Risk assessment for clients with diabetes.
We are pleased to present the second in a series of four case studies that highlight the skills needed for dental hygiene risk assessment. Each of these cases will illustrate factors that require consideration when forming dental hygiene diagnoses and when developing the comprehensive dental hygiene treatment plan. Risk assessment is an essential component throughout all aspects of the dental hygiene process of care, from identifying disease- and drug-induced systemic risks during the review of systems through post-treatment evaluation. In this column, we present a case of a client with diabetes, with an emphasis on early diagnosis, disease acceptance and client education. The case also depicts the importance of treatment planning appropriate therapeutic and preventive interventions to improve oral health status and benefit the client's systemic health.
Client Profile: Susan is a seamstress for a high-end fashion designer in New York City. She is 35 years of age and has not had an oral examination and "cleaning" in almost two years due to her busy work and travel schedule traveling and working.
Chief Concern: The client decided to schedule an appointment as part of her new focus on health, and because she has noticed an area of "bleeding and puffiness of the gums" along the maxillary right molars, which is accompanied by an unusual taste.
Health History: The client appears to have an unremarkable medical history. She reports that recently she weighed herself at home and discovered that she had gained over 20 pounds during the course of this last year. She presents at 5'4" and 170 pounds. The client admits that she had not been exercising or watching her caloric intake, and decided that it was time to focus on her health. She had a physical examination with a nurse practitioner several weeks ago and was informed that she had high blood pressure. Blood work was performed, but the client does not know the results. She was offered antihypertensive medication, but declined this treatment because she wanted to try weight management and exercise for three months prior to considering medication. She states that she is very reluctant to take medication.
The client states that she researched online weight loss programs and has begun eating almonds and oranges for snacks, and adds cinnamon to her breakfast foods, all to burn fat. She has stopped drinking carbonated beverages and caffeine, replacing them with water or diet decaffeinated green tea. She admits to consuming one glass of red wine typically with dinner each night. In addition, Susan is walking three miles every other day, and reports that she has already lost five pounds. Her goal is to lose 30 pounds within one year.
The client presents with vital signs of 150/96 mm Hg right arm, a pulse rate of 80 bpm, and respiration of 16 breaths per minute. The client appears to take short, deep breaths.
Medication List: The client reports that she prefers not to take any drugs including natural herbs and vitamins. Rarely, she reports taking acetaminophen for headaches. Recently, she has begun to take an acai berry supplement to help her lose weight.
Allergies: The client reports no known allergies to medications, bee stings or foods.
Dental History: Susan reports a history of restorative treatment for caries with amalgam restorations present on the occlusal surfaces of all maxillary molars, and MOD restorations on the mandibular first molars. She cannot recall the last time radiographs were performed. She states that her usual oral care regimen includes brushing multiple times per day to have fresh breath while working with models and clients. She tends not to floss or use mouthrinses because they contain alcohol. The examinee reports chewing gum frequently due to the recent onset of an unusual taste in her mouth and some minor oral malodor. When she noticed some gingival bleeding while brushing, Susan felt it was time to schedule a dental examination.
Patient Assessment and Diagnosis
Intraoral Assessment: Clinical examination reveals mild extrinsic stain along the lingual aspects of the mandibular anterior teeth and palatal aspects of the maxillary anterior teeth. Generalized mild gingivitis is present. The gingival tissues along the buccal aspect of teeth #2 and #3 appear to have severe inflammation and bleed easily; pus can be expressed with compression. Generalized probing depths range from 1 mm to 4 mm, with localized 5-6 mm pocketing interproximally between teeth #2 and #3. A fruity, acetone breath is noted upon expiration.
Based on these findings, the client was asked to complete a risk factor assessment for type 2 diabetes mellitus (Table I). The client reported the following risk factors: hypertension, obesity and inactivity. When questioned further about signs of diabetes, the client denied polyuria and nocturia but does admit to drinking more water. She explained that she does often feel thirsty, which she attributes to increasing her exercise and that drinking more water is good for her weight loss program. She admitted to general fatigue and intermittent parasthesia sensations of the fingers, which she attributed to her job duties and long hours at work. A blood glucometer reading was obtained at chairside, and findings revealed a value of 288.
Table I. Risk factors for Type 2 diabetes
* Age greater than 45 years
* Family history of type 2 diabetes
* Racial descent
* History of GDM or a history of delivering a baby > 9 lbs.
