The Challenge of Metabolic Control (HbA1c) for dentist communication to a physician requesting this Associated with Periodontal Infection information is included in Templates of Letters for Dentist- The cornerstone of medical management of a diabetic Physician Communications, which may be accessed and patient is centered on achieving and sustaining glycemic downloaded at www.thesystemiclink.com. Another way (metabolic) control at the same level as a healthy, non- of obtaining this information is for the dentist to directly diabetic individual. ³⁰ Improved control of blood glucose refer the patient to a medical laboratory, i.e., hospital or reduces the risk of a number of long-term complications, treatment center laboratory. Also emerging is the use of particularly retinopathy, nephropathy, and neuropathy. ^{3, 31-36} point-of-care monitoring of HbA1c with chairside/bedside Evidence is emerging that intensive glycemic control may analyzers that are now available. This allows for on-the-reduce CVD, ^34-36 although this has not yet been demon- spot decisions that may result in alteration of treatment strated in a randomized clinical trial. plans. On-site availability of this technology may not only apply to physicians but also dental practitioners consider-

The major marker of metabolic control for physicians is ing more invasive surgical procedures. The use of HbA1c
the level of HbA1c (abbreviation previously referenced), testing for the diagnosis of diabetes is not recommended
which is a long-term marker of metabolic control mea- at this time since the vast majority of people who meet
suring the patients average glycemia over the past 2 to the diagnostic criteria for diabetes by oral glucose toler-
3 months³⁷ (unlike blood glucose which fluctuates daily ance test (OGTT), but not by fasting plasma glucose (FPG),
and as we eat). HbA1c levels of 4% to 6% are normal, <7% will have an HbA1c <7%. ¹⁰ Improvements in biochemical
is considered good diabetes control, 7% to 8% is moder- diagnostics for periodontitis might soon allow physicians,
ate control, and >8% is considered poor metabolic con- nurses and even patients to send samples to a central-
trol. Clinical practice recommendations of the ADA for the ized laboratory for evaluation and preliminary detection
standards of medical care in diabetes¹⁰ suggests a general of periodontal inflammation and breakdown with subse-
goal for patients is <7% but for the individual patient <6% quent referral to the oral healthcare provider for a com-
is preferred if this can be accomplished without signifi- plete oral evaluation and treatment.
cant hypoglycemia. The less stringent goals are for pa-
tients with a history of severe hypoglycemia, patients with Progressive Disease Management Benefits
limited life expectancies, very young or old individuals, Both Periodontal Status and Glycemic Control
and those with comorbid conditions. It has been estimated Diabetic patients with poor glycemic control most often
that every percentage point drop in HbA1c (e.g., from 8% experience delayed and impaired wound healing. ¹⁰ Conse-
to 7%) reduces risk of microvascular complications (eye, quently, there are challenges to achieving and sustaining
kidney, and nerve diseases) by 40%. ¹¹ Accordingly, it is the optimal therapeutic outcomes. In addition to traditional
primary objective of most physicians to keep the levels mechanical therapy of scaling and root planing, a pro-
of HbA1c low to prevent long-term complications. HbA1c gressive treatment regimen for periodontally involved pa-
testing is recommended at least twice a year for patients tients with poor glycemic control may also require the use
with stable glycemic control and quarterly for those who of adjunctive therapies such as systemically administered
do not meet the goals for glycemic control. ¹⁰ or locally applied antimicrobials (i.e., Arestin^®iv, Atridox^®v
or Periochip^™vi). Another valuable therapeutic addition
Periodontal infections, like other chronic infections, can to scaling and root planing is prescription of Periostat^®vii
impair a diabetic patient’s ability to process and/or utilize (sub-antimicrobial dose of doxycycline hyclate), a phar-
insulin. This leads to less optimal diabetic control. Moni- maceutical product that targets the non-microbial, host
toring HbA1c against periodontal status may provide key response component of periodontal disease. Recently
information in assigning appropriate periodontal mainte- reported pilot clinical studies using the two-pronged ap-
nance intervals, or provide evidence that definitive peri- proach of scaling and root planing in addition to Periostat
odontal treatment must be reinstituted. Diabetic patients demonstrated excellent clinical results³⁸ of periodontal
who are well controlled may not require the frequency of treatment with simultaneous improvements in the glyce-
maintenance visits and the careful monitoring required mic control of diabetic patients, as assessed by significant
for poorly controlled diabetic patients. One way of gather-
^{iv ®} ing information about diabetic patients’ glycemic control ^{Arestin , OraPharma, Inc., Warminster, PA
v} Atridox^®, CollaGenex Pharmaceuticals, Newtown, PA

is to request from their physicians a history of HbA1c lab vi _Periochip™_{, Dexcel Pharma, Jerusalem}
values and the results of most recent lab tests. A template ^vii Periostat^®, CollaGenex Pharmaceuticals, Newtown, PA