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Year : 2017  |  Volume : 3  |  Issue : 2  |  Page : 56-60

Role of Oral Health Professional as Team Care for Diabetes Mellitus

Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi, India

Date of Web Publication28-Jun-2017

Correspondence Address:
Vipul Yadav
Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2394-7438.209027

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India leads the world with largest number of diabetic patients and is termed as “Diabetes capital of the world.” Diabetes mellitus is a major public health problem with incidence rising rapidly at alarming rate. To reduce both the acute and chronic complications arising from diabetes, one needs to provide continuous, proactive, planned, patient-centered, and population-based care through team approach. Team care is the key component of health-care reform initiatives that incorporate an integrated health-care delivery system, especially those for chronic disease prevention and management. Team care can minimize patients' risks of diabetes by assessment, intervention, and surveillance to identify problems early and initiate timely treatment. Oral health-care professionals play an important role as part of the health-care team by providing oral care to patients with or at-risk for diabetes. Collaborative teamwork among dentists and other medical professionals calls for a new model of care, with the dentist playing a leadership role both internally, within the oral health profession, and externally, in relation to other health professions. The increasing focus of dentistry on team effort requires dentists to assume the role of team leader as they are in the front line of prevention, early detection, and treatment of both oral and systemic diseases, and are in a good position to provide screening, diagnosis, and referral services for systemic diseases. Team care is likely to play a major role in future health-care systems designed to provide comprehensive lifetime prevention and management of chronic diseases such as diabetes.

Keywords: Diabetes mellitus, Oral Health, Teamwork

How to cite this article:
Yadav V, Mohanty V, Aswini Y B. Role of Oral Health Professional as Team Care for Diabetes Mellitus. MAMC J Med Sci 2017;3:56-60

How to cite this URL:
Yadav V, Mohanty V, Aswini Y B. Role of Oral Health Professional as Team Care for Diabetes Mellitus. MAMC J Med Sci [serial online] 2017 [cited 2021 May 6];3:56-60. Available from: https://www.mamcjms.in/text.asp?2017/3/2/56/209027

  Background Top

Diabetes is a major public health concern affecting 380 million people with prevalence rising rapidly at an alarming rate. It is reported that about 50% of the people with diabetes may be undiagnosed and about 80% of patients with diabetes are from low- and middle-income countries. The status of diabetes over the past 30 years has changed from being considered as a mild disorder of the elderly to one of the major causes of morbidity and mortality affecting the youth and middle-aged people.[1]

It is a chronic disease prevalent worldwide with an increasing frequency in both developed and developing countries. In the year 2000, there were an estimated 175 million people with diabetes worldwide and by 2030, the projected estimate of diabetes is 354 million. In India alone, the prevalence of diabetes is expected to increase from 31.7 million in 2000 to 79.4 million in 2030.[2]

The World Health Organisation (WHO)-Indian Council of Medical Research and national noncommunicable diseases risk factor surveillance study reported an overall frequency of self-reported diabetes of 4.5% with urban population scoring higher (7.3%) over the rural areas (3.1%). These studies also reported three-fold higher (18.9/1000 person-years) mortality in diabetes compared to nondiabetic (5.3/1000 person-years, P = 0.004). The WHO predicted a 50% increase in deaths from diabetes over next 10 years, and by 2030, diabetes is projected to be the seventh leading cause of death.[3]

Indians have a peculiar genetic composition leading them to a greater risk of developing diseases at younger age which may be due to an increased insulin resistance, greater abdominal adiposity (higher waist circumference despite lower body mass index), higher prevalence of impaired glucose tolerance, and lower adiponectin.[4]

These observations have led to a dilemma of interactions between diabetes and inflammatory process in periodontitis. The International Diabetes Federation (IDF) and World Dental Federation (FDI), therefore, came together under the lead of the IDF Task Force on Clinical Guidelines to address whether the evidence base in this area allowed formal recommendations on oral health and diabetes care to be made. The focus has been placed here on activity within diabetes care.[5]

  Oral Changes Associated with Diabetes Mellitus Top

Mouth is the mirror of systemic health. The effects of diabetes in the mouth may be reflected as gingivitis, periodontitis, fungal infections, dental caries, tooth sensitivity, cracking of oral mucosa, angular cheilitis, xerostomia, taste dysfunction, salivary dysfunction, neurosensory dysfunction, lichen planus, burning mouth syndrome, premalignant lesions, and malignancy.[6]

Dental caries

Patients with diabetes are at risk of developing new and recurrent dental caries. Type 2 diabetics are often associated with intake of high-calorie and carbohydrate-rich food which are highly cariogenic. Furthermore, diminished salivary flow in diabetics is a risk factor for dental caries.[6]

Salivary dysfunction

Dry mouth or xerostomia are more likely to be seen in patients with diabetes who experience salivary gland dysfunction, which may be due to a variety of conditions including the use of prescription medications and increasing age.[7]

