Académique Documents
Professionnel Documents
Culture Documents
Disclaimer: Participants must always be aware of the hazards of using limited knowledge in integrating new techniques or
procedures into their practice. Only sound evidence-based dentistry should be used in patient therapy.
Diabetes is a complex, chronic illness that requires ongoing medical care with strategic risk reduction
strategies beyond glycemic control. Patients require self-management education and support to prevent acute
complications and reduce the risk of long-term complications. A range of evidence-based interventions are
available to improve diabetes outcomes.1 Recognized as a major global public health problem and the seventh
leading cause of death in the U.S., proper management of diabetes will positively impact a patient’s oral health,
especially as it relates to risk for periodontal disease. Determining whether or not medical issues warrant
immediate care before elective dental procedures is an important part of patient protocol and needs to be
instituted by dental practitioners. Better overall communication and ongoing interaction between medical and
oral healthcare providers is needed to improve the overall health of individuals with diabetes.
ADA CERP
The Procter & Gamble Company is an ADA CERP Recognized Provider.
ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality
providers of continuing dental education. ADA CERP does not approve or endorse individual courses or
instructors, nor does it imply acceptance of credit hours by boards of dentistry.
1
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
Overview
Diabetes is a complex, chronic illness that requires ongoing medical care with strategic risk reduction
strategies beyond glycemic control. Patients require self-management education and support to prevent acute
complications and reduce the risk of long-term complications. A range of evidence-based interventions are
available to improve diabetes outcomes.1
With an aging population and an increasing number of overweight adolescents, teenagers, and adults, the
U.S. and other countries are experiencing a rapid increase in the prevalence of the disease, particularly type
2 diabetes. Oral healthcare professionals might make a difference in the 35-50% of undiagnosed cases of
diabetes by focusing on the clinical recognition of short and long-term diabetes-related symptoms at dental
visits. Proper management of diabetes will positively impact a patient’s oral health, especially as it relates to
risk for periodontal disease. Determining whether or not medical issues warrant immediate care before elective
dental procedures is an important part of patient protocol and needs to be instituted by dental practitioners.
Better overall communication and ongoing interaction between medical and oral healthcare providers is needed
to improve the overall health of individuals with diabetes.
Learning Objectives
Upon the completion of this course, the dental professional will be able to:
• Define metabolic abnormalities related to diabetes.
• Differentiate between the pathophysiology of type 1 and type 2 diabetes.
• Distinguish between DKA and HHS.
• Determine the appropriate protocol to prevent a medical emergency during dental treatment for a patient
with type 1 and type 2 diabetes.
• Analyze the dental management suggestions related to patients with uncontrolled diabetes.
• List five questions that might be appropriate to help determine a patient’s glycemic control or disease
management.
• Explain why blood glucose levels should be less than 200 mg/dl before invasive dental treatment.
• Describe several strategies for stabilizing blood glucose levels for dental patients.
• Define normoglycemia in a way that a patient will understand.
• State the three psychological factors that have been identified with successful patient education outcomes.
• Name the two most important risk factors that are associated with increased susceptibility to periodontal
disease.
• Discuss the potential of a bidirectional relationship between diabetes and periodontal disease.
• Identify the various environmental factors that impact periodontal disease associated with diabetes.
• Examine the prevalence of systemic and periodontal disease(s) in the Pima Indian population group based
on longitudinal study data.
• Contrast the inevitability of risk factors for periodontal disease in type 2 diabetes with strategies to prevent
periodontal disease.
• Describe two common oral health complications of diabetes besides periodontal disease.
• Debate the presence of oral candidiasis with different levels of glycemic control.
• Provide recommendations to a patient with diabetes following a dental procedure that may impact their
ability to eat.
• Examine the role of parotid glands in diabetes-associated xerostomia.
• Describe specific guidelines that dental professionals can recommend to patients following dental
procedures that affect blood glucose control and/or eating ability.
2
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
Course Contents ketosis – Presence of urinary ketones.
• Glossary
• Introduction latent autoimmune diabetes of aging (LADA) –
• Diabetes Overview A slowly progressive form of type 1 diabetes in
• Type 1 Diabetes: Characteristics older individuals.
• Type 2 Diabetes: Characteristics
• Pre-Diabetes: A Silent Epidemic nephropathy – Disease of the kidney. Diabetes
• Long-term Complications is the most common cause of End Stage Renal
• Dental Professionals as Certified Diabetes Disease (ESRD) in the U.S.
Educators
• Diabetes in a Dental Environment neuropathy disorders – Affects the nervous
• Dental Management system with classic symptoms of pain or
• Hypoglycemia numbness such as foot ulcers, bladder
• Hyperglycemia dysfunction, or sexual dysfunction.
• Patient Education
• Research on Periodontal Disease Risk and normoglycemia – Blood glucose values of
Diabetes individuals with diabetes that are near or at the
• Host Modulation, Diabetes, and Periodontal level of individuals without diabetes.
Disease
• Xerostomia and Oral Candidiasis polydipsia – Increased thirst.
• Discussion
• Case Study polyphagia – Increased hunger.
• Course Test
• References polyuria – Frequent urination.
