verfasst von:
Aznida Firzah Abdul Aziz, Tuti Ningseh Mohd-Dom, Norlaila Mustafa, Abdul Hadi Said, Rasidah Ayob, Salbiah Mohamed Isa, Ernieda Hatah, Sharifa Ezat Wan Puteh, Mohd Farez Fitri Mohd Alwi
The practice of referring diabetic patients for dental intervention has been poor despite awareness and knowledge of the oral health effects of diabetes. Likewise, dentists treating patients receiving diabetes treatment are rarely updated on the glycaemic status and as a result, the opportunity for shared management of these patients is missed. This study aimed to provide a standardised care pathway which will initiate screening for diabetes from dental clinics and link patients with primary care for them to receive optimised care for glycaemic control.
Method
A Modified Delphi technique was employed to obtain consensus on recommendations, based on current evidence and best care practices to screen for diabetes among patients attending dental clinics for periodontitis. Expert panel members were recruited using snowball technique where the experts comprised Family Medicine Specialists (5), Periodontists (6), Endocrinologists (3) and Clinical Pharmacists (4) who are involved in management of patients with diabetes at public and private healthcare facilities. Care algorithms were designed based on existing public healthcare services.
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Background
Diabetes mellitus is a disease linked to a spectrum of other non-communicable diseases (NCDs) and complications and providing a holistic management for patients with this condition involves a multidisciplinary involvement. The rising prevalence and incidence of diabetes in Malaysia calls for efforts to increase awareness among stakeholders to focus on early detection and to optimise resources in managing patients at risk of diabetes. The National Health and Morbidity Survey in 2019 reported that 8.9% of the 18.3% diabetics were unaware that they had diabetes (i.e., FBS > 7.0 mmol/L) [1]. The bidirectional link between diabetes and periodontitis therefore presents an ideal logistic opportunity for detection of both diseases among patients attending healthcare services at earliest possible opportunity [2].
Periodontitis is also a major public health problem. It has significant impacts on individuals by reducing their quality of life and dental care can consume between 10–15% of the total allocation towards healthcare [3, 4]. Current estimates projected that periodontitis affects 20–50% of the world population while the average prevalence of severe periodontitis globally is at 9.2% [5]. Locally, periodontal disease prevalence declined between 1990 (92.8%) and 2000 (87.2%); however, a sharp rise was observed in the 2010 National Oral Health Survey for Adults (NOHSA) (94.0%) [6, 7]. The extremely high prevalence of periodontitis among adults is also challenged by the poor oral healthcare utilisation practices among Malaysian adults where only 13.2% reportedly saw a dentist within the last 12 months as highlighted in the National Health and Morbidity Survey in 2019 [8].
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As an added concern, the prevalence, severity, and progression of periodontal diseases are significantly increased in patients with diabetes due to the poor glycaemic control [9] and insulin resistance [10]. Moreover, patients with diabetes are 2 to 3 times more likely to have periodontitis compared to non-diabetic patients, and this is related to long term metabolic control and duration of diabetes [11]. Patients with diabetes have greater risk of developing more severe medical complications including retinopathy, nephropathy, cardiovascular complications and even risk of cardiorenal mortality [10]. There are evidence demonstrating the effect of periodontal therapy on the HbA1c level. Non-surgical periodontal treatment results in a modest reduction of -0.36% of HbA1c [12] and a statistically significant reduction in HbA1c levels at 3 months, with a lower reduction at 6 months, ranging from − 0.27% (95% CI: − 0.46, − 0.07, p = 0.007) to − 1.03% [13]. A systematic review on randomised clinical trials found that periodontal therapy significantly contributed to glycaemic control in T2DM patients and there was a greater reduction in HbA1c after periodontal therapy for patients with higher baseline HbA1c level [14]. Periodontal therapy, therefore, has the potential to reduce mortality in T2DM patients and may be a useful adjunct to medical management of diabetes [15].
The oral healthcare system in Malaysia operates mostly as a separate entity from the primary healthcare system where there is no established pathway for bilateral case referrals. The oral health status of diabetes patients attending primary healthcare facilities is not monitored, and the lack of awareness regarding the bidirectional relationship between periodontal diseases and diabetes mellitus among both healthcare personnel and patients in Malaysia compounds the problem [16]. In the Malaysian public health system, primary healthcare and dental care services are provided by 1114 health centres, of which a total of 577 dental clinics are based within the same premises as these health centres [17]. The geographical location of the public primary healthcare and dental care services, particularly periodontal specialist care, which is within the community health centre complex presents an opportunity for providing coordinated care for diabetic patients with periodontitis or for addressing oral healthcare surveillance of patients with diabetes [18]. Yet, there remains a lack of coordination between medical and dental professionals; this situation is not unique to Malaysia as healthcare systems in the UK and most parts of the world are reported to have faced similar experiences [19].
The research team discussed and identified all the disciplines involved in healthcare provision for periodontitis patients with diabetes in an ideal seamless healthcare set-up. The team agreed that the expert panel members should include Periodontists, Family Medicine Specialists, Endocrinologists and Clinical Pharmacists. All members of the expert panel are clinicians from the public and private sectors including those at university health care facilities, and were actively involved in providing care for patients with diabetes. Members of the expert panel were recruited using snowball technique (Fig. 1) through which multidisciplinary experts who were directly involved in the management of patients with diabetes or periodontitis or both were identified.
