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August 18, 2008 

 

Dentistry and the Diabetic Dilemma

By Richard H. Nagelberg, DDS, and Kimberly Miller, RDH, BSDH, RDHMP

Ongoing global research continues to address the oral systemic connections and their impact on total health and wellness. The consensus in the medical and dental professions is that there is an association between the mouth and the body; however, the strength of the association will be determined by further research — in particular, interventional studies in which periodontal treatment is provided and the effects on systemic events are observed.

Among the various systemic links to gum disease, the strongest is the connection to diabetes. Diabetes is a group of chronic diseases characterized by hyperglycemia (high blood sugar levels) resulting from defects in insulin production, action, or both. It is estimated that diabetes affects approximately 23.6 million people of all ages in the United States. The National Institute of Diabetes 2007 statistics also estimate that about 5.7 million of these people are undiagnosed diabetics. These individuals are totally unaware they are diabetic. This report goes on to say that about 2.6% of those aged 20 to 30 have diabetes while 10.8% of those aged 40 to 59 have diabetes. It was staggering to discover that of those aged 60 and above, 23.8% have diabetes. In other words, one out of every 4.2 patients you see in your dental office over the age of 60 will likely have diabetes.


The mechanism of Diabetes

To better understand the mechanism of diabetes it’s important to know the primary players, which are carbohydrates and insulin. Insulin is a protein hormone which gets its name from the Latin insula for island, which is appropriate since it is produced by the beta cells in the Islets of Langerhans in the pancreas. Insulin is an essential element in the control of intermediary metabolism, which are the processes within cells that extract energy from nutrient molecules and use that energy to construct cellular components.

Ingested carbohydrates are broken down in the small intestine into glucose, which is then absorbed into the bloodstream. The elevated glucose in the blood stimulates the release of insulin from the pancreas into the bloodstream. Insulin facilitates the uptake and utilization of glucose in muscle and fat cells throughout the body. All tissues in the body do not require insulin for glucose uptake including the brain and the liver. These tissue types use another, non-insulin dependent glucose transporter.1

There is a receptor for insulin embedded in the cell membrane of the target cells. Insulin binding to the receptor causes activation of the receptor, which then sets off a series of events inside the cell, rapidly culminating in the movement of internal compartments, or vesicles, inside the cell, to another part of the cell membrane. The vesicles contain the glucose transporters which then provide an opening in the cell membrane for the uptake of glucose from the bloodstream into the interior of the cells, (see Figure 1). Insulin also stimulates the liver to store glucose in the form of glycogen and is involved in the importing of proteins into the cells. Any disease or condition that interferes with the movement of glucose into the cells leads to hyperglycemia.

Type I Diabetes

Type I diabetes, formerly called juvenile diabetes, is most commonly diagnosed in children and young adults and accounts for 5 to 10% of all diagnosed cases of diabetes. It is characterized by the failure of the pancreas to make insulin. This malfunction is usually caused by auto-immune destruction of the pancreatic beta cells. People with Type I diabetes need several insulin injections per day or an insulin pump to survive. Most people with type I diabetes eventually develop one or more complications including damage to the eyes, nerves, kidneys and blood vessels. Type I diabetics are about ten times more likely to have heart disease than non-diabetics.2

 

Type II Diabetes

Type II diabetes is the most common form and accounts for 90 to 95% of all diagnosed cases. Type II diabetes, formerly called adult onset diabetes, is characterized by insulin resistance in the target cells, in other words the fat and muscle cells do not use insulin properly. Type II diabetes is treated with a combination of dietary modifications, oral medications and insulin injections if necessary.2

 Another staggering statistic reported by a recent study suggests that 82% of diabetic patients with severe periodontitis experienced the onset of one or more major cardiovascular, cerebrovascular or peripheral vascular events compared to only 21% of diabetics without periodontitis.3,4 Take just a moment to reflect upon how many patients you see with diabetes and their periodontal condition; you too will feel the magnitude of these statistics. We have an incredible opportunity as clinicians to assist our diabetic patients with their overall health by treating periodontal disease activity early and assertively.