• About the Authors
retinopathy – Damage to the blood vessels in the
Glossary retina. The leading cause of adult blindness is
apoptosis – In biology, apoptosis (from the Greek diabetic retinopathy.
words apo = from and ptosis = falling, commonly
pronounced ap-a-tow’-sis) is one of the main Introduction
types of programmed cell death (PCD). As such, Just before she turned 17, Katie Haley weighed
it is a process of deliberate life relinquishment by in at 239 pounds at the pediatrician’s office and
a cell in a multicellular organism. she was told that her cholesterol was high. She
was on the cusp of diabetes and her insulin level
diabetic ketoacidosis (DKA) – A life-threatening was also a bit elevated. Katie had experienced
hyperglycemic state in those individuals with exclusion and ridicule by her peers in high
diabetes with very little or no insulin production. school, and we now know that 31.8% of youth
are overweight or obese.1 At the suggestion of
hyperglycemia – High blood glucose levels. her family physician, Katie’s mom, who was also
overweight, scheduled Katie to see a registered
hyperlipidemia – Elevated levels of lipids in the dietitian. Katie and the dietitian worked together
blood. to modify her lifestyle by making better food
choices, being aware of portion size of foods and
hyperosmolar hyperglycemic state (HHS) – A beverages, and incorporating a plan for regular
hyperglycemic state in individuals with type 2 exercise.
diabetes; the absence of significant ketosis and
acidosis distinguishes HHS from DKA. Katie is lucky that her general practitioner cared
enough to call her every two to three months to
hypoglycemia – Low blood glucose levels. check on her progress. It took about 12 months
for Katie to lose the recommended weight, and
ischemic heart disease (IHD) – Ailments caused she continues to follow her new lifestyle to
by a decreased blood supply due to narrowing of maintain her weight loss.
the coronary arteries.
3
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
Dentistry plays a major role in reaching these
goals by accepting our responsibility in helping
individuals reach their full health potential, which
includes an active role in diabetes screening and
overall care. Improved outcomes in the health
of the patient with diabetes are accomplished
through the collaboration of all members of
the healthcare team along with an education
component from each discipline on management
and self-care.
4
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
compensate for the additional carbohydrate intake,
thus, keeping the blood glucose levels in a normal
range (target: premeal 80-130 mg/dL; postmeal
less than 180 mg/dL). Since the body is unable
to produce insulin in type 1 diabetes, the patient
relies on exogenous insulin, which is injected as
needed throughout the day.
5
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
questions regarding indications of the long-term Table 1. Recommended Diabetes Values.29
complications.
Long-term Complications
Hyperglycemia appears to be a key factor in
the long-term complications associated with
diabetes (Table 2). The Diabetes Control and
Complications Trial (DCCT), Epidemiology of
Diabetes Interventions and Complications (EDIC)
study, and the U.K. Prospective Diabetes Study
(UKPDS) demonstrated the need to aim for
6
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
near normal glucose levels or normoglycemia in dental professionals to begin working toward
order to delay or minimize chronic complications becoming a CDE. A CDE is defined as, “a health
(Table 3). professional who possesses comprehensive
knowledge of and experience in prediabetes,
Dental Professionals as Certified Diabetes diabetes prevention, and management. The
Educators CDE educates and supports people affected
The National Certification Board for Diabetes by diabetes to understand and manage the
Educators (NBCDE), the credentialing organization condition. A CDE promotes self-management to
for Certified Diabetes Educators (CDE), has achieve individualized behavioral and treatment
opened an opportunity for adequately trained goals that optimize health outcomes.”8
7
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
Several health professionals, such as physicians, h. Do you experience low blood sugar levels? If
nurses and dietitians, have always had the ability so, how often? What are your symptoms?
to prepare for the certification. Currently there When was your last event?
are 17,870 CDE’s.8 In 2014, NBCDE proposed a i. Do you smoke or use any tobacco products? If
Unique Qualification Pathway that will potentially so, how much?
allow a master-prepared dental professional, with j. Do you drink alcoholic beverages? If so, how
a health-related degree, to prepare for and submit often and how much do you drink on a weekly
an application. This certification provides the basis?
dental professional with the valuable expertise
and experience that establishes them as a * A1C level refers to the hemoglobin A1c test.
