The treatment of diabetes has always centered on the control of blood sugar through medication and appropriate nutritional intake. Preventing oral infection, as an adjunct in controlling blood sugar, has been given little attention. Its significance in a population with a high prevalence of tooth decay and gum disease, such as the Philippines, may be underestimated.
This paper addresses the problem of oral health in diabetic patients and what physicians and dentists can accomplish with a concerted effort to address the problem. Traditional ways of dealing with the problem of oral health will be examined and recommendations will be made promoting preventive strategies against oral infection, early diagnosis of oral problems, and utilization of dental services among diabetic patients.
The current model for management of diabetic patients in the Philippines is the diabetes clinic. The clinic is usually staffed by: a diabetologist or a physician trained in the management of diabetes; a nurse, who aside from providing the usual patient care, functions even more so as an educator on the subject of diabetes; a medical technologist tasked with collecting blood and performing blood glucose determinations and other tests; and a secretary who takes care of administrative matters.
When a patient is diagnosed with diabetes, he is educated on the do’s and don’t’s of being a diabetic. Foremost in the curriculum is familiarity with the type and amount of food appropriate for a diabetic. Familiarization with the medications used to treat diabetes and the factors that promote high blood sugar or low blood sugar is also discussed at this time. A brief mention of the acute and chronic complications of diabetes is also included.
A large part of the management of diabetes is education. Education is so important in the management of diabetes that nurses in diabetes clinics are given the special name of Diabetes Nurse Educator. Their valuable role as educator has been recognized and given proper emphasis. It is not expected that the diabetic patient will be able to grasp all the necessary concepts in a single sitting.
The follow-up visit serves to allow the physician to monitor the patient's blood sugar and to detect at an early stage the development of complications associated with diabetes. The follow-up visit also allows the patient to discuss with the physician any problems he may have regarding compliance and control of blood sugar. Topics discussed in previous visits are reinforced and new ones are introduced. The education of the diabetic patient is a continuous process.
Diabetes affects almost all organ systems of the body, including the gums and teeth. The pathological changes caused by diabetes on the organs of the body are termed diabetes complications. Diabetics are educated on the topic of complications in order to enable the patient to monitor himself and allow for early detection of symptoms of these complications when they occur. Appropriate referrals to specialists are then made when complication develops.
The diabetologist is the prime source of information for patients with diabetes. He wields an enormous amount of influence on the patient's acceptance of and reaction to his diabetes condition. Unfortunately, the topic of oral health is rarely discussed with the patient. It is kept in the background until such time when the diabetic patient presents with a dental problem. Diabetic patients are inadvertently deprived of much needed preventive dental care.
Not everything a diabetic patient learns comes from health care givers. Patient interactions while waiting for their turn with their doctors are notorious for the spread of misinformation. From these obscure beginnings originated the unfounded fears commonly held by diabetics regarding dental treatment.
It is common to hear diabetic patients express their fear to undergo dental treatment, particularly tooth extraction. Reasons given for these fears are uncontrolled bleeding and delayed healing. A review of the literature on diabetes yielded no articles that correlated uncontrolled bleeding in diabetic patients. In fact, the opposite is true. Recent findings reveal that diabetic patients have elevated factors in their blood that promote clotting which may be related to the increasing prevalence of cerebral and myocardial infarction among diabetics. Delayed healing of extraction wounds in diabetics may occur in the presence of elevated blood sugar, but even then, it does not present much of a clinical problem.
Fear, even if unfounded, effectively stymies the motivation to seek dental treatment. In St. Luke’s Medical Center, where the diabetes check-up package includes a dental examination, the presence of root fragments requiring tooth extraction in the mouths of diabetics is quite common.
Root fragments can remain asymptomatic for a long time. For this reason, the patient falls into the mistaken belief that it is all right to let the root fragment remain in the mouth. However, it is expected that this nidus of infection may suddenly cause an acute episode at a time when the blood sugar is elevated and/or when the immune system is under assault. The acute infection can in turn trigger an episode of diabetes ketoacidosis which can easily lead to coma.
Infection has been singled out as the most common cause of diabetes ketoacidosis among type II (non-insulin dependent) diabetics. It is ironic that the patient fears the exact procedure that can prevent the occurrence of more odious conditions.
While patients have fears regarding dental procedures, a good number of dentists too have fears in treating diabetic patients. These fears are caused by a poor understanding of the pathophysiology of diabetes.
From interviews with diabetic patients that I have conducted in my clinic, dentists commonly require them to obtain a medical clearance and/or a recent blood sugar determination prior to rendering dental treatment. Some patients have voiced their doubts about the need for this protocol for every dental procedure.
In addition, it is not only once that I have heard doctors complain that dentists would refuse dental treatment to their patients, even if a medical clearance has already been issued. Some dentists even require that the patient first lower his blood sugar to normal levels, a task which most diabetic will tell you is almost next to impossible.
Feedback from dentists during my talks on diabetes reveals that this fear is rooted in perceived probable consequences that might occur in a patient with high blood sugar. Most dentists are aware that high blood sugar can eventually lead to diabetes ketoacidosis and even to coma or death but only a few are knowledgeable on the guidelines in treating diabetic patients. Somehow, dental education received by dentist have concentrated on the morbid conditions brought about by hyperglycemia.
