Healthy Heart DentistryHealthy Heart Dentistry®®

Diabetes Risk Assessment in the Dental Office

a Hu-Friedy Special Presentation for Dentists and Hygienists

Ron Schefdore, DMD and Jack A. Maggiore, PhD

May 2009

About The PresentersDr. Ron Schefdore practices adult general dentistry in the Chicago area and is the president of Healthy Heart Dentistry and Pharmaden Nutraceuticals. He is the author of the popular book Better Service, Better Dentistry, Better Income. He can be reached at celebritysmiles@aol.com, or by fax at 630-986-1524. Additional information can be found by visiting www.healthyheartdentistry.com and www.Pharmaden.net.

Dr. Jack Maggiore is President and Chief Scientific Officer of Healthy Life Laboratories. He is a Medical Technologist, certified by the American Society for Clinical Pathology, with a Master of Science in Clinical Chemistry and Doctorate in Pathology from the University of Illinois. His expertise includes clinical trials and regulatory affairs, having cleared six medical products through the U.S. Food and Drug Administration. His clinical research interests include diabetes disease management, and development of novel biomarkers for chronic diseases

Learning ObjectivesAt the end of this program, participants will be able to:

• Identify the connections between oral inflammation and systemic disease.

• Detail the benefits of a dental practice engaged in active diagnosis and treatment of periodontal inflammation.

• Explain the importance of recognizing the symptoms of diabetes.

• List the most common risk factors of diabetes.

• Describe the diagnostic tests for diabetes.

Retaining Patients

The future dentist and dental hygienist will focus on improving oral inflammation and overall health … the public will demand it.

 -Dr. Ron SchefdoreFounder and President - Healthy Heart Dentistry®.

Dr. McGuire...Our Job Dr. McGuire...Our Job Nov 2008, Journal of PeriodontologyNov 2008, Journal of Periodontology

• As clinicians we must translate the happenings in inflammation research and incorporate it into our practices to provide the best possible care to our patients.

• My conclusion is that I should err on the side of aggressive control of periodontal inflammation, since, until proven otherwise, the consequences of under treatment could be more than the loss of a few teeth.

• This is where dentistry meets medicine and will be the foundation for all future general dental practices.

The Dentist and Diabetes

• If a dentist suspects a patient is diabetic but cannot confirm the diagnosis, both the dentist and the patient are placed at a considerable risk

• Encouraging findings from clinical studies have revealed a correlation between gum health and general health

1

• Making a difference in the overall health of dental patients links the dentist professionally to the entire medical community

1 Lindhe, J., Karring, T., & Lang, N.P. Clinical Periodontology and Implant Dentistry, (Chapter 16) FourthEdition, Blackwell Munksgaard, Oxford, UK, 2003. Jeffcoat, M.K., et. al., "Periodontal disease and pre-term birth: Results of a pilot intervention study," Journal of Dental Research, 82:1446, 2003.

Why Aggressively Treat Oral Inflammation?

• Diabetes• Heart Disease and Stroke• Osteoporosis• Pregnancy Complications • Pneumonia• Respiratory Disease• Sinus Complications• Gastric Ulcers • Pancreatic, Kidney, and Blood Cancers

Periodontitis is associated with:

Blood Screening Periodontal Patients

Periodontal disease has shown to elevate:

glucose, hemoglobin A1c (HbA1c), cholesterol, and high-sensitivity C-reactive protein

(hs-CRP) levels

Blood Screening Advantages

• Identify undiagnosed or poorly controlled diabetics

• Identify pre-diabetics and those at risk of developing diabetes

• Determines to what extent periodontal disease is causing elevations in metabolic and inflammatory markers, like glucose, HbA1c and hs-CRP

• Demonstrates the effectiveness of The Healthy Heart Dentistry system on blood chemistries, including glucose, HbA1c and hs-CRP

Retaining patients

Recent Survey Results of Dental Patients:

72% said they usually bleed when getting their teeth cleaned at their dentist

93% said their dentist does not do an oral cancer exam

100% said their dentist did not do blood pressure checks

100% said their dentist does not do blood screenings

68% said they would consider going to another dentist offering more advanced services if the dentist was similar in cost

Healthy Heart DentistryHealthy Heart Dentistry®®

Can help retain your current patients and attract quality minded patients that are not price or insurance driven as their main focus of choosing a dentist.