respected member of the diabetes team. Table 1 provides the accepted value. This
is a simple lab test that shows the average
Diabetes in a Dental Environment amount of glucose in a patient’s blood over the
Many people have symptoms of type 2 diabetes last three to four months. Glucose binds to
when they are diagnosed, but diabetes screening hemoglobin in the red blood cells, which has
and identification procedures are oftentimes a life span of 120 days. It’s the best way to
inadequate.9 Less than half complain of diabetes find out if the patient’s blood glucose is under
symptoms like polyuria, lethargy, or polydipsia. control. Monitoring blood glucose values via a
Because classic symptoms do not always appear, glucometer can be equated to taking pictures
it is imperative that healthcare providers, including with a camera. Each value is a snapshot
dentists and dental hygienists, participate in more of that moment. Blood glucose levels vary
aggressive recognition of symptoms of patients throughout the day. Having and A1c is similar
with type 2 diabetes or pre-diabetes. The updated to a video. This value gives a longer running
medical history and oral exam offer excellent value, an average over 3-4 months. All people
opportunities to assess each patient. In reviewing with diabetes should have a hemoglobin A1c
a patient’s medical history, here are some practical test two to four times a year depending on their
questions that you can ask, keeping in mind glycemic control and changes to therapy.6
that questions should be individualized to help
determine the patient’s glycemic control and Since many undiagnosed patients may be
overall approach to diabetes care management: asymptomatic, probing questions related to the
chronic complications during the medical history
a. What type of diabetes do you have, and when and a thorough oral examination can lead the
was it diagnosed? dental professional to be the first to recognize
b. Have you been experiencing any health the possibility of undiagnosed diabetes. The oral
problems over the last few days, weeks, or exam in an individual with undiagnosed diabetes
months? might reveal:
c. Are you taking all of the medications that have
been prescribed for you? If not, which one(s) • Candidiasis
don’t you take and why? Have you taken your • Gingival inflammation
diabetes medication today? • Suppuration
d. What is your A1C level? When was the last • Tooth mobility
A1C taken?* • Fruity smelling breath
e. How often do you check your blood glucose • Recurrent, acute or chronic gingival and
level, and what was the most recent value? periodontal infections and abscesses
f. Do you watch your carbohydrate intake and • Xerostomia
follow an exercise regime? What time did you • Increased salivary viscosity
last eat? What did you consume? • Angular cheilosis
(This question will give you hints about • Enlargement of parotid glands
how well-educated the patient is about their • Oral burning sensation
disease.) • High caries rate in patients with uncontrolled or
g. Who helps you manage your diabetes? Do poorly controlled diabetes
you see your physician, nurse, or dietitian on a (See Recommended Diabetes Values in
regular basis? When was your last visit? Table 1)
8
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
The American Diabetes Association recommends a blood pressure reading should be obtained
testing for high-risk patients for early diagnosis (Table 1). A thorough oral examination will
of diabetes and to prevent the associated chronic provide additional facts for creating a plan
complications (Tables 4A and 4B). Testing is towards a healthful and preventive environment
to be done within a health care setting in which for the patient with diabetes. A comprehensive
appropriate follow-up is available. periodontal examination which includes an annual
circumferential probing of all teeth, tracking
Dental Management clinical attachment loss, bleeding and exudate
For patients with known diabetes, questions on probing, mobility and furcation involvement
related to each individual’s diabetes regime, and a full mouth set of periapical radiographs,
difficulties they may be experiencing related complete dental charting, and a treatment plan
to diabetes, results of their last medical visit, will supplement the findings. To start treatment,
changes in their medication, and their compliance random blood glucose values should be between
are essential to begin to formulate a dental plan. 70-200 mg/dL. Most glucometers will provide
Because of the increased risk of hypertension, a reading of the blood glucose level in seconds.
Table 4A. Criteria for Type 2 Diabetes Testing for High-risk Patients.
Table 4A. Criteria for Type 2 Diabetes Testing for High-risk Patients.
9
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
Requesting the patient to bring their blood glucose The antidiabetes medication, alpha-glucosidase
monitoring system and obtain a blood glucose inhibitors, alone does not cause hypoglycemia.
value prior to treatment is imperative. Relying on However, it is usually prescribed in combination
the patient’s memory to provide an accurate value with another antidiabetic medication that causes
is risky. Some patients may be too embarrassed hypoglycemia or insulin. Only a glucose or
or unwilling to share high blood glucose values lactose food source is effective for treating
and may modify the true number. hypoglycemia with this combination. The dental
emergency kit should, therefore, contain a
Hypoglycemia glucose (i.e., glucose tablets or gel) or a lactose
Not all patients with diabetes experience (i.e., lowfat or nonfat milk or yogurt) source for
hypoglycemia. Those taking insulin or treatment of hypoglycemia.
antidiabetes medications (i.e., sulfonylureas
and meglitinides) whose side effects include If the hypoglycemic episode is severe and the
hypoglycemia may experience difficulties. An patient is unable to swallow, glucagon should be
appointment scheduled after a meal or snack is administered to raise the blood glucose values.
recommended for those patients who are at risk Glucagon will increase the hepatic glucose
of hypoglycemia. Most patients with diabetes are release, resulting in a release of insulin. Glucagon
recommended to eat a meal or snack every 4-5 should also be a component of the dental
hours. Those patients with gestational diabetes emergency kit with specified or all members of
are recommended to eat every 2-3 hours. the dental team having the ability to administer.
10
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
minutes and be retested. If the blood glucose
level is still above 200 mg/dL, the patient should
be referred to their diabetes healthcare team and
the dental appointment rescheduled. Conducting
noninvasive procedures, such as radiographs or
an oral examination, may be warranted prior to
dismissal.
