Diabetes Mellitus & Dentistry
Public Health Preventive Strategy
In the section on individual preventive strategy I emphasised the need for in depth education and consistent educational reinforcement. In practice this means that Public and Professional Bodies need to get their act together with front line clinicians. There is no sign that this is happening yet. I strongly suspect that there will be the usual amateurish fudge so typical to British responses to issues of this kind.
The matter is made more complicated because health care in the UK is devolved to the Welsh and Northern Irish Assemblies, the Scottish Parliament as well as the Westminster Government for England. The likelihood is then that each will invent its own wheel in the short term, but in the long term there may just be the possibility of adopting best practice from each jurisdiction.
Here are my suggestions to start this process.
National Health Departments
The main general educational focus has to be yours. You could start with a simple poster campaign placed in every hospital diabetic clinic (and GP practice ?) to advise diabetics to seek regular dental care because diabetes and periodontal disease are interrelated. When all these extra patients require extensive dental treatment in the future you will be picking up that bill. Remember an ounce of prevention is better than a pound of cure. Will this happen? I doubt it, but challenge the four Chief Dental Officers to prove me wrong.
The new NHS dental contract is claimed to promote the prevention of dental disease. With the above risk factors, diabetics will need special, extra consideration.
The Diabetes Now website does mention periodontal disease as a complication of diabetes without explaining in detail what it is or what the consequences can be. I found no mention of the other dental complication xerostomia with that disease’s potential for significantly increasing the risk of rapidly developing and extensive caries.
British Dental Association
Where is your voice on this matter? You seem to me to be just a reactive organisation answering specific questions from journalists, as reported in the popular press, from time to time. You obviously have good contacts with the Press. I suggest you need to become proactive and start to publish articles on a regular basis to inform the public of the medical problems associated with periodontal disease, diabetes, heart disease, miscarriages, rheumatoid arthritis, possibly some forms of nephropathy and Alzheimer’s and urge attendance for preventive care.
Have you considered the manpower implications for all the extra dental treatment that could be required in future? Do you have an information and guidance leaflet for your Members on this important issue? When will you publish a comprehensive examination, advice and treatment schedule for UK dentists to follow for this group of patients rather than leaving matters to individual choice, which are likely to range from, on a normal distribution curve, from excellent to inadequate?
British Dental Health Foundation
You have done a great job to increase the awareness of oral cancer and promote early attendance for professional assessment. However, the numbers though important are relatively small when compared with the potential number of patients with diabetic periodontopathy. Can I urge you to start a new campaign for this group too.
General Medical Practitioners
Advise each diabetic patient to attend for dental examination and care and record who is the GDP. This may be a ‘tick box’ exercise, but hopefully it will start an interprofessional dialogue between doctors and dentists, something I have found consistently lacking during my career. Provide the GDP with details of your care including HbA1C blood test results.
General Dental Practitioners
You will already have taken a comprehensive medical history for each patient and updated it regularly at recall appointments. You should record the name of your patient’s GP and their phone number and be prepared to discuss individual patients especially if their periodontal status is continuing to deteriorate and be prepared to share your dental findings whilst requesting medical results. It also follows that, if you have a patient with developing periodontal disease that has an atypical pattern you must consider diabetes or prediabetes as a contributing factor and refer your patient to his/her GP for blood sugar investigations, especially Hba1C levels.
Accurate, ongoing dental records are essential and here I think the Basic Periodontal Examination is insufficient as it is avery crude measurement of periodontal disease originally devised for epidemiological studies. The scle of 0 to 4* is confusing for patients as it implies a gradual worsening rather than the real apples and pears distinctions with each number dentist know to be the case. I urge full 6 point pocket depth measurements, a bleeding index, record of gingival recession, plaque control and full mouth radiographs to establish bone levels against which comparisons can be made at future appointments, and intra-oral photographs. The move away from chemically processed to digital radiographs is a welcome development, as they can be rapidly viewed. However, if you have more traditional films then the worst thing you can do is put them into one, or more, of those white film packets, simply because they will rarely be viewed again. The human eye is better able to see change on a series of radiographs, so at the very least, all such films should be mounted and dated for this purpose. This also raises the question about the timing of repeat radiographs to avoid unnecessary radiation. This will have to be determined by clinical presentation and the rapidity or otherwise of periodontal deterioration. For apparently well controlled cases, perhaps further radiographs at 3 yearly intervals is indicated.
The Access to Medical Records Acts of 1991 and 1998 gives every patient the legal right to obtain their notes from you. In my experience you will obtain a better patient response if you show your patients what is happening from your examination and special investigations. Even better give your patient a copy of their pocket measurement chart, and Spacemark interspace brushing chart if you have prepared one, and further copies at yearly intervals. In this way patients can see for themselves where there is any deterioration, and this could well be a powerful motivator to improve plaque control.
Stage one of treatment is to remove supra and subgingival calculus and biofilm, the latter of which can only be removed by ultrasonic scaling, teaching OHI and interproximal plaque control.
In the first instance recalls are likely to be at three monthly intervals, depending on patient response, this interval may be increased. The classic signs of periodontal improvement are:
- Reduction in the number of bleeding points
- Reduction in pocket depth
- Reduction in plaque score
- No further bone loss radiographically.
In my experience prescribing a Spacemark chart for correct interproximal brush sizes for each, individual space, patients would regularly report that they could use a larger diameter brush in some spaces. The reason, better plaque control had allowed for further reduction at a microscopic level of the inflammatory response. The fifth sign of periodontal improvement is therefore
- Increase in interspace brush diameter in some interproximal spaces with time. This can be quantified for both clinical improvement and research records.
Dentists also need to be aware that another dental complication of diabetes is xerostomia, and burning mouth or tongue and altered taste, which may be an early sign of diabetic neuropathy.