Making the Connection

• The Oral Cavity provides an opportunity to recognize systemic diseases early in their onset

• Chronic and systemic diseases that manifest in the mouth include:–Diabetes–Anemia and Blood Disorders–Heart Disease –Osteoporosis

Diabetes – the Staggering Statistics

• 23.6 million Americans have Diabetes, or 8% of the population

• 6.2 million (or nearly one-third) are unaware and undiagnosed

• 1 in 3 Families are touched by Diabetes

• 93 % of diabetes is Type 2 or adult onset, with obesity

serving as the primary risk factor

Type I vs. Type 2 Diabetes

Type IType I Type 2 Type 2

• Insulin Dependent• Pancreas does not

produce insulin• Usually Manifests in

Juveniles• Autoimmune Cause

– Viral Component ?– Body destroys insulin-

producing cells

• ~7% of all Diabetes

• Usually Adult Onset• Strong Genetic Link• Lifestyle Triggers

– Obesity– Lack of Exercise

• Pancreas produces insulin

• Usually managed by oral medications & diet

• ~93% of all Diabetes

Type 2 Diabetes – the Risk Factors

• Ethnicity - African Americans, Hispanics and American

Indians are more than twice as likely to be diagnosed with

type 2 diabetes

• Family History – Having a father, mother, brother or sister

with Diabetes increases your risk of type 2 Diabetes

• Age – Being over age 45 is a risk factor for type 2 Diabetes

• Physical Inactivity – Lack of regular cardiac exercise

places you at increase risk of type 2 diabetes

• Hypertension – High Blood Pressure increases the risk of

type 2 Diabetes

• Weight – Obesity is at epidemic proportions and has become

the fastest growing preventable cause for type 2 Diabetes.

Diabetes – The Classic Symptoms

• Bleeding Gums – At the top of this list since it is now

recognized as the first symptom of diabetes

• Excessive Thirst

• Excessive Hunger

• Frequent Urination

• Dizziness

• Extreme Fatigue

• Change in Vision

• Unexplained Change in Weight

• Numbness in the Hands, Arms, Legs or Feet

• Slow-Healing Wounds – Inflammation that is slow to respond to treatments

Diabetes – The Complications

Uncontrolled Diabetes Often Leads to:• Advanced Periodontal Disease

• Kidney Disease

• Blindness

• Heart Disease

• Stroke

• Foot Ulcerations

• Nerve Damage

• Lower Limb Amputations

• Depression

• Cognitive and Mental Impairment

Pre-Diabetes: the Silent Stalker

• Before Diabetes is diagnosed, many people unknowingly exist in a state of “pre-diabetes”

• An estimated 57 million Americans have pre-diabetes, and are likely to develop diabetes if they do not alter their lifestyle: Exercise, Eat Right, Manage Weight

• The body’s metabolism of blood sugar is not as sharp

Pre-Diabetes: the Silent Stalker

• In pre-diabetes, blood sugar levels will often spike, followed by quick drops

• Diabetes complications of the heart, kidneys and eyes frequently occur in the pre-diabetic state

• Pre-diabetes is often reversible with commitment to lifestyle change

Identifying Diabetes and Pre-Diabetes

• Fasting Blood Glucose testing remains the test of choice to test for Diabetes, according to the American Diabetes Association.

- The primary diabetes marker has not changed for many decades

- The diabetes cut-off level has recently dropped from 110 to 100 mg/dL

• Diabetes may be “missed” when screening with just a fasting glucose test; this test cannot show spikes that occur after meals

Identifying Diabetes and Pre-Diabetes

• The recommended second-line test is a glucose tolerance test, which tests the body’s ability to metabolize glucose

• A more convenient test than the glucose tolerance test is HbA1c, which is an indicator of long-term glucose control

• A new consensus among Diabetologists at Johns Hopkins University School of Medicine is to use HbA1c as a screening test for Diabetes

The Diabetes Risk Assessment Kit

• Combining Fasting Blood Glucose WITH HbA1c is the concept behind the Healthy Heart Dentistry Diabetes Risk Assessment Kit

