The Dynamic Duo

How dental hygienists and diabetes educators can form a formidable team

by Lauren Ann Gueits, RDH, and Donna L. Jornsay, BSN, RN, CPNP, CDE

November is Diabetes Awareness Month! Who better to bridge the existing gap between the medical and

Donna Jornsay, left, and Lauren Ann Gueitsdental communities than the RDH and CDE (certified diabetes educator) or, as I like to say, “The Dynamic Duo?”

I want to share with dental hygiene colleagues the power of collaborating with our “other colleagues,” certified diabetes educators (CDEs). I had the privilege of presenting “Healthy Mouth, Healthy Body: The Link between Periodontal Disease, Diabetes and other Systemic Diseases,” at the American Association of Diabetes Educators (AADE) national meeting this past August in Las Vegas. This was the first AADE seminar ever presented by a dental professional.

My co-presenters were Donna Jornsay, RN, CPNP, CDE, and Maria Emanuel Ryan, DDS, PhD. (Dr. Ryan, my mentor, was the first dental professional to speak about oral health at the American Diabetes Association annual meeting in 2008.) It was an incredibly rewarding professional experience and truly a wake-up call for interdisciplinary collaboration between medicine, dentistry, and education. Despite both dental hygienists and CDEs each addressing their patients’ educational needs according to their expertise, the lack of collaboration between these two health-care occupations is not allowing either one to fully appreciate the scope of the problem. Here is an e-mail from Beth Mitchell, RD, CDE, in Columbus, Ohio, who attended the presentation at the conference:

“I found the talk alarmingly informative. As educators, we tend to brush over the importance of dental health and its role in diabetes care. After the talk, I called my husband (who has diabetes) and said, ‘You have to schedule your appointment with the dentist this week!’ He has diabetes and heart disease, and I explained the correlation. As an educator, I will be spending more time on the importance of oral health and diabetes care. Thank you for your expertise and enthusiasm.”

The AADE meeting occurred just one week after attending the RDH Under One Roof conference in Chicago. I felt empowered, renewed, and proud to represent our dental hygiene community among CDEs. When I was walking through the exhibition floor, it certainly did not feel like Kansas anymore! The companies were foreign, the faces unfamiliar; however, the meeting’s slogan that was visible everywhere, “Advancing Minds that Care,” felt like home to me.

What other health-care professionals truly care about their patients as much as dental hygienists? Well, I feel like I met our match — our “sister professionals” in diabetes educators.

Both professionals spend an extraordinary amount of one-on-one time with patients compared with the time spent by the doctors. Both thrive on patient adherence, and both genuinely care about their patients’ overall health and well-being. Subsequently, both professionals are valued, trusted, and respected by patients.

I am only half of the “Dynamic Duo.” I would like to share Donna Jornsay’s input of her experience with our collaboration. Donna states:

“I first met Lauren Gueits, RDH, when she volunteered to speak to one of the diabetes patient support groups I facilitate. Lauren gave a stirring talk to the group and presented some very impressive data on the systemic links between diabetes, periodontal disease, and heart disease. Having been a CDE since the inception of the certification, I was astounded that the information she presented was data I had never before seen. I knew that many of my CDE colleagues were also unaware of these statistics. I knew then that Lauren and I needed to collaborate and make an impact on our local health community and somehow further disseminate this knowledge to our professional colleagues as well.”

Donna also added: “On a personal note, being that I have type 1 diabetes, I made it a priority to see Lauren for my ‘cleaning’ shortly after her lecture. I did indeed need nonsurgical periodontal therapy. I now routinely go for my periodontal maintenance visits (as Lauren informed me, a ‘cleaning’ to hygienists is as taboo as being called ‘diabetic’ for people with diabetes) every three months and consider myself a ‘born again’ hygiene patient. I am borderline obsessed with using those SoftPicks dipped in Listerine and use Colgate Total with a power toothbrush at least twice a day. I like knowing that I have 12-hour protection against the 700 species of bacteria in my mouth! (See, Lauren, I heard you — loud and clear!) Xylitol five times a day has been an easy edition to my regimen since I already used sugar substitutes. The best part is my A1C dropped 0.8% as a result of having my teeth cleaned, helping me achieve even better glycemic control! This is a great anecdote that I share with my patients.”