Complications of Diabetes

The importance of preventing hyperglycemia cannot be overstated. The effects of elevated blood sugar on the vascular system are the major source of complications in Type I and Type II diabetes. Diabetic complications include retinopathy, nephropathy, neuropathy and cardiovascular diseases. These complications are dramatic and potentially life changing.5

Diabetic retinopathy is responsible for approximately 10,000 new cases of blindness in the US each year. Diabetic nephropathy is the leading cause of kidney failure in the U.S while more than 80% of foot amputations are the result of injury from diabetic neuropathy. Furthermore, cardiovascular disease is the leading cause of death in Type I and Type II diabetes.5


Periodontal Disease and Diabetes

Diabetic individuals are predisposed to periodontal disease through several mechanisms. Poorly controlled diabetics have diminished salivary flow, leading to xerostomia. The body’s ability to kill oral bacteria is considerably diminished as well. Hyperglycemia significantly diminishes the ability of white blood cells, neutrophils in particular, to track, adhere to and kill bacteria.5,6 Additionally, elevated blood sugar leads to elevated glucose levels in the gingival crevicular fluid (GCF). Elevated GCF glucose levels hinder the wound healing capacity of fibroblasts.7

Evidence also indicates that periodontal disease can worsen glycemic control.8,9,10 It is well established that infectious and inflammatory processes increase insulin resistance, leading to hyperglycemia. Periodontal disease has both infectious and inflammatory components.

If research demonstrates that periodontal treatment has a beneficial effect on diabetic control, it would provide evidence for the impact oral health has on general health. Two studies demonstrated significant improvement in blood sugar levels after non-surgical perio treatment. In these studies, nonsurgical treatment was provided for diabetic and non-diabetic perio patients. Both groups of patients showed improvement in their perio condition. The diabetic subjects showed improved blood sugar control 3 and 6 months after perio treatment.11,12 This information should be highly motivating for dental professionals to continue to assertively recommend treatment to all periodontal patients with diabetes.

It is interesting to note that there are only small differences in the subgingival microbiota between diabetic and non-diabetic perio patients,13,14 which suggests that the body’s immuno-inflammatory response plays the major role in the increased incidence and severity of gum disease commonly seen in poorly controlled diabetic individuals.3


The Dental Professionals Role

It is clear at this point that maintaining good oral health and controlling existing periodontal diseases has implications far beyond the oral cavity. Optimal oral health is only possible if dental providers and patients do their respective parts.

A few suggestions to improve your clinical protocols involving the treatment of diabetic patients follow:

This blood test measures the percent of glucose that is attached to red blood cells. This test gives an accurate indication of how well diabetes has been managed over the preceding 2-3 months. The HbA1c level is the primary parameter physicians use to monitor blood sugar control for their diabetic patients. Well controlled diabetics have an HbA1c of 5-7%. Readings of 8% and above indicate poor glycemic control. Well controlled diabetics have the same risk of developing periodontal disease as non-diabetic individuals. Poorly controlled diabetics have a much greater risk of several complications including periodontal disease. Periodontal treatment outcomes for well controlled diabetic patients will be the same as non-diabetics. Poor glycemic control contributes to less predictable treatment results, and may factor into the type of periodontal therapy undertaken.

      1. Every new patient with a family history of diabetes

2. Annually for all patients over the age of 60

3. All existing patients during health history and risk assessment updates and thereafter every 5 years unless over the age of 60

 

With the current understanding of the relationship between periodontal diseases and overall health and wellness, as dental professionals we are obligated to educate our diabetic patients on the importance of good oral health. It is no longer optional for us to provide in depth risk assessment, including questions about diabetes. According to the AAP, “Risk assessment goes beyond the identification of the existence of disease and its severity, and considers factors that may influence future progression of disease. Identifying adverse changes in risk factors, which might be suggestive of disease onset or progression, is an important clinical concept.”15

As ongoing research continues to address the oral systemic connections and their impact on total health and wellness, the consensus in the medical and dental professions is that there is an association and in our opinion, this association should be addressed with every patient who could be impacted by this information. While interventional studies and ongoing research continue to expand our knowledge, we must recognize our obligation to our patients and do our part now. For every patient under our care, everyday, we must make the effort to thoroughly assess their risk factors and incorporate that data into our comprehensive treatment recommendations.

References:

1    Physiologic Effects of Insulin, p.2 2007 Nov, R. Bowen, Colorado State University

2    National Institute of Health, US Department of Health and Human Services, NIH News June 5, 2004

3    Measley BL, Oates TW. Periodontal Inflammation and Diabetes Mellitus. J Periodontol 2006 Aug;77(8):1289-1303.

4    Thorstensson H, et al. J Clin Periodontol 1996;23:194-202.

5    Fowler MJ. Microvascular and Macrovascular Complications of Diabetes. Clinical Diabetes. 2008;26(2):77-82

6    Manuchehf-Pour M, et al. Comparison of neutrophil chemotactic response in diabetic patients with mild and severe periodontal disease. J Periodontol. 1981;52:410-415.

