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From Research Into Practice
September-October, 2008 edition

Commentary on “Survey of Diabetes Knowledge and Practices of Dental Hygienists”

By Linda D. Boyd, RDH, RD, EdD

Boyd LD, Hartman-Cunningham M, Calomeni J. Survey of diabetes knowledge and practices of dental hygienists. Journal of Dental Hygiene, Vol. 82, No. 5, Fall 2008.

Abstract

Background: Increasing incidence of diabetes in the United States and risk for more severe periodontal disease in individuals with poorly controlled diabetes make it essential to provide access to education to prepare oral health providers to care for this population.

Objective: The purpose of this survey was to assess the dental hygienist’s diabetes knowledge, beliefs concerning the disease and clinical practices to identify professional continuing education needs.

Methods: A five-part survey was constructed using the American Diabetes Association 2007 Clinical Practice Guidelines and the American Association of Periodontology Commissioned Review of diabetes and periodontal disease. Invitations to participate were disseminated electronically to American Dental Hygienists’ Association (ADHA) members. A convenience sample of dental hygienists (n=392) representing 48 states participated.

Results: The majority of the respondents were female (99 percent), ages 41 to 60 (60.1 percent), and in practice > 16 years (58.3 percent). Major deficits in knowledge were associated with the patient’s hemoglobin A1c (HbA1c) value and implications for diabetes control (50 percent). The survey responses indicated confusion about the current classifications of diabetes, with 70 percent of respondents using classifications that are no longer recognized. Seventy-five to 90 percent of participants were unfamiliar with the impact of various types of diabetes medications on dental care.

Conclusion: Dental hygienists in this survey demonstrated a need for enhancing knowledge about diabetes as it applies to clinical patient care. The areas of greatest need included the American Diabetes Association Clinical Practice Guidelines for standards of care, diagnosis of diabetes mellitus, medications and best practices for interacting with other health professionals caring for people with diabetes.

Summary of Key Findings in This Article

A common chronic medical condition encountered in dental hygiene practice is diabetes mellitus (Type 1 and 2). The Centers for Disease Control and Prevention (CDC) released 2007 data indicating 23.6 million people have diabetes (diagnosed and undiagnosed) and 57 million had prediabetes.[1]

Approximately 70 percent of the population visits a dental office at least annually.[2] Dental visits provide opportunities to give the patient encouragement for self-care to manage their prediabetes or diabetes as well as to educate them about potential connections between oral health and good diabetes control. The dental hygienist has the chance to build trusting relationships with patients to facilitate discussion of health concerns that few health professionals enjoy. Dental hygienists may be the only health care professional who routinely spends more than 15 minutes per appointment with each patient, and they have frequent (three to six months) visits.

Increasing prevalence of diabetes makes it critical that dental hygienists become better prepared to actively work with other health care providers in diabetes prevention and management.[3] The article by Boyd, Hartman-Cunningham and Calomeni investigated dental hygienists’ 1) knowledge about oral health and diabetes, 2) beliefs about addressing diabetes in the dental office, 3) current practices in providing care to patients with diabetes, 4) barriers to addressing diabetes in the dental office and 5) preferences for topics and modalities for continuing professional education.

Findings from the survey included:

General diabetes and oral health knowledge was relatively current.
A major knowledge deficit was identified associated with the significance of the patient’s hemoglobin A1c (HbA1c) value.
Respondents identified risk factors for diabetes with the exception of polycystic ovary syndrome (PCOS).
Confusion exists about current classifications of diabetes, with 70 percent using obsolete terminology.
Eighty percent of respondents reported not being familiar with the new generation of oral medications, i.e. Byetta®, Precose®, Starlix®.
Half of respondents reported that assessing glycemic control through consultation with the patient’s medical professional was not within their scope of practice, even though the majority believed that educating, assessing and referring patients with diabetes was within their scope of practice.
Respondents were least likely to ask about fasting blood glucose, HbA1c levels and history of hypoglycemia.
Respondents demonstrated a strong desire to increase their knowledge of diabetes (84 percent - 91 percent) with continuing professional education.

What Are the Implications of this Article for Clinical Practice?

Dental hygienists’ ability to effectively collaborate with patients and other health professionals about diabetes control depends on being current in diabetes knowledge. With the movement to increase access to oral health care, many state practice acts permit dental hygienists to work with general supervision or unsupervised in alternative practice settings, making it critical that they be able to interpret the values used to assess glycemic control.