I was truly inspired by Donna’s enthusiasm and willingness to “spread the gospel” and take our message to the next level. Working with a diabetes educator as caring and professional as Donna has been a blessing.

Donna invited me to participate in her “Nurse Champion Program” that she developed for Long Island Jewish Medical Center. My role was to educate the nurses on the importance of oral health/education and why it needs to be implemented in the daily care regimen for patients with diabetes.

If dental hygienists around the country collaborated with CDEs in their area, the epidemic rates of prediabetes and undiagnosed diabetes could be decreased, and the depressingly prevalent rate of heart disease and diabetes complications could be reduced. There is a heavy burden on health-care professionals today regarding the recognition, treatment, and proactive management of a disease that has reached epidemic proportions worldwide.

We need to work together; our patients are depending on us!

The facts about diabetes

The Centers for Disease Control and Prevention included these statistics in its 2011 National Diabetes Fact Sheet.¹ Diabetes affects 25.8 million people (8.3% of the U.S. population); 18.8 million have been diagnosed with the disease; 7 million are undiagnosed; and an estimated 79 million American adults aged 20 years or older are classified with prediabetes:

Among U.S. residents aged 65 years and older, 10.9 million, or 26.9%, had diabetes in 2010.
About 215,000 people younger than 20 years had diabetes (type 1 or type 2) in the United States in 2010.
About 1.9 million people aged 20 years or older were newly diagnosed with diabetes in 2010 in the United States.
During 2005–2008, based on fasting glucose or hemoglobin A1C levels, 35% of U.S. adults aged 20 years or older had prediabetes (50% of adults aged 65 years or older). Applying this percentage to the entire U.S. population in 2010 yields an estimated 79 million American adults aged 20 years or older with prediabetes.
Diabetes is the leading cause of kidney failure, non-traumatic lower-limb amputations, and new cases of blindness among adults in the United States.
Diabetes is a major cause of heart disease and stroke.
Diabetes is the seventh leading cause of death in the United States.

Researchers presenting at an International Association of Dental Research noted that patients with diabetes cost insurance companies $2,484 more per year if they don’t receive routine dental care and immediate treatment for periodontitis.²

The American Academy of Periodontology’s (AAP) 2020 Vision Statement marked the beginning of the need for interdisciplinary collaboration between dentistry and medicine. Some of the highlights from that statement include:

Periodontists will treat patients with periodontal conditions related to systemic health.
Dental professionals will see an increase in referrals of patients with systemic considerations.
Dental professionals will collaborate more with medicine in patient care and research.
Medical protocols will include periodontal evaluation and management by periodontists.

Additionally, former Surgeon General Dr. David Satcher stated in the 2000 Surgeon General Report, Oral Health in America, “A framework for action that integrates oral health into overall health is critical if we are to see further gains.”3 Former Surgeon General Dr. C. Everett Koop added, “You are not healthy without good oral health.”4 Medical and dental professionals were finally called upon to work collaboratively. Recently, we were challenged again last July when the AAP released a statement on Comprehensive Periodontal Therapy.⁵ This new 2011 challenge from the AAP included these recommendations for interdisciplinary collaboration:

Establishing a diagnosis, prognosis, and treatment plan should include medical and dental consultation or referral for treatment when appropriate; and consideration of risk factors including diabetes and smoking, which play a role in development, progression, and management of periodontal diseases.
Evaluation of therapy should include professional management of those risk factors associated with development and/or progression of periodontal diseases including smoking and diabetes.

Almost 12 years after the initial push, how are we doing? We are continually being challenged to “raise the bar” and become part of our patients’ health-care team. The modern RDH is truly an acronym for “Really Delivering Healthcare.” By implementing risk factor assessment and proper referrals to the appropriate professionals for those patients who present poor or delayed healing responses to nonsurgical periodontal therapy, we are entrenching ourselves into our patients’ health-care team.

We can finally rid ourselves of being the “tooth cleaner,” and to female dental hygienists, we can finally say, “Bye-bye, cleaning lady!”

