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Managing Diabetes in the Dental Office
By Nancy D. George-Streiner, RDH, MHA
Abstract
Diabetes is a disease which causes the body to not produce or properly use insulin. Insulin is a hormone which converts sugars and other foods into glucose that the body uses for energy (Mealey, 2006). Periodontal disease is an inflammatory disease of the bone and gingival tissues that hold the teeth in place. New research has recently been found that the correlation between diabetes and periodontal disease goes both ways – diabetics are more prone to contracting periodontal disease and periodontal disease can make controlling the blood sugar more difficult (Mealey, 2006). Mealey (2006), states that studies have shown that periodontal therapy in diabetic patients will help to keep the metabolic condition under control. Minimizing the risk of an emergency in the dental office relies on the management strategies of the organization (Lalla and D’Ambrosio, 2001).  This paper will discuss the quality core measures used in a dental practice when caring for diabetic patients with periodontal disease, leadership styles and strategies for implementing the initiative, organizational culture, external social, economic and political drivers, demographic and disease profiles, and technology used.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has devised a plan through research and development to measure the quality of care and services provided by healthcare organizations (as cited by Mealey, 2006). This program requires hospitals to collect and report performance data on three of the following measure areas:
  • Acute myocardial infarction
  • Heart failure
  • Pregnancy and related issues
  • Community acquired pneumonia.
These requirements are to improve the safety and quality of services provided by hospitals (as cited by Mealey, 2006). The same principles can be used in other healthcare organizations that strive to improve the care of the patients serviced.
Dental offices play a significant role in identifying and diagnosing diabetes (Lalla and D’Ambrosio, 2001). The organization being discussed is implementing a new quality measure for the diagnosing and maintaining of patients with this disease. In the past, diabetic patients in this dental practice were treated like any other patient, he or she would fill out the medical history and the provider would acknowledge the diabetes but would go no further. The new quality plan, designed using the Hoshin Planning Tree (see related illustration), will aid providers to help these patients stay healthy metabolically and periodontally.
Change Initiatives
New research has recently been found that the correlation between diabetes and periodontal disease goes both ways – diabetics are more prone to contracting periodontal disease and periodontal disease can make controlling the blood sugar more difficult (Mealey, 2006). Diabetes is manifested in the mouth; therefore, dentists play a significant role in the screening of the disease in the general population (Gillis and Saxon, 2003). Periodontal disease increases blood sugar. Studies have shown that periodontal therapy in diabetic patients will help to keep the metabolic condition under control (American Academy of Periodontology, 2006). The current trends in research show the necessity for a management initiative within dental offices to help diagnose and maintain diabetic patients (Gillis and Saxon, 2003).
Lalla and D’Ambrosio (2001) state that the first important step for clinicians is to take a thorough medical history and assess glycemic control at each visit. Patients should be asked about recent blood glucose levels, frequency of hypoglycemic episodes, and dosages and times of antidiabetic medications (Lalla and D’Ambrosio, 2001). Mealey (2006) discusses the importance of scheduling morning appointments when cortisol levels are generally higher (cortisol increases blood sugar levels). For insulin dependent patients, appointments should be scheduled so as not to coincide with peak insulin activity (Mealey, 2006). Diet is another factor for clinicians to consider and discuss with the patient (Lalla and D’Ambrosio, 2001). If a diabetic patient has not eaten normally, the risk for a hypoglycemic episode is increased according to Lalla and D’Ambrosio (2001).
Patients need to bring his or her glucose monitor to each appointment. Depending on the medical history, medication regime, and procedure to be performed, clinicians may need to measure the blood glucose prior to treatment (Mealey, 2006). Patients with a <70mg/dL should be given an oral carbohydrate before treatment (Lalla and D’Ambrosio, 2001). For patients with a significantly higher blood glucose reading, a consultation with the patient’s physician is recommended (Lalla and D’Ambrosio, 2001).
Initial signs and symptoms of a hypoglycemic episode include: mood change, decreased spontaneity, hunger, weakness, sweating, incoherence, and tachycardia (Lalla and D’Ambrosio, 2001). Clinicians should be educated on these signs in order to recognize when a patient in crisis and to take proper action. The patient should be given 15 grams of sugar, candy, orange juice, soda, or glucose tablets (Mealey, 2006).
