What you should know and how you can help
By Jamie Collins, RDH, CDA
Diabetes—it’s a word that no patient wants to hear from his or her physician. The diagnosis of diabetes, no matter the type, is life altering; it elicits fear of major lifestyle changes and unknown consequences. Type I (insulin-dependent), type II (non-insulin-dependent), or a combined type of diabetes create questions and increased health risks for most people affected by the disease.
Diabetes mellitus is a largely underdiagnosed condition worldwide, with nearly 33 million Americans affected by it in 2015 according to the American Diabetes Association. Of those, a large number, 7.2 million, are undiagnosed, with 84 million Americans considered to be prediabetic (i.e., having an elevated glucose level that can be reversed with diet and exercise). Prediabetics should be closely monitored to evaluate if they cross the bridge to full-blown diabetic status. Within our culture of easy meals and drive-throughs, accompanied with our sedentary lifestyle, more and more of our society is at risk of developing diabetes. The CDC approximates that if the current trend continues, one in three Americans will be diabetic by the year 2050, which is disheartening given the risks of this somewhat preventable disease.
Approximately 193,000 American youth under the age of 20 are affected with diabetes, with nearly 18,000 new cases of type I diagnosed annually, and 5,300 of type II diagnosed in children. Our children are more sedentary and generally heavier than they were a generation ago, which contributes to the increase of type II diabetes in children. In the United States, diabetes ranks as the seventh leading cause of death, which does not include those deaths where it may be an underlying factor or contributing to another cause of death.
The cost of diabetes care in the United States was a staggering $245 billion in 2012, which is the most recent statistic from diabetes.org; I assume it is only higher now. Insulin has been in the news in recent months as the cost of it has soared, but for many, it is a life-saving medication. There are manufacturer coupons available online to assist in the out-of-pocket cost of most brand name medications on the market, something I have seen many people take advantage of over the years. I have noticed that some patients will stop taking or alter the dosage of very expensive medications.
Think of how many patients say they quit a medication on their own for one reason or another when you ask them for updates. I have had patients do that with oral diabetes, blood pressure, and cholesterol medications, among others. Health-care costs for diabetics are 2.3% higher than for those not affected by the disease; without good insurance coverage, diabetes can force patients to choose between having a heated home or medication.
Since January 1, 2018, dental offices have had a CDT code to administer chairside testing for HbA1c to diabetic or at-risk patients. The goal is to identify those patients whom you suspect may be prediabetic or diabetic, and make the appropriate referral to a physician.
The associated risks to overall systemic health are staggering. Despite this, a general physical does not routinely run HbA1c screenings, which help diagnose the disease, especially in the younger population. For those who are not familiar with the range of the HbA1c, nondiabetics are generally under 6.0, with 6.0–7.0 considered controlled diabetes; if the disease is poorly controlled, the number goes up from there. In uncontrolled cases of diabetes, we often see increased risks and incidence of impairment of other body systems and damage to organs. Damage to the retina (possibly blindness), neuropathy, and kidney damage are among the most significant systemic complications. Poorly controlled diabetics also exhibit an increased risk of heart attack and stroke. However, with good glucose control, diabetics can live a long life with few complications.
The role of the dental hygienist
As a clinician, I have found it surprising how many patients will come in for dental recall visits faithfully, but have not seen a medical doctor for a physical for years. I have seen patients experience drastic changes in the oral cavity, even when oral care is spot-on, and no routines or products have recently been changed. There have been patients over the years whom I have referred to a physician for evaluation if I see unexplained changes in oral health and suspect the cause is an underlying systemic condition.
Since January 1, 2018, dental offices have had a CDT code to administer chairside testing for HbA1c to diabetic or at-risk patients. The goal is to identify those patients whom you suspect may be prediabetic or diabetic, and make the appropriate referral to a physician, thus aiding in a diagnosis and possibly preventing full-blown diabetes and potential complications. It is my hope that this code, D0411, will become an integrated diagnostic tool in all dental offices.