7    McMullen JA, et al. Neutrophil chemotaxis in individuals with advanced periodontal disease and a genetic predisposition to diabetes mellitus. J Periodontol. 1981;52:167-173.

8    Nishimura F, et al. Periodontal disease as a complication of diabetes mellitus. Ann Periodontol. 1998;3:20-29.

9    Sammalkorpi K. Glucose intolerance in acute infections. J Intern Med. 1989;225:15-19.

10 Yki-Jarvinen H. et al. Severity, duration and mechanism of insulin resistance during acute infections. J Clin Endocrinol Metabol. 1989;69:317-323.

11  Navarro-Sanchez AB et al. J Clin Perio. 2007 Oct;34(10):835-43. 

12 Faria-Almeida R, et al. J Periodontol. 2006 Apr;77(4):591-

13 Zambon JJ, et al. Microbiological and immunological studies of adult periodontitis in patients with noninsulin-dependent diabetes mellitus. J Periodontol. 1988;59:23-31.

14 Sastrowijoto SH, et al. Periodontal condition and microbiology of health and diseased periodontal pockets in Type I diabetes mellitus. Clin Periodontol. 1989;16:316-322.

15 American Academy of Periodontology statement on risk assessment. J Periodontol. 2008 Feb;79(2):202.

Dr. Richard Nagelberg has been practicing general dentistry in suburban Philadelphia for over 26 years. He has international practice experience, having provided dental services in Thailand, Cambodia, and Canada. Richard has served on many boards and advisory panels and is currently a member of the Georgetown University Board of Governors and the National Multiple Sclerosis Society Advisory Panel. He is a co-founder of PerioFrogz, an information services company, and is on the speaker’s bureau of OraPharma and the Seattle Study Club. A respected member of the dental community, Richard lectures extensively around the country on a variety of topics centered on understanding the impact dental professionals have, beyond the oral cavity.

Kim Miller, RDH, BSDH, RDHMP is a partner of the JP Institute and a founder of PerioFrogz. As a graduate from Loma Linda University in 1981 she received a Bachelor of Science Degree in Dental Hygiene. She is a published author and speaks throughout the United States and Canada as a workshop/seminar leader and a presenter for state and local meetings. In addition to clinical practice, Kim has been a consultant and trainer with the JP Institute since 1992 coaching more than 500 practices teaching a hands-on curriculum. Kim displays her experience and passion for Dentistry in her refreshing speaking style and those in her audience walk away with information that is applicable on the very next business day.

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Creating the Ultimate Doctor-Hygiene Patient Exam
By Karen Davis, RDH, BSDH
We’ve all been there. Frustrated! It seems as though the examination portion of the hygiene visit often lends itself to increased stress. See if any of these scenarios sounds familiar:
While there is not an easy fix to these common frustrations, there really are keys to make the doctor-patient examination more valuable and less stressful for all concerned. Warning, however, some of these concepts may take you out of your “comfort zone,” and some may require practice, in order to go smoothly and feel natural. Here is a brief look at a few strategies to create your own ultimate exam within the hygiene appointment.
1. Let go of the idea that a prophylaxis appointment is all the patient needs!

In practice after practice, hygienists are desperately attempting to educate the patient, change behavior, scale supra and subgingival calculus, remove all stain and plaque, perform and record periodontal evaluations, update radiographs, apply fluoride, identify restorative concerns, and so on, all in one appointment that lasts 40 to 60 minutes, if you get started on time!

Sound impossible? It often is. Even though most practices aren’t clear on the distinctions, the American Dental Association has done a great job defining the difference between a prophylaxis, scaling and root planing and periodontal maintenance. Ever wonder why the majority of adults have periodontal disease, yet the most common procedure provided in the hygiene department is still a prophylaxis? Perhaps it is because too often we are attempting to do too much in too little time, short of an actual diagnosis for what the patient really needs. Sometimes prophylaxis is just the beginning!

2. Don’t wait until the last five minutes of the appointment to have the exam

Time management is a challenge in any service industry where you are taking care of patient’s health needs, answering their legitimate questions, and providing treatments within a wide range of clinical conditions. In most busy dental practices, waiting until the hygienist is completely finished before notifying the doctor for an exam is almost a guarantee of running behind. Many times it is impossible for the doctor to immediately leave a tedious or technique-sensitive procedure to go examine a hygiene patient. The end-result? Everybody waits, and soon a “domino effect” takes place within the schedule.

Having a hygienist notify the doctor once data has been collected and potential treatment discussed will enable the doctor to look for a natural break in a procedure, interrupt the hygienist during his or her treatment, perform the examination, then both return to completion of their treatments. This approach requires hygienists get in the habit of notifying the doctor after the data collection and clinical discussion, but prior to beginning their instrumentation.