Careful review of the medical history to gather information about the patient’s diabetes, level of control, and medications is essential. Respondents tended to routinely ask about self-monitoring of blood glucose, medications taken and last meal/snack. However, these questions provide limited information about glycemic control, which can impact the ability to heal after nonsurgical periodontal therapy and increase risk for severe periodontal disease.[3] Therefore, the HbA1c is one of the most important pieces of information a dental provider should gather. If the patient does not know this information, obtain permission to have the information faxed to the dental office from the primary care provider.

Another area addressed by less than half of respondents involved questioning the patients about awareness of and history of hypoglycemia. Patients with Type 1 diabetes are at higher risk of hypoglycemia, and a history of hypoglycemia is a predictor of future episodes.[4] Therefore, questions about hypoglycemia are essential to prevent a potential emergency situation. It is important to use drug references to research diabetes medications and become familiar with side effects and possible dental considerations since some medications may increase the risk of hypoglycemia.

It is also essential to understand complications the patient may be experiencing from poorly controlled diabetes. Many of these issues have implications for dental care, e.g., those with retinopathy may have visual impairment and those with neuropathy may have loss of sensation in their hands and fingertips that require changes in oral self-care instructions.

Another area of practical importance is prevention and management of hypoglycemic events. Prevention is the key to avoiding hypoglycemia. Ideally, patients with diabetes should have morning appointments. However, if a patient is seen in the afternoon when the risk for hypoglycemia is much greater, it can be easily managed with early intervention. Preferably, a glucose monitor that the hygienist knows how to use will be in the operatory along with a glucose or glucagon source. Symptoms of hypoglycemia can vary and may include dizziness, perspiration, confusion, shakiness and irritability. Usually the patient knows when the symptoms begin and will alert the care provider. If hypoglycemia occurs, do not leave the patient to get assistance until you have administered at least the first dose of carbohydrate. Postponing treatment for even a few minutes can result in a much more serious emergency. It is also important not to overtreat hypoglycemia with excess glucose as this makes it more difficult for the patient to attain glycemic control. Follow the Rule of 15: Step 1) Eat or drink 15 grams of glucose or fast-acting carbohydrate, such as that found in 1/2 cup of orange juice; Step 2) Wait 15 minutes; Step 3) Check blood glucose with a glucose monitor. If the blood glucose is low (<70 mg/dl), repeat steps 1 through 3.5 Glucagon can be used for more severe hypoglycemic events. If the patient does not begin to feel better after repeating these steps three times the emergency system in your office should be activated.[6] Dental staff needs to be trained to use the glucose monitor as they would for any emergency equipment in the office. A CLIA (Clinical Laboratory Improvement Amendments) certificate is necessary to use a glucose monitor in the dental office and it can be obtain biannually for a fee of $150.[7] The form is available from the Centers for Medicare and Medicaid Services, Health and Human Services Web site at www.cms.hhs.gov/clia/01_overview.asp.

Finally, the dental hygienist needs to be proactive in interacting with other health care professionals to ensure the patients overall health and prevent complications.

Conclusion

Given the increasing incidence of diabetes in the United States and the risk for more severe periodontal disease in individuals with poorly controlled diabetes, it is essential to provide access to regular professional education to prepare oral health providers to care for this population.

The sample of dental hygienists in this survey demonstrated a need and desire to enhance knowledge about diabetes as it applies to clinical patient care. Professional education will increase confidence and competence, thereby enhancing the importance of the role of dental hygienists on the multidisciplinary diabetes care team.

Glossary of Terms

Prediabetes is defined as fasting plasma glucose (FPG) or impaired glucose tolerance (IGT), but with blood glucose levels below those used to diagnose diabetes (100-125 mg/dl).[1,5]

Type 1 Diabetes usually occurs in children as a result of failure of insulin production (previously called Insulin Dependent Diabetes Mellitus [IDDM])

Type 2 Diabetes tends to occur in adults. The body either cannot properly utilize the insulin produced or inadequate amounts of insulin are produced. (previously called Non-Insulin Dependent Diabetes Mellitus [NIDDM]).

Gestational Diabetes occurs during pregnancy and places the woman at higher risk for developing Type 2 diabetes.

Fasting Plasma Glucose (FPG) or Impaired Fasting Glucose (IFG) is when fasting blood sugar levels are between 100 and 125 mg/dl (milligrams/deciliter) on at least two occasions.[8]

Impaired glucose tolerance (IGT) is identified by blood glucose levels 140 to 199 mg/dl two hours after drinking a 200gr glucose load during a glucose tolerance test.[8]

Glycated Hemoglobin or Hemoglobin A1c (HbA1c or A1c) provides an average blood glucose over the previous two to three months and an indication of long-term glycemic control.

Self-monitoring of blood glucose (SMBG) refers to an individual using home blood glucose monitoring to manage their diabetes.

