April 2009
Volume 30, Issue 3

Education and Attitudes about the Association between Periodontal Disease and Diabetes: Recent Studies for Dental and Medical Professionals

Pamela Allweiss, MD, MPH

The evidence is growing about the bidirectional relationship between periodontitis and diabetes. Is this information being disseminated to oral health and medical providers as well as to people with diabetes? These articles examined the “awareness and attitudes” of providers and patients about the oral-systemic disease relationship and the need to educate providers and patients about the interdisciplinary approach to treating oral health and diabetes. Some private groups (insurance plans) and public health agencies are looking at how this education can be done. For example, the National Diabetes Education Program—a joint Centers for Disease Control and Prevention and National Institutes of Health program (www.ndep.nih.gov)—has materials about diabetes and oral health geared toward dentists and people with diabetes. These materials discuss the oral health-diabetes connection and how important the dental practitioners are in an integrated approach to care.

The consensus review by Williams et al concludes that oral health education should be considered part of the general healthy lifestyle messages to improve outcomes in the growing population of people who have diabetes or are at risk for developing diabetes and/or cardiovascular disease. Allen et al analyzes the attitudes and knowledge about the oral-systemic connection in people with diabetes and finds that more education is needed. Finally, Wilder et al analyzes the curricula for dental and dental hygiene students that focus on the oral-systemic connection and how these future practitioners are trained to deliver the message of the oral-systemic health connection. These articles illustrate the recurrent theme: closer collaboration and cross-discipline education is needed between oral health professionals and the medical providers who care for people with diabetes as well as the need for education about the periodontal-diabetes connection targeted toward people with diabetes.

Williams RC, Barnett AH, Claffey N, et al.  The potential impact of periodontal disease on general health: a consensus view. Cur Med Res Opin. 2008;24(6):1635-1643.

A consensus group of physicians and dentists convened in 2008 to review and debate the evidence about the periodontal-systemic health relationship and to recognize the role that each group plays in team care. The article gives a summary of at-risk patient groups and the possible two-way relationship of oral health and diabetes and concludes that more large scale prospective studies are needed to further examine the effect of periodontal treatment on glycemic control and clinical outcomes in people with diabetes (as well as research of the oral health-cardiovascular relationship).

Allen EM, Ziada HM, O’Halloran D, et al. Attitudes awareness and oral health-related quality of life in patients with diabetes. J Oral Rehabil. 2008;35:218-223.

This study looks at the knowledge and attitudes about oral health in people with diabetes. Many participants were aware of their increased risk of cardiovascular and eye disease (84% and 98%, respectively); however, only 33% knew of their higher risk for periodontal disease. In the past year, 43% of the participants saw a dentist but only 43% were aware of the higher risk of periodontal disease. Of the participants who were cognizant of the increased risk of periodontal disease, one half received this information from a dentist. A total of 62% of the participants with poor metabolic control (hemoglobin A1c [HbA1c] > 9%), and 77% with moderate metabolic control (HbA1c 7.5% to 9%) were not aware of their higher risk for periodontal disease. Further research is needed to see the impact of oral health on dietary choices and its effect on metabolic control.

Wilder RS, Thomas KM, Jared H. Periodontal-systemic disease education in United States dental hygiene programs. J Dent Educ. 2008;72(6):669-679.

The article acknowledges the importance of the science linking oral health to systemic conditions and mentions that a few third-party providers have modified their dental reimbursement for patients who have periodontal disease and other preexisting conditions. A survey was sent to 286 directors of accredited dental hygiene programs (response rate of 63%), asking how students are taught about the periodontal-systemic disease connection and whether it was incorporated into the didactic and clinical aspects of the program. The survey examined the following: 1) resources for teaching material; 2) content in an interdisciplinary format with dental hygiene students and other health professional students; 3) opinions of dental-hygiene education directors regarding the level of education the students received about periodontal-systemic health connection; 4) program directors’ opinions about the knowledge of other health professional faculty in their community concerning the periodontal-systemic health connection; and 5) information about how the students were evaluated in their ability to assess the periodontal-systemic disease connection, discuss the risks, and refer to the appropriate specialist.

The top three topics covered in the curricula in oral-systemic disease were diabetes, tobacco use, and cardiovascular disease. The top three resources for education in the curricula were journals, Web sites from national healthcare agencies, and dental hygiene textbooks. Only 4% had joint content with other health professional students, such as those in nursing, medicine, or allied health. Only 9% thought physicians and nurses were knowledgeable of the oral health-systemic disease connection, and 25% taught 6 or more hours about diabetes. Of these programs, 80% provided formal training on how to discuss the periodontal-systemic disease connection with patients. More than 90% of the programs had curricula that evaluated students on how to assess risk and perform diagnosis with regard to diabetes, 92% of the programs evaluated students on how they discussed the risk with patients about diabetes, and 68% assessed the students’ performance on referring to a specialist.

The directors were confident that their students were knowledgeable about the inflammation and oral-systemic connection and the students would play a role in assessing patients’ risk. The directors were unsure if nurses and physicians had a sufficient knowledge of the oral-systemic health connection. They also wanted more evidence-based teaching materials, including patient pamphlets in English and Spanish, updated PowerPoint® presentations, DVDs, and case studies.

Wilder RS, Iacopino AM, Feldman CA, et al. Periodontal-systemic disease education in U.S. and Canadian dental schools. J Dent Educ. 2009;73(1)38-52.

Wilder et al continues the review of curricula in dental school education programs, showing that information on the oral-systemic health connection is integrated into schools of dentistry, both in the classroom and clinical curriculum. A survey was sent to academic deans at 65 dental schools in the United States and Canada (response rate 77%). The primary topics covered in the didactic curriculum regarding periodontal-systemic disease were aging, cardiovascular disease, diabetes, and tobacco use. Of the respondents, 88% reported their students are knowledgeable about the role of inflammation and its impact on oral-systemic conditions, and 48% said they provide formal training for students on how to discuss aspects of periodontal oral-systemic disease with patients. The survey also found 53% spent more than 6 hours teaching the oral health-diabetes connection. Most used journal articles and textbooks as resources. Only 16% included periodontal-systemic content in interdisciplinary student groups (dental hygiene, nursing, medical, or other allied health). Only two schools conducted joint projects with other health professional students and 47% of the schools trained their students on how to communicate aspects of the oral health-systemic disease connection. Almost 60% of schools evaluated their students on whether they discussed the risks or oral health-systemic disease connection and diabetes. Few programs evaluated whether the students refer to other specialists; however, when they do, 77% referred patients with diabetes to a dentist and 61% referred to a medical specialist.

Surveys of the directors of both dental hygiene and dental school programs showed these directors believed nurses and physicians were not very knowledgeable about the periodontal-systemic disease connection. More work is needed to educate dental students on how to work with other healthcare providers to co-manage patients at risk for oral-systemic conditions.

About the Author

Pamela Allweiss, MD, MPH
University of Kentucky
Lexington, Kentucky

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