The United States is facing a new epidemic—diabetes. The Department of Health and Human Services (HHS) estimates that approximately 40% of Americans aged 40 to 74—more than 41 million people—have prediabetes (higher than normal blood sugar levels without the diagnosis of diabetes).1 Oral health care professionals have a responsibility to educate clients about diabetes and make appropriate referrals. The initial symptoms of the disease can manifest in the oral cavity.
The new HHS estimate is more than double the previous estimate of 20 million people with prediabetes in this age group.1Many people with prediabetes go on to develop type 2 diabetes within a decade. In April 2004, former HHS Secretary Tommy G. Thompson and the HHS-sponsored National Diabetes Education Program launched the first national multicultural diabetes prevention campaign, “Small Steps. Big Rewards. Prevent Type 2 Diabetes.”2 African-Americans, Latinos, American Indians, Alaska natives, Asian-Americans, Pacific Islanders, and adults over 60 are at particularly high risk for type 2 diabetes. The campaign enlists the aid of community groups to empower people at high risk to make modest lifestyle changes that can prevent or delay the onset of type 2 diabetes. Campaign materials, including consumer-friendly motivational tip sheets, are written in several languages specifically tailored for high-risk groups.
THE OBESITY CONNECTION
The rapid increase in the number of people with diabetes and those at risk for the disease is closely following the nation’s increasing obesity rates. In March 2004, the Centers for Disease Control and Prevention (CDC) released a study that found that deaths due to obesity will soon overtake tobacco as the leading preventable cause of death.3 Obesity is a key risk factor for developing type 2 diabetes.
Without intervention, one in three children born in the year 2000 will develop diabetes in his or her lifetime. Latina girls have a one in two chance of developing diabetes in their lifetime. We need to get the word out that type 2 diabetes can be prevented.
The Diabetes Prevention Program (DPP), a ground-breaking study sponsored by the National Institutes of Health (NIH), found that people at increased risk for type 2 diabetes can prevent or delay the onset of the disease by losing 5% to 7% of their body weight through increased physical activity and a reduced fat and lower calorie diet.4 In the Diabetes Prevention Program, moderate weight loss proved effective in preventing or delaying type 2 diabetes in all groups at high risk for the disease. This study also showed that, in addition to diet and exercise, the oral diabetes drug metformin (Glucophage) could prevent or delay the onset of type 2 diabetes in people with impaired glucose tolerance. 5
Another area of concern is gestational diabetes or diabetes during pregnancy. Risk factorsinclude: over 25; overweight or obese; family history of diabetes; member of a highriskethnic group; previous gestational diabetes; and history of stillbirth or very large baby. Having two or more risk factors signifies high risk, one is average risk.6 A revised version of the former publication— Managing Gestational Diabetes: A Patient Guide to a Healthy Pregnancy —is available for download at: www.nichd.nih.gov/publications/ pubs/gdm/gdm.htm.ORAL INDICATIONS OF DIABETESWhen diabetes is not controlled properly, high glucose levels in blood and saliva can increase the number of oral bacteria and periodontitis can exacerbate blood glucose levels. As diabetes reduces the body’s resistance to infection, the oral cavity is often affected,resulting in periodontal disease. Other oral conditions associated with diabetes include oral candidiasis, gingivitis, periodontitis, salivary and taste dysfunction, xerostomia, lichen planus, dental caries, glossodynia (pain in the tongue), and neurosensory dysesthesia (distortion of a sense, especially touch).7 Oral health professionals should be alert for the symptoms of diabetes: signs of acute infection, such as bleeding and exudate; signs of gingivitis and/or periodontitis, such as bleeding, redness, or exudate; xerostomia; dental caries, especially rampant caries; oral lesions associated with fungal infections, such as angular cheilitis, pseudomembranous Candidiasis with white patches, or denture stomatitis; burning mouth or tongue; and paresthesia, tingling, numbness, or pain associated with pathological changes in the nerves.
RISK FACTORS FOR DIABETES
Age: Risk increases with age.
Overweight: Body mass index of 25 or higher (23 or higher if Asian-American, 26 or higher if Pacific Islander).
Blood pressure: 140 over 90 mm/Hg or higher.
Cholesterol: Abnormal lipid levels—HDL cholesterol less than 40 mg/dL for men and less than 50 mg/dL for women; triglyceride level 250 mg/dL or higher.
