The Diabetes Epidemic--Part II
Preventing, Controlling, and Managing Diabetes
THE NEXT DDS
This is part II of a series of articles about the subject of
diabetes and its impact on oral health and healthcare providers. For part I of
this article, visit This Link. This
portion of the article deals with the prevention, management, and treatment
options for diabetic patients, specifically oral healthcare requirements and
best practices to share with your patients.
PREVENTING AND CONTROLLING
DIABETES AND ITS COMPLICATIONS
Type 2 diabetes can be prevented or its onset delayed
through lifestyle changes. A large scale study by the Diabetes Prevention
Program Research Group found that modest weight loss and physical activity were
the most effective in achieving this outcome. Specifically, a 5% - 7% reduction
in weight coupled with modest physical activity, about 150 minutes per week,
resulted in a 58% relative reduction in the progression to type 2 diabetes. For
those over 60, the reduction was even greater; 71%.1,2 Smoking
cessation should also be a consideration as the risk for the development of
type 2 diabetes was shown to be lower in former smokers compared to current
ones.3
Preventing Diabetes
Complications
According to the Standards of Medical Care from the American
Diabetes Association, people with diabetes need regular medical and preventive
care from a physician coordinated team. The team may include (but not be
limited to) nurses, pharmacists, dieticians, and mental health practitioners.4
Working together with these healthcare providers can reduce the occurrence of
diabetes complications by controlling blood glucose, blood pressure, and
lipids.1
Tight glucose control is regulated/obtained by using two
different types of tests; daily self monitoring of glucose and the A1C reading.
Daily self-management of blood glucose is useful for preventing hypoglycemia,
and adjusting medication, food intake, and physical activity. Any individual
that is either insulin-dependent or not achieving glycemic goals should
self-monitor their blood glucose. Self-monitoring generally involves a
finger-stick and is often accomplished via glucometer. Blood glucose before a
meal should be between 70-130 mg/dl and less than 180 mg/dl after a meal. Those
with type 1 need to test at least three times or more a day. Optimal testing
for those with type 2 is not known. The accuracy of self-monitoring is
user-dependent, so even those who regularly self-monitor will need to have an
A1C test.4
An A1C test measures hemoglobin components and most
accurately reflects the previous two to three months of glycemic control. The
test should be routinely performed on anyone with diabetes. It is recommended
at least twice a year in people meeting treatment goals and quarterly in those
whose treatment has changed or are not meeting glycemic goals. The American
Diabetes Association (ADA) recommends that individual patients achieve an A1C
goal below or around 7%. The A1C may also be reported as an estimated glucose
average or eAG. The eAG is a new way to help people understand how well they
are managing their diabetes.4
The Diabetes Control and Complications Trial and the UK
Prospective Diabetes Study have shown that improved glucose control (as
measured by an A1C test) is fundamental in decreasing retinopathy, nephropathy,
and neuropathy. Both clinical trials found that intensive treatment regimes
that were able to reduce the A1C to ~7% were associated with fewer long term
microvascular complications.4
There have been mixed results from studies that have sought
to intensively lower the A1C reading to reduce macrovascular complications. The
ACCORD trial found that intensively lowering the A1C to 6% or below increased
mortality and did not reduce cardiovascular events.5 A study by the
ADVANCE Collaborative group found that lowering the A1C to 6.5% resulted in a
21% reduction in the risk for new or worsening nephropathy. There was no
evidence of reduction of macrovascular events.7
Good diabetes control also involves the management of blood
pressure and lipids. The American Diabetes Association recommends that blood
pressure be measured at every routine diabetes visit. For cholesterol and
triglycerides, testing is recommended yearly for those with levels not within
normal limits; for others, testing is recommended every two years.1
(Continued from page 1 )
DIABETES AND ORAL
HEALTH
Diabetes can have many oral manifestations and complications
that can impact the quality of life and potentially the length of life.6,8,9,10,11,12
It increases both the risk and severity of periodontal disease.6
Xerostomia is very common and may be debilitating, and/or increase the risk for
fungal infections and/or caries.8
Xerostomia
Dry mouth in patients with diabetes can result from a
variety of causes including metabolic control, endocrine function, and
medications.8,12 Xerostomia can range from a feeling a dryness to
difficulty speaking or swallowing without the aid of liquid.13 It
can increase the risk for caries especially root caries in older patients.