We complete an intraoral and extraoral evaluation at each visit; the HbA1c test can be another screening that takes only minutes to complete. The ADA suggests recommending chairside HbA1c testing for patients who are overweight, have a sedentary lifestyle, and have a family history of diabetes, and those patients with an ethnic background associated with a higher risk of diabetes (The publication, Diabetes Care, reported in 2006 that blacks, Asians, and Hispanics may have a greater risk). The test does not require the patient to fast, and can be done at any time throughout the day. Having the ability to screen for diabetes in-office using the D0411 code can give us a better understanding of the cause of a patient’s periodontal diagnosis. Knowing a systemic root cause may better help us treat the periodontal disease by getting the diabetes controlled, as these two disease processes often go hand in hand.
Comorbid disorders and oral risk factors
Many people with type I diabetes, which is an autoimmune disease, will also develop other autoimmune disorders over time. Of individuals who are affected by autoimmune disorders, nearly 25% will eventually develop a codisorder. Hashimoto’s disease, Graves’ disease, Addison’s disease, vitiligo, and celiac disease are among the most common codisorders associated with type I diabetes. One of the most notable associated disorders that we may also see in the dental office is Sjogren’s disease, which can have oral complications due to its effect on the salivary glands.
Periodontal disease is not the only oral risk factor in diabetic patients. Patients may often be on multiple medications to manage the disease, ranging from oral medications, insulin, or a combination of both. In my experience, even those who are only on oral medications often take a combination of multiple diabetes medications to obtain glucose control. Combining medications to treat diabetes and associated conditions can leave us wondering about other side effects. With nearly 90% of medications potentially causing xerostomia, the potential oral risks related to diabetes increase. As a diabetic myself, I took oral medications for years, some of which caused xerostomia in my own mouth. Often, many oral medications help the body to expel the extra glucose through urination, and thus can cause dehydration to some extent. As a hygienist, I was aware of the oral complications and took measures to prevent decay and the periodontal disease process. One of my favorite go-to products for those with high caries risk is Prevident for home use; it is 1.1% sodium fluoride paste that is prescription only. As a perk, it helps greatly with sensitivity for most people as well.
As we have all learned, diabetics are also more prone to certain oral conditions and periodontal disease risks, but recognizing these risks takes vigilance and knowledge. The oral signs of diabetes may present as aggressive periodontal disease, bleeding upon probing without the usual presence of heavy biofilm, and increased caries risk. An undiagnosed or poorly controlled diabetic individual may exhibit excessive thirst, which can lead to the habit of sipping on soda or juice throughout the day, and in turn, this same patient who has not been caries prone in the past may present in your chair with multiple areas of decay. With the medical and dental worlds collaboratively trying to recognize the oral-systemic connection, the ability to screen for diabetes in the office puts us one step closer to prevention and appropriate care. I believe those who display evidence of periodontal disease should be tested for diabetes, using the new HbA1c code, especially since so many Americans are blissfully unaware of their diabetes risk. Remember, 7.1 million Americans are undiagnosed diabetics. Some medical insurance companies are now contributing to the cost of dental care for diabetes, as it has been well proven that poor glycemic control and periodontal disease go hand in hand. If periodontal disease is uncontrolled, it is harder to obtain glycemic control, and likewise, if the diabetes is not well controlled, the periodontal disease can rapidly progress.
A personal case study
I had a patient recently who was a textbook case of this scenario. I saw Jay every three months for years for perio maintenance visits; he follows his home-care instructions with enthusiasm. He was diagnosed with diabetes years before, and took 500 mg metformin twice daily for years. Jay had no pockets over 5 mm and very little bleeding with scaling at each visit, and his disease was well controlled for years, until one visit. He had increased pocket depths to 7 mm with generalized heavy bleeding upon probing, and the tissue was red and inflamed, but he stated he was still consistent with home care. Light plaque and calculus buildup was no different from previous visits, and he was still using his Waterpik daily. We updated the medical history at the beginning of the appointment and he stated no changes had occurred and he was still taking metformin.
I sat Jay up and stated what I had found, and voiced my concerns about the drastic change in his oral health. I laid out questions one after another and told him I felt like something in his health had changed because of my findings. It wasn’t until I asked him pointedly what is HbA1c was that he stated it was a “little high” . . . at 11.2! At that level, he is not only at risk for oral complications, he is also at risk for organ damage such as kidney failure or retinal damage of diabetic ketoacidosis, which are life threatening. Jay said his physician just told him to take 1,000 mg twice daily now and has never had him test his glucose daily or even have a glucometer or meet with a diabetes educator.