Oral mucosal diseases

Oral mucosal lesions such as lichen planus, recurrent aphthous stomatitis are commonly associated with Diabetic patients which may be due to chronic immunosuppression and alteration in immune responsiveness.[8]

Gingivitis and periodontitis

There has been a bidirectional relationship between diabetes and periodontal diseases which can stimulate the chronic release of pro-inflammatory cytokines that have a deleterious effect on periodontal tissues. Patients with diabetic are at risk for developing aggressive periodontitis, chronic periodontitis and acute necrotizing ulcerative gingivitis and perioodntitis.[9]

  Periodontal Disease Markers Top

The risk for an individual to develop periodontal diseases and its response to periodontal treatment therapy is assessed by periodontal diseases markers, i.e., saliva and gingival crevicular fluid (GCF). Eley and Cox (1998) have attempted to relate the Aspartate amino transferase (AST) and lactate dehydrogenase (LDH) enzymes to periodontal disease severity and activity.[10]

Fungal infections

Studies have reported that diabetic patients have increased predisposition to manifestation of oral candidiasis, including median rhomboid glossitis, denture stomatitis, and angular cheilitis. It could be due to xerostomia, increased salivary glucose levels, or salivary dysregulation.[11]

Oral burning and taste dysfunction

Taste disturbances have been reported in some patients with diabetes mellitus. Perros and colleagues reporting that some diabetic patients have a mild impairment of the sweet taste sensation which may be related to xerostomia or disordered glucose receptors.[12]

  Health-care Environment Top

There are several significant factors which affect health care environment, including greater numbers of aging and older people, the development of new technologies, advances in medical treatments, and the tremendous increase in scientific knowledge about health and illness. In spite of the growing diabetes population and the high cost of treatment of this disease, people with diabetes are often poorly served by the current health care system that is primarily symptom oriented and focused on acute illness. Additionally, cost for the treatment is heavily weighted toward medical procedures or treatment of late complications of disease, rather than toward the cognitive and time-consuming efforts required for successful primary or secondary disease prevention. Therefore, there is an urgent need that current payment policies need to be modified to support team care for effective chronic disease management.[13]

  Team-based Health Care Approach Top

Team-based health care is the provision of health services to individuals, families, and their communities by at least two health providers who work collaboratively with patients and their caregivers to accomplish shared goals within and across settings to achieve coordinated, high-quality care.[14]

  Health-care Team for People with Diabetes Top

There are many other possible members of the health care team in addition to physicians (e.g., primary care, endocrinologist, obstetrician-gynecologist, and ophthalmologist).

This team could include (but is not limited to):

  • Pharmacists
  • Podiatrists
  • Optometrists
  • Dental care professionals
  • Primary care physicians
  • Physician assistants (PAs)
  • Nurse practitioners (NPs)
  • Dietitians certified diabetes educators (CDEs)
  • Community health workers (CHWs)
  • Mental health professionals

  Role of Primary Care Providers Top

Primary care providers include primary care physicians, PAs, and NPs, all play important roles in the delivery of primary care for people with chronic diseases such as diabetes. Although endocrinologists or other diabetes specialty physicians are involved in caring for many people with diabetes, primary care physicians can provide more than 80% of diabetes care.

System's constraints can make it difficult for primary care providers to carry out elements of comprehensive diabetes care, such as to:

  • Identify a practice's subpopulation of patients with diabetes and target those at highest risk for comorbidities.
  • Conduct ongoing self-management education and behavioral interventions.
  • Provide remote management of glycemia.
  • Promote risk-factor reduction and healthy lifestyles.
  • Provide periodic examinations for early signs of complications.[16]

The challenge is to broaden the delivery of primary care by expanding the health-care team to effectively address the various elements of comprehensive diabetes care.

  Role and Competencies of Community Health Workers Top

CHWs provide a bridge between health care systems, communities, and people diagnosed or at risk for diabetes.[17]

CHW's can provide basic lifestyle recommendations, provide support, facilitate communication between the patient and provider and assist with care coordination. They can also promote primary prevention (e.g. lifestyle changes) and secondary prevention (e.g. smoking cessation and self-management skills). In addition to promoting healthy lifestyle skills, the CHW can reduce the burden on other medical providers by supporting patient's needs that do not require the expertise of a clinician.[18]

Integrating and supporting the role of the CHW as a member of the clinic team serves to promote trust between the provider and the CHW. CHWs use a number of core skills and competencies to provide this community-based system of care and social support.[18]

These core skills and competencies include skill development in communication, interpersonal relations, capacity building, organizational development, problem solving, and assistance with obtaining access to care.[18],[19]

  Integral Role of the Patient and Family Top

Team care integrates the skills of primary care providers and other health care professionals with those of the patient and family members into a comprehensive lifetime diabetes management program [21],[21] that is of high quality and cost-effective. The patient is the central team member, since most diabetes care is carried out by the person with diabetes or his or her family. Patients need to understand their roles as self-care managers and decision-makers to effectively work with members of their health care team.[22]

  Health-Care Professionals Top

Teams usually include health-care professionals with complementary skills who are committed to a common goal and approach.[23] Some health-care professionals may choose to become CDEs.

