The Perio-Systemic Link

by Carol Jahn, RDH, MS

More than 18 million people in the United States have diabetes. It is estimated that one-third to one-half of these individuals are undiagnosed. The majority (90 to 95 percent) of people living with diabetes have Type 2, previously known as either adult-onset or non-insulin-dependent diabetes.¹ Worldwide, the number of people with diabetes is expected to double by the year 2030.² Currently, in a dental practice with 2,000 patients, a dental hygienist can expect to see about three patients per week with diabetes.³ Dental hygienists who treat patients in nursing homes or public health settings may see even larger numbers of individuals with diabetes. This occurs because diabetes is more prevalent in people over the age of 65 and in African American, Hispanic and Latino populations.¹

Facts versus myths

Several advancements have been made over the years in the diagnosis and treatment of individuals living with diabetes. Some of these changes may have a direct impact on how dental professionals manage those with diabetes. Therefore, as diabetes becomes more prevalent, it is wise for dental hygienists to assess the relevancy of their treatment protocols for those with diabetes. In many cases, some of the old rules still apply, but there are more contingencies and exceptions to these rules than previously.

One common mistake that some professionals make is the belief that medication is a good distinguishing characteristic for differentiating diabetes type. In the past, it was believed that only people with Type 1 took insulin. Today, while it is still true that individuals with Type 1 must take insulin, it is becoming more common for those with Type 2 to take insulin along with an oral hypoglycemic agent. This is necessary because some individuals with Type 2 diabetes may over time have decreased insulin production.⁴

Another protocol that is changing somewhat is the concept that individuals with diabetes need an early morning appointment. Today, dental practitioners should avoid periods of peak insulin action.⁵ When insulin peaks, the risk for a hypoglycemic episode increases.⁶ The new goal for individuals with diabetes is to have "tight control" to maintain optimal glycemic control. This means they may have more frequent injections or use an insulin pump. Because of this, the number of peak insulin activity periods may increase, raising the risk for hypoglycemia.^4,6 Therefore, it is important to ask the person with diabetes what time is best for them to avoid this situation. For many, this time may still be early morning; but for some it may be after lunch.

A new term that may sound outdated is "prediabetes." Years ago, people would report that they had "a touch of sugar diabetes," they were "borderline," or in a "pre" diabetes state. With a change in diagnostic criteria, the threshold number for diagnosis was lowered; more people were diagnosed with diabetes and many of the aforementioned terms were discarded.

In 2002, the American Diabetes Association developed the classification "prediabetes" to identify individuals with impaired glucose tolerance. Prediabetes now means any individual with a fasting glucose level between 100-120. An April 2004 government study estimates that prediabetes affects 41 million people in the United States. Research indicates that those with prediabetes are likely to develop Type 2 diabetes within 10 years. Importantly, the study also showed that people with this condition could reduce their risk and thereby delay or prevent the onset of Type 2 diabetes by decreasing their weight by 5 to 7 percent and getting 20 to 30 minutes of exercise per day.⁷

When providing treatment for patients with diabetes, it is important to know how well controlled the diabetes is. In the past, many dental professionals asked for blood glucose levels. This is important because it provides the dental professional with information about how that person is doing at that exact moment in time. Because self-monitoring is recommended for most individuals with diabetes via home glucometers, anyone with diabetes can bring their device and testing can be done in-office.⁵ This is wise because it can help prevent an emergency by identifying those who might become hypoglycemic.

However, blood glucose does not provide an accurate picture of the overall control of the individual with diabetes. That measure is attained through glycated hemoglobin testing, often referred to as the HbA1c or simply the A1c. This test is routinely performed on all individuals with diabetes and reflects a mean level of glycemic control over a two to three month period. The American Diabetes Association recommends that the A1c level be less than 7 percent.⁸ Knowledge of an individual's A1c level can help the dental professional assess the long-term effectiveness of periodontal therapy.

Lastly, many believe that any individual with diabetes may benefit from being premedicated.

However, the routine premedication of people with diabetes is not warranted. Those with diabetes are not at greater risk for infective endocarditis. Some individuals with diabetes may need an antibiotic prior to or after certain procedures. Another indication for antibiotic use may be a compromised immune system or to limit or prevent secondary infections.⁵

The perio-diabetes link

It is well established that having diabetes is a risk factor for periodontal disease. This risk is independent of diabetes type. The strongest association appears to occur in individuals with poor glycemic control as it has been demonstrated that those with poor control have the most severe disease. An increased incidence of periodontal disease also may be found in those living with the disease for a long period of time. It has also been shown that children with diabetes are more likely to have gingivitis than their counterparts without diabetes, even when both groups have the same level of plaque control. Therefore, it appears that in the presence of diabetes, periodontal disease may develop sooner.⁵

Recently, the question surrounding the link between diabetes and periodontal disease concerns the role periodontal disease plays in diabetes control and/or severity. Taylor and co-workers found that people who had severe periodontal disease were four times more likely to have poor glycemic control.⁹ Thorstensson et al. studied people with both severe periodontal disease and diabetes and found that those that had severe periodontal disease had more renal disease and cardiovascular complications, including stroke, transient ischemic attacks (TIA), angina, myocardial infarction, and intermittent claudication than people with diabetes and little or no periodontal disease.¹⁰

