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Sugar Gum - Diabetes and Gum Disease

Project Added:
23 March 2015
Last updated:
25 March 2015

Sugar Gum - diabetes and disease

Summary

Gum disease is a chronic inflammatory disease which has a direct impact on blood sugar levels, yet diabetic patients are not routinely referred for oral health checks. This project works with high risks groups such as the elderly, people with chronic disease and Aboriginal people. It encourages people with diabetes to make healthy choices by educating them on the importance of oral health and its impact on blood sugar levels. Following dental evaluation, treatment and education, home packages are given to the patients to maintain their oral health.

Sugar Gums promotional poster showing two Aboriginal women and messages about healthy gums

Aim

  • To reduce the number of diabetic patients with gum disease (associated with high glycosylated haemoglobin levels) following oral health evaluation, treatment and education.

Benefits

  • Improved patient outcomes through a preventative, patient-centred approach to diabetes and oral health.
  • Improved education about oral self-care, gum disease and periodontal disease for patients, so they can manage their oral health at home.
  • Professional development of oral health therapists and use of their oral hygiene skills.
  • An interdisciplinary approach to managing diabetic patients.
  • Promotes a collaborative approach to patient care amongst the oral health team and organisations across the network.
  • Possibility of reduced financial impact of diabetic patients on health services.

Project Status

Project status: Sustained - the project has been implemented, is sustained in standard business.

Background

Periodontal or gum disease is a chronic inflammatory disease, which results in the loss of supporting structures of the teeth, through the formation of pathological pockets around the diseased teeth. Periodontal disease is responsible for a substantial proportion of tooth loss in adults.

Patients with diabetes have a higher risk of developing gum disease. A review of the medical history of dental patients indicated that significant numbers of diabetic patients in Menindee, FWLHD had high glycosylated haemoglobin levels (HbA1c >7). Periodontitis is recognised as the sixth complication of diabetes1.

Aboriginal people are three to four times more likely to have diabetes2 and 1.3 times more likely to have periodontal disease3. This project aims to help close the gap in both these areas.

Treatment of gum disease is associated with reduction in glycated haemoglobin4. This treatment provides an opportunity to improve lifestyles by targeting the public health priorities of both diabetes and oral health. By improving and maintaining patients’ HbA1c levels, acute diabetic episodes should be minimised. Maintenance of diabetic patients’ HbA1c levels is a good indication of the stability of the disease.

Implementation

There have been dental services offered in FWLHD for many years, dealing with emergency appointments. With the expansion of dental services to include oral health therapy, there is an opportunity to treat people with chronic diseases such as diabetes, by providing preventative services which will decrease the need for emergency appointments.

This project required a multidisciplinary approach to the treatment of diabetic patients. Quality Improvement Methodology was used, including flowcharts, Ishikawa Diagrams and pareto charts.

Diabetic patients are often referred to a number of specialists, including endocrinologists, podiatrists, cardiologists and renal experts. However, they are not routinely referred for oral health checks. Referral to oral health services provides an opportunity to help maintain glycated haemoglobin levels, decrease acute exacerbations of the diabetes and maintain patients’ teeth for longer, decreasing denture waiting list times.

Kit with toothbrushes, toothpaste and patient information about diabetes and oral health

There was a clear need for teamwork, both within the oral health team as well as the Menindee Health Service and its staff, including Aboriginal health workers, transport officers and administrative staff, who were instrumental in following up patients. This included allocating initial appointments, follow up appointments, and scheduling blood tests as required.

Appropriate appointment times are required for initial oral examination and education. Follow up home maintenance education and cleaning can be completed by oral health therapists. This allows the dentist to concentrate on treatments which cannot be provided by other clinicians. After treatment has been completed, new blood tests are performed. These may be done as part of the patient’s routine diabetic checks and can be followed up with the diabetes educator or Aboriginal health worker.

Amongst the dental team, training tools such as Basic Periodontal Charting instruction, patient education and home care packages, and a collaborative approach to providing excellence in oral health care were paramount to the project’s success.