• FBG may be normal in pre-diabetes• HbA1c will be elevated during episodes of high

glucose over past 90-120 days and identifies– Glucose Intolerance– Insulin Resistance – Metabolic Syndrome

• Combining the 2 technologies increases the likelihood of diabetes detection

• May be administered chairside in participating dental practices

The Diabetes Risk Assessment Kit

Kit Components

Easy to Understand

Instructions

Laboratory Authorization Form

Prep Pak (Alcohol pad,

Lancets, Adhesive Bandage,

Gauze pad)

Instant Glucose Test

Foil Transport Pouch

Postage Paid Return Envelope

Dental Product Shopper Best Product Award for 2009Best Product Award for 2009

Dual Technologies: Fasting Glucose

Single drop of blood is applied to test area of card. Wait 3 minutes and remove tab.

Compare green color of test pad to reference card.

Top tab of card is sent to laboratory for HbA1c testing.

Dual Technologies: HbA1c

Laboratory Analysis of Long-Term Glucose Control

Lab Report presents numerical results compared to a target reference range

Illustrates graphical depiction of Diabetes Risk based on approved American Diabetes Association Guidelines

Provides patient education and interpretive narrative

Suggests continuity of care with primary care physician

Why People Aren’t Being Tested for Diabetes

• Lack of Awareness– Patients do not know the full impact of the

disease– Patients do not recognize the warning signs

• Incomplete Education– Patients have not been educated on the

disease complications• Misconceptions about Testing

– May have been previously tested for Fasting Glucose (only)

– May believe that testing is complicated or expensive

• Absence of a Professional’s Call to Action– A doctor has not prompted the patient to be

tested

Four Benefits in Single Patient Contact

• Step One – Awareness– Diabetes Risk Assessment Questionnaire– Six Questions Raising Awareness and Need for Testing

• Step Two – Education– Take-Home Message With Facts About Diabetes– Highlights Diabetes Risks, Symptoms and Complications

• Step Three – Diagnostic Testing– Take Home Kit for Fasting and Long-Term Glucose – Categorically Assesses Diabetes Risk

• Step Four – Call to Action– Detailed Laboratory Risk Assessment Report– Drives dialogue between educated patient and primary care

physician

Participant Questionnaire

The Dentistry Against Diabetes process starts with:

EVERY dental patient given this questionnaire upon arrival at office

Six Easy-to-Answer Questions provided by American Diabetes Association

Any YES answer shows an increased risk to Diabetes and prompts patient to ask about test

Risk Assessment kit provided in-office for at-home testing

Take home

message helps

to establish

dialogue with

patient’s

personal

physician

Highlights

diabetes risks,

symptoms, and

complications

Why Dentists and Why Now?

• Historical diabetes screening lacks convenience and sensitivity as evidenced by the number of undiagnosed diabetics

• Criteria for detecting diabetes has not changed in nearly 50 years, with fasting blood glucose serving as the primary test

• Health care consumers are more likely to see their dentist than primary care physician

• A study by MetLife1 reveals that most consumers (85%) believe there is a strong connection between oral health and overall medical health

1The MetLife Oral Health Insights study ,GfK NOP 2006

Dentistry and Diabetes:Dentistry and Diabetes:A Two-Way StreetA Two-Way Street

December 3, 2008 Article: Studies Probe Oral Health - Diabetes Link

–“Diabetes can adversely affect oral health, and poor oral health can worsen diabetic complication.”

–“Diabetes leads to unwanted changes in gums and periodontal tissues.”

–“Significant data now support that if a person has diabetes and they also have periodontal disease that is left untreated, it is very difficult to gain glycemic control of the patient.”

– “Periodontal disease including gingivitis and periodontitis worsens diabetes when bacteria released into the bloodstream contribute to inflammation.”

–Dentists and Physicians must work together in the detection of diabetes, its complications, and course of treatment.

JAMA, December 3, 2008, 300(21);2471-3.

Learning Objective #1

Identify the Connections Between Oral Inflammation and Systemic Disease:

• For each occurrence of oral inflammation there is likely an underlying systemic cause.

- Nutritional in the form of a vitamin deficiency

- Pathologic in the form of an underlying disease

- Physiologic in the form of a metabolic disorder

• Treating the symptom is an important first step, but identifying the underlying cause is essential to overall better health and wellness.

