Diabetes and Oral Health

Working as a team, oral healthcare professionals, diabetes educators and primary care providers and endocrinologists can deliver services that result in better healthcare for diabetic patients.

People with diabetes have a marked increase in risk for periodontal disease, and experience almost three times more periodontal pathology than their non-diabetic counterparts, points out the Association of Diabetes Educators in its recent white paper, “Diabetes and Oral Health.” “In fact, diabetes is the only recognized systemic risk factor for periodontal disease.”

In turn, periodontal disease has been proposed as a sixth clinical complication of diabetes. Additionally, tooth loss is up to two times more frequent in people with diabetes than people who do not have diabetes.

For all those reasons, it makes sense for dentists and their staff, primary care physicians, and diabetes educators to collaborate for the sake and good health of their patients, conclude the authors of the white paper.

The diabetes educator
Diabetes educators are healthcare professionals – primarily nurses, dietitians and pharmacists, according to the AADE. Though not every diabetes educator is certified, approximately 86 percent of professionals in this group have earned the designation of Certified Diabetes Educator® (CDE®). Earning a CDE® requires at least two years of professional experience, a minimum of 1,000 hours in direct diabetes teaching experience, and successful completion of an exam administered by the National Certification Board for Diabetes Educators.

In most cases, it is the primary care physician or endocrinologist who refers the patient to a diabetes educator, the authors write. Such a referral pattern allows the primary care doctor to better facilitate the patient’s multifactorial care. “It is essential that oral healthcare providers communicate with [primary care physicians] about their oral exam findings and make management suggestions based on those findings.”

Diabetes educators seek to assess the patient’s understanding of diabetes as well as identify risk factors for poor control or complications. Educators may review blood glucose logs and attendance at scheduled provider visits, screen for lipodystrophies, or perform basic foot exams.

“Assessing the patient is a critical first step in providing appropriate patient education and management,” write the authors. “In the case of oral health, inquiring whether the patient has had a dental exam within the last six months or has a history of periodontal disease can begin the process. Additional information can be gleaned by simply observing the patient and assessing for missing teeth or inflamed gingival tissue. Educators can also inquire about available insurance, as many patients may not be aware of their insurance-provided dental benefits. Of those patients with dental benefits, patients may have limited coverage or may not appropriately utilize their covered services.”

Patients may be unaware
The focus of diabetes educators is to provide patients with tools and resources to better understand and manage their disease, according to the AADE. “Patients are frequently unaware of the various manifestations of their disease. Educators have the ability to tailor education to the patient’s specific needs and coach them in the skills needed to be able to self-manage their diabetes and its comorbidities.”

Examples may include instruction regarding administration of insulin injections, how to use an insulin pump to manage diabetes, or setting individualized nutrition and lifestyle goals. Educators can also determine a patient’s barriers to successful diabetes management and provide solutions that enhance successful outcomes. For instance, educators may inquire about economic hardship that may impair a patient’s access to quality nutrition, or they may assess for vision challenges that result in difficulty administering the appropriate insulin dose.

“Educators can help patients move beyond feelings of guilt or associated depression to allow them to take ownership of their disease and become part of the decision-making process.”

Another vital role of diabetes educators is alerting patients to the possibility of comorbidities the patient may have not considered to be related to their diabetes, the authors write. People with diabetes are often aware of the importance of podiatric and ophthalmic screening, but many do not realize the bi-directional relationship of oral health and diabetes. Patients may be unaware of the role of diet in the prevention of tooth loss. Educators can not only increase patients’ self-management and knowledge, but facilitate appropriate referrals and, in some cases, suggest treatment plans to maximize the patient’s health.

The oral healthcare professional’s role
Dental exams are frequently performed in clinical settings that are isolated from where patients receive their medical care, point out the white paper’s authors. Though oral healthcare providers regularly inquire about the patient’s health history and medications, additional screening may improve the patient’s overall health care.

“A new practice paradigm for oral health may involve assessing risk for diabetes – including asking the patient about family diabetes history – and, in the case of people with diabetes, metabolic control. Assessing the patient’s overall appearance and being alert for signs and symptoms of hypoglycemia are important when caring for people with diabetes. A number of studies have confirmed the effectiveness of screening for dysglycemia in the dental office. Determining whether a patient is already seeing a diabetes educator can provide added value to their care.”

An important part of diabetes management is evaluation and treatment, as necessary, by an oral healthcare professional. “Unfortunately, a major hurdle to overcome is simply getting the patient to visit the oral healthcare professional,” according to the AADE. “In the general population, only 35 to 45 percent of people 18 years or older see their dentist yearly, with older patients seeking dental care more frequently. More alarming are findings that people with diabetes tend to visit their dentist less frequently than people who don’t have diabetes. Patients may be fearful or overwhelmed by the requirements of their diabetes management.

“A patient may not be aware of the important role their oral health plays in diabetes care, but statistics show that receiving dental care reduces average medical costs ($2,800 per year in one study).”

Referral mechanisms
To facilitate maximum utilization of resources for people with diabetes, appropriate pathways for referral must exist, says the AADE. Oral healthcare providers need to be made of aware of the availability of diabetes educators and how they work with primary care providers and endocrinologists.

Diabetes educators benefit from knowing which oral healthcare providers have the knowledge and willingness to care for people with diabetes. Finally, primary care providers need to be aware of the value of working with diabetes educators as well as the importance of enlisting the help of oral healthcare providers to maximize patient outcomes.

“Regardless of type, diabetes is a chronic, progressive disease. To best serve people with diabetes, all members of the health care team must unite to inform not only their patients, but colleagues, about the important interplay between diabetes and oral health. Working as a team, oral healthcare professionals and diabetes educators, alongside primary care providers and endocrinologists, can deliver services that result in better oral health care and, ultimately, better health outcomes.”