• “ ... the challenge of providing uniformly effective from overwhelming demands for diabetes treatment.
diabetes care has thus far defied a simple solution.” Until complications develop clinically, diabetes is mostly
• “A major contributor to suboptimal care is a delivery asymptomatic, and medical providers’ attempts to fully
system that too often is fragmented, lacks clinical in- implement guidelines for diabetes care often take a back
formation capabilities, often duplicates services, and seat to immediate concerns of diabetic patients. Before
is poorly designed for the delivery of chronic care.” we take aim at the medical profession, we must consider
Despite efforts to translate research on diabetes care into the magnitude of the challenges inherent in reversing the
primary medical care, it is increasingly apparent that trends in obesity and diabetes.
there is a large gap between what is known about diabe-
tes care and what is practiced. ³ Dentistry’s Current Capacity to Impact the
Diabetes Epidemic

The Standards of Care-Practice Gap Managing diabetic patients’ special needs is not new Empirical evidence for a gap in standards of care and to dentistry. Oral manifestations of diabetes, treatment practice in treating diabetes has been cited in numerous guidelines, and emergency protocols have been taught in professional journals. Some state that the level of dia- dental schools and dental hygiene programs for decades. betes care provided in primary care medical practices, What also has been taught and extensively discussed in where most patients are seen, consistently falls short of professional literature is that diabetic patients are at 2-4 what is recommended. ¹⁴ Even ordering blood tests or times greater risk of developing periodontal disease than regularly checking HbA1c is performed less frequently non-diabetic patients, ³ and once periodontitis is estab-than recommended. ¹⁴ Saydah and colleagues reported lished in a diabetic host, metabolic control of diabetes is other evidence of suboptimal diabetes care, as follows: ³ complicated from the constant reservoir of periodontal pathogens responsible for infection. ³ Thus, assessment

• Only 37% of adults with diagnosed diabetes achieved and treatment of periodontal disease are essential for di-
an HbA1c of < 7% (goal). abetic patients, ¹⁸ and dental providers who treat diabetic
• Only 36% of adult diabetics had a blood pressure patients with periodontitis should monitor serum glucose
< 130/80 mmHg (goal). or HbA1c as part of patient management. ³ Over the last
• Only 48% of adult diabetics had a cholesterol decade, the American Academy of Periodontology has
< 200mg/dL (goal). addressed appropriate care of the diabetic patient with
• Fewer than 7.3% of diabetics achieved all 3 goals. periodontal disease in numerous position statements and
parameters of care. ^3-7 However, the number of dental

Other standards of care-practice gaps emerge when ex- providers who incorporate these guidelines into every-
amining national diabetes-related objectives for year day patient care has never been quantified. A well de-
2010. Three of the national objectives related to diabetes signed study that captures data on how diabetic patients
care include: increasing to 75% the proportion of adults are managed in dental practices may determine whether
with diabetes who undergo an annual dilated eye exam; there is a standards of care-practice gap in diabetic pa-
increasing to 50% those who have an annual foot exam; tient management in the dental profession that parallels
and increasing to 50% those adults who have HbA1c that within the medical profession.
measurements at least twice a year. ³ To determine the
percentage of adults with diabetes who received 1 or all What is less well understood by dental and medical pro-
3 of these services, the Centers for Disease Control and fessionals alike is the concept of the risk continuum of
Prevention (CDC) analyzed data from surveillance sur- periodontaldisease, namely, the risk periodontal infection
veys collected from 2002 through 2004.¹⁶ Their findings poses to systemic health. Recent research³ suggests that
indicate that only 4 out of 10 diabetic adults received all obesity, mediated by insulin resistance, may increase the
3 preventive care services, and they concluded that con- risk for periodontal disease; however, this risk continuum
tinued interventions to ensure delivery of diabetes care does not end here. Although traditional thinking within
are necessary. ¹⁶ An even more startling finding is that the broader healthcare arena is that periodontitis is an
of the estimated 7% of the U.S. population with diabetes, oral disease with tissue destruction which remains local-
only 70% has been diagnosed. ¹⁶ ized, the sequelae of periodontal disease appears signifi-
cantly more threatening than simply a localized infection.
The standards of care-practice gaps cited above result Escalating evidence over 20 years of research suggests