Xerostomia along with poor metabolic control and a compromised immune system
can create the ideal environment for fungal infections. Burning mouth syndrome
has been found in undiagnosed cases of type 2 diabetes. Lichen planus has been
observed to occur more frequently in people with diabetes.8
Periodontal Disease
Diabetes is a well-established risk factor for gingivitis
and periodontal disease, and those with poor glycemic control seem to be at the
highest risk. Both adults and children with poor glycemic control have been
shown to have more bleeding and inflammation than those with good control.6,11
Periodontal destruction can begin early in life for children with diabetes and
may become more pronounced into adolescence. Children as young as 6-11 years
have been shown to have teeth with attachment loss and the incidence was even
higher in those 12-18 years old.11 For adults, the data indicates
that as glycemic control worsens there tends to be deeper periodontal pockets
and more severe attachment and bone loss.6
Although evidence is limited, it appears that people with
poorly controlled diabetes do not respond as well to treatment in the long term
as people with good or even moderate control. Patients may not respond to
therapy or there may be an initial response followed by a rapid reoccurrence of
deep pocketing. Conversely, over a five year period, people with good or
moderate control who received non surgical and surgical therapy followed by
regular maintenance had outcomes similar to people without diabetes.6
The Influence of
Periodontal Disease on Diabetes
Several studies have evaluated the effect that the
periodontal infection has on diabetes control and/or complications. Periodontal
disease has been shown to significantly (6-fold) increase the likelihood of poor
glycemic control over time.13 The presence of severe periodontal
disease has also been associated with more serious complications including an
increased risk for mortality from those complications.9,10,14 Saremi
et al found that severe periodontal disease was a strong predictor of mortality
from both ischemic heart disease and diabetic nephropathy in a Pima Indian
population with type 2 diabetes.9 Likewise, Shultis showed that
severe periodontal disease predicted the development of overt nephropathy and
end stage renal disease, also in the same population with type 2 diabetes.10
The periodontal infection triggers low level inflammation
that leads to increased cytokine production. Researchers have theorized that
this increase may contribute to the total systemic inflammatory burden.15
One cytokine, TNF-is often elevated with periodontal disease and has been
shown to play a role in insulin resistence.6 To substantiate this
theory, studies have looked at the effect of periodontal therapy on glycemic
control. An early study showed that a combination of aggressive non surgical
therapy and an antibiotic regime of systemic doxycycline, 100 mgs for two
weeks, helped control the periodontal infection and reduce the level of
glycated hemoglobin for three months post treatment. By six months, AIC levels
had returned to baseline reading.16 A meta-analysis of 10 studies
that looked at periodontal treatment and glycemic control found that overall
the reduction in A1C to be non significant. The investigators noted that many
confounding effects such as smoking, BMI, and diet, play a role in glycemic
control and this may have had an influence on outcomes.15
(Continued from page 2 )
MANAGING THE PATIENT
WITH DIABETES
A thorough medical history and oral exam are the primary
steps in assessing any individual seeking care. This is critical for screening
individuals who may be undiagnosed or at-risk for diabetes as well as planning
treatment for those with diagnosed diabetes. Knowledge of disease type,
duration, level of control, and complications can help determine appropriate
periodontal therapy and maintenance.17
A good medical history will ask about the signs and symptoms
of undiagnosed diabetes as well as gather information pertinent to the
treatment of someone with diabetes. Oral conditions in an individual with
undiagnosed diabetes can include pronounced edematous gingival enlargement of
unexplained cause, multiple or recurrent periodontal abscesses, rapid bone
destruction, or delayed healing. When these conditions are present with or without
corresponding signs/symptoms noted in the medical history, a medical
consultation may be warranted.17
For those with diagnosed diabetes, it is important to
include information related to disease type, duration, medication type and
frequency of use, use of self-monitoring and frequency, latest A1C tests, and
history of complications in addition to other traditional information gathered
on the medical history.17 The medical history must be updated at
each appointment. Since many individuals with type 2 diabetes may go
undiagnosed for long periods of time, asking about duration of disease in
addition to date of diagnosis can provide more meaningful information since
periodontal complications are associated with disease duration. Type of
medication and frequency of use are critical so that scheduling can be done to
avoid periods when the risk of hypoglycemia is high. In addition to asking
people about glycemic control, copies of the most current A1C test should be
reviewed before a treatment plan is developed since level of control may
influence treatment outcomes.17 Knowledge of complications can help
the dental professional better understand the medical, social, and societal
aspects of living with diabetes.
