Oral Health in Diabetes: Provider Attitudes at Staywell Health Center

1. Oral Health in Diabetes: Provider Attitudes at Staywell Health Center Jessica Johnson SEARCH Program August 2, 2010

2. Outline • Background • Objectives • Methods • Survey Results • Conclusions • Next Steps

3. Background • Diabetes Mellitus Type II • 10.7% of U.S. adults diagnosed in 2007 • 26% of U.S. adults with impaired fasting glucose • Disease burden • Heart disease and stroke • Nephropathy • Systemic neuropathy • Retinopathy and blindness • Decreased immunity and wound healing.

4. Periodontal Disease and Oral Health • Periodontal Disease – “the sixth complication” • Bi-directional effect • HgA1c >9% 3x more likely to have severe periodontitis • 1/3 of diabetics have severe periodontal disease • Other oral disease in diabetes • Dental caries • Salivary dysfunction • Oral mucosal diseases • Oral infections such as candidiasis • Taste and other neurosensory disorders • Fewer patients with diabetes have regular dental care than those without diabetes

5. Provider Attitudes – Past Studies • Dental Providers – more comfort with assessment and advising rather than active management • Lack of confidence in their ability to screen • Disavowal of responsibility for active management • Belief that patients and colleagues did not expect them to perform diabetes screening and management • Medical Providers • Not until 2008 that ADA recognized the importance of dental care in their “Standards of Medical Care” (routine check) • Inadequate job of discussing specific oral health needs with diabetic patients

6. Interdisciplinary Communication • Increasing interest • Patient-Centered Medical Home • Graduate training programs • Role of Community Health Centers • Medical and dental inter-departmental communication

7. Objectives (1) • Assess medical and dental provider knowledge and attitudes regarding providing oral health care to patients with diabetes • Assess medical and dental provider attitudes about interdisciplinary communications • Compare the attitudes and knowledge of medical and dental providers about oral health care in diabetes

8. Objectives (2) • Compare the attitudes about diabetic oral health between different CHC locations in Connecticut • Provide an initial survey of provider knowledge and attitudes to be correlated with patient attitudes • Provide an initial survey of provider knowledge and attitudes that can be correlated with patient outcomes over time.

9. Methods • PubMed literature search • Dental literature – many articles • Medical literature – few articles • Developed survey of previously validated questions • Professionals – MD/DO, PA, APRN, RN, CDE, DDS/DMD, RDH • Survey roll-out • Paper format to Staywell employees over 2 week period • Adapted to online version, released to all CHCACT sites for a separate 2 week period • Collect and analyze data

10. Survey Themes • “Buy-in” • Belief that this is important • Colleague/patient expectations • Do other people think it’s important? • Training, capabilities, protocols • Patient education and services provided • Interdepartmental communication

11. Respondent Demographics • N = 18 • Gender – 66.6% female • Age • 61% between age 26-35 • 28% between age 36-45 • Ethnicity • 36% Asian • 53% White • 5% African American

12. Respondent Demographics

13. Data and Results –Perceived Importance • Improved glycemic control will improve the oral health of my patients • Dentists (4.75) • Physicians (4.2) • Treatment of periodontal disease will improve my patient’s glycemic control • Dentists (4.0) • Physicians (4.8) • Improved preventive oral health care will improve glycemic control • RDH (4.4) • Dentists (3.67) • Discussing diabetes/oral health is important to my role as a medical.or dental professional • All medical (4.87) • All dental (4.55)

14. Data and Results –Colleague and Patient Expectations • Limited perceived expectations • No differences between perceived patient or colleague expectations. • Results were similar across all levels of training.

15. Data and Results –Training, Capabilities, and Protocols • Formal training in diabetes

16. Data and Results –Training, Capabilities, and Protocols • Perceived preparedness • Both groups felt best prepared in their own specialty • Dental providers felt more comfortable with diabetes (4.22) than medical providers did with oral health (3.55).