11
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
physician for an adjustment. Even patients had mixed effects on diabetes outcomes and some
on MNT and exercise alone may temporarily have been positive. “Among patients with poorly
need diabetes medication. The patient may controlled diabetes receiving specialty care, an
also need to obtain additional blood glucose earlier study of cognitive behavioral therapy and
levels to monitor changes due to trauma from diabetes education showed a clinically significant
treatment. Maintaining adequate hydration reduction in A1C level at the six-month follow
needs to be recommended. When regular foods up when compared to a control group receiving
are not tolerated, the carbohydrate levels still diabetes education only.”11
need to remain consistent throughout the day
with recommendations of soft foods or liquids In a study that enrolled patients from nine primary
as substitutes. Depending on the nature of the care clinics, participants received an evidence-
dental treatment, the patient may need a referral based collaborative depression treatment that
to a dietitian prior to the treatment. Blood included pharmacotherapy, problem-solving
glucose levels should be tested more frequently therapy, or both. Surprisingly, diabetes self-
and values 250 mg/dL or higher may require a management did not improve among the enhanced
call to the physician. depression group during a 12 month period. Self-
care interventions for dental patients with specific
In examining the psychological features which oral conditions should also be studied, and it is
characterize oral health behavior and the diabetes recommended that a coordinated therapeutic
self-care health status among patients with approach that considers coexisting chronic
type 1 diabetes, Kneckt discovered that those diseases is a suggested approach.11
patients who reported success with gingivitis also
had better overall metabolic balance (glycemic Research on Periodontal Disease Risk and
control).10 Effort, ability, and interest were the Diabetes
most common causes of success in these Based on many years of periodontal research, it is
patients. By identifying and enhancing these now understood that one of the strongest systemic
common psychological features, this information risk factors for periodontal disease is diabetes
should be considered in designing initiatives mellitus.12,13 In addition, a preponderance of
that enhance patient-centered health education evidence indicates that there is a direct relationship
programs for individuals with diabetes.10 between diabetes mellitus and periodontal
disease.13,14 Evidence is also steadily mounting and
“Among patients with diabetes, major depression shows that:
is often associated with more diabetic
complications, lower medication adherence, and 1. Some individuals with diabetes (i.e., those with
poorer self-care of diabetes.”11 Unfortunately, poor glycemic control) are at increased risk of
this topic is not often discussed among oral periodontitis. Other than smoking, metabolic
healthcare professionals; to date, there is limited control of diabetes seems to be the most
research on this topic as it pertains to oral health important risk factor between periodontal health
education initiatives. Self-care is not only the and type 1 diabetes.13,14
cornerstone to diabetes management but it is 2. Individual control of diabetes may affect the
also the cornerstone to good oral health and is extent and severity of the disease.12
the key to success in disease prevention and 3. Diabetes is positively associated with
management. The prevalence of depression attachment loss and this relationship appears to
is about twice as high among individuals with be strong within special population groups.13,14
diabetes as it is among the rest of the population.
Not only does depression affect adherence to Hyperglycemia and hyperlipidemia in patients with
diabetes medications, depression is also highly diabetes may result in metabolic alterations that
correlated with physical inactivity, poor nutrition, exacerbate periodontopathic-induced periodontitis,
and smoking.11 but there is another plausible hypothesis that
proposes interaction of genes and environmental
Randomized controlled research trials to improve stressors could develop either periodontitis or
depression among individuals with diabetes have diabetes or both.15
12
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
Both type 1 and type 2 diabetes increases the Periodontal therapy is beneficial, however, to
risk of periodontal disease three- to four-fold.16 patients with diabetes, but not as a means of
Greater incidence and severity of periodontal improving glycemic control.18,19
disease in patients with diabetes may also
be due to: diminished neutrophil recruitment Populations of individuals with diabetes (types
and function, a more severe inflammatory 1 and 2) are exposed to different environmental
response, and delayed wound healing. Another factors which affect susceptibility and severity
possible explanation for bone loss in periodontal of periodontal disease. For example, smoking,
disease modified by diabetes is the reduction socioeconomic status, individual home care,
of osteoclasts following a bacterial challenge.16 history of dental care, emotional stress,
In one particular animal model study where a hematologic disorders, hormonal changes,
bacterial challenge was initiated, mice with type 2 and medications are significant modifiers of
diabetes not only had a reduction in osteoclasts periodontal diseases.17 In one particular study,
but new bone formation was suppressed which men with diabetes at a VA Medical Center had
coincided with increased apoptosis of bone-lining more severe periodontal disease compared to
cells. Increased apoptosis of bone-lining cells men without diabetes.19 Those men who smoked
decreases the amount of new bone formation. with or without diabetes had significantly higher
Mice with type 2 diabetes also have increased measurements for all parameters of periodontal
levels of apoptosis in soft tissue wounds which status studied. Neither the duration of diabetes
explain the interference with wound healing.16 nor the degree of glycemic control had a
significant effect on periodontal status, but it was
Many periodontal researchers have described concluded that diabetes increased the prevalence
a bidirectional relationship between diabetes and severity of periodontal disease.
and periodontal disease. There is evidence that
poor glycemic control has been shown to be Since 1965, residents of the Gila River Indian
associated with significantly greater alveolar Community of Arizona, most of who are Pima
bone loss over time compared to individuals with or closely related Tohono O’odham Indians,
well-controlled diabetes.17 Similarly, a weaker have participated in a longitudinal population-
body of evidence has emerged that suggests that based study of diabetes and its complications.