Hoshin Tree
Hoshin Tree Image
The Hoshin Tree is a planning and management tool designed to help organizations identify, create, and follow through with strategic planning. There are six key elements to this process:
  • Focus for the organization
  • Commitment to customers
  • Deployment of the organization's focus
  • Collective wisdom to develop the plan
  • Tools and techniques
  • Ongoing evaluation of progress (Hoshin Planning, 2000).
Evaluation Strategy
The major evaluation techniques include: monitoring, case studies, survey research, trend analysis, and experimental design (Gillis and Saxon, 2003). The dental office in this paper will use monitoring as the primary strategy for the quality initiative. Patients’ periodontal health will be checked at each prophylaxis visit. These visits include medical history review, a complete periodontal probing chart, scaling and root planning if needed, x-rays annually, and glucose checked by the hygienist. The hygienist will determine the frequency of recare appointments depending on the status of the periodontal health. Recare appointments can range from three months to six months.
Challenges and Perceptions
No quality initiative is without some challenges. The challenges which will be faced with this plan are patient compliance and patient behavioral patterns (Gillis and Saxon, 2003). Patient compliance has long been an issue in any dental office. No matter how much counseling and education a patient may get from a dental provider, it is his or her responsibility to make the effort to take care of their health. Many patients are unmotivated, uninterested, apathetic, or just lazy. Repeated attempts at behavioral change cause frustration for both the hygienist and the patient (Mealey, 2006). Patients must take responsibility for keeping appointments and doing their home care. The ability and readiness to change is different for everyone. “People often pass through several stages before actually incorporating change into their life” (Jahn, 2002. See Table 1).
Patient education needs to be set according to the level of the patient’s acceptance (Mealey, 2006). Patience is a key factor for the provider; do not expect huge overnight results (Gillis and Saxon, 2003). If a patient feels overwhelmed, he or she may not do anything towards the changes needed. Mealey (2006) states to make sure patients are aware of the importance of regular visits. Missed maintenance appointments can severely disrupt any progress in periodontal patient’s therapy, thus causing his or her diabetes status to falter (Mealey, 2006). A simple phone call to confirm appointments can mean fewer missed appointments.
TABLE 1. Prochaska's Stages of Change
Precontemplation Unawareness of needed change
Contemplation Early awareness of the need to change
Preparation Active planning for change
Action Implementing change into a habit
Maintenance Establish the habit
Termination The habit is firmly established
Theory Domain
Strategic planning is essential for the survival of any organization and determines where the organization is headed in the future and the path necessary to reach goals (Sidney, 2004). The type of strategic plan most often used for an organization depends on the product or service provided. According to McNamara (1997), the most common type of planning is goals based and begins with the organization’s mission and vision,  strategies to achieve the goals, and action planning (who will do what and by when). Effective leadership from the top down is the most important element and definitive organizational enabler (Sidney, 2004). Sidney (2004) states that direct leadership in a dental office is the face-to-face or hands on approach of the immediate supervisor directing staff to meet specific goals. A good leader aids in allowing the staff to see the whole picture and pushes them to increase performance levels (Sidney, 2004).
The role manager’s play in an organization is usually multi-faceted (McNamara, 1997). Not only are managers typically responsible for a team of employees, but the organization also holds managers accountable for being fiscally responsible for his or her function (McNamara, 1997). Managers then ensure the direction of his or her team is aligned with that of the overall organization. As such, managers and leaders of organizations must be aware of the theory behind the functions of management, how they can apply those functions, and how the general management functions impact the operations management functions (Johnson, 2003). One tool often used in strategic planning is an analysis which determines the strengths, weaknesses, opportunities, and threats (SWOT) of a proposed project.