* History of impaired glucose tolerance or impaired fasting glucose
* Hypertension (> 140/90)
* Dyslipidemia (HDL cholesterol <35mgdL or triglyceride level >250mgdL)
* History of cardiovascular disease
* Inactivity, exercises < 3x/week
* Other clinical conditions associated with insulin resistance (acanthosis nigricans)
* Polycystic Ovary Syndrome (PCOS)
From: National Diabetes Information Clearinghouse. National Institute of Diabetes and Digestive and Kidney Diseases. Am I at risk for type 2 diabetes? Taking steps to lower your risk of getting diabetes. Available at: http://diabetes.niddk.nih.gov/dm/pubs/riskfortype2/index.htm. Accessed September 5, 2008.
Radiographic Assessment: Due to periodontal findings and the fact that the client cannot recall when she had any radiographs performed, a full-mouth series was advised. The client declined exposure to radiographs, but consented to a periapical radiograph of the right maxillary molars. This radiograph demonstrated moderate horizontal bone loss and a slight vertical bone loss appearance along the mesial aspect of tooth #2.
Risk Factor Assessment: The client presents with several risk factors that should be considered during the development of the dental hygiene diagnosis and treatment plan. Take a moment and identify these risk factors below.
DHDX: The following diagnoses were presented to the client:
Systemic Health--hypertension, obesity, type 2 diabetes mellitus (to be confirmed)
Oral Health--generalized mild gingivitis, periodontal abscess between teeth #2 and #3
The client was advised to have further evaluation for possible type 2 diabetes mellitus and was examined by her nurse practitioner. Blood glucose levels were obtained on two separate occasions, and findings were 260 mg/dL and 240 mg/dL, respectively. A diagnosis of type 2 diabetes mellitus was confirmed, and the nurse practitioner prescribed metformin. The client declined this medication because she had read that it caused weight gain, opting instead to try her own weight management and exercise program. She agreed to a follow-up evaluation in three months to see if her hypertension and diabetes conditions improved. Susan reported that she would consider taking medication at that time, if results showed no improvement, but again, expressed reluctance about using medications to treat these conditions.
Risks and Strategies for Risk Reduction
Systemic Health Risks
Diabetes mellitus (DM) is a chronic metabolic disease associated with high levels of blood glucose resulting from defects in insulin production, insulin action or both. Recent statistics concerning this disease indicate 23.6 million people in the United States (U.S.) have DM and another 57 million are estimated to have prediabetes. Approximately 25 percent of those with DM do not know they have the disease. (1) According to the Centers for Disease Control and Prevention, those with DM represent an increase of more than 3 million in almost two years. (1) A recent study published in Diabetes Care suggests that approximately 44 million people in the U.S. will have DM by 2034. (2)
DM is often associated with other disease cofactors including hypertension, obesity and dyslipidemia. Results from the 2005-2006 National Health and Nutrition Examination Survey (NHANES) revealed that an estimated 32.7 percent of U.S. adults 20 years and older are overweight, 34.3 percent are obese, and 5.9 percent are extremely obese. Obesity is a major risk factor for cardiovascular disease, certain cancers and DM. (3), (4)
Further, it is estimated that one of three American adults has hypertension. Hypertension is referred to as the "silent killer" because it usually has no noticeable warning signs or symptoms. (5) Nevertheless, hypertension is a major risk factor for heart disease, stroke, congestive heart failure and kidney disease. (6) In 2005, hypertension was listed as a primary or contributing cause of death for 319,000 Americans. (7)
The client presents with stage I hypertension for which she is refusing medication. (8) Hypertension is a common comorbidity with diabetes and is often a component of the metabolic syndrome. (9) Hypertension markedly increases risks for vascular complications leading to peripheral vascular disease, retinopathy, kidney damage, coronary artery disease, stroke and neuropathies. (9) Studies show that hypertensive people with diabetes have twice the risk of cardiovascular disease than hypertensive people without diabetes. (9) Hypertension contributes to the development of retinopathy and neuropathy in clients with diabetes. (9)
Her respiratory rate is elevated at 16 breaths per minute, which is consistent with the accumulation of ketones in the body. Ketones are the metabolic byproducts of burning fats instead of glucose for fuel. The fruity smell on the client's breath is also suggestive of increased ketone production. Diabetic ketoacidosis is a condition that is typically associated with poorly controlled type 1 DM, but can also occur in clients with type 2 DM. Ketoacidosis can develop slowly over time, but can quickly become more serious, leading to an increased risk for diabetic coma. (10) Both the symptoms of increased respiratory rate and the fruity smell on the breath are suggestive that the client's diabetes is not under control.
