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Last month's column, “Diabetes and dentistry — Part 1,” discussed the relationship between diabetes and periodontal disease, in particular the adverse effect each has on the other. Part 2 will focus on practical aspects of managing patients with diabetes and periodontal disease.
There are three types of diabetes: Type 1, Type 2, and gestational diabetes. Type 1 was previously called juvenile diabetes and is characterized by autoimmune destruction of the insulin–producing beta cells in the pancreas. Insulin regulates the movement of sugar from the bloodstream into the cells. Type 1 diabetics are on an insulin pump for life.
Type 2 diabetes used to be called adult onset diabetes. Type 2 diabetics do not produce enough insulin, and the body is resistant to the effects of insulin. Type 2 diabetics are commonly on oral medications such as Glucotrol, Actos, or many others. Some Type 2 diabetics also need insulin. Gestational diabetes is similar to Type 2 and occurs during pregnancy.
The primary reason to know the level of glycemic control when treatment planning diabetic patients with periodontitis is the likelihood and predictability of favorable treatment outcomes depend heavily on it. Well–controlled individuals have the same treatment challenges as nondiabetics. Favorable results are much less likely for people with poor glycemic control.
Physicians monitor diabetic control by utilizing a blood test that measures the percent of glucose attached to red blood cells, called hemoglobin A1c (HbA1c). Readings of 6.5% to 7.0% and under represent good glycemic control. Levels of 8% and above occur in individuals whose blood sugar is out of control.
We need to know the HbA1c level of all diabetic patients, especially those with periodontal disease. Simply ask the patient. If his or her A1c level is in the well–controlled range, treatment expectations will be similar to nondiabetics, which is challenging enough. Patients with high A1c levels are considerably more difficult to manage and will need more frequent monitoring of perio treatment results.
If the patient does not know his or her HbA1c level, simply call the physician's office. Well–controlled diabetic individuals have their A1c levels checked twice a year. Poorly controlled diabetics are checked four times per year.
Treatment planning should include the manner in which nonresponding sites will be addressed. Utilizing the wide array of adjunctive therapies should be considered. Bacteria–reducing adjuncts to consider include: irrigation during the scaling and root planing appointments with chlorhexidine or 10% povidone iodine, locally applied antibiotic usage such as Arestin, and systemic antibiotic use.
It is important to keep in mind, especially when treating perio patients with diabetes, that periodontal tissue destruction is caused by the interplay between the bacteria and the body's immunoinflammatory response to the bacteria. Addressing the host response by prescribing 20 mg doxycycline should be kept in mind as well.
The two most important determinants of how long favorable treatment outcomes last are meticulous home care to reduce biofilm levels, and adhering to three–month professional maintenance intervals.
This is true for all periodontal patients, but critical for those patients with diabetes. Strong consideration should be given to recommending power toothbrushes, rinsing daily with an antimicrobial mouthwash, and flossing devices and interdental cleaners as needed.
Researchers conservatively estimate that the number of diabetic people will nearly double in the next 25 years. By the year 2034, there will be at least 44 million diabetics in the United States. These are conservative estimates since the numbers do not take into account the increasing incidence of obesity among children and teenagers, or population changes.
Physicians are struggling with large diabetic caseloads. In the near term, dental professionals will be able to diagnose diabetes using gingival crevicular blood samples. Managing the oral contribution to diabetic control by preventing and treating periodontal disease is critically important.
Understanding how to treat and monitor diabetic perio patients, keeping up with research and advances in technology, and utilizing new information and treatment modalities as they become available will help us do our part in managing the diabetes epidemic in this country. We are truly in a position as dental professionals to impact our patients' health beyond the oral cavity.
Dr. Richard Nagelberg has practiced general dentistry in suburban Philadelphia for more than 27 years. He is a speaker, advisory board member, consultant, and key opinion leader for several dental companies and organizations. He lectures extensively on a variety of topics centered on understanding the impact dental professionals have beyond the oral cavity. Contact him at [email protected].