As a diabetic myself, all kinds of alarms went off in my head. Jay was clueless that he should be doing these things and was blissfully unaware of the serious risks involved with his health. I encouraged him to talk to his doctor or seek another opinion to help get the diabetes in check. Jay had not had any dietary counseling, and I spent a little time explaining what I have learned about being a diabetic myself. He was not scheduled to see his physician for another six months; had I not been diligent and questioning the changes in oral care, he likely would still be on the same path in another three months or longer. Jay returned to the office at his next three-month perio maintenance visit, and presented with a much improved oral appearance. He had taken the advice to be more proactive about his health and is still taking steps to get control.
Now, in my case, I didn’t fit the typical diabetic scenario; I wasn’t overweight and my body still made some insulin, but just didn’t use it properly and didn’t make enough to be effective. For many years, oral medications to help my body utilize what insulin I made had worked fine, until they didn’t.
The transition to insulin was a difficult adjustment that came after a life-threating reaction to the oral medication I was taking, and being in the field of health care didn’t make it any easier. Learning how to adjust and compensate with insulin requirements in relation to exercise, illness, and stress is a science that I am not sure anyone ever masters without work and self-control. And with any diabetic, it’s a game of ups and downs and finding what works for the individual—no two days are the same. The pharmaceutical device companies are making strides to help diabetics control the disease and limit complications more easily than a decade ago.
For example, a continuous glucose monitor (CGM) makes knowing what my body is doing much easier than ever before. The CGM reads the glucose levels every five minutes and graphs the trends. It is not only about which way the body is trending, but it also limits the amount of times a day that the person is required to perform a finger stick. Having a CGM has made glucose control not only easier, but much less awkward in social situations than taking a finger stick in public. Many type I diabetics use an insulin pump to deliver insulin as needed, while others use the insulin pen that requires self-dosing. The pens are easy to use with short replacement needles and don’t need refrigeration as insulin vials do. Other patients may be on a combination of oral medications and insulin to provide the control needed.
Conclusion
No matter the method of care, a diabetic patient struggles with control on a daily basis, and I personally don’t know a diabetic that hasn’t had ups and downs with care and control at some point. The risks and side effects not only affect the organs, they show up intraorally as well. The new CDT code D0411 to test HbA1c in a dental setting can help identify the number of undiagnosed patients and hopefully reduce the cost of associated complications. With the ability to educate and now test those patients who are at risk or suspected of being diabetic, we can all work together to create a healthier society, and maybe limit the systemic and oral damage if diabetes is caught early.
Jamie Collins, RDH, CDA, resides in Idaho with her husband, Cory, and their four children. She currently works as a full-time hygienist as well as an educator at the College of Western Idaho. In addition, she acts as a content expert and contributor in multiple upcoming textbooks. She can be contacted at [email protected].
References
1. Statistics About Diabetes. American Diabetes Association website. http://www.diabetes.org/diabetes-basics/statistics/. Updated July 19, 2017.
2. D0411 – ADA Guide to Point of Care Diabetes Testing and Reporting. American Dental Association website.
http://www.ada.org/~/media/ADA/Publications/Files/D0411_ADAGuidetoPointofCareDiabeteTestingandReporting_v1_2017Jul17.pdf?la=en. Published July 17, 2017.
4. Cojocaru M, Cojocaru IM, Silosi I. Multiple autoimmune syndrome. Mædica. 2010;5(2):132-134. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3150011/.
5. Krzewska A, Ben-Skowronek I. Effect of associated autoimmune diseases on type 1 diabetes mellitus incidence and metabolic control in children and adolescents. BioMed Research International. 2016;2016:6219730. doi:10.1155/2016/6219730. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4971288/
6. Preshaw PM, Alba AL, Herrera D, et al. Periodontitis and diabetes: a two-way relationship. Diabetologia. 2012;55(1):21-31. doi:10.1007/s00125-011-2342-y. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3228943/.