17. Data and Results –Patient Education and Services Provided • Dental providers are more likely than medical to address specific oral health issues • Asking patients with periodontal disease about diabetes (4.78 dental vs. 3.89 medical) • Addressing diabetes with all dental patients (4.33) • Asking diabetic patients about last A1c (3.33) • Specific symptoms • Dental providers – 100% • Medical providers – vary • Low for xerostomia (dry mouth) • Low for odontalgia (pain)

18. Data and Results –Patient Education and Services Provided • Patient Education • For all measures, dental providers rated higher than medical • Physicians gave higher rating than dentists on: • Addressing effect of uncontrolled diabetes on periodontal disease (1.8 to 1.75/2.0) • Effect of periodontal disease on glycemic control (1.8 to 1.5/2.0) • Indirect related issues – smoking cessation, alcohol use, nutrition and diet counseling, and good glycemic control • Dental was far higher on: • Proper brushing and flossing techniques • Care of removable oral appliances • Importance of good oral hygiene

19. Data and Results –Patient Education and Services Provided • Recognizing hypoglycemia • 100% have been trained • Few agree there is a protocol, and fewer could repeat it back • Referrals • All dental providers believed there was a referral protocol in the medical office, but no similar protocol for dental office • Medical providers had low confidence in protocol in either office • Both groups believed more strongly in a protocol in the other office

20. Data and Results –Interdepartmental Communication • Adequate communication with colleagues • Dentists (4.0) • Physicians (3.0) • Dental hygienists (2.8) • PAs and APRNs (2.0) • Barriers to communication • Time • Lack of access to record • Items they would most like shared • No consensus between individuals.

21. Data and Results –Barriers • Prompted Questions • Physicians • Time – 75% • Lack of referral source – 75% • Dentists • Inadequate training – 75% • Lack of protocols – 50% • PAs and APRNs • Time – 100% • Inadequate training – 66% • Lack of referral source – 0% • Dental Hygienists • Lack of protocols – 80% • Inadequate training – 0%

22. Conclusions • Both providers believe in the importance of addressing oral health care in diabetes • Medical providers are not as successful in doing this (education, symptoms) • Recognize time and referral sources as a barrier • Dental providers assess oral health; less so diabetes presence and severity • Inter-departmental education • Dental providers – specific education points, symptom assessment • Medical providers – screening, assessing severity • Review hypoglycemia treatment protocol • Create and administer inter-departmental referral system • Strong negative feelings regarding communications • Focus groups, clinic flow diagrams • Limitations • Size and power • CHCACT data not yet available • Survey long, unwieldy

23. Next Steps • Patient survey – knowledge and oral health beliefs • Patient outcomes • Pilot information-sharing system • 6 month study period • Repeat provider survey

24. Selected References • National Institute of Diabetes and Digestive and Kidney Diseases. National Diabetes Statistics, 2007. “http://diabetes.niddk.nih.gov/dm/pubs/statistics”. Accessed July 19, 2010. • Lamster IB, Lalla E, Borgnakke WS, Taylor GW. The relationship between oral health and diabetes mellitus. Journal of the American Dental Association 2008;139(10 suppl):19S-24S. • Macek MD, Tomar SL. Dental care visits among dentate adults with diabetes and periodontitis. Journal of Public Health Dentistry 2009 Fall;69(4):284-289. • Kunzel C, Lalla E, Albert DA, Yin H, Lamster IB. On the primary care frontlines: the role of the general practitioner in smoking-cessation activities and diabetes management. Journal of the American Dental Association 2005;136(8):1144-1153. • Yuen HK, Mountford WK, Magruder KM, Bandyopadhyay D, Hudson PL, Summerlin LM, Salinas CF. Adequacy of oral health information for patients with diabetes. Journal of Public Health Dentistry 2009 Spring;69(2):135-141. • Esmeili T, Ellison J, Walsh MM. Dentists' attitudes and practices related to diabetes in the dental setting. Journal of Public Health Dentistry 2010 Spring;70(2):108-114. • Mealey BL. The interactions between physicians and dentists in managing the care of patients with diabetes mellitus. Journal of the American Dental Association 2008;139:4S-7S. • Yuen HK, Onicescu G, Hill EG, Jenkins C. A survey of oral health education provided by certified diabetes educators. Diabetes Reseach and Clinical Practice 2010;88:48-55. • Joint Principles of the Patient Centered Medical Home. American Academy of Family Physicians, American Academy of Pediatrics, American College of Physicians, American Osteopathic Association. Released February 2007. • Swanson Jaecks KM. Current perceptions of the role of dental hygienists in interdisciplinary collaboration. Journal of Dental Hygenists. 2009 Spring;83(2):84-91. • Mouradian WE, Corbin SB. Addressing health disparities through dental-medical collaborations, part II. Cross-cutting themes in the care of special populations. Journal of Dental Education 2003 Dec;67(12):1320-6.