Dental Tribune U.S. Edition

News DENTAL TRIBUNE | December 20114A f DT page 1A for achieving greater awareness? Some of the talks I have given have been at the Centers for Disease Con- trol and Prevention. They have an interest in this area because to them diabetes is an epidemic. Each year we have 1.9 million new cases diag- nosed in people 20 years of age and older. If the population of people with diabetes keeps growing at this rate, in the very near future it will be about one in three, which is a very signifi- cant number. What can dental professionals do to help identify patients who have diabetes or prediabetes but have not been diagnosed? Certainly we can screen for diabetes. And this is being recommended by the CDC. One way is by risk assess- ment: knowing a patient’s family history, looking at obesity as a risk factor, looking to determine if the patient is in one of the populations where risk factors may be higher [African Americans, Pacific Island- ers, Native Americans, Latinos and Hispanics]; asking about gestational diabetes. Most patients with diabetes are type 2 patients, who tend to be older than 45 years of age. Risk factors such as hypertension and dyslipidemia are also impor- tant to consider. Of course, there are the classic signs and symptoms: thirst, frequent urination, infections, numbness in extremities, leg cramps, vision problems. Unfortunately, with type 2 diabe- tes, there are many people who are unaware they have it. That’s why the CDC is looking to oral health care professionals for help. If a person has any of the risk factors, signs or symptoms, dental professionals can refer to the physician for additional screening, or obtain a random blood glucose level or even a fasting blood glucose level and then refer appro- priate patients to the physician for diagnosis. What do dentists need to be aware of with their patients who have diabetes or prediabetes? If patients are poorly controlled, then you may need to be very cautious in what procedures you might be doing because the patients’ wound healing may be affected. You need to know if they have any other long-term com- plications of diabetes. You need to work closely with the patients’ phy- sician and other health care profes- sionals. Many patients with diabetes, espe- cially those who have a physician working very hard to tightly con- trol their diabetes and whose blood glucose levels tend to run low, may have a higher risk for hypoglycemic events. Ask patients if that is common for them, because the more hypogly- cemic events patients have had, the more likely they are to have more — and the more likely they are to develop hypoglycemia unawareness. That’s when they don’t get any of the classic signs: getting dizzy, feeling like they are going to pass out or get- ting confused. Some patients don’t get those signs and symptoms; they can just suddenly become uncon- scious or have seizures. What can the dental professional do to confirm whether or not patients with diabetes have their blood sugar in good control prior to treatment? You can actively take the blood glu- cose level by doing either a random screening for blood glucose or even a fasting for blood glucose. If the level is greater than 126, the patient can be referred to a physician for further work. Another way to screen is the hemoglobin A1C test, a long-term marker of control that lets you know how well-controlled someone with diabetes has been over the past two to three months. It used to be that only a centralized laboratory could do this, but now there are point-of- care tests. The only way you can help predict a hypoglycemic event in your patient is to check blood glucose levels. Patients on insulin are at the highest risk of having a hypoglycemic event at the time of peak activity of the insulin that has been administered, which is not when you want to be treating them. You also need to know what oral medications they may be taking because some may have a higher risk than others of causing hypoglycemia. Research indicates that serious periodontal disease may affect blood glucose control and contribute to the progression of diabetes. Why is this? In fact, the impact of periodontal disease may even be evident before someone develops diabetes. Recent research suggests that patients who have untreated periodontal disease, when followed for over 20 years, may be twice as likely to develop diabetes. Periodontitis is driven by infection and inflammation; and infection and inflammation can drive insulin resis- tance. Insulin resistance can lead to development of diabetes and prevent good control of diabetes. By reducing infection and inflam- mation, you may actually prevent development of diabetes, and cer- tainly you can make it easier to con- trol diabetes. Some recent papers have suggested that if you don’t treat the periodontal disease, not only is it more difficult to control diabetes, but people with diabetes are then at higher risk for long-term complica- tions such as cardiovascular disease and kidney disease, thereby increas- ing risk for mortality. Are people with diabetes and prediabetes at risk for other dental problems? If patients are not well controlled, they also tend to get more cavities or caries. They have a higher risk of developing oral yeast infections such as candidiasis. They may have enlarged parotid glands, which can lead to dry mouth. And because of the yeast infections in a dry mouth, they could report burning mouth or dry tongue. Dry mouth due to salivary gland dysfunction will drive peri- odontal disease and caries formation. Poorly controlled patients are also at greater risk for abscess formation. Gingival crevicular fluid is a serum transudate, so if your blood sugar lev- els are high, you have more glucose coming out of those pockets around the teeth. Your mouth has more glu- cose in it, so your teeth are bathing in glucose, increasing the risk for developing cavities. Working to improve home care with their patients is of great help, because such patients need to keep levels of bacteria as low as possible in the mouth. They can use antibac- Monitoring of blood glucose levels is critical as a guide to dental therapy for people with diabetes. (Photo/Provided by CDC, Amanda Mills) terial toothpaste or rinses. One of the toothpastes that’s very effective at reducing the levels of bacteria for 12 hours is Colgate Total. I recom- mend that to a lot of my patients with diabetes. And, of course, we need to pro- vide adequate care in the office. The treatment of infection and inflamma- tion, providing periodontal therapy whether it’s surgical or nonsurgi- cal, absolutely needs to be provided and should never be considered an optional or elective procedure. Are insurance organizations responding to the growing evidence of the connection between oral health and diabetes? Some dental insurance companies are reimbursing dentists for screen- ing, not only for diabetes but also for hypertension by checking blood pressure and for obesity by determin- ing body mass index. Some dental insurance companies are beginning to create expanded plans that begin to better address the oral health care needs of patients with diabetes. This may help with access. Some patients — especially those without dental insurance — complain that if they go to the podiatrist, it’s covered by their medical insurance, but if they’re going to the dentist, it isn’t covered by medical in most cases. This may be changing. Are there dental professionals specializing in the treatment of people with diabetes? If so, how does one develop such a specialty? When your comfort level goes up, you will see more and more of these patients [by referral]. Patients say, “You know, Dr. Ryan asks me ques- tions that other dentists never asked me about my diabetes. And she seems to base her treatment plan around the answer to those ques- tions.” If you’re comfortable talking