Family history of diabetes: Having a parent, brother, or sister with diabetes.
Ethnicity: African-American, American Indian, Alaska native, Asian-American, Pacific Islander, or Latino heritage.
Pregnancy: History of diabetes in pregnancy or giving birth to a baby weighing more than 9 lbs.
Inactive lifestyle: Exercise less than three times per week.
Source: National Institute of Diabetes and Digestive and Kidney Diseases.
Crisis situations can arise during oral health care sessions. An insulin deficient client with acute hyperglycemia may have fruity breath and a hypoglycemic client may have weakness, sweating, mental confusion, lack of coordination, and trembling. Your office should be prepared to manage these emergency situations.
To ensure safety in your office:
- Assess the client’s glycemic control;
- Refer client to a physician if diabetes is suspected but not diagnosed;
- Consult with client’s physician regarding any oral complications;
- Use a glucometer;
- Assertively treat oral infections;
- Maintain frequent preventive maintenance appointments;
- Reinforce optimal oral hygiene measures; and
- Support tobacco cessation efforts.8
Patients with uncontrolled diabetes may need antibiotic premedication due to increased susceptibility to infection. Also, adjustment of insulin or other diabetes medications may be necessary for some oral procedures. Dental hygienists should use local anesthetics with epinephrine sparingly, as large amount of epinephrine can antagonize the effects insulin and result in hyperglycemia. Patients with diabetes should receive nutritional counseling by medical and oral health care professionals. In addition, optimal oral hygiene should be emphasized, including frequent toothbrushing; interdental cleaning with dental floss and/or interdental brushes; oral irrigation; mouth rinses and gels for caries control, such as fluorides; mouth rinses for gingivitis control, such as chlorhexidine; and locally delivered antibiotics (in-office) for treatment of periodontitis.
Lifestyle changes are integral to preventing diabetes for those at high risk. DPP lifestyle materials can be found at www.bsc.gwu.edu/dpp/lifestyle/dpp_dcor.ht ml. This information can be posted in your office or shared with clients one-on-one. The materials focus on lifestyle choices, healthy nutritional habits, and frequent exercise.
As preventive oral health care specialists, dental hygienists play a large role in preventing systemic disease. The increased prevalence of obesity is driving the epidemic of type 2 diabetes in America.9 Sharing educational materials and information about the pathophysiology of obesity is necessary to address this major threat to public health. We must be cognizant of confounding factors, such as puberty or middle age, associated with weight gain and patterns of weight gain, which are associated with diabetes. We must ensure that our clients benefit from research and that evidence-based medicine from clinical trials is speedily but scrupulously translated into clinical practice across various models of health care delivery. We can join groups and institutions in supporting diabetes prevention and science-based approaches to modify behavior and enhance delivery of effective diabetes care.
- American Diabetes Association. All about diabetes. Available at: www.diabetes.org/about-diabetes.jsp. Accessed January 13, 2005.
- National Diabetes Education Program. Small Steps Big Rewards, Prevent Type 2 Diabetes. Available at: www.ndep.nih.gov/campaigns/SmallSteps/SmallSteps _index.htm. Accessed January 13, 2005.
- Mokdad AH, Marks JS, Stroup DF, Gerberding JL. Actual causes of death in the United States, 2000. JAMA. 2004;291:1238-1245.
- Diabetes Prevention Program. Lifestyle manuals of operations. Available at: www.bsc.gwu.edu/dpp/manuals. htmlvdoc. Accessed January 13, 2005.
- Diabetes Prevention Program Research Group. Reduction in the incidence of type 2 diabetes with lifestyle intervention or metformin. N Engl J Med. 2202;346:393-403.
- National Institute of Child Health and Human Development. Are you at risk for gestational diabetes? Available at: www.nichd.nih.gov/publications/pubs/gest_diabetes.htm. Accessed January 13, 2005.
- Ship JA. Diabetes and oral health. J Amer Dent Assoc. 2003;134(suppl):4S-10S.
- Vernillo AT. Dental considerations for the treatment of patients with diabetes mellitus. J Amer Dent Assoc. 2003;134(suppl):24S-33S.
- Franklin J. Diabetes clinical trials: what is new at NIDDK? Clinical Diabetes . 2004;22:109-112.