Team composition varies according to the patients' need, patient load, organizational constraints, resources, clinical setting, geographic location, and professional skills.[24] It is essential that a key person coordinates the team effort. Non-traditional approaches to health care such as telehealth, shared medical appointments, and group education, all expand access to team care.

  Role of Oral Health-care Professional in Diabetes Management Top

Oral health professionals can play an important role to educate other members of the health care team about the oral/systemic health connection in diabetes. Unfortunately, many health care providers have had little, if any, training about the oral/systemic health link.[25] Pharmacy, Podiatry, Optometry, and Dentistry (PPOD) providers can help change this as they collaborate with other members of the health care team and educate others about what they do.

More than 80% of recent internal medicine trainees never ask patients if they have been diagnosed with periodontitis. 90% did not receive any training about the periodontal/systemic link in medical school and as many as 40% believe that discussing periodontal disease is not related to their roles as physicians. Twenty-two percent state that they never refer patients to dentists.[26]

Diabetes educators also report a lack of knowledge about the oral health/systemic link. A survey of CDEs found that most do not routinely provide oral health education to people with diabetes primarily due to lack of time and knowledge related to oral health. Of 130 respondents, 94% felt that oral health should be a part of the curriculum, yet only 23% reported that the curricula used for their patients included an oral health module.[27] Another study showed that only 51% of CDEs discussed oral health with their patients. Most, however, agreed with the need to collaborate with dental professionals in the total diabetes care management of their patients and agreed that adding an oral health component to their own continuing education would be useful. The bottom line is that increased training for both dental and medical providers about the oral health/systemic connection is important and may help improve clinical outcomes in people with diabetes.[28]

  Recommendation Top

  1. Dental professionals are important participants in a collaborative team care approach for diabetes management.
  2. Oral health care providers play a key role in treating and controlling periodontal disease, maintaining oral function, developing self-efficacy via self-management behaviors that prevent and control oral disease, and addressing common modifiable risk factors.
  3. Oral health care providers also may be able to identify people with undiagnosed diabetes by screening those at risk and referring them to their primary health care provider for diagnosis.
  4. Education of people with diabetes should include explanation of the implications of diabetes, particularly poorly controlled diabetes for oral health.
  5. Look for early signs of gum disease: Report any sign of gum disease including redness, swelling, and bleeding gums to a dental hygienist. Furthermore, mention any other signs and symptoms such as dry mouth, loose teeth, or mouth pain. In those people with possible symptoms of gum disease, advise them to seek early attention from a dental health program.
  6. Maintain good oral hygiene
    • Brush twice a day for 2 min with a soft toothbrush and fluoridated toothpaste.
    • Clean or floss between teeth once a day to remove food and plaque.
    • Clean or scrape the tongue daily.
    • Avoid mouth rinses with alcohol as they tend to make dry mouth worse.
    • Remove and clean dentures daily.

  Implementation Top

Professional education and awareness within the diabetes community will need to be enhanced before these recommendations are likely to be widely adopted. Health-care professionals should be empowered to explain the need for oral hygiene and the background to their inquiries about gum disease. They should be aware that certain medications (notably calcium channel blockers, tricyclics) may result in dry mouth (xerostomia), which is likely to increase the accumulation of plaque and the risk of oral diseases. Communication between diabetes and oral health-care professionals could facilitate this empowerment.[30]

Dental hygienist involved in care of diabetics should be involved for:

  • Updating the patient's medical history and any change in medication.
  • Implement a treatment plan and develop a structurally customized homecare program.
  • Give advice on the various types of oral care products and how to use them with adding the importance of each product.
  • Instruct patients on the most effective way to brush and floss and maintain his/her oral hygiene.
  • Provide information and counseling on tobacco cessation and dietary measures to support diabetic management.
  • Refer patients to a physician/NP, if diabetes is suspected but not diagnosed.
  • Educating the patients with the common signs and symptoms of diabetes during the screening of the community so as to create awareness among both diabetic and nondiabetic patients.

  Conclusion Top

Oral Health Professional as a team care plays an important role in diagnosing and management of diabetes.

Role of oral health care professional involved in the diabetes care should be involved in as:

  • Updating the patient's medical history and any changes in medication.
  • Implement a treatment plan and develop a structurally customized homecare program.
  • Give advice on the various types of oral care products and how to use them with adding the importance of each product.
  • Instruct patients on the most effective way to brush and floss and maintain his/her oral hygiene.
  • Provide information and counseling on tobacco cessation and dietary measures to support diabetic management.
  • Refer patients to a physician/NP if diabetes is suspected but not diagnosed.
  • Educating the patients with the common signs and symptoms of diabetes during the screening of the community so as to create awareness among bothe diabetic and non diabetic patients.[31]

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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