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Cause and Effect

Although inconclusive thus far, studies continue to investigate what role periodontitis plays in an individual’s ability to maintain diabetic control. It is fact, however, that diabetes increases the risk for periodontal disease and that periodontal disease initiates the body’s inflammatory response. Here’s how these relationships are presently understood.

Periodontitis is a bacterial infection of the gingiva (gums) and periodontium (the connective tissue and bone supporting the teeth). Such infections may induce chronic inflammation, which, in turn, may decrease insulin-mediated glucose uptake, leading to high blood sugar and reducing diabetic control.

Oral inflammation begins when bacteria accumulate in the mouth and form plaque. These bacteria can release toxins that infiltrate inflamed oral tissue, enter the bloodstream and spread systemically. Circulating toxins can stimulate the immune response and trigger release of inflammatory markers that are thought to increase insulin resistance, boosting glucose levels in diabetics.

The risk runs both ways: Diabetics with poor control of blood sugar get periodontal disease more often and more severely than do persons with good control. Among young adults, those with diabetes have about twice the risk for periodontal disease compared to those without diabetes. In one study of 263 diabetics, the prevalence in individuals aged 19 to 32 was 39%.

What’s the connection? Insulin is needed to take up blood glucose and store it as glycogen in the liver and muscles. Too much sugar in the blood may increase the risk for vascular complications associated with diabetes, such as thickening of blood vessels. Thickened blood vessels may slow the flow of oxygen and nutrients to inflamed oral tissue and hinder the removal of harmful wastes, increasing the risk for gum disease.

Treating periodontitis may lower the rate of vascular complications associated with uncontrolled blood glucose. In fact, complete metabolic control of diabetes may not be possible when periodontal infection is present, according to the National Diabetes Information Clearinghouse.

Collaboration between medical and dental professionals will strengthen as research continues to investigate the oral-systemic link.

Diabetes mellitus is thought to affect 4.8% of the 2.2 million inmates in the United States, according to estimates in NCCHC’s 2002 Health Status of Soon-to-Be-Released Inmates report. Health care professionals struggle daily to help these patients control their diabetes. Unfortunately, this population tends to have poor compliance with diabetes control regimens, which typically focus on diet, exercise and lifestyle.

But there’s another promising strategy in the fight to control diabetes: good oral health. Several recent studies have reported an association between diabetic control and periodontitis. Although a causal relationship has not been proven, it is believed that oral inflammation associated with periodontitis increases the risk for diabetic complications. (See box at right to learn more about this relationship.)

Many inmates possess risk factors associated with periodontitis, including stress and smoking, as well as backgrounds marked by poverty, poor nutrition and hygiene, lack of education, dental phobia and poor dental treatment. They also are afflicted with diseases predisposing them to periodontitis, such as HIV, TB, syphilis, herpes, cancer and diabetes. In prisons, widespread use of prescription medications contributes to xerostomia, or dry mouth, which also increases the risk. Ethnicity may play a role, as well. It is estimated that periodontal disease affects 35% of Hispanic-Americans and 42% of African-Americans, although the reason for these differences is unclear.

Furthermore, the costs of treating periodontitis and diabetes are staggering. In 2006, researchers evaluated the effects of periodontal disease on the use and cost of medical and dental health care among 4,285 civil officers aged 40-59. Those with severe periodontitis accrued a 21% higher total cost of medical and dental care.

Because periodontal infection may complicate management of diabetes, and because both conditions are so costly to treat, it is important to include periodontal assessment and therapy as part of the diabetic treatment plan in correctional facilities. That’s why the Edna Mahan Correctional Facility for Women, Clinton, NJ, has initiated a performance improvement program to aggressively treat periodontal disease in its diabetic population.

Taking Measure
The average population at EMCFW is about 1,000 at any given time. Of these 1,000 women, 80 to 90 have some form of diabetes mellitus, a rate higher than the NCCHC estimate. Our goal was to monitor and improve the periodontal health of the inmates, reduce diabetic complications, increase compliance with treatment regimens and improve continuity of care between medical and dental professionals.

The current standard for periodontal therapy in the New Jersey Department of Corrections is to offer a complete dental prophylaxis within 60 days of intake and once every two years thereafter. If periodontitis is diagnosed at the initial visit, the inmate is generally rescheduled for follow-up.

