Module 205.5 en

Hinweis der Redaktion

1. Oral health is an often neglected aspect of diabetes management. Oral heath needs to be incorporated into the diabetes management regimen because: People need to be informed about the relationship between blood glucose management and oral health Poor oral health may affect one’s ability to eat properly and affect their nutrition Oral health behaviour may be an indicator of behaviour related to diabetes self-management
2. The oral health – general health relationship: 1.The relationship between periodontal disease and diabetes is well established while the relationship between other oral diseases and diabetes remains inconclusive (International Diabetes Federation, 2009). Periodontal disease if not treated can result in tooth loss and negatively impact one’s overall health and well being. This module will focus primarily upon the relationship between periodontal disease and diabetes. Further research is needed to strengthen the relationship between diabetes and oral health. 2. Xerostomia (dry mouth) can be a side effect of some medications such as anti-hypertensives, but also can be noted during prolonged periods of hyperglycaemia 3. People with diabetes have an altered immune response thereby affecting their ability to resist infections such as oral candidiasis 4. People with diabetes may be more susceptible to neuropathies affecting the mouth such as burning mouth syndrome 5. Factors which may increase the risk of dental caries are dry mouth (saliva buffers mouth acids, therefore a decrease in buffering capacity may result in a greater risk of caries development) and consumption of sugary foods to treat hypoglycaemia 6. Delayed healing of sores and ulcers in the mouth follows the same rationale as foot ulcers; therefore oral self-examination accompanied by good self-care is vital International Diabetes Federation Guidelines Task Force. (2009). IDF guideline on oral health for people with diabetes. Brussels: International Diabetes Federation. (Retrieved: August 2, 2010) http:// www.idf.org/idf-guideline-oral-health-people-diabetes
3. The self-examination (Glavind & Attström, 1979) is performed at a washbasin in front of a wall mirror. The participant is asked to record the following findings: Missing teeth Appearance of gums: are gums more red and inflamed than usual? Brushing test: bleeding following tooth brushing Toothpick test: bleeding following placement of a toothpick between teeth Mobility test: check for tooth mobility using the handle of the toothbrush’ Migration test: check to see if teeth have moved out of position (signs of this include tipped or rotated teeth, teeth that appear to have lengthened, a change in spacing between the teeth) The individual then provides the results to their oral health care professional at a recall appointment for assessment and treatment. In cases where access to oral health is limited, the results can be provided to their diabetes care professional for advice. American Academy of Periodontology. (2010). Frequently asked general periodontal questions. (Retrieved May 14, 2010). http://www.perio.org/consumer/faq_general.htm National Diabetes Education Program. (2007). Working together to manage diabetes: a guide for pharmacists, podiatrists, optometrists, and dental professionals. Atlanta, GA: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, 2007. Accessed 02/08/10 at http://ndep.nih.gov/publications/OnlineVersion.aspx?NdepId=NDEP-54
4. The slide of the healthy mouth shows a person who has good oral health. There are no visible signs of oral disease. The slide for periodontal disease shows a person who is not so fortunate. There are visible signs of periodontal disease: Red and inflamed gums Gum recession Teeth which have shifted position The self-care is not up to standard as there is noticeable plaque and stain on the lower teeth. The stain is characteristic of a smoking habit. This individual requires professional oral health care and needs to improve self-management with better oral hygiene and quitting tobacco use.
5. Pathophysiology: It is possible that there is a bi-directional relationship between periodontal disease and diabetes. Dental plaque is a sticky film containing bacteria that can adhere to tooth surfaces. These biofilms initiate an immune response. People with diabetes have compromised immune and inflammatory responses creating greater susceptibility to bacterial infections such as those encountered in periodontal disease. Inflammatory mediators such as CRP can alter insulin sensitivity leading to hyperglyaemia that can facilitate the growth of bacteria in the biofilm. Gestational Diabetes Mellitus: Intraoral changes occur during pregnancy due to hormonal changes, creating an increased susceptibility to oral infections (Russell & Mayberry, 2008). There is also an enhanced inflammatory response to dental plaque and tartar which can cause the development of intraoral pyogenic granuloma. Early studies show that gestational diabetes may pose an increased risk for the development of periodontal disease (Xiong et al, 2009).