effective periodontal therapy may have a positive The National Institute of Diabetes & Digestive
effect on glycemic control.17 Keep in mind, & Kidney Diseases (NIDDK) performs biennial
however, that numerous conflicting studies exist (every two year) examinations of each member
that do not support the bi-directional association of the community aged five and over. These
between periodontal disease and diabetes.14 standardized health exams include periodic dental
exams including periodontal exams based on set
A large, multicenter randomized controlled clinical criteria. In a periodontal study that analyzed data
trial which studied the effect of nonsurgical on the effect of periodontal disease on overall
periodontal therapy for individuals with type 2 and cardiovascular disease mortality in these
diabetes and periodontitis over a six month Indians with type 2 diabetes, several significant
period showed no improvement in glycemic findings emerged. This study was the first of its
control. The periodontal treatment included two kind to study the risk of cardiovascular disease
or more sessions of scaling and root planing with mortality associated with periodontal disease in
local anesthesia (more than 2.5 hours in duration) patients with diabetes.21 It is also important to
plus supportive periodontal care (periodontal note that the impact of common risk factors for
maintence).18 both diabetes and cardiovascular disease (like
smoking) were taken into consideration. Nearly
In 2013, Corbella et al. conducted a systematic 60% of this particular Indian population studied
review and meta-analysis of clinical trials that had severe periodontal disease, and 70% of those
assessed whether periodontal therapy improved with severe periodontal disease were edentulous.
glycemic control. The best available evidence
does not suggest that short-term diabetes The prevalence of periodontal disease is quite
outcomes are improved following non-surgical high in Pima Indians, even those who have not
periodontal therapy.18,19 yet been diagnosed with type 2 diabetes but
13
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
diabetes further increases the risk. Diabetes, that is triggered by periodontopathogens. Certain
in this population group is also a strong, components of bacteria have been found to
independent risk factor for cardiovascular disease be potent stimulators of a variety of cytokines
and diabetic nephropathy. Individuals with and growth factors that eventually lead to an
diabetes are susceptible to microvascular and increased inflammatory response resulting in
macrovascular complications like neuropathy, eventual tissue damage and destruction.23 In
nephropathy, vision disorders, heart disease, and addition to the bacterial component triggers
stroke; therefore, they are at increased risk of inflammatory mediators of the immune response
morbidity and mortality associated with these may play an important role in local periodontal
diseases/disorders. Also, cardiovascular disease tissue destruction, but the mechanisms are
and periodontal disease have many common still being studied intensively. In other words,
risk factors like diabetes, age, smoking, health chronic hyperglycemia may create a host hyper-
behaviors and habits, socioeconomic factors, diet, inflammatory response that results in periodontal
and access to care. These shared risk factors tissue and bone destruction.
may confound results of many of the Pima Indian
studies. Therefore, whether or not the prevention Host Modulation, Diabetes, and
or treatment of periodontal disease can reduce Periodontal Disease
the death rate from cardiorenal disease in this In discussing host modulation, scientists refer
population group cannot yet be determined. to the inoculation of healthy individuals with
weakened or attenuated strains of disease-
One revealing statistic, as a result of this Pima causing agents to protect against disease.23 A
Indian study, showed that 204 of the 628 study good example of an attenuated (weakened)
subjects died during the follow-up period of the virus that serves as a successful vaccine is the
study which averaged 11 years. That’s about influenza vaccine which first became available
almost a quarter of the study participants. Forty- in 1945. Manipulation of the immune response
four of 54 deaths were attributed to ischemic is desirable in diseases like graft rejection,
heart disease (IHD) and most of the diabetes- autoimmunity and allergy, and it aids the
related deaths (28 of 35) were due to diabetic host in fighting against infectious agents like
nephropathy.21 periodontopathic microorganisms. Individuals
with diabetes get a double dose of inflammatory
In another Swedish study, smoking followed by cascades or events that lead to a host response
A1C levels was discovered to be the best predictor because the host is not only reacting to the
for severe periodontal disease in subjects with periodontopathic microorganisms but to a
type 2 diabetes. Those individuals who were prolonged response to hyperglycemia. As we
less controlled also had more cardiovascular already know, hyperglycemia is often the result
complications.22 of an immune-mediated destruction of islet beta
cells of the pancreas. A genetic predisposition in
It seems that many of the risk factors for patients with type 1 diabetes contributes to this
periodontal disease in individuals with type 2 immune destruction. Type 1 diabetes develops
diabetes are preventable. This reinforces the as a result of immune-mediated destruction. In
notion that individuals with diabetes should be latent autoimmune diabetes in adults (LADA),
informed about their increased risk for periodontal “The underlying immune-mediated destruction of
disease, and these patients need intensive home beta cells in patients with LADA leads to insulin
care intervention and shorter recare intervals, dependency more rapidly than in type 2 diabetes,
especially if their glycemic control is poor or but the more attenuated genetic and immune
erratic and their medical visits are infrequent. In factors associated with LADA compared with
addition, patients in the Swedish research study type 1 diabetes lead to an older age at onset and
lack sufficient knowledge about oral health a slower progression to insulin dependency.”24
complications in relation to diabetes.22 The development of type 2 diabetes may have
some genetic etiology but is thought to be a
Much of the periodontal research during the last combination of genetic predisposition, lifestyle,
decade has focused on the host immune response and environmental factors.
14
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
Xerostomia and Oral Candidiasis parotid glands.28,29 In addition, cigarette smoking,
Oral candidiasis is another complication of dysgeusia (report of a bad taste), more frequent
diabetes and the condition is caused by a fungus snacking, xerogenic medications, and elevated
called Candida albicans. The most common fasting blood glucose concentrations have also
etiology of oral candidiasis in individuals with been significantly associated with decreased
diabetes is xerostomia, and the condition salivary flow.
sometimes appears in patients with poor glycemic
control. The most common type associated In patients with type 1 diabetes and neuropathy,
with diabetes is chronic atrophic (erythematous) more cases of xerostomia and decreased salivary
candidiasis which appears as a red patch or velvet flow were reported. A comprehensive evaluation
textured plaque. Patients sometimes complain of salivary function is recommended.30
of a burning sensation or an alteration of taste.
