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  

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  

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:

1. 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.
2. 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.
3. Willi C et al. Active smoking and the risk of type 2 diabetes: A systematic review and meta-analysis. JAMA 2007; 298:2654-2664.
4. American Diabetes Association position statement: Standards of Medical Care 2010. Diabetes Care 2010; 33(Suppl 1): S11-S61.
5. 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.
6. Mealey BL et al. Diabetes mellitus and periodontal diseases. J Periodontol 2006; 77:1289-1303.
7. 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.
8. Vernillo AT. Dental considerations for the treatment of patients with diabetes mellitus. JADA 2003; 134:24S-32S.
9. Saremi A et al. Periodontal disease and mortality in type 2 diabetes. Diabetes Care 2005; 28(1):27-32.
10. Shultis WA et al. Effect of periodontitis on overt nephropathy and end-stage renal disease in type 2 diabetes. Diabetes Care 2007; 30(2):306-311.
11. Lalla E et al. Periodontal changes in children and adolescents with diabetes. Diabetes Care 2006; 29:295-299.
12. Fox PC. Xerostomia: Recognition and management. Access. Special supplementary issue; Feb 2008:1-7.
13. 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.
14. Thorstensson H et al. Medical status and complications in relation to periodontal disease experience in insulin-dependent diabetics. J Clin Periodontal 1996; 23:194-202.
15. Janket 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.
16. Grossi S et al. Treatment of periodontal disease in diabetics reduces glycated hemoglobin. J Periodontol 1997; 68:713-719.
17. Rees TD. Periodontal management of the patient with diabetes mellitus. Periodontology 2000 2000; 23:63-72.
18. Mealey BL. Managing patients with diabetes: First, do no harm. J Periodontol 2007; 78:2072-2076.
19. 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.
20. Al-Mubarak S et al. Comparative evaluation of adjunctive oral irrigation in diabetes. J Clin Periodontol 2002; 29:295-300.
21. 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.
22. 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.
23. Rosema NAM et al. The effect of different interdental cleaning devices on clinical parameters. Presented at IADR, Barcelona, Spain. July 17, 2010. Abstract #3797.
24. Gorur A et al. Biofilm removal with a dental water jet. Compend Contin Educ Dent 2009; 30 (Suppl 1):1-6.