• Oral inflammation is recognized as causing or exacerbating many systemic diseases such as diabetes, heart disease and stroke

Learning Objective #2

Detail the Benefits of a Dental Practice Engaged in Active Diagnosis and Treatment of Periodontal Inflammation:

Healthy Patients ⇉ Healthy Practice

• Better Outcomes

• Fewer Complications

Reduced Liability

• Failure to recognize underlying causes places the dental professional at liability risk

Better Practitioner

Awareness Education

Detection Call to Action

Explain the Importance of Recognizing the Symptoms of Diabetes:

Learning Objective #3

High blood glucose levels make the periodontium susceptible to injury, as the microvasculature undergoes repeated cycles of dehydration and swelling.

•Bleeding gingiva are now recognized as one of the earliest indicators of diabetes

High blood glucose levels are a source for the bacteria-rich biofilm matrix of dental plaque, increasing the likelihood of a bacteremia or a blood borne bacterial event.

List the Most Common Risk Factors of Diabetes:

Learning Objective #4

THOSE WHICH CAN NOT BE CHANGED

• Ethnicity - African Americans, Hispanics and American Indians are at 2x risk

• Family History - Father, Mother, Brother or Sister with Diabetes doubles your risk of type 2 Diabetes

• Age - Incidence of type 2 diabetes increases at age 45

THOSE WHICH CAN BE CHANGED

• Physical Inactivity - Lack of regular cardiac exercise increases diabetes risk

• Hypertension - High Blood Pressure increases risk of type 2 Diabetes

• Weight - Obesity is the fastest growing preventable cause for type 2 Diabetes.

Learning Objective #5

Describe the Diagnostic Tests for Diabetes:Fasting Blood Glucose

• After overnight fast of 8 hours• Levels >126 mg/dL are diagnostic for diabetes• Levels >100 mg/dL and <126 mg/dL are indicative of pre-diabetes

Glucose Tolerance Test• In a fasting state, a beverage containing 75g of glucose is taken

orally.• Glucose levels tested in the fasting state, and hourly up to 5 hours.• One hour glucose levels >200 mg/dL are diagnostic for diabetes.

Hemoglobin A1c• Blood hemoglobin binds with excess glucose, so the percent of

glucose-bound hemoglobin can be determined in a blood sample.• Since red blood cells live for 90-120 days, the level of HbA1c is

indicative of the blood glucose levels over the past 3 months.• Levels <6.0% are considered normal, and values >6.5% considered

as high risk for diabetes.• Levels between 6% and 6.5% indicate pre-diabetes.

Case study — Dr. Schefdore’s Office

• 57 year old white male. Long standing patient of record with no past history of periodontal disease presents for his normal 6 month recare visit. Perio- generalized 3mm with bleeding. Eleven sites of 4mm pockets. No change in his medical history. No extreme thirst, weight loss, dizziness, or changes in medication. No family history of diabetes.

• Our blood screening indicated an Instant Fasting Blood Glucose of 125 mg/dL, and HbA1c of 8.5%. Patient was diagnosed at his physician with diabetes and began medical treatment. Go to www.Pharmaden.net and click on “in the media” to see KDKA television interview.

Healthy Heart Dentistry®

History and Mission

Healthy Heart Dentistry® was founded in 2007 by

Dr. Ronald Schefdore, DMD, to raise awareness of the mouth-body connection, to implement dental office assessments of periodontal-associated markers of metabolism and inflammation, and to promote therapies to treat periodontal inflammation orally and systemically.

About Healthy Heart Dentistry®

OUR MISSION:• Awareness• Education• Testing• Call to Action

OUR METHOD:• Detection• Treatment• Monitoring• Partnerships

National Media Coverage

Healthy Heart Dentistry has also been featured in The Wall Street Journal, U.S. News and World Report, Dental Economics, The Profitable Dentist, DOCS Digest, Dental Product Shopper, DentalTown.com and on the NBC News

Dentistry Today feature article on the Healthy Heart Dentistry Program.

How do I get started?

Start by visiting the

Dentistry Against Diabetes™ program

www.DentistryAgainstDiabetes.com

and for information on other chairside assessment kits, visit Healthy Heart Dentistry at:

www.HealthyHeartDentistry.com