Down a rabbit hole

July 1, 2005
Like Alice’s experiences in the classic tale Alice’s Adventures in Wonderland, I also recently went down a rabbit hole and entered the new and exciting world of oral medicine.

Like Alice’s experiences in the classic tale Alice’s Adventures in Wonderland, I also recently went down a rabbit hole and entered the new and exciting world of oral medicine. This is how my adventure began.

In May 2004, I met Dr. Frank Varone, a small-town dentist from Nebraska who manages anything but a typical small-town dental practice. Frank has special training in diabetes management, and he cares deeply about the overall health of his clients. With the tremendous increase of diabetes in the United States, Frank is committed to working closely with health-care professionals in his community to improve the quality of life for people with type 1 and type 2 diabetes. He encouraged me to learn more about diabetes, and informed me about a May 2005 diabetes conference sponsored by the Centers for Disease Control and Prevention (CDC). The CDC requested abstracts on diabetes research including oral health. At Frank’s urging, I submitted an abstract for a pilot study on developing a brief risk assessment quiz for health-care practitioners to use to determine periodontal disease susceptibility in clients with type 1 and 2 diabetes who have poor glycemic control (hyperglycemia). Never in my wildest dreams did I imagine that I would receive an invitation from the CDC asking me to present my research findings!

To prepare for this study, I made several important decisions. First, I included as co-investigator my good friend Cheryl Thomas, RDH, who has expertise working with immunocompromised individuals. Cher and I knew, based on 25 years of clinical research, that adults with type 1 and type 2 diabetes and poor glycemic control are at high risk for gingivitis and periodontitis. Individuals with hyperglycemia (higher than normal blood glucose for several years) experience long-term systemic complications such as kidney disease, eye disease, hypertension, and nerve disease. High blood glucose levels increase the risk of coronary artery disease (CAD) in people with type 2 diabetes, and CAD is the most common cause of death in type 2 individuals. People with diabetes suffer from depression at a rate about two to four times higher than the general population. Lack of interest in home care recommendations may be due to poor glycemic control, depression, and lethargy.

Why are individuals with type 1 and type 2 diabetes and poor glycemic control at high risk for gingival and periodontal disease?

Researchers are continually testing theories to answer this question, but to date, the pathogenesis of periodontal disease in diabetes remains unclear. It is possible that a higher concentration of glucose in the oral cavity promotes the growth of periodontal pathogens, or that the excessive glucose creates a hyper-inflammatory state which triggers soft tissue and bone loss.

While preparing for the CDC presentation, I attended a Diabetes Expo in the Atlanta area, a huge interactive health fair with “one-stop shopping” for everything related to diabetes and healthy living. When I telephoned the Georgia Diabetes Association to confirm my attendance, an Association representative asked me to develop a convention exhibit. She said there were no dental exhibitors for the Expo, so I decided to accept the challenge.

My convention exhibit was not exactly the type that draws people like moths to a flame, but I would have a wonderful opportunity to interact with health-care providers and people with diabetes.

The highlight of the show was a preview of a new television documentary called The Debilitator. The 30-minute film features an African-American family that experiences the impact of diabetes and its complications. The purpose of the health education docudrama is to help the audience understand the importance of diabetes testing, especially when symptoms are not present.

At the Atlanta Diabetes Expo, I administered a simple, six-question quiz to adults with type 1 and type 2 diabetes. The purpose of the quiz was to determine a person’s risk of developing periodontal disease. About 50 adults with type 1 or 2 diabetes participated, and the results were fairly dramatic. Almost 50 percent indicated that their diabetes was poorly controlled and that their gums bled. Here are some other comments I noted when I spoke about the high risk of periodontal disease associated with poor glycemic control:

• “Can I have implants?”

• “I already know I have gum disease. I see a periodontist.”

• “I already know my gums are bad. I have had. . . what do you call it?” (after questioning them, it turns out that they have already had deep cleanings ... that’s what people like to call SRP.)

• “I don’t have dental insurance. How can I get my teeth cleaned?”

• “I didn’t know anything about this.”

• “What kind of mouthwash can I use? Can I use Listerine?”

One man amused me. When I asked if he was aware of his risk for developing gum disease, he replied that he was well aware of the risk. Then he opened his mouth and popped out a lower full denture to prove it!

After Cher and I completed our research and PowerPoint presentation for the CDC conference, we were on our way to Miami. We were a bit nervous, but excited by the prospect of attending the various diabetes exhibits and lectures.

We also spent some time with a fascinating certified diabetes educator named Cynthia Stegeman, who was scheduled to present a paper on blood glucose monitoring in dental practice. From 2002-2004, Cyndee, a dental hygiene faculty member at the University of Cincinnati dental hygiene program, monitored blood glucose levels in clients with diabetes who presented for treatment at the University of Cincinnati dental hygiene clinic. Out of 170 clients with diabetes, 20 percent needed intervention before being treated and presented with either hyper- or hypoglycemia.

So what’s the clinical significance of research pertaining to poor glycemic control? If you perform scaling and root planing on a client with poorly controlled diabetes, or on a client with diabetes who has not yet been diagnosed, long-term results from your efforts to control the periodontal infection will be poor. After 12 months or so following non-surgical periodontal therapy, the client’s therapeutic outcome from scaling and root planing will be insignificant and the client will probably experience more attachment loss.

Here are some key points discussed at the conference that pertain to clinical dental hygiene:

Don’t assume that diabetic clients are telling you the truth when reviewing their medical history. When asked if his/her blood glucose level is within a normal range, the client with diabetes might brush you off with something like, “Oh, yes, everything is OK.” If you find a periodontal infection, make sure you fax the client’s physician and ask for hemoglobin A1c levels over a two-year period. Hemoglobin A1c is a test that reflects blood glucose levels over a 60 to 90 day period. An individual blood glucose test with a meter only tells you the blood glucose level at that particular time and does not show the big picture.

In reviewing a client’s medical history, here are some additional questions you should ask clients with diabetes:

• What medications do you take?

• How well controlled is your diabetes?

• Do you follow a special diet and exercise program in addition to taking medication? (These questions will give you hints about how well-educated the client is about his/her disease.)

• Ask the client to bring his medications to the appointment so that you can become familiar with his or her medical regimen.

• Be on the alert for long-term complications that may accompany diabetes like kidney disease (nephropathy), hypertension, nerve disease (neuropathy), eye disease like retinopathy, and coronary artery disease (CAD).

Don’t underestimate the importance of determining a blood glucose level on diabetic clients, especially before scaling and root planing. Here’s an easy way to accomplish this. Ask your client to bring his or her glucometer to every hygiene appointment. Most glucometers will give a printout of blood sugar level in five to 35 seconds. Blood glucose level should be 70-200 mg/dl. Make sure you record the client’s blood glucose level in his or her chart.

Continue to think outside the confines of the traditional prophy box, and your clinical expertise will soar to new and extraordinary heights.

Lynne H. Slim, RDH, BSDH, MSDH, is a practicing hygienist/periodontal therapist who has more than 20 years experience in both clinical and educational settings. She is also President of Perio C Dent Inc. (Perio-Centered Dentistry), a practice management consulting firm that specializes in creating outstanding dental hygiene teams. Lynne is a member of the Speaking and Consulting Network (SCN) that was founded by Linda Miles and has won two first place journalism awards from ADHA. Lynne is also owner/moderator of a periodontal therapist yahoo group: She can be contacted at [email protected].