Our performance improvement initiative determined that an aggressive approach for diabetes patients with periodontitis would involve more frequent recall, monitoring of infected areas, site-specific periodontal scaling, root planing and curettage, antibiotic therapy and antimicrobial irrigation.

To monitor the periodontal health of these inmates, the dental hygienist recorded data using five dental indices. The information was documented in the electronic medical record of each inmate and on a spreadsheet for quick reference. The indices are as follows:

• Plaque index (0-3 scale): This measures the level of plaque along the gumline or in the gingival pocket (the natural space surrounding each tooth). Plaque is an indicator of bacterial accumulation and a risk factor for periodontal disease.

• Calculus index (0-2 scale): When plaque calcifies in the oral cavity, it is known as calculus, or tartar. Subgingival tartar calcifies below the gumline and poses a greater risk for inflammation.

• Debris index (0-3 scale): This records the amount of stain or debris on the tooth surface. Stain accumulation aids the build up of plaque and tartar and indicates poor hygiene.

• Bleeding index (percentage): Theoretically, healthy gums do not bleed, and bleeding is a major indicator of periodontal health. This index records the percentage of bleeding points per tooth surface. Generalized bleeding is defined as affecting 30% or more of tooth surfaces, whereas localized bleeding affects less than 30%. The goal was to reduce gingival bleeding to less than 30%, signifying control of the periodontal infection.

• Gingival inflammation index (0-3 scale): Gum inflammation is another key indicator of periodontal health. Normal to mild inflammation was considered controlled and not aggressively monitored.

Target Patients
After deciding on these oral indices, we consulted the medical staff to determine the target population among the 81 diabetes patients we had at that time. The medical staff actively monitors all diabetes patients for HbA1c level (a measure of the glycosylated hemoglobin in the blood). An HbA1c level close to or within a range of 4% to 5.9% indicates good glucose control; levels exceeding 7% indicate compromised control. When this project began, 31 inmates were labeled “uncontrolled,” with HbA1c levels greater than 7%. These inmates became the target population for aggressive treatment of periodontal disease.

The women were recalled for periodontal assessment and therapy as needed. At each visit, oral indices for periodontal disease were documented. Depending on the degree of infection, the women were rescheduled from two weeks to three months later for aggressive periodontal therapy. The disease was considered localized when less than 30% of bleeding sites remained. The patients were then scheduled for a dental prophylaxis in one year.

During this time, the dental hygienist also monitored the HbA1c level of these uncontrolled diabetic inmates using the medical record. The HbA1c level was documented before the initial dental prophylaxis, immediately before the aggressive periodontal treatment intervention and then tracked thereafter. The medical staff was supportive of the project and helped by conducting the additional HbA1c testing.

Measurable Improvement
Of the 31 inmates targeted for aggressive periodontal treatment, 22 accepted treatment (the other nine were either released, transferred to another prison, refused to participate or had no teeth). The average HbA1c level of the uncontrolled diabetic inmates before aggressive periodontal treatment was 8.2. After the intervention, the average level was 7.3. Furthermore, the HbA1c level remained the same or decreased in 17 inmates. Of the remaining five inmates, two had a higher HbA1c level, but no data were available for the other three.

Approximately six months after we started the performance improvement project, the periodontium of 10 of the 22 diabetic inmates was considered healthy. The remaining 12 continued to be actively rescheduled for periodontal treatment, and at this writing, only five of the inmates still have an HbA1c level above 7%. Thus, good diabetic control has been restored for more than three-fourths of the women in this study.

Monitoring and tracking HbA1c levels of diabetic inmates by dental staff also has improved continuity of care. On intake, through collaborative efforts of all health care professionals, inmates can be educated to help them understand the relationship between diabetes and periodontal disease. Signs and symptoms of periodontal disease can be explained to promote their acceptance of preventive oral health care.

— About the authors: Lori Strunck, RDH, is a dental hygienist at at the Edna Mahan Correctional Facility for Women in Clinton, NJ. She can be reached at ljstrunck@yahoo.com. Carl B. Ausfahl, RN, MS, CCHP, is the quality improvement director for Correctional Medical Services’ Maryland office; at the time this article was written, he served in the same role in the CMS New Jersey office.