Examples of Medical History Questions for Patients with Diabetes and Possible Answers[4,8]

When did you last see your diabetes doctor or diabetes educator?
Answer: Those with stable glycemic control should be seen twice/year and those with poor glycemic control should be seen at least quarterly.

What medications have you taken today and how much of each?
Answer: Medications should be taken prior to the appointment and patient knowledge about the medications indicates someone taking responsibility for diabetes self-care.

When did you eat last? What did you eat for your last meal/snack?
Answer: The patient should have eaten foods containing complex carbohydrates and protein and/or fat approximately 1-2 hours before the appointment to prevent rapid drops in blood sugar.

Do you monitor your blood sugar at home?
Answer: Yes, SMBG is a critical component of diabetes self-care

How often do you monitor your blood glucose on a daily or weekly basis?
Answer: Those taking multiple doses of insulin should conduct SMBG three or more times daily. Once or twice daily is typical for those using oral medications.

What is your usual fasting blood sugar readings first thing in the morning?
Answer: Glucose levels between 90 and 130 mg/dl and below 180 mg/dl two hours postmeal, although these numbers may be higher for those at high risk for hypoglycemia.

What is your hemoglobin A1c measurement? How often does your doctor check it?
Answer: Less than 7 percent and preferably 6.5 percent or less, A1c testing is recommended twice/year in those with good glycemic control and quarterly in those with poor control.

(If the patient reports poorly controlled diabetes) Are you experiencing frequent urination?
Answer: A response of ‘yes’ may indicate hyperglycemia and poor diabetes control and requires referral to the primary care provider.

Do you have frequent episodes of hypoglycemia (low blood sugar)? Can you tell when your blood sugar is getting low?
Answer: A response of ‘yes’ to the first question and ‘no’ to the second question identify a patient at risk for a medical emergency in the dental office.

(For those with a history of hypoglycemia, ask this question) What time of day does it usually happen and how do you treat it?
Answer: If the appointment is during a critical time of day for hypoglycemia, precautions should be taken to prevent and treat an episode should it occur. If possible, the appointment should be rescheduled for a less critical time of day.

Have you ever been hospitalized for hypoglycemia?
Answer: If the response is ‘yes’, the patient is at extreme risk and preparation should be made to rapidly treat hypoglycemia.

Are you having problems with your eyes, feet, hands, or legs? If so, what kind of problems are you experiencing?
Answer: A patient experiencing complications may be poorly controlled, and a medical consult is advised.

References

Centers for Disease Control and Prevention. National diabetes fact sheet: general information and national estimates on diabetes in the United States, 2007. Atlanta: U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, 2008.
Centers for Disease Control and Prevention (CDC). Behavioral Risk Factor Surveillance System Survey Data. 2006, Department of Health and Human Services, Centers for Disease Control and Prevention: Atlanta.
Mealey BL, Oates TW. Diabetes mellitus and periodontal diseases. J Periodontol 2006; 77(8): 1289-1303.
Diabetes Control and Complications Trial Research Group. Hypoglycemia in the diabetes control and complications trial. Diabetes 1997; 46(2): 271-86.
American Diabetes Association. Standards of medical care in diabetes—2007. Diabetes Care 2007; 30 Suppl 1: S4-S41.
Waslaski J, Benson G. Managing and preventing hypoglycemia. American Dietetic Assoc Diabetes Care and Ed Practice Group; July 2008. Available at www.dce.org/publications/files/managing_hypoglycemia.pdf Accessed Sep. 25, 2008.
Centers for Medicare and Medicaid. Clinical laboratory improvement amendments of 1988 (CLIA): Application for certification. U.S. Dept of Health and Human Services: Baltimore; 2005.
American Diabetes Association. Diagnosis and classification of diabetes mellitus. Diabetes Care 2007; 30 Suppl 1: S42-47.

Linda D. Boyd, RDH, RD, EdD, is an associate professor and director of the online Master of Science Degree in Dental Hygiene in the Department of Dental Hygiene at Idaho State University. She has practiced for 30 years in general and periodontal practices. She serves as a CODA curriculum consultant. Dr. Boyd presents continuing education and publishes widely in textbooks and journals on the topic of nutrition and oral health as well as the development of critical thinking in students.

ADHA members can access the full article online by linking directly to the Journal of Dental Hygiene through the Members section of the ADHA Web site. To view journal articles, log in to the Members section of the ADHA Web site and click on the Member Resources link. Scroll down to the Journal of Dental Hygiene link, which will take you directly to a list of all the available issues online.

This column was made possible by an educational grant sponsored by Colgate Oral Pharmaceuticals.