Patient Education

A patient with diabetes presents an education moment for the dental professional. Patients with diabetes do not typically receive thorough information regarding the care of the oral cavity and its relationship to diabetes in a formal education program. It is the responsibility of the dental professional to tailor the dental information to meet the needs of the patient. The primary message is the importance of normoglycemia, which should be reinforced by all healthcare professionals. Normalizing blood glucose values will lead to improved oral health which ultimately affects the patient’s overall health. In most cases, a patient with diabetes should be making the same lifestyle choices as any other healthy individual with the exception of monitoring the timing, quantity, and sometimes quality of carbohydrate intake. The oral hygiene regime would be the same message given to any patient.

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As with any other patient, dental professionals should encourage smoking cessation for many reasons including strong evidence implicating smoking as an established risk factor for periodontal disease and a major element in inflammation control. Carbon monoxide and the vasoconstricting effect of nicotine will lower the ability of the hemoglobin to transport oxygen, thereby, causing a greater accumulation of plaque. In addition, it is valuable to demonstrate and encourage the practice of monthly oral self-examinations to identify early signs of infection or abnormal tissue involvement.

Several dental procedures may result in a need for modification in the diabetes regime. These situations may require the expertise of the other members of the diabetes team. Inform the patient of what to expect following a given procedure, such as several tooth extractions, placement of one or more implants, or a periodontal debridement. The physiological stress caused by the infection or the dental procedure can cause hyperglycemia. The patient on a diabetes medication regimen may need to consult their physician for an adjustment. Even patients on MNT and exercise alone may temporarily need diabetes medication. The patient may also need to obtain additional blood glucose levels to monitor changes due to trauma from treatment. Maintaining adequate hydration needs to be recommended. When regular foods are not tolerated, the carbohydrate levels still need to remain consistent throughout the day with recommendations of soft foods or liquids as substitutes. Depending on the nature of the dental treatment, the patient may need a referral to a dietitian prior to the treatment. Blood glucose levels should be tested more frequently and values 250 mg/dL or higher may require a call to the physician.

A bidirectional relationship between diabetes and depression has been suggested in the scientific literature, resulting in poorer control of blood glucose levels which will ultimately increase the risk of long-term complications and decrease the quality of life. Unfortunately, this topic is not often discussed among oral healthcare professionals; to date, there is limited research on this topic as it pertains to oral health education initiatives. Self-care is not only the cornerstone to diabetes management but it is also the cornerstone to good oral health and is the key to success in disease prevention and management. The prevalence of depression is about twice as high among individuals with diabetes as it is among the rest of the population. Not only does depression affect adherence to diabetes medications, depression is also highly correlated with physical inactivity, poor nutrition, and smoking.32,33

Randomized controlled research trials to improve depression among individuals with diabetes have had mixed effects on diabetes outcomes and some have been positive. “Among patients with poorly controlled diabetes receiving specialty care, an earlier study of cognitive behavioral therapy and diabetes education showed a clinically significant reduction in A1C level at the six-month follow up when compared to a control group receiving diabetes education only.”10

In a study that enrolled patients from nine primary care clinics, participants received an evidence-based collaborative depression treatment that included pharmacotherapy, problem-solving therapy, or both. Surprisingly, diabetes self-management did not improve among the enhanced depression group during a 12 month period. Self-care interventions for dental patients with specific oral conditions should also be studied, and it is recommended that a coordinated therapeutic approach that considers coexisting chronic diseases is a suggested approach.10

A 2017 systematic review of knowledge and practices of diabetes care providers in oral health care and their potential role in oral health promotion discovered that most diabetes care providers are not addressing oral healthcare.37 Five databases were searched and relevant studies published through October 2016 were included (n=30).

Even though diabetes educators can engage in oral health promotion, few studies show how this model of care could translate into improved patient outcomes.37

A 2018 systematic review confirms that many individuals with diabetes have inadequate oral health knowledge, poor oral health attitudes and lower compliance of recommended oral hygiene behaviors and dental visits.38 The authors recommend a multidisciplinary approach involving oral health professionals.38 In reviewing 15 studies about patients’ attitudes towards oral health, it appears that individuals with diabetes rated their oral health as poor and their rating was lower than those without diabetes.38 Individuals from higher income nations perceived their oral health status as higher than those from lower income nations.38 One study included in the review (from the U.S.) showed that about half of the participants acknowledged that taking care of their oral health was important as their general health, but only a third considered the accumulation of plaque/biofilm and calculus as a problem.38 Some of the participants denied there was a link between diabetes and oral health.38