Risk Reduction Strategies: The client has already identified several risk reduction strategies to manage her systemic health conditions. Weight management and exercise are two important considerations in restoring health. Controlled trials have demonstrated that maintaining modest weight loss through sustained lifestyle interventions such as diet and physical activity reduces the incidence of type 2 DM in high-risk persons by 40 to 60 percent over three to four years. Blood pressure, cholesterol and other lipid control have also reduced diabetes complications. Lowering blood glucose reduced the risk of eye disease by 76 percent, kidney disease by 50 percent, and nerve disease by 60 percent. (11-17) Studies have shown that treatment must be tailored to individual needs, lifestyle, culture and personal values. A one-size-fits-all approach by health care providers was shown to be ineffective in helping people with diabetes improve their health. (18), (19) Encouraging the client to pursue her weight reduction goal and exercise plan for a given period of time seems realistic when considering her concern about avoiding use of medications.
In addition, nutrition counseling can support the client's weight management and exercise program. Balancing use of proteins and carbohydrates will assist with her management of DM. However, the client should be cautioned that a recent study of gustatory function in patients with DM found that those with type 2 DM had a blunted taste response for sweet. This abnormality may influence the choice of nutrients suggesting a preference for sweet-tasting foods. This gustatory influence can exacerbate hyperglycemia. (20)
In addition, a recent consensus report stressed the need for improved assessment and referral mechanisms among health care providers for those clients presenting with periodontal disease and cardiovascular disease (CVD). These recommendations indicate that oral health practitioners need to conduct careful medical assessments to identify risk factors for both periodontal disease and CVD and refer patients for a complete physical examination, annual measurement of blood pressure, blood lipid profile, blood glucose measurement and a plasma hsCRP evaluation. Further, for those clients diagnosed with hypertension, dentists and physicians should coordinate the selection of antihypertensive medication to avoid the worsening of periodontal conditions with the development of gingival hyperplasia. (21)
Since this client has been diagnosed with type 2 DM, she should also be advised to have an annual dilated eye examination and regular exams (every three to four months) with a podiatrist. The client should be instructed to use a glucometer on a daily basis. If she finds learning how to use this device difficult or has other questions about potential medications for diabetes and hypertension management, her pharmacist can be a resource to address these concerns. (22)
The dental hygienist should monitor the client's vital signs at every appointment. Caution should be used when administering local anesthetics containing vasoconstrictors to clients with uncontrolled hypertension. Since epinephrine could be beneficial for hemostasis during scaling and root-planing areas with gingival inflammation, the hygienist should limit the dose of epinephrine to the safe cardiac dose of 0.04 mg per appointment. (23)
According to the American Diabetes Association, experts advise clients to check their urine for ketones when blood glucose levels exceed 240 mg/dl. (10) The client should be counseled to monitor her blood glucose levels daily, especially during this period of time when she is refusing medication. The client should also be taught to use ketone test strips to check her urine daily. (10)
The client reports taking an acai berry supplement to assist with weight loss. The acai berry contains anthrocyanins, which have been shown to demonstrate important antioxidant, anti-inflammatory and anti-cancer effects in the body. (24) However, there is insufficient research that supports the benefits of this supplement for weight loss.
Risk Reduction Strategies: Numerous studies show that drug therapy to reduce hypertension significantly reduces adverse cardiovascular outcomes, especially retinopathy and nephropathy associated with microvascular disease. (25) Weight reduction and exercise can also reduce hypertension and improve glucose control. Treatment recommendations based upon the highest level of scientific evidence suggest that hypertensive clients with diabetes with pressures that are [greater than or equal to]140/90 mmHg be treated with drug therapy as well as lifestyle modifications. (25)
The client is to be commended for her commitment to exercise regularly and to lose weight. However, the client must also be educated about the importance of medical re-evaluation after three months of lifestyle modification, as drug therapy may be an essential risk reduction strategy to improve her long-term health outcomes.