Treatment
Before providing non-surgical or surgical therapy on an
individual with diabetes or scheduling for a long appointment, a medical
consultation should be considered. It is important for practitioners to have an
A1C reading taken within the last three months and to have a current, chairside
blood glucose reading. The A1C can help predict long-term treatment prognosis
and the current blood glucose reading can help avoid patient emergencies.6,17,18
The most common medical emergency that occurs in people with diabetes is
hypoglycemia. Hypoglycemia generally occurs in those using insulin but can
occur with oral agents. People at the greatest risk for hypoglycemia are the
ones with the lowest A1C (<7%). Symptoms of hypoglycemia can start with
blood glucose readings around 60 mg/dl although as more patients achieve
tighter glucose control, hypoglycemia can occur without symptoms.18
Conscious patients can be treated with 4 ounces of a sugar sweetened beverage
or three glucose tablets. For people that lose consciousness, call for
emergency help. Do not inject insulin, glucagon or try to provide food or
fluids.19 Hypoglycemia can be avoided by reminding individuals to
maintain a normal eating schedule and taking their medication on schedule.
Another preventive measure is to ask patients to bring their glucometer to the
appointment. With a glucometer, testing can take place before dental treatment
begins. In some instances, depending on the blood glucose reading, length of
appointment time, it might be beneficial to provide the patient with an oral
carbohydrate prior to the start of treatment.18
Maintenance
Like anyone treated for periodontal disease, people with
diabetes should have periodontal maintenance visits at close intervals (2 - 3
months).17 In a five-year study, those with good or moderately controlled
diabetes who had regular maintenance visits showed similar percentages of
stable sites as well as those gaining or losing attachment as compared to those
without diabetes.6 Tobacco cessation therapy should continue to be
recommended for those in need.17
Meticulous self-care is important for all individuals with
diabetes. Study results showed adding a water flosser was superior to normal
oral hygiene in reducing the traditional measures of periodontal disease; 44%
more effective at reducing bleeding and 41% more effective at reducing gingival
inflammation. The water flosser also reduced the serum levels of the
pro-inflammatory cytokines IL-1ß and PGE2, as well as the level of reactive
oxygen species.20
All patients, especially patients with diabetes, need some
type of interdental care. Water flossers are clinically proven to be an easier,
more effective alternative to string floss. Three studies with three different
types of tips have compared the water flosser to string floss. In each study,
the water flosser provided superior results over string floss for reducing
gingival bleeding.21,22,23 The Orthodontic Tip was three times more
effective at removing plaque than string floss and five times more effective
than brushing alone.22 Both the jet tip and the plaque seeker tip,
when compared to string floss, have removed plaque similarly, with no
significant differences shown.21,23
Another recent study with the water flosser was undertaken
at the University
of Southern California Center
for Biofilms. The investigators evaluated the effect of a three-second
pulsating (1,200 per minute) lavage at medium pressure on plaque biofilm using
scanning electron microscopy (SEM). The results showed that the water flosser
with the jet tip removed 99.9% and the Orthodontic Tip 99.8% of biofilm. The
researchers concluded that the hydraulic forces produced by the water flosser
with 1,200 pulsations at medium pressure can significantly remove plaque
biofilm from treated areas of tooth surfaces.24
Conclusion
The rise in the number of people with diabetes will be a
challenge to all health care providers, including dental practitioners. In
addition to oral considerations, especially periodontal disease, dental
professionals will be called upon to treat individuals with significant medical
complications and physical limitations. Coordination of care via medical
consultation, treatment needs, frequent maintenance, and evidence-based
self-care can enhance the delivery of care. New information regarding the
treatment of diabetes is available on a daily basis.
