Susan Maples, DDS, discusses the importance of screening for diabetes in a dental practice.
In light of the well-documented impact diabetes mellitus (DM) has on oral disease, and vice versa, our ability to detect DM has become our opportunity as dentists, and perhaps soon, our responsibility! Data from the 2009-2010 National Health and Nutrition Examination Survey revealed that a startling 60% of those with DM had moderate to severe periodontal disease (PD). There is, in fact, a bidirectional relationship between active PD and uncontrolled DM, meaning each makes the other worse! Thus, a dual epidemic is upon us. Sixty to 70% of US adults have active PD. Similarly, DM and its precursor, prediabetes (PDM), together affect one-third of our population. And just like our patients with periodontitis, most DM/PDM patients don’t know it unless they are diagnosed and properly informed.
Q: How can dental professionals help?
A: Unfortunately, 24% of patients with DM and 89% with PDM are undiagnosed. Evidence suggests that periodontal changes are the first clinical manifestation of diabetes.1 The following are some minimum action steps to take.
1. Learn to recognize DM risk factor criteria as well as oral signs of DM, such as gingivitis, periodontitis, xerostomia, dental caries, candidiasis, oral infections, and neurosensory disorders (eg, taste, smell, swallowing interferences, etc). Xerostomia and caries are often missed telltale signs of DM.
2. Acknowledge the bidirectional effects of DM on PD and realize our critical role in helping diabetic patients gain both glycemic control and periodontal stability, simultaneously. When you start to find patients with unidentified or uncontrolled diabetes, you’ll realize why you’ve been unsuccessful in arresting their active PD.
3. Address the root causes of DM and help patients make better decisions around diet (reducing sugar and flour) and increasing body movement (30 min/day, 5 days/week). Influencing lifestyle change might become dentistry’s greatest gift since we touch patients’ lives on such a regular basis at their preventive recall visits. Multiple studies have concluded that intensive lifestyle intervention effectively prevents diabetes progression better than pharmaceuticals.2,3
Q: What is the bidirectional relationship between diabetes and periodontitis?
A: We have valid evidence that diabetes promotes periodontitis through an exaggerated inflammatory response to periodontal microflora.1 Now flip it around: We also have evidence that active periodontitis is a risk factor for poor glycemic control. Thus, for our patients with PD and DM, we must individualize our approach to simultaneously stabilize both.1 If 60% of adults with diabetes better managed their gum disease, the United States would realize a $39 billion savings in healthcare costs.4
Q: How did the DM epidemic get this bad?
A: Most know that type 2 DM (T2DM) stems from problems controlling blood sugar, which is primarily a cascading effect from overexposure to sugar itself. Our bodies do one of 2 things with sugar: use it as an immediate energy source or store it (as fat) for another time. When we eat or drink foods high in sugar and/or flour, we trigger an insulin spike to aid our cells in sugar uptake. With repetitive sugar spikes and insulin pump activity, we become resistant to insulin and the pump becomes overactive. We develop a condition called insulin resistance, which is considered both inflammatory and progressive. Eventually, our pancreases’ beta cells (insulin manufacturers) burn out. And voilà: T2DM.
Q: When should you perform an HbA1c test?
A: To identify patients with unknown (and uncontrolled) DM before periodontal therapy, consider the known risk factors: being overweight/obese, family history, being over age 45, race (African Americans, Alaskans, American Indians, Arabs, Hispanics, and Native Pacific Islanders), hypertension, hypercholesterolemia, and being inactive.3
Some symptoms of unstable DM are tingling, pain, or numbness in hands/feet; unexplainable hunger; excessive thirst; frequent urination; blurred vision; cataracts; glaucoma; bleeding gums; and tooth loss. If your patient has 3 risk factors or is overweight/obese and has at least one other risk factor or symptom, consider a Hemoglobin A1c (HbA1c) test.5
Q: What will you do with HbA1c test results?
A: The HbA1c test is a simple blood test that measures circulating blood sugar over an average of the past 2 to 3 months. In the United States, the FDA still doesn’t recognize point-of-care testing for A1c as “diagnostic,” so elevated A1c levels, indicative of PDM and DM, should be shared with your patients’ medical team, along with his or her risk factor criteria. You must collaborate with your medical colleagues for a definitive diagnosis and any necessary pharmacologic treatment. Not so incidentally, you may have noticed that the ADA, along with major dental insurance carriers, have established a code (0411) for HbA1c testing in the dental office.6
Q: What can we do differently?
A: Get comfortable completing a quick finger stick A1c blood test for prediagnostic data. Routinely monitor HbA1c on periodontal maintenance patients who also have DM. Conveniently, periodontal maintenance prophys are generally done every 3 months; that’s the same time interval recommended for A1c monitoring. Work collaboratively with your medical colleagues for pharmacologic assistance in gaining glycemic control and preventing DM progression. Develop a current and evidence-based protocol for full-mouth periodontal disinfection for the unstable diabetic—one that includes saliva testing for pathogen identification. Learn better facilitation skills for helping patients create lasting lifestyle behavior changes for health.
While you are saving lives and saving teeth, you will soon be recognized as a practice of distinction around total health dentistry and begin to draw health-seeking patients from far and wide.
References
1. Lamster IB, Lalla E, Borgnakke WS, et al. The relationship between oral health and diabetes mellitus. J Am Dent Assoc. 2008;139(suppl):19S-24S.
2. Ramachandran A, Snehalatha C, Mary S, et al; Indian Diabetes Prevention Programme (IDPP). The Indian Diabetes Prevention Programme shows that lifestyle modification and metformin prevent type 2 diabetes in Asian Indian subjects with impaired glucose tolerance (IDPP-1). Diabetologia. 2006;49:289-297.
3. Classification and diagnosis of diabetes: Standards of medical care in diabetes—2018. Diabetes Care. 2018;41(suppl 1):S13-S27.
4. Jeffcoat M. The Mouth: The Missing Piece to Overall Wellness and Lower Medical Costs [whitepaper]. Harrisburg, PA: United Concordia Dental; 2014.
5. Maples S, Aldasouqi S, Little R et al. Detection of undiagnosed prediabetes and diabetes in dental patients: a proposal of a dental-office friendly screening tool. Journal of Diabetes Mellitus. 2016;6:25-37
6. Lalla E, Kunzel C, Burkett S, et al. Identification of unrecognized diabetes and pre-diabetes in a dental setting. J Dent Res. 2011;90:855-860.
Dr. Maples is a practicing dentist and health educator/speaker from Holt, Mich. She can be reached at susan@drsusanmaples.com.
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