A RARE opportunity

At the AADE national conference, I called upon our sister colleagues to become “RARE” health-care professionals:

Recognize periodontal disease as a chronic inflammatory disease that has systemic ramifications
Assume that your patient with diabetes is at risk for periodontal disease. (Dr. Loe recognized periodontitis as the sixth complication of diabetes.)12
Refer for periodontal screening.
Educate your patients on the importance of oral health and regular dental visits.

I now call upon my fellow “periodontal therapists” to become “RARE” health-care professionals as well:

Recognize diabetes and periodontal disease is a two-way street.
Assess risk factors for diabetes and inquire about A1C levels.
Refer for medical evaluation and A1C testing when applicable.
Educate your patients on the importance of oral health as it relates to overall health.

Like periodontal disease, the best way to treat diabetes is to prevent it. In many patients, the early symptoms of diabetes can go undetected for years.

It is the responsibility of both medical and dental professionals to become part of bilateral risk assessment for the betterment of our patients’ health and well-being.

Dr. Maria Emanuel Ryan presented case studies where A1C levels where reduced between 1% and 2% as a result of nonsurgical periodontal therapy utilizing submicrobial dosage of doxycycline.9,10

What is the value of A1C reductions?

A 1% reduction in A1C can reduce the risk of all diabetes-related deaths by 25%, as well as significantly reducing other diabetic complications.13,14 In addition, it could be the “tipping point” between diabetes, prediabetes, or a healthy diagnosis.

This is incredible! Isn’t it plausible then, that by treating our patients comprehensively, we can prevent diabetes, maintain glycemic control, decrease life-threatening complications, and even save our patients’ lives? Now that is truly taking our patients’ oral health to heart!

The American Diabetes Association also emphasizes that a 1% drop in A1C:

Reduces the risk of nerve damage, vision loss, and kidney disease by 35%
Reduces the risk of peripheral vascular disease by 22%
Reduces the risk of myocardial infarction by 18%

After the AADE conference, The Wall Street Journal published an article titled, “Dental Exams May Help Diagnose Diabetes,” in its Aug. 9 issue.

Ah, the power of one voice. Please join me in our crusade to take our profession to the next level by “Really Delivering Healthcare.” Team up and become a “Dynamic Duo” with a CDE in your area. The American Association of Diabetes Educators (www.diabeteseducator.org) publishes a list of local CDEs by zip code. Not only will you feel empowered to take your career to the next level, you will potentially save lives and become part of the solution for this country’s epidemic diabetes crisis.

I would like to extend my gratitude to Colgate–Palmolive and Fotinos S. Panagakos, DMD, PhD, director of clinical research relations and strategy, for having faith in my ideas, courage to think “outside the box,” and believing in the concept of “educating the educators.” With the support of Colgate, I was able to provide numerous groundbreaking presentations to the medical community. The nurses, diabetes educators, physicians, dieticians, and pharmacists that I have encountered are all onboard to bridge this current gap and embrace us as an integral part of the health-care team.

Author’s Note: This article is in loving memory of my father, John Mauro Calabrese, who passed away at 59 from diabetes complications. He has been the driving force behind my efforts. Somehow I know he is with me for the journey.

Lauren Gueits, RDH, is president and founder of Healthy Smile Consultants, which specializes in continuing education, practice management, and community health as it relates to the oral/systemic link. She has raised the importance of oral health as it relates to diabetes and other systemic disease nationally after appearing on WABC, WB11, and WNBC. Lauren still has a passion for patient care working as a “periodontal therapist” in Dr. Jonathan Richter’s periodontics/prosthodontics office in Great Neck, N.Y., since 1993. Recently, she joined Dr. Laura Torrado’s office in New York City as clinical hygiene coordinator as well as becoming clinical practice manager for Dr. Daniel Noor of Smile Café in New York City. Lauren received her dental hygiene degree from SUNY Farmingdale in 1991, and is an ADHA member. Lauren is also a member of the American Academy For Oral Systemic Health. She is a recipient of the 2010 Sunstar/RDH Award of Distinction and is founder of “Smiling Heart Associates,” a pilot group of collaborating medical/dental specialists in the New York metropolitan region. She can be contacted at [email protected]