References:
- National
Diabetes Fact Sheet. United
States, 2007. Department of Health and Human
Services. Centers for Disease Control and Prevention. Available at http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2007.pdf
Accessed 04-13-10.
- Knowler
WC et al. Diabetes Prevention Program Research Group. Reduction in the
incidence of type 2 diabetes with lifestyle intervention or metformin. N
Engl J Med 2002; 346:393-403.
- Willi
C et al. Active smoking and the risk of type 2 diabetes: A systematic review
and meta-analysis. JAMA 2007; 298:2654-2664.
- American
Diabetes Association position statement: Standards of Medical Care 2010.
Diabetes Care 2010; 33(Suppl 1): S11-S61.
- The
Action to Control Cardiovascular Risk In Diabetes (ACCORD) Study Group. Effects
of intensive glucose lowering in type 2 diabetes. N Eng J Med 2008; 358:2545-2559.
- Mealey
BL et al. Diabetes mellitus and periodontal diseases. J Periodontol 2006;
77:1289-1303.
- The
ADVANCE Collaborative Group. Intensive blood glucose control and vascular outcomes
in patients with type 2 diabetes. N Engl J Med 2008; 358:2560-2572.
- Vernillo
AT. Dental considerations for the treatment of patients with diabetes mellitus.
JADA 2003; 134:24S-32S.
- Saremi
A et al. Periodontal disease and mortality in type 2 diabetes. Diabetes Care
2005; 28(1):27-32.
- Shultis WA
et al. Effect of periodontitis on overt nephropathy and
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- Lalla
E et al. Periodontal changes in children and adolescents with diabetes. Diabetes
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- Fox
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- Taylor
GW et al. Severe periodontitis and risk for poor glycemic control in patients
with non-insulin dependent diabetes mellitus. J Periodontol 1996; 67:1085-1093.
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H et al. Medical status and complications in relation to periodontal disease
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SJ et al. Does periodontal treatment improve glycemic control in diabetic
patients? A meta-analysis of intervention studies. J Dent Res 2005; 84:1154-1159.
- Grossi
S et al. Treatment of periodontal disease in diabetics reduces glycated hemoglobin.
J Periodontol 1997; 68:713-719.
- Rees
TD. Periodontal management of the patient with diabetes mellitus. Periodontology
2000 2000; 23:63-72.
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- American
Diabetes Association: Hypoglycemia. Available at: http://www. diabetes.org/living-with-diabetes/treatment-and-care/blood-glucose-control/
hypoglycemia-low-blood.html Accessed 04-23-10.
- Al-Mubarak S et al. Comparative
evaluation of adjunctive oral irrigation in diabetes. J Clin Periodontol
2002; 29:295-300.
- Barnes
CM. et al. Comparison of irrigation to floss as an adjunct to
toothbrushing: Effect on bleeding, gingivitis, and supragingival plaque. J
Clin Dent 2005; 16(3):71-77.
- Sharma
et al. The effect of a dental water jet with orthodontic tip on plaque and
bleeding in adolescent patients with fixed orthodontic appliances. Am J Orthod
Dentofacial Orthop 2008, 133:565-571.
- Rosema NAM
et al. The effect of different interdental cleaning devices
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- Gorur
A et al. Biofilm removal with a dental water jet. Compend Contin Educ Dent
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