Periodontal abscesses in clients with diabetes should be treated with a combination of mechanical debridement and systemic antibiotic therapy. (26) Antibiotics are beneficial for clients with impaired host response and/or those with medical conditions that predispose them to periodontal complications. (26)
Oral Disease Risks
The client presented with concerns about oral malodor and lack of regular dental and dental hygiene treatment. The clinician noted the presence of a periodontal abscess, gingivitis and acetone breath, all signs associated with DM. These periodontal changes reflect host-response abnormalities such as nonenzymatic glycation and oxidation, imbalance in lipid metabolism, altered collagen metabolism and neutrophil dysfunction. (27) Bacterial invasion of the gingiva stimulates the formation of inflammatory mediators including interleukin-1, tumor necrosis factor-alpha (TNF-[alpha]), prostaglandins and cytokines. These inflammatory mediators lead to production and activation of enzymes that destroy gingival connective tissue and resorb bone. In periodontal disease among persons with diabetes, it appears as though there is an impairment to produce new bone after bone loss has occurred. The cytokines that stimulate loss of tissue, most notably TNF-[alpha], may be responsible for killing cells that repair damaged connective tissue or bone. Further, there may be more TNF-[alpha] produced, which can lead to an even more limited ability to repair periodontal tissues. (28) Without aggressive dental hygiene treatment, this client will be at further risk for periodontal destruction.
Risk Reduction Strategies: Re-evaluation appointments should be scheduled on a monthly basis to evaluate healing of the periodontal abscess and gingivitis. Once the client has been restored to improved oral health, she can schedule continuing care appointments on a three-month basis. Frequent continuing care is essential to monitor effects of DM on the periodontium. If the client continues to have localized pocketing from the abscess after mechanical debridement and systemic antibiotic therapy, a locally delivered antibiotic should be considered. In addition, meticulous oral home care must be stressed. This includes daily toothbrushing, interdental cleaning and use of an antimicrobial mouth rinse. For those clients who are already challenged by both oral and systemic diseases, toothpaste recommendation should be offered based on its ability to control bacteria and reduce inflammation. A toothpaste that contains triclosan is known for its ability to both kill bacteria in biofilm and reduce inflammation (Colgate Total[R]).
This client may be measuring success in terms of improved health with weight reduction. However, this case demonstrated that there are other health considerations and supportive measures that must be employed to avoid further systemic and oral health risks.
Given the oral-systemic connections with diabetes mellitus, it is imperative that dental hygienists reframe their appointments with clients who present with this disease to address their health risks adequately.
(1.) Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007. Atlanta, Ga.: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2008.
(2.) Huang ES, Basu A, O'Grady M, Capretta JC. Projecting the future diabetes population size and related costs for the U.S. Diabetes Care 2009; 32(12): 2225-9.
(3.) Centers for Disease Control and Prevention. U.S. Obesity Trends. Available at http://www.cdc.gov/obesity/data/trends/html. Accessed Dec. 4, 2009.
(4.) Centers for Disease Control and Prevention. Prevalence of overweight, obesity and extreme obesity among adults: United States, trends 1960-62 through 2005-2006. Available at http://www.cdc.gov/nchs/data/hestat/overweight/overweight_adult.htm. Accessed December 4, 2009.
(5.) Centers for Disease Control and Prevention. Department of Health and Human Services. High Blood Pressure. Available at http://www.cdc.gov/bloodpressure. Accessed Dec. 4, 2009.
(6.) National Center for Health Statistics. Health, United States, 2008, with Chart-book on the Health of Americans. Hyattsville, Md, 2008. Available at http://www.cdc.gov/nchs/data/hus/hus08.pdf. [PDF 13.6M]. Accessed Dec. 4, 2009.
(7.) American Heart Association. Heart disease and stroke statistics--2006 update. Circulation. 2009.
(8.) National Heart Lung and Blood Institute. The Seventh Report of the Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC 7). Available at: http://www.nhlbi.nih.gov/guidelines/hypertension/jnc7full.htm. Accessed Dec. 9, 2009.
(9.) American Diabetes Association. Treatment of hypertension in adults with diabetes. Diabetes Care. 2003; 26(suppl 1): s80-s82.
(10.) American Diabetes Association. Ketoacidosis. Available at: http://www.diabetes.org/living-with-diabetes/complications/ketoacidosis-dka.html. Accessed Dec. 9, 2009.