6. The World Health Organization (WHO) notes that non-communicable diseases (NCDs) such as diabetes and oral health share preventable risk factors related to lifestyle such as diet, nutrition and tobacco use (Petersen, 2005). Improving health outcomes by modifying these common behavior-related risk factors would assist in prevention, primary care and ongoing management of NCDs. Nutrition: Diets rich in carbohydrates, high in sugar content and saturated fat compromises oral health and are leading factors in the rise of type 2 diabetes. Globalisation of this western dietary trend is a component of the growing incidence of dental caries and type 2 diabetes in the developing world. Public education related to the importance of making the right dietary choices will help in battling oral disease and diabetes (Goldman et al, 2008, IDF Diabetes Atlas, 2009). The American Dietetic Association supports the collaboration between dietitians/nutritionists and dentistry in research, curriculum, referrals and clinical practice (Tougher-Decker et al, 2007). Tobacco: Diabetes and tobacco use are common risk factors for the development of cardiovascular disease, the complication that accounts for the highest morbidity, mortality and healthcare costs in diabetes (WHO, 2008). In oral health, tobacco use can promote periodontal disease, poses greater risk for development of oral cancer, suppresses the immune system and delays healing (Petersen, 2003). Tobacco use is a modifiable risk factor which must be mitigated through prevention and cessation protocols and no smoking policies. Petersen PE.(2005). Priorities for research for oral health in the 21st century--the approach of the WHO Global Oral Health Programme. Community Dent Health. 22(2), 71-4.). Mannarini L, Kratochvil V, Calabrese l, Gomes Silva, Morbini P, et al. (2009). Human papilloma virus (HPV) in head and neck region: review of literature. Acta Otorhinolaryngol Ital. 29: 119-26. Goldman, A.S., Yee, R., Holmgren, C.J., et al. (2008). Global affordability of fluoride toothpaste. Globalization and Health, 4:7. Touger-Decker R, Mobley CC, American Dietetic Association. (2007). Position of the American Dietetic Association: oral health and nutrition. J A Dietet Assoc., 107: 1418-1428. Other modifiable risk factors which can damage oral health are alcohol consumption and acquiring HPV through oral sexual activity increasing oral cancer risk (Mannarini et al, 2009).
7. Note to the educator: Example: Chewing betelnut is a risk factor in some areas.
8. Good oral health is an important aspect of diabetes management. People with diabetes need to be vigilant with routine oral self-examinations and perform necessary oral health self-management to achieve this goal. Risks to oral health need to be avoided and good oral hygiene must be practiced to sustain a healthy mouth. People with diabetes are not alone in the fight against oral disease. Oral health and diabetes health professionals perform important roles in managing oral health. Diabetes health professionals provide self-management education and oral health care professionals provide preventative and oral health services to maintain good oral health. Most oral diseases are preventable, therefore people with diabetes have the most important role in avoiding oral disease because it relies heavily on their daily lifestyle and oral health self-management skills.
9. Optimal diabetes management and oral health are impossible to attain without good self-management skills. It is important to convey not only the necessary information people need to perform these skills but also to motivate people in order to achieve self-efficacy for sustainable positive outcomes (Sandberg, Sundberg & Wikblad, 2001). Studies of the psychosocial characteristics of oral health habits and diabetes adherence among people with diabetes suggests there is an association between these behaviours (Syrjala et al, 2004). Self-efficacy is the best determinant of oral health and general health behaviours and may be the best predictor of a health-promoting lifestyle. Promoting self-efficacy in one aspect of healthcare may translate into improved self-efficacy in other aspects of healthcare. Health care professionals may be able to help people increase self-efficacy by promoting a positive psychological state through support and positive feedback (Knecht, 1999).
10. Note to the educator: Take a few minutes for group discussion.
11. The frequency for recall oral health examinations varies according to risk for oral diseases such as periodontal disease, dental caries, and oral cancer. Some recommendations are: National Institute for Clinical Excellence (NICE): the interval is determined specifically for each person and is based on their risk levels for disease. The recall interval ranges from a minimum of 3 months to a maximum of 12 months (people 18 years or younger) to 24 months (people over 18 years) (NICE, 2004). American Academy of Periodontology (AAP): risk assessment was used to create criteria to assist the dental team in identifying and referring patients for specialty care (AAP, 2006). Canadian Dental Association (CDA) : recall frequency based on risk assessment and is determined by the dentist in partnership with the patient (CDA,2010) Diagnosis: Visual and radiographic check for dental caries, periodontal disease, and other oral pathology. The primary instrument used in the diagnosis of periodontal disease is the periodontal probe. It measures pocket depth, which is the distance between the gingival margin and the base of a pocket. Probing depth greater than 3 mm indicates periodontal disease. Other measures such as bleeding on probing, bone loss (assessed radiographically), gingival (gum) recession, and tooth mobility are all factored into a diagnosis of gingivitis (affecting soft tissue) or mild, moderate or advanced periodontitis (affecting both soft and hard tissues). Probing requires skill and specific training and should only be performed by a qualified oral health care professional.