What most dentists fail to take into account is that diabetes ketoacidosis, a consequence of high blood sugar, is a condition that takes several hours to several days to develop. Its slow onset allows it to be detected before starting dental treatment. However, the mere mention of the word coma is enough to conjure images of a diabetic patient lying unconscious in the dental chair.
As mentioned earlier, some dentists even require that the patient first lower his blood sugar to normal levels. This requirement is not necessary. The 1994 Oral Health Guidelines set by the American Dental Association for treating diabetic patients stipulates that a blood glucose reading of 70 mg/dl up to 300 mg/dl is acceptable for out-patient oral surgical procedures.
The dentist, however, is not fully to blame. Guidelines for the delivery of dental services to Filipino diabetic patients are lacking. Guidelines that are available from other countries are not widely known nor practiced and may not be suitable for the Philippine setting. In a survey that I conducted 2 years ago among diabetes doctors in government hospital diabetes clinics (unpublished), diabetes doctors gave varied answers when asked the following questions:
In the same survey, the doctors voiced their patient's complaint of needing a medical clearance each time they have to go the dentist.
Faced with all these problems, I formulated the following recommendations in the hope that dentists and physicians who are in a position to improve the current status of diabetes dental care, may take the appropriate steps to improve the delivery of dental services to diabetic patients.
I recommend the formation of a tripartite committee composed of diabetic patients, dentists and diabetologists (endocrinologists/internist included) to establish safe and acceptable guidelines for the delivery of dental services to diabetic patients. Dental management of diabetic patients with co-morbid conditions that commonly accompany diabetes such as hypertension, stroke, myocardial infarction and nephropathy, should also be addressed.
The guidelines not only should be acceptable to healthcare givers but also to the diabetic patient. It should be easy to understand and applicable to most situations in the Philippines, urban and rural areas alike. Dissemination of these guidelines to government dentists and physicians, private medical and dental practitioners, medical and dental schools, should be ensured.
Currently, there is mounting evidence to support the belief that diabetic patients are more prone to develop periodontal disease than non-diabetics. A survey of the diabetic patient’s periodontal status during the first dental visit and once a year thereafter should be made mandatory for dentists when treating diabetic patients. Periodontal screening is a simple procedure that can easily be learned by the dentist and performed expeditiously.
The teaching of diabetes in dental schools should be modified with more emphasis given on the safe delivery of dental treatment to diabetic patients and less emphasis on the morbidity that accompany the disease. It is ironic that most dentists fear patients with high blood sugar when, in fact, it is more probable for an emergency episode of hypoglycemia to occur while treating diabetic patients.
Because of this misconception, a dentist may find himself unable to respond appropriately when a hypoglycemic episode occurs. Hypoglycemia can develop rapidly in contrast to hyperglycemia that develops slowly. It may not be present at the start of treatment but may suddenly occur in the middle of a dental procedure. Inability to correct a hypoglycemic state immediately can potentially result in damage to the brain, coma, or even death.
Physicians should be made aware of the value of preventive dental visits for patients with diabetes. Encouragement coming from physicians can become an effective motivation tool to persuade diabetic patients to make preventive dental visits regularly.
It is suggested that a cursory examination of the mouth be incorporated in the follow-up visits of diabetic patients in the diabetes clinic. Physicians and diabetes nurse educators can easily be trained to look in the patient’s mouth and detect the presence of broken down teeth or root fragments. Appropriate referral to the dentist can then be made.
Dentists knowledgeable in the management of diabetic patients, whose clinics are located near diabetes clinics, should be encouraged to share their expertise by providing information or even cursory oral examination to diabetic patients. In this way, the presence of the dentist can further motivate the patients to take care of their teeth. In addition, the line of communication between the diabetologist and the dentist is opened and issues regarding proper management are easily discussed.
Ultimately, the dentist becomes part of the diabetes team, actively participating in the management of the patient. It may be opined that this strategy may not be appropriate in urban areas like Metro Manila. But, in rural areas, it may prove to be the difference between having dental treatment in one’s own locality and traveling several hundred miles to get a tooth extracted.
Educational materials on the topic of oral health should be made and provided to diabetic patients. It should furnish information not only on therapeutic measures to treat oral diseases but also on preventive measures to avoid these diseases. These materials should also try to correct prevailing misconceptions among patients and dentists alike. Commonly found oral diseases like caries and periodontal disease, as well as oral diseases not commonly recognized by the diabetic patient, like xerostomia and candida infection, should also be given emphasis in these brochures.
Although the task that lies ahead seem enormous, little steps have been taken towards the achievement of this goal. In St. Luke’s Medical Center, dental examination is now part of the comprehensive check-up for diabetics.
The Association of Diabetes Nurse Educators of the Philippines has incorporated oral health as part of the curriculum for teaching diabetes nurse educators. The Institute for Studies in Diabetes, Incorporated, has also included oral health in the training of their fellows in diabetes. Patient information brochures have already been prepared, however, funding for mass production of these brochures is lacking.
Lastly, Project Oral Health for Juvenile Diabetics has been launched several months ago. The project aims to provide free/discounted dental treatment to children with diabetes up to nineteen years of age. It hopes to provide assistance to families burdened by the cost of treating diabetes. Dental treatments for these children are provided by dentists undergoing post-graduate training in pediatric dentistry at the Pediatric Dentistry Center. Training of the dentist on diabetes was provided by the consultants of the Institute for Studies in Diabetes, Incorporated.
It is to be hoped that these little steps will one day translate to a better appreciation of the importance of oral health among diabetics, physicians and dentists.