3. Use visuals to replace wordy descriptions

Patients will understand and retain information significantly better if audible and visual learning takes place together. Instead of us doing all of the talking (while working on the patient) and them doing all the listening, we should intentionally let the “pictures speak 1000 words” for us. Dental professionals have a tendency to use terms that are too technical and describe more detail than most patients really need when relying on our own verbal skills to explain the need for treatment.

Intraoral pictures, before and after pictures, educational pamphlets, radiographic pictures, etc., all assist in the co-discovery process necessary for patients to really understand and desire recommended treatment.

4. Sit the patient upright for communication

If ever you have been the patient in the dental chair you know what an uncomfortable position that is to carry on a conversation with someone who is seated above you. In fact, communication experts agree that as apprehension rises (as a result of someone with sharp instruments working in your mouth while lying on your back), listening ability diminishes. If you are willing to pause, sit the patient upright to describe conditions, discuss possible treatment, focus on the benefits to build value and use visuals, you will find you actually have to say less, because their ability to hear and retain information is significantly greater with the use of good eye contact and body positioning. Sitting upright also enables us to become a good listener, as patients feel more comfortable to discuss their true concerns.

5. Rise above insurance dictation

Patients all across the country tend to approach dental decisions much the same way: “If insurance pays for it, okay. If not, no thanks.” Particularly, if no symptoms are involved. In order to have an ultimate exam experience, patient’s questions concerning dental insurance should be consistently answered with a response that educates them about insurance reality. The reality is that dental insurance really is not “coverage.” That implies something that’s complete. Dental insurance is simply assistance to help defray costs. Most patients will never look at their own dental benefits any differently unless one by one in the dental office we are consistent in spreading the message that dental insurance was never intended to be complete coverage, and therefore shouldn’t be the only factor in deciding whether or not to proceed with treatment. It is simply a supplement, and wonderful when some assistance is offered, but all dental health decisions should be based upon need and desire, not insurance reimbursement.

Having an ultimate experience does require planning and forethought and may include change for some, but the rewards of being deliberate about how we approach this important time allotment in the hygiene appointment can directly lower stress throughout the practice, increase the patient’s understanding, and most importantly, improve case acceptance to achieve optimal clinical results we desire for all our patients.

Karen Davis, RDH, BSDH, is founder of Cutting Edge Concepts. Her 28 years experience as a practicing dental hygienist, and vast experience as consultant with The JP Institute, of San Diego, California, creates the context in which she relates, inspires, and challenges her audiences to “think outside their boxes”. Karen received her Bachelor of Science in Dental Hygiene from Midwestern State University, and since then has been an active participant in the dental profession. She speaks internationally, has authored numerous articles and has served on many advisory boards within the profession to share her passion for practicing comprehensively.
 
July 1, 2008
Dental Hygiene Diagnosis and Therapy
by Howard M. Notgarnie, RDH, MA
Abstract
As the scope of dental hygiene broadens and the practice becomes more specific, definitions of dental hygiene diagnosis and care must follow suit. This article calls for a taxonomic system of nomenclature for dental hygiene diagnosis and treatment, which can be used for current treatment modes available from dental hygienists and can expand along with the breadth of care and depth of knowledge.
Background

The current terminology used to describe dental hygiene diagnosis and treatment is minimal. Furthermore, diagnoses and treatments have been defined from outside the dental hygiene profession, leaving dental hygienists to practice within guidelines that do not fit the goals of dental hygiene practice toward client care. Dental hygienists need to define diagnoses and treatments more specifically than the currently available descriptions provide. Definitions as such should reflect the profession's holistic focus on prevention and early intervention of disease rather than on a perspective of pathology. This philosophy will help distinguish dental hygiene care from other forms of health care and accentuate its complementary, rather than competitive, relationship to dentistry and medicine.

The growth in dental hygiene’s scope and practice settings suggests a need for dental hygienists to formulate more distinct diagnoses and treatment plans. Furthermore, the dental hygiene diagnosis is becoming a more widely recognized entity. Noted organizations recognizing the dental hygiene diagnosis include the American Dental Hygienists’ Association1, 2 and the Oregon Board of Dentistry.3 Krisberg looks at the role dental hygienists are playing in rural areas of Maryland, Vermont, Washington, and Wisconsin to fill the void left by dentists. Dental hygienists are the key to prevention of oral diseases that are much more prevalent in rural areas due to the deficiency of dentists in those areas.4 Additional factors suggesting the need for a formal lexicon of dental hygiene diagnosis and treatment include:
  • The complexity of conditions and treatment options that may exist
  • The increasing frequency with which dental hygienists lack other qualified practitioners to whom to relinquish the responsibility of a thorough dental hygiene diagnosis
  • The increasing number of dental hygienists practicing in settings where they are unsupervised by individuals conversant on clinical issues facing dental hygienists

While ceding to the legal restrictions opposing the dental hygiene diagnosis, Levin5; identifies the centrality of the dental hygienist in diagnosis and treatment. He suggests that dental hygienists “evaluate the level of periodontal health … help create a system of standard diagnoses … and … initiate the majority of treatment.”