Management is creative problem solving. The four functions of management include planning, organizing, leading and controlling (Frappaolo, 1998). Frappaolo (1998) states using the organization’s resources to achieve the goals and mission are the intended outcome. The functions of management are: 1) Planning: the planning phase lays out the strategic process and the steps necessary to complete the project; 2) Organizing: organizing is deciding who, what, when and how the process will unfold; 3) Controlling: Frappaolo (1998), states that controlling consists of 4 steps in developing standards for performance which are based on the organization’s mission and vision; 4) Leading: leading is the phase where managers motivate staff. This can be accomplished through communication, incentives, team dynamics, or leadership qualities (Sidney, 2004).
The SWOT analysis is a powerful tool for managers to use in order to determine where the organization stands in relation to competitors or to determine the organizations niche in the market (Johnson, 2003). At all times, clear and concise communication throughout the healthcare organization is a must in order for this process to work (Johnson, 2003). According to Johnson (2003), the priorities will differ from one organization to another depending on their needs. A not-for-profit organization may be more interested in public education projects, whereas another may be more involved in capital gains. Whatever the intended outcome the process should be the same; communication, planning, prioritizing, implementing (Sidney, 2004).
Change process
Diabetes that is not properly controlled has the possibility of leading to periodontal disease in patients of any age (University of Virginia Health Systems, n.d.). Periodontal diseases are infections in the supporting structures of the teeth which include the bone and gingiva (Perio.org, n.d.). Diabetes causes blood vessel changes and the thickening of the vessel hinders the flow of nutrients and waste removal from the bodies’ tissues (University of Virginia Health Systems, n.d.). The impaired blood flow has the capability of weakening the gingiva and bone. In addition, Mealey (2006) states, if diabetes is poorly controlled, higher glucose levels in the mouth fluids will encourage the growth of bacteria that can cause gum disease. A third factor is smoking. Smoking is harmful to the oral cavity even in non-diabetics. However, a smoker with diabetes puts him or herself at a much higher risk for periodontal disease than a non-smoker (Mealey, 2006). These factors paired with poor oral hygiene, can lead to the first stage of periodontal disease, gingivitis (Mealey, 2006).
Conclusion
Periodontal diseases are inflammatory diseases and can be risk factors for systemic conditions. Assessment of periodontal status is a part of risk factor analysis for patients (Saremi and Tulloch-Reid, 2005). Treatment of inflammatory periodontal diseases is simply management of a potential modifiable risk factor – is no different from treatments to positively impact other modifiable risk factors like smoking or high cholesterol (Mealey, 2006). Using the Hoshin Tree model, an organization will be able to work out a program to improve the quality of diabetic patients with careful monitoring and treatments. The goal is to never have a diabetic crisis in a dental office, to educate patients on the seriousness of periodontal disease, and the impact this disease can have on the rest of the body. Taking care of teeth means taking care of the body!
Recommendations
The vision of the new program is to help staff and diabetic patients understand his or her disease and the complications that may arise. The entire staff will be educated on the effects and complications of diabetes as well as how to handle a diabetic patient in crisis. The key areas which needed modification were the correspondence between the dental office and the patient’s physician, and dialogue between the dentist or hygienist and the patient. The new policy requires staff to ask specific questions when going over a patient’s medical history. The staff member will ask what type of diabetes, what type of control regime is being used, and refer to the patient’s physician for a history of glucose levels.  Each diabetic patient will bring his or her glucometer to every visit. This protocol will help decrease any diabetic emergencies in the office and will continue to be updated and improved as needed.
Nancy George-Streiner, RDH, MHA, is an experienced dental hygienist and current doctoral student. She was first licensed as a hygienist in 1985 and later attended a graduate program to obtain her masters in health care management at the University of Phoenix. It was during her master’s studies that she became interested in health care policy and decided to pursue her PhD at Capella University. Nancy’s goal is to someday have dental care available to everyone. Besides being a veteran hygienist, Nancy has volunteered at Safeplace (a non-profit for victims of domestic violence and sexual assault) and helped research a paper on health care reform for Hope Street Group. To contact Nancy, please e-mail her at NancyStreiner@austin.rr.com
Table 1. Prochaska’s Stages of Change.
Figure 1. Hoshin Tree. This diagram is the Hoshin Tree for the diabetes quality initiative.
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