By providing oral health education and treatment, there is an opportunity to impact public dental wait lists, by maintaining the patient’s own teeth for longer. Following dental evaluation, treatment and education, home packages were given to the patients to maintain their oral health. Data collection included pre- and post-oral health treatment HbA1c blood tests.

By using the existing workforce and combining the skills of dentists and oral health therapists, the dentist’s time can be spent on specific treatment needs, while the oral health therapist’s oral hygiene skills are maintained.

Partnerships

Lead organisations: Royal Flying Doctor Service and Far West Local Health District (FWLHD)

Partners: Oral Health Team and Menindee Health Service, FWLHD

Results

The results showed a reduction in glycosylated haemoglobin levels (HbA1c) in 66% of patients treated, with a significant reduction of 0.5 or more in 22% of patients.

As part of the oral health treatment and education, Basic Periodontal Evaluation (BPE) was completed.

Patients who returned for subsequent visits showed an improvement of at least one. For example, probing depths of four improved to a three and pockets of more than 3.5mm decreased to less than 3.5mm. This is significant in improving the retention of the patient’s dentition by improving periodontal health and showing improved HbA1c, which is indicative of improved stability in their diabetes.

Stable glycosylated haemoglobin levels (HbA1c) at seven or less, decreases the possibility of further complications of diabetes, while retention of the patient’s own dentition allows them to follow a better diet and decreases possibility of other diseases (due to improved mastication and digestion of food.

Lessons Learnt

  • Improvements in the efficiency of oral health services are achieved by better use of the oral health therapist’s skills to provide oral health education and hygiene services to adult diabetic patients. This allows the dentist’s skills to be better used in areas not able to be provided by other clinicians.
  • There is an opportunity to increase productivity, by providing services to more patients, due to less time required for oral health education and cleaning treatments.
  • Subsequent improvement in diabetic patients HbA1c stability would also improve the number of appointments required with the medical practitioner, which can be managed by health care workers.
  • The implementation of this project in other areas of FWLHD, outside of Broken Hill, will require minimal disruption to existing services.
  • Referral to oral health services should be incorporated in the chronic disease care plan and followed up accordingly.
  • It will provide an opportunity for the oral health therapist to visit other areas as well as maintain hygienist skills.
  • In Broken Hill, patients can be referred by their general practitioner (GP). Patients who are seen off the waiting list and indicate that they are diabetic on the medical questionnaire can be followed up by oral health staff.
  • Many patients may require multiple appointments, however timely oral health care reduces dental waiting lists and emergency appointments, and helps maintain better control of patients’ diabetes.
  • Good periodontal and oral health influences the HbA1c of diabetic patients. A multidisciplinary approach using existing personnel, educational posters, home care kits and oral health treatment can have a positive effect on the HbA1c levels.

References

  1. Löe, Harold., Diabetes Care, 16: 329-334, 1993. (Harold Löe 1993)
  2. Diabetes Australia. Aboriginal and Torres Strait Islanders and Diabetes Action Plan: 12 March 2013.
  3. Roberts-Thomson, K., Slade, G.D.: 2007 Australia’s dental generations: the national survey of adult oral health 2004-6.
  4. Preshaw, P.M, Alba, A.L. (...) R Taylor: Diabetologia. Jan 2012; 55(1): 21-31.

Other reading

  1. Grossi S., Skrepcinski, F., DeCaro, T., Robertson D., Ho, A., Dunford, R., Genco, R.: Treatment of Periodontal Disease in Diabetics reduces Glycated Hemoglobin, Journal of Periodontology August 1997; Vol 6: 713-719.
  2. Mealey B.L., Ocampo, G.L., Diabetes Mellitus and Periodontal Disease, Periodontal 2000-2007; 44: 127-153.

Contact

Dr Lyn Mayne
Senior Dentist
Royal Flying Doctor Service
Phone: 08 8080 3777
Email: lyn.mayne@rfdsse.org.au

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