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(12.) The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. The Diabetes Control and Complications Trial Research Group. N Eng J Med. 1993; 329: 977-86.
(13.) UKPDS Group. Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes. (UKPDS) Group. Lancet. 1998; 352; 837-53.
(14.) UK Prospective Diabetes Study Group. Tight blood pressure control and risk of macrovascular and microvascular complications in type 2 diabetes. IKPDS 38. UK Prospective Diabetes Study Group. BMJ. 1998;317:703-13.
(15.) Goldberg RB, Mleeies MJ, Sacks FM, et al. Cardiovascular events and their reduction with pravastatin and diabetic and glucose-intolerant myocardial infarction survivors with average cholesterol levels; Subgroup analyses in the cholesterol and recurrent events (CARE) trial. The Care Investigators. Circulation. 1998; 98: 2513-9.
(16.) Heart Outcomes Prevention Evaluation Study Investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus. Results of the HOPE study and MICRO-HOPE substudy. Heart Outcomes Prevention Evaluation Study Investigators. Lancet 2000; 355: 253-9.
(17.) Schwartz IS, Boccuzzi SJ, Glick H, et al. Cost-effectiveness of LDL-C reduction in diabetic CHD patients: Implications from the Scandinavian Simvastatin Survival Study (4S). Circulation. 1997; 96(Supp1 1): 1504-5 [Abstract].
(18.) Little JW, Falace DA, Miller CS, Rhodus NL. Dental management of the medically compromised patient, 7th ed. 2008. St. Louis: Mosby Elsevier, 212-35.
(19.) Sack K: Doctors miss cultural needs, study says. The New York Times. June 10, 2008. Available at http://www.nytimes.com/2008/06/10/health/10study.html. Accessed Jun. 10, 2008.
(20.) Gondivkar SM, Indurkar A, Degwekar S, Bhowate R. Evaluation of gustatory function in patients with diabetes mellitus type 2. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2009; 108: 876-80.
(21.) Friedewals VE, Kornman KS, Beck JD, et al. The American Journal of Cardiology and Journal of Periodontology Editors' Consensus: Periodontitis and atherosclerotic cardiovascular disease. J Periodontol. 2009; 80: 1021-32.
(22.) Centers for Disease Control and Prevention. Working together to manage diabetes: a guide for pharmacists, podiatrists, optometrists, and dental professionals. Atlanta, Ga.: U.S. 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.
(23.) Malamed SF. Handbook of local anesthesia, 5th ed. St. Louis: Elsevier Mosby, 2004: 46-7.
(24.) Zafra-Stone S, Yasmin T, Bagchi M, et al. Berry anthocyanins as novel antioxidants in human health and disease prevention. Mol Nutr Food Res. 2007 Jun; 51(6): 675-83.
(25.) Arauz-Pacheco C, Parrott MA, Raskin P. The treatment of hypertension in adult patients with diabetes. Diabetes Care 2002; 25: 134-47.
(26.) American Academy of Periodontology. Position paper: systemic use of antibiotics in periodontics. J Periodontol. 2004; 75:1553-65.
(27.) Ryan ME, Carnu O, Kamer A. The influence of diabetes on the periodontal tissues. J Am Dent Assoc. 2003; 134:34S-40S.
(28.) Graves DA, Al-Mashat H, Liu R. Evidence that diabetes mellitus aggravates periodontal diseases and modified the response to an oral pathogen in animal models. Compend Contin Educ Dent. 2004; 25(7) (Suppl 1): 38-46.
JoAnn R. Gurenlian, RDH, PhD is president of Gurenlian & Associates, and provides consulting services and continuing education programs to health care providers. She is a visiting scholar at Capella University.
Ann Eshenaur Spolarich, RDH, PhD is clinical associate professor, Herman Ostrow School of Dentistry of the University of Southern California, and adjunct associate professor and course director of Clinical Medicine and Pharmacology at the Arizona School of Dentistry and Oral Health.
This column was made possible by an educational grant sponsored by Colgate Oral Pharmaceuticals.
By JoAnn R. Gurenlian, RDH, PhD, and Ann Eshenaur Spolarich, RDH, PhD
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|Title Annotation:||periodontal therapy|
|Author:||Gurenlian, JoAnn R.; Spolarich, Ann Eshenaur|
|Date:||Jul 1, 2010|
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