Donna Jornsay, BSN, RN, CPNP, CDE, received her associate’s degree in nursing from the State University of New York at Upstate Medical Center where she went on to receive her certificate as a pediatric nurse practitioner. She completed her bachelor’s degree in nursing at the University of the State of New York in 1983. Donna has worked as a diabetes nurse educator and nurse practitioner for the past 30 years, and has held positions in pediatrics, adult medicine and high risk obstetrics. She has been a clinician in areas of direct patient care, as well as a clinical supervisor of pediatric nurse practitioners. She has also been the clinical coordinator of several university based diabetes and pregnancy programs. Donna has also worked in the diabetes industry, as a clinical scientific liaison for Abbott Diabetes Care, and as a clinical nurse specialist for Medtronic Diabetes. In these roles, she gained research and development experience, sales experience, and patient training and management experience with continuous glucose monitoring and insulin pump therapy. Currently, Donna works as a diabetes clinical specialist at Long Island Jewish Medical Center where she is responsible for inpatient diabetes education, staff development, and quality improvements in the care of patients with diabetes.

References

1. CDC: 2011 National Diabetes Fact Sheet: http://www.cdc.gov/diabetes/pubs/pdf/ndfs_2011.pdf
2. www.perio.org/consumer/cdc-research.htm
3. U.S. Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000.
4. Koop CE. Oral Health 2000. Second National Consortium Advance Program, 2, 1993.
5. Comprehensive Periodontal Therapy: A Statement by the American Academy of Periodontology. J Periodontol 2011;82:943-946.
6. Grossi SG, Genco RJ. Periodontal Disease and Diabetes Mellitus: A Two-Way Relationship. Ann Periodontal 1998;3:51-61.
7. Southerland JH,Taylor GW, Offenbacher S. Diabetes and Periodontal Infection: Making the Connection. Clinical Diabetes 2005;23:171-178.
8. National Institute of Dental and Craniofacial Research. Looking at the Periodontal-Systemic Disease Connection: 2005 www.nidcr.nih.gov/Research/ResearchResults/InterviewsOHR/TIS072005.
9. Al-Ghazi, MN, Ciancio SG, Aljada A, et al. Evaluation of Efficacy of Administration of Sub-antimicrobial-dose Doxycyline in the Treatment of Generalized Adult Periodontitis in Diabetics. J Dent Res 2006;82(Spec Iss A) (abstract).
10. Engebretson SP, Hey-Hadavi J, Celenti R, Lamster, IB. Low-dose Doxycyline Treatment Reduces Glycosylated Hemoglobin in Patients with Type 2 Diabetes: A Randomized Controlled Trial. J Dent Res 82(Spec Iss A)(abstract) no. 1445.2003.
11. American Diabetes Association: Standards of Medical Care in Diabetes 2010 Position Paper http://care.diabetesjournals.org/content/33/Supplement_1/S11.full.pdf+html
12. Loe H. Periodontal Disease: the sixth complication of diabetes mellitus. Diabetes Care 1993;16(1):329-34.
13. American Diabetes Association. “Standards of Medical Care in Diabetes.” Diabetes Care: Jan, 2005.
14. “Implications of the United Kingdom Prospective Diabetes Study,” Diabetes Care 2002. UK Prospective Diabetes Study Group. “UKPDS 59: Hyperglycemia and Other Potential Factors for Peripheral Vascular Disease in Type 2 Diabetes” Diabetes Care, May 2002.

The relationship between diabetes and periodontal disease is a two-way street!

People with diabetes are at greater risk for developing infections6,7
Periodontal disease (chronic infection) can impair diabetes control6,7
More definitive link than cardiovascular disease, osteoporosis, preterm, low birth-weight infants8
Management of periodontitis can result in significant reduction in A1C9,10

A1C is a blood test that measures the weighted, average glucose level over a two to three month period, which is the life cycle of the red blood cell. It is the standard for assessing glucose control for patients with diabetes and, as of February 2010, is an acceptable test to be used for diagnosis of diabetes.

The accepted diagnosis guidelines for the American Diabetes Association follows these parameters for A1C: