The right questions about diabetes: Do dental patients know that blood sugar levels are linked?

By Jannette Whisenhunt, RDH, BS, MEd, PhD

The mouth is the gateway to the body, yet we often focus on the teeth and gingival tissues and don’t think as much about how that tissue health affects the rest of the body. There are several inflammatory disease processes that affect the mouth, and there are conditions we see in the mouth that might alert us to a patient’s systemic disease. Diabetes mellitus is a disease we deal with frequently. Since it is so common, we need to be familiar with how it affects the oral health of our patients. Diabetes is the “fourth leading cause of death in the United States.”1

As dental health-care professionals, we know many basic facts about diabetes that we use in our everyday practices. Sometimes we suspect a patient has the disease before the patient even has it diagnosed. If we ask the right questions during our medical history review, this might help patients figure out what is happening to them sooner. We need to encourage dental teams to connect with the medical world.

We need to encourage hygienists to ask more in-depth medical history questions to find connections to any systemic diseases patients might have. We can hope that this mindset will start to spread and make dentistry more involved with medicine. We should be active partners with medicine to improve patients’ overall health.

If you have a patient who has been having any of these symptoms - polyuria, hunger, thirst, dry mouth, fruity smelling breath, losing weight without trying, eyesight problems, or foot ulcers that won’t heal - think undiagnosed diabetes.

Positive answers to several of the questions in the chart could be the first indication of prediabetes. If a patient has already been diagnosed with diabetes and has been having higher blood sugar levels than usual, you can help the person understand why this may be happening. It might be because of poor oral health. Your investigation might help patients control their sugar levels better.

It is very important for us to reiterate excellent oral health in diabetic patients because of their slow-healing wounds and high risk for periodontal disease. We need to educate our patients more concerning how oral health can affect blood sugar. When the mouth is healthy, diabetes is easier to control. I think we do a good job of telling patients to maintain excellent oral care, but I don’t think we tell them why as often as we should.

We also need to be aware of other oral conditions, such as angular cheilitis, decreased saliva flow, xerostomia, oral candidiasis, burning tongue, diminished taste perception, and high caries rate.²

The variety of bacteria found in periodontal disease produces inflamed oral tissues that can destroy bone and the periodontium if left untreated. Diseases will progress much faster in a diabetic patient than in a nondiabetic patient. When the bacterial load is high, it can have a negative effect on the blood sugar and make it more unstable. Patients with an uncontrolled blood glucose level tend to be more susceptible to infections, peripheral neuropathy, retinopathy, limb amputations due to vascular disease, and a shorter life span.²

A couple of numbers hygienists should be familiar with when discussing diabetic testing with their patients are:

• HbA1c level (glycosylated hemoglobin) should be under 7 (some sources state 6.5).
• Daily blood glucose test should be between 80 to 120, and if that number gets up to 200, the medical doctor should test for diabetes.

Having high blood sugar every day can negatively affect every organ in the body and require more insulin for balancing the sugar. When the body has a high level of insulin for a long period of time, a person can become insulin resistant, and this makes the tissues unable to respond to insulin in the normal way.²

A hypoglycemic or low blood sugar episode can be very dangerous, and like high blood sugar readings, can be life threatening. The brain has to have glucose to function properly and for a person to survive. Glucagon can be injected directly into the bloodstream in an emergency situation when a patient cannot voluntarily swallow a sugar source. High or low blood sugar can be difficult to deal with, and both can occur in a diabetic patient.

Hygienists need to be able to recognize the symptoms of both high and low blood sugar levels and know how to treat them. Ensuring that a patient has eaten recently and knowing what the person ate can help you be prepared for an emergency. If you’re not sure if the sugar level is too high or too low, then emergency instructions suggest trying to give a sugar source to the patient if the person can swallow.

Performing lab tests for levels of bacteria in saliva, prescribing antibiotics for periodontal disease, and consulting with cardiologists and endocrinologists are becoming commonplace procedures in dental offices. I encourage you to learn all you can about the various inflammatory-based diseases, and try to connect how the oral health of your patients affects their whole body health. Educating diabetic patients to take great care of their mouths to help control their diabetes should be great news to them, and will hopefully encourage them to take better care of their mouths.

Helping patients understand that taking care of their periodontal disease can lead to easier control of their diabetes is something we need to talk about every day with our patients. Use this information to help them become healthier all over. Keeping ourselves updated and informed of the disease processes that our patients may have is a responsibility hygienists have to the profession. We have to remind ourselves that we’re part of the “health care system” and not just “in dentistry.” Happy scaling! RDH

Some questions you can ask patients to further discuss their medical history include:

• Have you lost weight without trying lately?
• Have you noticed any sores in your mouth that take a long time to heal?
• Do your gum tissues bleed easily when you brush or floss?
• Have you noticed a bad smell or peculiar taste in your mouth in the last few months?
• Have you had any eyesight issues lately?
• Have you had any foot sores that take a long time to heal?
• Have you noticed that you’re hungrier or thirstier than usual lately? Are you urinating more frequently?
• Have you had higher than normal blood sugar readings? (Ask this if the patient has already been diagnosed.)

References:

1. Daniel SJ, Harfst SA, Wilder RS. Mosby’s Dental Hygiene Concepts, Cases and Competencies. Mosby Elsevier, 2nd Ed. 2008. Chapter 46. Immune System Dysfunction.
2. Wilkins E. Clinical Practice of the Dental Hygienist 11th Ed. Lippincott Williams & Wilkins. 2013. Chapter 68. The Patient with Diabetes Mellitus.

Jannette Whisenhunt, RDH, BS, MEd, PhD, is the Department Chair of Dental Education at Forsyth Technical Community College in Winston-Salem, N.C. Dr. Whisenhunt has taught since 1987 in the dental hygiene and dental assisting curricula. She has a love for students and served as the state student advisor for nine years and has won the student Advisor of the Year award from ADHA in the past. Her teaching interests are in oral cancer, ethics, infection control, emergencies and orofacial anatomy. Dr. Whisenhunt also has a small continuing education business where she provides CE courses for dental practices and local associations. She can be reached at [email protected].