Gurenlian6 demystifies diagnosis as the identification of a condition, recognized through deductive reasoning based on objective and subjective criteria, which can be addressed by further professional actions of the diagnostician.

A diagnosis entices a practitioner to make responsible therapeutic decisions. The diagnosis justifies the therapy offered and performed, provides reason to the wide range of services available, and provides the basis for measuring the standard of care. Clinical decisions must uphold to legal measures as well. Dental hygienists’ education and professional association define dental hygiene standard of care. Dental hygiene education accreditation standards recognize the dental hygiene process of care, which includes diagnosis. The ADHA supports this process of care. Many dental hygiene schools teach this process of care, and the dental hygiene diagnosis is a part of several texts used in dental hygiene schools.

Dental hygienists have been reluctant to accept diagnosis as part of their professional repertoire. This reluctance stems from several bases:

  • Lack of acceptance of capabilities
  • Fear of error
  • Lack of clarity on what constitutes a diagnosis
  • Fear of embracing responsibility to clients
  • Tradition of relinquishing to dentists the definition of dental hygiene’s profession
Consequently, Gurenlian recommends that the dental hygiene diagnosis be made more palatable to dental hygienists by:
  • The ADHA creating a position statement indicating the necessity of the dental hygiene diagnosis;
  • Changing legislation to recognize the dental hygiene process of care;
  • Finding and using the professional socialization mechanisms that will lead to dental hygienists accepting the responsibility for the diagnoses they make; and
  • Accepting that there will be opposition to our professional growth from outside entities

Indeed the profession is responding to the above recommendations. The American Dental Hygienists’ Association formally recognizes the dental hygienists’ capability and responsibility to formulate a diagnosis. ADHA characterizes the dental hygiene diagnosis as following nursing diagnosis by identifying challenges to general health and function rather than following medical and dental diagnosis that focus on systemic processes and pathology.7 Furthermore, the American Dental Association Commission on Dental Accreditation specifies dental hygiene education must develop students’ competency in dental hygiene diagnosis and treatment planning.&sup8; Likewise, the American Dental Education Association stresses that someone entering the profession of dental hygiene must be competent in diagnosing a client’s needs and planning appropriate treatment using data collected during assessment and collaboration with other health professionals.9 Mueller-Joseph and Peterson describe the formulation of a dental hygiene diagnosis from the processing of data collected during the assessment phase of the dental hygiene process. The dental hygienist makes an inference using evidence from a variety of sources. The dental hygienist then determines how the findings will lead to a dental hygiene care plan and continuously validates the decision as more information is accumulated. The dental hygiene diagnosis describes conditions amenable to dental hygiene care. It consists of two statements: a response and its relationship to an alterable etiological factor. Guidelines to keep in mind when formulating a dental hygiene diagnosis are to keep it factual rather than judgmental; make the first statement a problem that summarizes the signs and symptoms; make the second statement the etiology that resulted in the problem; and define the problem and etiology in terms that can be addressed by a dental hygienist.10

Pamela Emard, RDH, described herself as "member of the ADHA, CDHA, IFDH, focused on patient quality care and an advocate for the advancement of the dental hygiene profession."
 
Annette Comey Billups, RDH, BS, stated she "graduated from the dental hygiene program at the University of Southern California, in 1998. Works in a private practice in Los Angeles, and is raising a beautiful daughter in Corona with her husband."
 
Mary Glassock Johnston, RDH, earned an Associate of Science in Dental Hygiene from Asheville Buncombe Technical Community College, in Asheville, North Carolina. She is the "Primary Dental Hygienist for Extended Care Rehabilitation Center for VA Medical Center, Asheville, NC." Her work includes "Oral care for Cancer, Hospice, Rehabilitation, and Long Term Care geriatric patients as well as Educator for Nursing Staff."

Howard M. Notgarnie, RDH, MA, practices dental hygiene in Colorado, and has eight years’ experience in official positions in dental hygiene associations at the state and local levels.

July 1, 2008