The bi-directional relationship between periodontal disease and diabetes has led researchers to study what impact treating the periodontal infection has on metabolic control. In a landmark study by Grossi and co-workers, 113 Native Americans of the Pima heritage with severe periodontal disease and uncontrolled Type 2 diabetes were treated with ultrasonic bacterial curettage and either systemic doxycycline (100mgs) or a placebo for 14 days. While all groups improved in relationship to plaque, gingivitis, and probing depth scores at three months, the doxycycline groups had a reduction in glycated hemoglobin, currently called A1c. However, the reduction was short-term. At six months, A1c levels had returned to baseline measure.¹¹

A few other studies have shown some impact on the glycated hemoglobin as well, but sample sizes were too small to make generalizations to the entire population of those living with diabetes. Most researchers concur that while improvement of metabolic control is possible, its clinical significance is debatable and long-term studies are needed to clarify the effect of periodontal therapy on glycemic control.¹²

Periodontal management

Regardless of the impact on metabolic control, elimination of the periodontal infection is an important step in helping control/arrest periodontal disease. In most instances, those with good glycemic control will respond to periodontal therapy, surgical or non-surgical, similarly to other healthy individuals. Unfortunately, for those with poor or uncontrolled diabetes, while there may be some initial improvement in clinical parameters, there is often a rapid recurrence of deep pockets leading to a less favorable long-term response. Regular maintenance visits are extremely important for anyone with diabetes, regardless of glycemic control.^5,12

Individuals with diabetes need to practice regular, meticulous self-care. To assist individuals with plaque control, power toothbrushes are often the first recommendation that many professionals make. In concordance with this is the directive to floss or use some type of interdental aid. Oral irrigation is often a last thought. However, only home irrigation has been clinically tested and found safe and effective on individuals with diabetes. When home irrigation was added to routine brushing and flossing, individuals with diabetes had better reductions in the traditional periodontal parameters, gingivitis and bleeding compared to those who only brushed and flossed. Importantly, the group that added irrigation also had better reductions in systemic parameters including inflammatory mediators (cytokines) and reactive oxygen species (free oxygen radicals).¹³

Tobacco cessation is crucial for anyone with diabetes, especially those with periodontal disease. The position of the American Diabetes Association is that any person living with diabetes should be assessed for smoking status and history and advised to stop smoking. The organization also advocates including smoking cessation counseling as a component of routine diabetes care.¹⁴

This position fits well with a recent initiative by the American Dental Hygienists' Association to increase smoking cessation efforts of dental hygienists. The program, "Ask, Advise, Refer," simplifies the cessation process by having dental hygienists ask about tobacco usage, advise quitting, and refer to a state or national quit line. Quit lines have been developed in the past few years by more than 30 states and have been effective in helping people stop using tobacco products.^15,16

From the growing prevalence of diabetes and the relationship between diabetes and periodontal disease, it can be inferred that dental hygienists are going to be treating more individuals with diabetes and periodontal disease. As the dental profession seeks to strengthen the link between periodontal disease and systemic disease, such as cardiovascular disease and/or pre-term birth, it is important to not lose sight of the fact that evidence currently exists that provides a strong link between diabetes and periodontal disease. Dental hygienists have the opportunity to play an important role in the quality of life of those with diabetes.

Statistics from the National Institute for Diabetes and Digestive and Kidney Diseases indicate that approximately two-thirds of U.S. adults are overweight. It is estimated that 70 percent of the risks for diabetes in the United States is attributed to excess weight. More alarming, in 2000, more than 15 percent of children and adolescents were identified as overweight.¹⁷ This increase in overweight and obesity is leading to a rise of epidemic proportions in the diagnosis of Type 2 diabetes. Previously, Type 2 diabetes was most often diagnosed after the age of 40 with the highest prevalence in the over-60 age group. Today, Type 2 is being diagnosed at an earlier age in many people, and even afflicts children and adolescents.¹

The rise in diabetes will affect all health care practitioners including dental professionals. Since diabetes is a risk factor for periodontal disease, the current rise in diabetes could conceivably result in a rise in periodontal disease in the next several years. Additionally, dental hygienists will need to be prepared to treat more medically compromised individuals as diabetic complications may result in kidney failure, blindness, amputations, heart disease, and stroke.¹ These complications can lead to significant disability that may limit earning potential.¹⁸ Both an inability to travel to a dental office and/or lack of insurance or ability to pay may present significant health care problems.

Currently, 18 percent of home health visits are attributed to diabetes. Similarly, 15 percent of nursing home services and 14 percent of hospice care are attributed to diabetes.¹⁸

How dental hygienists will adapt to treating a growing number of individuals certain to have oral health maladies but unable to be treated in a traditional dental office setting is an important consideration. Some are already preparing for this challenge by obtaining collaborative practice agreements or limited access permits in states that allow this type of practice. These types of arrangements provide greater access to care by enabling dental hygienists to provide care without the prior authorization or supervision of a dentist in settings such as nursing homes. Additionally, approximately 10 states recognize dental hygienists as Medicaid providers.

• American Diabetes Association — www.diabetes.org

• National DiaÏbetes Education Program — www.ndep.nih.gov

• Centers for Disease Control — www.cdc.gov

• National Institute for Diabetes and Digestive and Kidney Diseases — www.niddk.nih.gov

Carol Jahn, RDH, MS is the educational programs manager for Waterpik Technologies where she designs multimedia educational programs for dental professionals. She provides continuing education programs in the areas of periodontics, patient compliance, and diabetes. Carol may be reached by phone at (800) 525-2020 or by e-mail at cjahn@waterpik .com.