Dental Hygienist and key opinion leader Jo Dickinson discusses how diabetes management is relevant to dentistry, and how our role is becoming increasingly more important.
In the UK Diabetes affects about 6.5% of the population and this is expected to rise significantly in the future. It is a huge concern to the medical community and the increase of type 2 diabetes has been described as a global epidemic.
There is a significant number of people with undiagnosed diabetes and it could be their dental team who start to suspect that an individual may have developed the condition. It makes sense, then, to have a good practice protocol where these patients are referred to their GP for tests and management. However, our duty doesn’t stop there.
An individual with diabetes will be monitored by their diabetic team to assess their average blood sugar level over the previous 3 months. This gives a very accurate index of how well the diabetes is being managed, which is done by assessing the level of glycated haemoglobin (HbA1c). A healthy count in a diabetic is less than 7%; however, many doctors are keen for patients to aim for less than 6.5%. Anything over 8% is considered to be poor glycaemic control. In comparison, a normal count for a non-diabetic would be about 5.5%. So, when a dental clinician asks a patient about their blood count, it should be bore in mind that the patient may well refer to their daily finger prick test, which will only give the readings of that day. This does not always reflect what is an average count for this patient. Therefore, it may then be prudent to contact the GP and request details of the more accurate HbA1c count.
There is now plenty of evidence that both type 1 and type 2 diabetes are risk factors for periodontitis and that this risk is directly related to the level of glycaemic control. Patients who keep their HbA1c level at 7% or below are at a similar risk level to non-diabetic patients. If periodontal disease is diagnosed, then they usually respond very well to Non Surgical Therapy (NST). There is little or no evidence to suggest that antibiotics should be routinely prescribed for diabetics going through NST. However, what is significant is that studies are suggesting that if periodontal disease is poorly controlled, this can have a negative effect on the glycaemic control, creating a two way effect. A recent Cochrane review identified an average reduction of 0.4% in HbA1c following NST. Given that a reduction of 1% in HbA1c is reported to reduce deaths related to diabetes by 21%, then this 0.4%, produced by NST is significant in improving the overall health of the individual. This is something that dental teams will be expected to do as more diabetics are referred from GPs after diagnosis.
Overall, the increased risk for periodontal disease is estimated at 2 to 3 fold for patients with diabetes. Considering the estimated rise expected in type 2 diabetes, we can expect to see a significant rise in periodontal disease as well.
Diabetes has also been associated with peri-implant disease. Although there is a lot less evidence, it would appear statistically that diabetics have a higher risk of developing peri- implantitis.
Diabetic patients may also present with higher levels of caries, xerostomia, burning tongue syndrome, and candidal infections. Frequently, diabetic patients are also prescribed calcium channel blockers, so drug-induced gingival growth from amlodipine and nifedipine may occur. Lichenoid reactions to metformin may also be observed. Therefore, it may be prudent to contact the prescribing doctor and discuss the possibility of an alternative drug.
In summary diabetes management is relevant to dentistry and our role is becoming increasingly more important.
Author Jo Dickinson
Posted by Gemma