Dental hygienists' role in diabetes education involves looking, listening, and feeling too
BY Gail Johnson, RDH
My husband and I took our two-year-old son, who was lethargic, constantly urinating, and had uncontrollable thirst and an insatiable appetite, to the emergency room. We informed the admitting nurse that our son had Type 1 diabetes.
"Did your doctor send you here?" the nurse asked as she took notes. "No," I replied, "he missed the diagnosis a couple of months ago when I took our son to his office."
In fact, the pediatrician had told us my son was probably anemic because he was drinking too much milk. I told the doctor of my suspicion of Type 1 diabetes and our family history. The pediatrician replied that we would "keep an eye on that," and that he would test for it "when Jac was old enough to urinate in a cup." That was the end of the appointment.
The nurse looked at me as if I was a bit crazy and asked, "And why do you think your son has diabetes, Mrs. Johnson?" My response made her sit up a bit straighter: "Polyuria, polydipsia, polyphagia, and a fasting blood sugar of 267. We bought a glucometer at the drugstore and tested him this morning."
"Oh, are you a nurse?" she asked respectfully.
"No, I'm a dental hygienist." She looked a bit surprised.
Our family's journey with diabetes started about 10 years ago. I researched all I could about the disease, how we could manage it, and how we could control it. I relentlessly sought answers, until I hit a brick wall when I realized that total control was not possible.
To manage blood sugar is a science and an art. Blood sugar control has many contributing factors. Food that affects sugar control one day will not have the same effect the next day. Stress, exercise, amount of sleep, seasonal allergies, moods, hormones, and even the weather have effects on diabetes management.
I began to incorporate what I was learning at home into patient care at my dental office. I began to hear from patients that they were learning more from me about diabetes than they learned at their doctor's office.
Understanding the disease
There are two major types of diabetes - Type 1 and Type 2. Both are disorders in which the body has trouble regulating its blood glucose, or blood sugar, levels. Type 1 diabetes (T1D) is an autoimmune disease in which a person's pancreas stops producing insulin. Insulin is a hormone made by the pancreas that allows the body to use sugar from carbohydrates in food for energy. T1D usually strikes in childhood, adolescence, or young adulthood, and it lasts a lifetime. People with T1D must take multiple injections of insulin daily or continually infuse insulin through a pump.
Type 2 diabetes (T2D) is usually diagnosed in adulthood and is a metabolic disorder in which a person's body still produces insulin but is unable to use it effectively. T2D can be managed by diet and exercise and oral medications, or it may require insulin injections. Increased obesity has led to a recent rise in cases of T2D in children and young adults.
The statistics according to the American Diabetes Association are staggering. Data from the National Diabetes Statistics Report, 2014 says that 9.3% of the population has diabetes. This means that for every 100 patients we see, over nine will have diabetes. On top of this statistic is the fact that many people go undiagnosed. As the population ages, the rate of diabetes is increasing drastically, with almost 26% of the population over age 65 having some form of diabetes.
Look, listen, and feel
Other than dietary guidelines, I've learned that the most important aspects of caring for a patient with diabetes is to look, listen, and feel.
During your initial assessment and oral cancer screening, look for these signs and symptoms of uncontrolled diabetes:
• Dry mouth-Uncontrolled diabetes can decrease saliva flow, resulting in dry mouth. Dry mouth can further lead to soreness, ulcers, infections, and tooth decay.
• Gum inflammation (gingivitis) and periodontitis-Besides weakening white blood cells, another complication of diabetes is that it causes blood vessels to thicken. This slows the flow of nutrients to and waste products from body tissues, including the mouth. With this combination, the body loses its ability to fight infections. Since periodontal disease is a bacterial infection, people with uncontrolled diabetes might experience more frequent and severe gum disease.
• Poor healing of oral tissues-People with uncontrolled diabetes do not heal quickly after oral surgery or other dental procedures because blood flow to the treatment site can be damaged.
• Thrush - People with diabetes who frequently take antibiotics to fight various infections are especially prone to developing a fungal infection of the mouth and tongue. The fungus thrives on the high glucose levels in the saliva. Constantly wearing dentures can also lead to fungal infections.
• Burning mouth and/or tongue-This condition is caused by the presence of thrush.3
It is important to allow a patient to tell his or her story and to listen without interruption. Patients have many unique contributing factors. Their stories will give you clues to treatment planning.
"Telling and listening to stories is the way we make sense of our lives," said Dr. Thomas K. Houston, lead author of the study and a researcher at the University of Massachusetts Medical School in Worcester and the Veterans Affairs Medical Center in Bedford, Mass. "That natural tendency may have the potential to alter behavior and improve health."