12. Treatment: Gingivitis and periodontitis: Initial therapy involves scaling and root planing teeth to disrupt the biofilm (plaque and tartar) which will reduce inflammation. Treatment of periodontal disease may also involve gum surgery to restore periodontal health. In cases of advanced periodontal disease, teeth with a poor prognosis would be removed. Individuals with a history of periodontal disease require more frequent recall appointments due to increased risk. Treatment: Dental caries: Restore teeth using operative dentistry to maintain dental function. In cases where there is gross decay, teeth with a poor prognosis are extracted. Individuals with greater risk of caries require more frequent recall appointments to assess for caries and provide preventative services such as fluoride treatments. Treatment: Missing teeth: Restore function using prosthetics such as dentures, bridgework or dental implants.
13. World Health Organization. Oral health services. (Retrieved May, 1, 2010) http:// www.who.int/oral_ health/action/services/en/print.html Watt RG. (2005). Strategies and approaches in oral disease prevention and health promotion. Bulletin of the World Health Organization, 83, 711-18.
14. The principal objective of integrating oral health care into diabetes management is to ensure that all individuals with diabetes have proper oral health (Gillis, 2010). Integrated prevention of oral disease and health promotion (WHO, 2007): Oral diseases are largely preventable An integrated common risk approach focuses efforts towards common risks and their social determinants; re-orient oral health services towards care models centered on prevention and health promotion The common risk approach provides a rationale for partnership and integration with other chronic disease prevention programs and with national public health programs; this approach holds importance in countries with limited numbers of health personnel Effective interventions are needed to prevent oral disease and promote oral health across populations; this will decrease the need for high cost dental treatments Gillis M.R. (2010). A place for oral health in diabetes management. J Can Dent Assoc, 76:a24 World Health Organization. (2007). Oral health: action plan for promotion and integrated disease prevention. (Retrieved April 26 2010) http://www.who.int/oral_health/ World Health Organization. (2007). Oral health; fact sheet No 318. (Retrieved May 7, 2010) http: www.who.int/mediacentre/factsheets/fs318/en/print.html
15. Screening for periodontal disease using clinical protocols is costly. A less-costly resource method that can be integrated into existing systems is self-reported measures (Eke & Genco, 2007). The development of an eight question, self-administered questionnaire is undergoing validation in the US by the CDC Periodontal Disease Screening Project. Success of this project will: Provide reliable, cost effective surveillance methods for predicting the prevalence of periodontal disease through interviews Provide a means for health professionals to screen for periodontal disease using the self-reporting questionnaire In the meantime, the questionnaire could help diabetes care professionals identify people with diabetes at risk for periodontal disease. Eke P.I., Genco, R.J. (2007). CDC periodontal disease surveillance project: background, objectives, and progress report. J Periodontol., 78, 1366 71.
16. Screening for undiagnosed diabetes: The dental office may be a setting to identify individuals with undiagnosed diabetes (Borrell et al, 2007; Strauss, 2008). As the incidence of diabetes continues to rise with a concomitant number of undiagnosed cases, dentists may be able to screen people using a self-reporting questionnaire for risk assessment. The self-reported information along with an intraoral periodontal exam could identify those at risk so that they can be referred to their primary health care provider for further assessment. Further validation studies need to be completed to determine the success of this screening protocol. Chairside screening by dentists for medical conditions is gaining increased attention. A random survey (Greenberg et al, 2010) of general dentists in the US revealed that most dentists support medical screening and were willing to incorporate it into their practices (55.9 % were willing to collect blood via a finger stick). The primary barriers to incorporating chairside screening into dental practices is a lack of training and knowledge. Borrell L.N., Kunzel C., Lamster I., Lalla E. (2007). Diabetes in the dental office: using NHANES III to estimate the probability of undiagnosed disease. J Periodontol Res, 42, 559-565. Greenberg B.L., Glick M., Frantsve-Hawley J., Kantor M.L. (2010). Dentists’ attitudes toward chairside screening for medical conditions. J Am Dent Assoc, 141(1), 52-62. Strauss S., Russell S., Wheeler A., Norman R., Borrell L.N., Rindskopf D. (2008). The dental office visit as an opportunity for diabetes screening: an analysis using NHANES 2003-2004 data. J Public Health Dent, 1-7.
17. Oral health is largely under recognised by diabetes health care professionals, whereas prevention and care of all the other complications of diabetes are addressed. Oral health professionals are generally not listed in the diabetes management team. People with diabetes are generally unaware of the importance of oral health in their diabetes management regimen. IDF advanced the importance of oral health in diabetes management with the release of its oral health guideline at the World Diabetes Congress in 2009.
18. Petersen PE. (2005). Priorities for research for oral health in the 21st century--the approach of the WHO Global Oral Health Programme. Community Dent Health, 22(2):71-4. International Diabetes Federation. (2009). Diabetes Atlas, 4th ed. Brussels: International Diabetes Federation.