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Panel recruitment
Panel members were invited to participate in the discussion via personalised email invitation; additionally, reminders to respond in relation to their willingness to participate were also sent out via email. If no response was received after two email reminders, they were considered as non-responders.
Conduct of data collection
All respondents who agreed to participate received an online link to the questionnaire (Google form). The questionnaire contained a brief introduction and summary of the diabetes-periodontitis link and related references from published credible sources. The latter was provided as full-length publications which the respondents were able to download and read at their convenience as they answered the questionnaire. The first section of the questionnaire gathered the sociodemographic background and work experience of the respondents. The second part of the questionnaire was on the respondents’ clinical experience in the screening, confirmation, and management of diabetes patients with periodontitis. The questionnaire addressed issues related to confirmation protocol of diabetes mellitus based on the clinical practice guidelines issued by the Ministry of Health Malaysia. A Modified Delphi technique was employed to achieve consensus on responses which were not unanimous. A face-to-face meeting was conducted on 17th October 2019 to finalise the care pathway and to endorse the final document. The finalised document was then shared with the expert panel members for checking and endorsement.
Data analysis
Data entry and analysis to calculate the descriptive statistics was performed using Microsoft Excel.
Results
Background of expert panel members
A total of 17 experts agreed to participate. The background of the experts is presented in Table 1. The experts had a minimum of 10.3 (SD4.9) years of experience in their clinical field and majority were from the public sector.
This care pathway was designed to screen patients who presented with symptoms and signs of periodontitis to any dental care practitioner (Fig. 2). History taking should include screening for possible diabetes or prediabetes by identifying other risk factors such as obese or overweight with central obesity, history of gestational diabetes mellitus (GDM), inactivity (exercises < 150 min per week), family history of diabetes (among first degree relatives), hypertension, dyslipidaemia, polycystic ovarian syndrome (PCOS), acanthosis nigricans or small for gestational age.
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Based on the current evidence and considering the national prevalence of diabetes and periodontitis, all patients diagnosed with periodontitis are recommended to undergo an evaluation of their glycaemic status. This screening procedure is best achieved by a fasting capillary plasma glucose level which can be scheduled from the second visit onwards or at least once while undergoing treatment at the dental clinic. If facilities are available for a venous plasma glucose testing, then this method should be employed.
The dental practitioner must obtain information or verify the glycaemic status of each patient suspected or confirmed to have periodontitis. The cut off point for referral to a primary healthcare practitioner is a fasting capillary plasma glucose level ≥ 5.6 mmol/L. The referral is to confirm and initiate the appropriate treatment for prediabetes or diabetes. This recommendation is made to ensure that individuals with periodontitis who are unaware of their prediabetes or diabetes status are provided with the opportunity to receive adequate and timely medical intervention to reduce diabetes-related morbidity and mortality.
Upon receiving the referral from the Dentists or Periodontists, the primary healthcare practitioner should proceed to confirm the glycaemic status of a symptomatic (i.e., periodontitis) prediabetic or diabetic patient (Fig. 3). Apart from re-confirming the risk profile of the patient, confirmatory testing should be performed using fasting plasma glucose levels. This procedure would also provide an opportunity for risk profiling of the patients in terms of risk for cardiovascular disease (i.e., coronary heart disease or cerebrovascular events or subclinical heart disease).
One of the challenges in multidisciplinary or transdisciplinary management is the acceptance of shared care initiatives by clinicians of different disciplines. It has been well documented that clinician behaviours are unpredictable and difficult to change [25, 28]. Not all clinicians embrace inclusivity, and some are more comfortable to practice within ‘silos’, believing that transdisciplinary management invades disciplinary boundaries. In addition, issues of poor communication which commonly occur with interprofessional referrals and consultation have become a risk management concern [28]. These issues need to be resolved in order to enhance patient-centred approach to diabetes care within the existing healthcare system navigation.
Bisset and colleagues in the UK [19] reported that since there was negative interprofessional feedback about treating periodontitis patients with diabetes, a measure of compromise was recommended involving patient-driven prompting (signposting) which may serve to avoid the friction among clinicians. However, this patient-driven strategy would require a good level of health literacy related to understanding of diabetes care and self-monitoring among the patients. Considering that one third of the Malaysian population have poor health literacy and lack the impetus for self-monitoring of illnesses, this approach would not yet be appropriate for adoption in Malaysia [1, 26]. Nonetheless, in relation to dental service utilisation, the low dental uptake among Malaysian adults could be improved after receiving a prompt triggered by the medical practitioner. This consequently could increase the dental attendance of patients with NCD, such as those with type 2 diabetes.
We were granted the permission and ethics approval to conduct this study by the Research and Ethics Committee of Universiti Kebangsaan Malaysia (UKM PPI/111/8/JEP-2020–150). All methods in this study were carried out in accordance with the ethical guidelines laid down by Declaration of Helsinki 2013. Informed consent was obtained from the clinical specialists who participated in this study.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no competing interests.
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Aznida Firzah Abdul Aziz Tuti Ningseh Mohd-Dom Norlaila Mustafa Abdul Hadi Said Rasidah Ayob Salbiah Mohamed Isa Ernieda Hatah Sharifa Ezat Wan Puteh Mohd Farez Fitri Mohd Alwi