Stories may help patients who struggle with more "silent" chronic diseases, such as diabetes or high blood pressure. In these cases, stories can help patients realize the importance of addressing a disease that has few obvious symptoms. "These types of patients and diseases may be a particular 'sweet spot' for storytelling," Dr. Houston noted.4
Empathy in patient care..."a cognitive attribute that involves an ability to understand the patient's experiences, pain, suffering, and perspective combined with a capability to communicate this understanding and an intention to help." (attributed to Thomas Jefferson University, Sidney Kimmel Medical College, Center for Research and Medical Education and Health Care)
In a study of diabetic patients who went to physicians with high empathy versus physicians with low empathy, the patients of physicians with high empathy were significantly more likely to have good control of hemoglobin A1c (56%) than were patients of physicians with low empathy (40%, P < .001).5
Can you imagine if every time you were hungry or wanted to sit down to a meal you had to draw blood, count carbohydrates, calculate insulin needs, and possibly inject yourself with insulin? This is what many people with diabetes face every single day.
When patients share their stories with you, do not reply with, "research shows" or "studies say." Also, anything that could be viewed as pontificating or too technical will fall on deaf ears. Don't answer feelings with facts. Connect, be present, engage more, and lecture less.
Jodi Hapern, PhD, author of "From Detached Concern to Empathy," explains, "Research over the past decade has confirmed that clinical empathy plays an essential part in effective health care. Studies show that because patients trust empathetic doctors, they communicate much more honestly with them about their physical and emotional issues. As a result, empathetic doctors recognize health problems that others might miss. Patients trust emotionally engaged doctors."
Diabetes and periodontal disease
There are multiple contributing factors that influence the development of periodontal disease and diabetes. When reflecting on these many contributing factors, including diet, exercise, stressors, hormones, and illness, to name a few, I view them as a chaotic intersection. Experience has taught me that these contributing factors function more like traffic going through a roundabout, constantly entering and exiting at various speeds and rhythms.
As anyone who has unwittingly come upon a roundabout knows, it can be daunting. Fortunately, with awareness and experience, one can become adept at navigating this roundabout and using the periodontal disease/diabetes relationship favorably, managing one to help bring the other under control.
The good news is that people whose diabetes is well controlled have no more tooth decay or periodontal disease than people without diabetes.1 The best safeguard against oral health complications are good oral hygiene and maintaining blood sugar within the accepted range.
The American Academy of Periodontology clearly defines the synergistic relationship of diabetes and periodontal disease. Some of the important factors that we need to share with patients include:
Diabetic patients are more likely to develop periodontal disease, which in turn can increase blood sugar and diabetic complications.
People with diabetes are more likely to have periodontal disease than people without diabetes, probably because people with diabetes are more susceptible to contracting infections. In fact, periodontal disease is often considered a complication of diabetes. Those people who don't have their diabetes under control are especially at risk.
Research suggests that the relationship between diabetes and periodontal disease goes both ways - periodontal disease may make it more difficult for people who have diabetes to control their blood sugar.
Severe periodontal disease can increase blood sugar, contributing to increased periods of time when the body functions with a high blood sugar. This puts people with diabetes at increased risk for diabetic complications.
Dispelling the myth: It is not just sugar
Just a generation ago it was thought if people maintained their sugar intake they could maintain diabetes. This is not true. The basic nutritional mantra for people with diabetes remains the same for those who do not have the disease - good nutrition, variety, balance, and moderation. There is no one perfect food, so including a variety of different foods and watching portion size are key to a healthy diet. Also, choices from each food group should provide the highest quality nutrients. In other words, foods rich in vitamins, minerals, and fiber are preferred to over those that are processed.2
Managing blood sugars starts with counting carbohydrates. Basically, almost all foods contain carbs except meat and fat. When consumed, carbs cause blood sugar to rise. Managing blood sugars depends on effectively balancing food, exercise, insulin, and other lifestyle choices. The American Diabetes Association has a list of "Diabetes Superfoods" on its website at Diabetes.org. The foods listed have a low glycemic index and provide key nutrients that are lacking in the typical Western diet, such as calcium, potassium, fiber, magnesium, and vitamins A (as carotenoids), C, and E.
The list includes beans, dark leafy green vegetables, berries, citrus fruit, sweet potatoes, whole grains, nuts, fish high in omega 3 fatty acids, tomatoes, and fat-free milk and yogurt. People with diabetes can eat the same foods other people enjoy. Sharing meals is important on many levels and everyone benefits from healthy eating. This has been our family's approach, and our son's average A1c has been 6.4 over nine years.
