [2009]
Refer to an ophthalmologist in accordance with the NHS Diabetic eye screening pathway standards [2009, amended 2026]
For guidance on managing and monitoring diabetic retinopathy in people under the care of hospital eye services, see NICE's guideline on diabetic retinopathy.
The recommendations on diagnosing and managing hypertension have been removed. For recommendations on hypertension in people with type 2 diabetes, see NICE's guideline on hypertension in adults. Diagnosis, treatment and monitoring of hypertension is broadly the same for people with type 2 diabetes as for other people. When a different approach is needed for people with type 2 diabetes, this is specified in the hypertension guideline.
Do not offer antiplatelet therapy (aspirin or clopidogrel) to adults with type 2 diabetes without cardiovascular disease. [2015]
For guidance on the primary and secondary prevention of cardiovascular disease in adults with type 2 diabetes, see NICE's guidelines on cardiovascular disease and acute coronary syndromes. [2015]