Smokers and denture-wearers with poor oral Discussion
hygiene are at greater risk of developing chronic Caring for our patients in a dental environment
atrophic erythematous candidiasis. requires critical thinking skills. Patients often
present with complex medical histories that
In a large epidemiological study, several oral soft include diabetes symptoms before a formal
tissue lesions were found to be more prevalent diagnosis is established. We have a golden
in subjects with type 1 diabetes. The use of opportunity to recognize short- and long-term
antimicrobials, immunosuppressants, or drugs diabetes-related symptoms in asymptomatic
with xerostomic side effects were not related patients. By investigating and asking pertinent
to the presence of the Candida organism. The questions when the opportunity arises, we can
presence of the candida organism was found to be impact our patients’ clinical course of diabetes
significantly associated with the use of dentures, and, hopefully, decrease the amount of time
cigarette smoking, and poor glycemic control.25 they will be exposed to high levels of adverse
risk factors like hypertension, obesity, and
Bartholomew et al. compared the frequency and impaired glucose tolerance. Once risk factors
severity of oral Candida in patients with type 1 are controlled, complications may be lessened
diabetes and found that 75% of subjects with because macrovascular (affecting large arteries)
diabetes compared to only 35% in the control and microvascular (affecting capillaries and small
group. As a result of this study, the authors blood vessels) are the major cause of morbidity
concluded that individuals with type 1 diabetes and mortality. In addition, the cost of managing
are predisposed to oral candidiasis and, that this these complications is prohibitively expensive.
predisposition is independent of glycemic control.26 Let’s continue to challenge ourselves to accept
a new paradigm of care in the 21st century that
In examining individuals with type 2 diabetes, includes a focus on patient wellness and early
Belazi el al. investigated the potential factors detection of systemic diseases like diabetes.
that influence the prevalence of oral Candida in
a small sample of patients. Oral Candida was Case Study
significantly higher in patients with type 2 diabetes John Brookshire, a 55-year-old morbidly obese
compared to healthy subjects, but the researchers male who smokes. He presents as the next recare
ruled out variables such as xerostomia, dentures, patient after having been away for several years.
age, gender and glycemic control as contributing He is interested in getting his teeth “cleaned” and
factors.27 he has just been seated in the dental hygienist’s
operatory. The dental hygienist has a 60 minute
Xerostomia in diabetes is related to structural appointment set aside for him and the hygienist is
changes in the parotid glands which creates poor about to begin a medical history review. Here are
salivary function and sometimes swelling of the her preliminary findings:
15
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
16
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
Does Diabetes affect oral health?
If you have diabetes, it can affect many parts of Periodontal disease
your body. This includes your teeth and gums.
If gingivitis is left untreated, it can turn into
The effect is even greater when your blood sugar
periodontitis. This is a more serious form of
is not well controlled, making it harder to fight
gum disease. Over time, it can cause your gums
bacterial infections. to pull away from your teeth, causing teeth
to become loose.
Plaque buildup
Plaque is a clear, sticky layer of bacteria that
forms on teeth. If it is not removed, it can lead to
Oral health can affect diabetes, too
infections such as gum disease.
Having an infection like gum disease can affect
If your high blood sugar your blood sugar. That’s why it’s vital to practice
is not controlled, you good oral care habits at home. It can help you
may have more plaque protect your oral health, as well as manage
bacteria than most your diabetes.
people. That means you
are more at risk for oral
health problems. Plaque buildup
Gingivitis
Gingivitis is a form of gum disease. It is caused by a
buildup of plaque and tartar on the teeth and gums.
If you have diabetes, it is harder for your body to
control plaque bacteria. That is why people with
diabetes are 3 to 4 times more likely to get gum
disease.
Be sure to use your blood
Be sure to see your dental professional if you have glucose meter! It can help you
any of these symptoms: control your blood sugar levels
• Red gums and protect your oral health.
• Swollen or
tender gums
• Gums that
bleed easily
Red, swollen gums
17
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
Does Diabetes
affect oral health?
Special oral health tips for people Quick facts about diabetes
with diabetes and oral health
Take good care of your teeth at home. Taking good care of your gums and teeth is key
when you have diabetes, helping you protect
• Brush at least twice a day. Be sure to use
your teeth and gums for life.
an antibacterial toothpaste that
contains fluoride. • Uncontrolled blood sugar can affect your
gums and teeth. It can cause an increase
• Make sure to floss at least once a day.
in plaque bacteria.
• Try using an antibacterial mouthwash (without
alcohol) at least once a day. This can help • People with diabetes are 3 to 4 times as
likely to get a gum infection.
kill bacteria and control plaque.
• Diabetes makes it harder to fight off
And be sure to:
infections, including gum disease.
• Tell your dental professional that you
have diabetes. • Gum disease can make it harder to
control diabetes.
• Go for regular dental cleanings every 6
months (more often if directed by your
dental professional).
• Tell your dental professional if you notice
any symptoms of gum disease, such as
bleeding and swelling.