Preparing for patients with diabetes
• Have some form of glucose gel or tablet in the emergency kit. Orange juice can be substituted. Everyone needs to be trained on the signs of hypoglycemia. These may include hunger, pale skin, nervousness, shaking, perspiration, dizziness, lightheadedness, sleepiness, and confusion.
• Instruct patients to check their blood sugar and eat before treatment if their blood sugar dictates. This is especially important before any invasive process. This should be mentioned when confirming a diabetic patient's appointment.
• Ask patients about their type of diabetes, their medication, the severity, and how they control their diabetes, the physician treating them, and the date of their last visit.
• Morning appointments should be preferred because this is the time of high glucose and low insulin activity. This reduces the risk of a hypoglycemic episode during dental procedures.
• To avoid hyperglycemia, use anxiety reduction protocol. Emotional stresses and painful conditions increase the amount of cortisol and epinephrine secretion, which induce hyperglycemia.
• The right diet is a critical part of diabetes therapy. If a patient is expected to have trouble eating solid food after a dental procedure, the diet should be modified to soft solids or liquids. Consult the patient's physician for postoperative period diet plan.7
Know your patients' A1c. Ask your patients with diabetes what their A1c number was at their last checkup. The A1c is an important measurement of how effectively they are managing their diabetes. It reflects the average blood glucose control for the two- to three-month period before the test. Keeping blood glucose levels within target range and keeping the A1c number at less than 7% decrease the chances of developing complications.
For some people to reveal their A1c is close to what it feels like to reveal one's true weight. People often feel shame when they share a less than ideal A1c. An A1c number does not tell the whole story and no one wants to be treated "like a number." You may also find that many patients do not know what an A1c is. They may only know they had a blood draw at their last appointment.
Just as patients do not want to receive oral hygiene instructions from someone with lack of oral home care, we need to be aware of our own health. If you're giving advice on nutrition, you need to appear as though you take it seriously. I've told patients that I understand their challenges and that it's hard for me to always make healthy choices. One decision I made is to eat a healthy lunch and use the rest of my lunch hour to walk. Surprisingly, I've seen many patients while I'm out walking!
A team approach among PPOD (pharmacy, podiatry, optometry, and dentistry) providers, as well as other health-care professionals, is important in helping patients manage their diabetes and lower their risk for complications, including those related to their feet, eyes, teeth, and medication management.116 Other team players include endocrinologists, primary care physicians, ophthalmologists, nurse practitioners, dieticians, certified diabetes educators, and mental health professionals.
"Working Together to Manage Diabetes: A Guide for Pharmacy, Podiatry, Optometry and Dentistry" is an excellent resource for collaborating with other health professionals to care for diabetic patients, and is available at cdc.gov/diabetes/ndep/pdfs/ppod-guide.pdf.
Build your knowledge through others' stories
Kerri Sparling writes a heartfelt and informative blog. One of my favorite quotes from her blog, "Six Until Me" (with the tagline "Diabetes doesn't define me but it helps explain me") sums it up perfectly. "Diabetes is not a perfect math where you can just solve for "x." Usually we are solving for "why."
The first comment on that blog reads, "Amen. I don't think people appreciate the 'work' we do as diabetics every day. I get dizzy thinking of how much planning around meals/exercise/insulin goes into my everyday life."
There are numerous websites and blogs where people post stories of their challenges, struggles, lessons, and wisdom learned along the way. Here are some links to get you started:
Ten years later and not a day goes by that Jac and our family do not have to manage diabetes. Each person knows how to read a label, make healthy food choices, and recognize the signs and symptoms of uncontrolled diabetes. Our family is stronger and our health better because of the lessons this disease has taught us. My patients look forward to learning more at their appointments as I continue to research and incorporate it into their care. RDH
Gail Johnson, RDH, is a certified holistic practitioner, specializing in mind-body-spirit modalities in nutrition and movement. Working 35 years clinically and currently in a bio-dental practice, Gail specializes in integrated wellness, working with a wide range of health-care providers from naturopaths to neurologists. Gail is a national speaker who offers a wide range of courses for dental teams. She can be reached at [email protected]
4. Houston TK, Allison JJ, Sussman M, et al. Culturally Appropriate Storytelling to Improve Blood Pressure: A Randomized Trial.
5. Hojat M, Louis DZ, Markham FW, et al. Physicians' empathy and clinical outcomes for diabetic patients. Acad Med 2011; 86: 359-364.
6. American Diabetes Association. Standards of medical care in diabetes - 2013. Diabetes Care 2013; 36 Suppl 1: S11-66.
7. Varon F, Mack-Shipman L. The Role of the Dental Professional in Diabetes Care. The Journal of Contemporary Practice, Volume 1, Number 2, Winter Issue 2000