• If you need to have dental surgery, ask
your dentist to talk to your doctor. You
may need to change your medicine or
take a new one to help prevent infection.
18
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
Course Test Preview
To receive Continuing Education credit for this course, you must complete the online test. Please go to:
www.dentalcare.com/en-US/dental-education/continuing-education/ce93/ce93-test.aspx
1. The occurrence of which three conditions are becoming more prevalent in the adolescent U.S.
population:
a. Type 1 diabetes, type 2 diabetes, and obesity
b. Obesity, poor eating habits, and type 1 diabetes
c. Type 2 diabetes, morbidity, and mortality
d. Hypertension, hyperlipidemia, and type 2 diabetes
5. Which of the following oral conditions are most frequently associated with diabetes:
a. Xerostomia, candidiasis, and burning mouth syndrome
b. Xerostomia, candidiasis, and dental caries
c. Xerostomia, candidiasis, and periodontal disease
d. Xerostomia, periodontal abscesses, and candidiasis
6. In assessing periodontal disease in a patient with diabetes, which of the following risk factors
should be considered:
a. Smoking
b. Genetics
c. Blood glucose control
d. All of the above.
19
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
8. A glucose or lactose source includes:
a. Glucose tablets
b. Lowfat or nonfat milk
c. Lowfat or nonfat yogurt
d. All of the above.
11. The best carbohydrate source for treating a patient experiencing hypoglycemia would be:
a. 3 Peanut butter crackers
b. 1 oz Snack chips
c. 4 oz Orange juice
d. 12 French fries
15. Treatment planning for John should include the following recommendations
a. Antifungal medication; oral hygiene instructions; caries risk assessment and dietary counseling;
xerostomia education; possible home fluoride; professional fluoride treatment; non-surgical
periodontal therapy; and restorative care for dental caries.
b. Antifungal medication; oral hygiene instructions; caries risk assessment and dietary counseling;
xerostomia education; prophylaxis, professional fluoride treatment, possible home fluoride; and
restorative care for dental caries.
c. Oral hygiene instructions; caries risk assessment and dietary counseling; professional home
fluoride, prophylaxis; and restorative care for dental caries.
d. All of the above.
20
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
16. John’s blood glucose level is 55 mg/dL. The dental professional should:
a. Proceed with treatment
b. Call 911 and administer glucagon
c. 15 grams of a carbohydrate source
d. 15 grams of a glucose or lactose source
17. John asks you for some advice on maintaining good glucose control. You tell him to:
a. See his primary care physician, nurse, or diabetes team for advice
b. Focus on meal planning, increase physical activity, and increase his insulin dosage
c. Exercise every day to include aerobics and weight lifting
d. Re-read his glucometer’s instruction manual since his glucometer may be broken
21
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
References
1. Ogden CL, Carroll MD, Kit BK, et al. Prevalence of childhood and adult obesity in the United States,
2011-2012. JAMA. 2014 Feb 26;311(8):806-14.
2. Kaufman FR. Diabesity. 2nd ed. New York: Bantam Books, 2006.
3. US Department of Health and Human Services. Oral Health in America: A Report of the Surgeon
General — Executive Summary. Rockville, MD. US Department of Health and Human Services,
National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. Accessed
October 2, 2015.
4. National Diabetes Fact Sheet. (2014). Centers for Disease Control and Prevention. Accessed
October 2, 2015.
5. Glick M. Exploring our role as health care providers: the oral-medical connection. J Am Dent Assoc.
2005 Jun;136(6):716-7.
6. American Diabetes Association. Standards of Medical Care in Diabetes-2015. Diabetes Care. 2015
Jan 1;38(suppl 1):S5-S87. Accessed October 2, 2105.
7. Matthews DR. The natural history of diabetes-related complications: the UKPDS experience. United
Kingdom Prospective Diabetes Study. Diabetes Obes Metab. 1999 Sep;1 Suppl 2:S7-13.
8. National Certification Board for Diabetes Educators (2015). Accessed October 2, 2015.
9. O’Connor PJ, Gregg E, Rush WA, et al. Diabetes: how are we diagnosing and initially managing it?
Ann Fam Med. 2006 Jan-Feb;4(1):15-22.
10. Kneckt M. Psychological features characterizing oral health behavior, diabetes self care health status
among IDDM patients. University of Oulu. Academic Dissertation. 2000 May:1-70.
11. Lin EH, Katon W, Rutter C, et al. Effects of enhanced depression treatment on diabetes self-care.
Ann Fam Med. 2006 Jan-Feb;4(1):46-53.
12. Nunn ME. Understanding the etiology of periodontitis: an overview of periodontal risk factors.
Periodontol 2000. 2003;32:11-23.
13. Taylor GW, Borgnakke WS. Periodontal disease: associations with diabetes, glycemic control and
complications. Oral Dis. 2008 Apr;14(3):191-203.
14. Kinane DF, Peterson M, Stathopoulou PG. Environmental and other modifying factors of the
periodontal diseases. Periodontol 2000. 2006;40:107-19.
15. Soskolne WA, Klinger A. The relationship between periodontal diseases and diabetes: an overview.
Ann Periodontol. 2001 Dec;6(1):91-8.
16. He H, Liu R, Desta T, et al. Diabetes causes decreased osteoclastogenesis, reduced bone formation,
and enhanced apoptosis of osteoblastic cells in bacteria stimulated bone loss. Endocrinology. 2004
Jan;145(1):447-52.
17. Taylor GW. Bidirectional interrelationships between diabetes and periodontal diseases: an
epidemiologic perspective. Ann Periodontol. 2001 Dec;6(1):99-112.
18. Engebretson SP, Hyman LG, Michalowicz BS, et al. The effect of nonsurgical periodontal therapy
on hemoglobin A1c levels in persons with type 2 diabetes and chronic periodontitis: a randomized
clinical trial. JAMA. 2013 Dec 18;310(23):2523-32.
19. Corbella S, Francetti L, Taschieri S, et al. Effect of periodontal treatment on glycemic control of
patients with diabetes: A systematic review and meta-analysis. J Diabetes Investig. 2013 Sep
13;4(5):502-9.
20. Bridges RB, Anderson JW, Saxe SR, et al. Periodontal status of diabetic and non-diabetic men: effects
of smoking, glycemic control, and socioeconomic factors. J Periodontol. 1996 Nov;67(11):1185-92.
21. Saremi A, Nelson RG, Tulloch-Reid M, et al. Periodontal disease and mortality in type 2 diabetes.
Diabetes Care. 2005 Jan;28(1):27-32.
22. Jansson H, Lindholm E, Lindh C, et al. Type 2 diabetes and risk for periodontal disease: a role for
dental health awareness. J Clin Periodontol. 2006 Jun;33(6):408-14.
23. Kantarci A, Hasturk H, Van Dyke TE. Host-mediated resolution of inflammation in periodontal
diseases. Periodontal 2000. 2006;40:144-63.
24. Nabhan F, Emanuele MA, Emanuele N. Latent autoimmune diabetes of adulthood. Unique features
that distinguish it from types 1 and 2. Postgrad Med. 2005 Mar;117(3):7-12.
22
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
25. Guggenheimer J, Moore PA, Rossie K, et al. Insulin-dependent diabetes mellitus and oral soft tissue
pathologies: II. Prevalence and characteristics of Candida and Candidal lesions. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod. 2000 May;89(5):570-6.
26. Bartholomew GA, Rodu B, Bell DS. Oral candidiasis in patients with diabetes mellitus: a thorough
analysis. Diabetes Care. 1987 Sep-Oct;10(5):607-12.
27. Belazi M, Velegraki A, Fleva A, et al. Candidal overgrowth in diabetic patients: potential predisposing
factors. Mycoses. 2005 May;48(3):192-6.
28. Kao CH, Tsai SC, Sun SS. Scintigraphic evidence of poor salivary function in type 2 diabetes.
Diabetes Care. 2001 May;24(5):952-3.
29. Quirino MR, Birman EG, Paula CR. Oral manifestations of diabetes mellitus in controlled and
uncontrolled patients. Braz Dent J. 1995;6(2):131-6.
30. Zunt S. Re-establishing a normal salivary flow. Dimensions of Dent Hyg. May 2006;4(5): 30-2.
Accessed October 2, 2015.
Lynne coaches conventional dental hygienists in periodontal disease risk assessment and state-of-the-
art, non-surgical periodontal therapy, ultrasonic instrumentation, and other advanced hygiene initiatives.
Lynne has been published in Dental Economics, RDH, Access and the Journal of Dental Hygiene on non-
surgical periodontal therapy and other topics of interest to the general dentist/auxiliary team, including
a new approach to team training for the 21st century. Lynne also applies her expertise in advanced
hygiene initiatives as the periodontal therapy columnist for RDH magazine.
Lynne is dedicated to evidence-based dental hygiene and has conducted research and taught research
methodology to baccalaureate dental hygiene students in a private dental school. Lynne also won two
first place journalism awards and is dedicated to writing about evidence-based dentistry and dental
hygiene.
Lynne is also the owner and moderator of a LinkedIn Group called Evidence-based Dental Hygiene:
Periotherapist.
Lynne welcomes speaking engagements on the topic of nonsurgical periodontal therapy and evidence-
based decision making in dentistry and can be reached at:
Lynne H. Slim
Perio C Dent, Inc
5168 Holly Springs Dr.
Douglasville, GA 30135-4953
770-947-2496
Email: periocdent@mindspring.com
23
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015
Cynthia A. Stegeman, RDH, EdD, RD, LD, CDE, FAND
Dr. Cynthia Stegeman is the Department Chair and Professor in the Dental Hygiene
Program at the University of Cincinnati Blue Ash, as well as a diabetes educator at
TriHealth Hospitals in Cincinnati. In addition to being a registered dental hygienist,
she is a registered dietitian and a certified diabetes educator. Cyndee received her
doctoral degree in Instructional Design and Technology. She has been in health care
for over 35 years working in private practice, hospitals, community, and academia.
Her unique blend of health care experiences lends to numerous publications in
professional journals and presentations at state, national and international conferences. She will soon
begin working on the 5th edition of The Dental Hygienists’ Guide to Nutritional Care. In addition, she is
serving as the Ohio Chair of Delegates for the Academy of Nutrition and Dietetics.
Email: stegemc@ucmail.uc.edu
24
Crest® Oral-B® at dentalcare.com Continuing Education Course, Revised October 9, 2015