of patients so that they can formulate specific preventive non-fatal myocardial infarction (MI). His familial history or treatment plans to mitigate diabetic complications. For of diabetes has been known for over 40 years, and hy-example, dental providers may prescribe more aggressive perlipidemia and hypertension were diagnosed over 25 treatment of periodontal disease or increased frequency years ago. Given what we now know, what interventions of maintenance care, and medical providers may be more could we have employed 40, 30, 20, or even 10 years ago vigilant in identifying patients with poor glycemic control that may have prevented this outcome? Diabetes, heart who are at risk for infection, including periodontal dis- damage and periodontal disease cannot be reversed to a ease. Accordingly, medical providers should update den- state of biological health even with the most progressive tists on a patient’s glycemic control, and dental providers medical and dental care. At best, our current healthcare should apprise physicians of a diabetic patient’s oral sta- system can only offer this man treatment aimed at mini-tus to help regulate their blood glucose levels. ³⁶ mizing the risk for future MIs, and delaying the advance of retinopathy and tooth loss. What can be said about the

Conclusion missed opportunities for prevention earlier in his life?
A shift to preventive medicine may very well be on the What’s more, if this patient does not control his blood
way. In the past few years, insurers have begun adding sugars, he is at significantly greater risk for a second MI
preventive-care benefits to many plans, and some insur- which is likely to be fatal.
ers are paying for preventive care, regardless of whether
deductibles have been satisfied. ⁴⁸ Yet, there is still con- It is time to take a fresh look at the pandemic of diabetes,
vincing to be done — financial models which demonstrate a tidal wave that threatens to engulf our current health-
that expenditures made for prevention and wellness pro- care system. The responsibility for diabetes prevention,
motion will translate into cost savings in the not-so-distant diagnosis, and treatment cannot rest primarily on the
future. The dream case for demonstrating that investment shoulders of medical providers. The problem is just too
in prevention reduces morbidity and related costs in the big. Mobilizing the dental profession is critical for large-
long-term is calculating the return on investment for to- scale intervention of diabetes. Dental professionals who
bacco-cessation services. ⁴⁹ Over the last 10 years, there fully understand the immuno-inflammatory relationship
has been a dramatic increase in benefits for tobacco-ces- between diabetes and other chronic disease states, and
sation interventions. Research has shown that investing adopt a syndemic orientation, will make the greatest con-
$.18-$.79 per member per month to offer a tobacco use- tribution to preventive interventions. Their commitment
treatment program involving the “ 5 A’s” plus “Quitline” and cooperation must be enlisted to implement preven-
support and nicotine-replacement therapy generated a tion strategies that reinforce and complement the recom-
positive net return on investment of over $1.70-$2.20 per mendations embodied within the most recent standards
member per month after 5 years. ⁵⁰ Some authorities sug- of medical care for diabetes (2006). ² Ultimately, the med-
gest that the framework now in place for treatment of ical and dental professions’ level of commitment will be
tobacco use could be adapted to address obesity. ⁵⁰ decided by individual practitioners. For those who de-
cide to “dig in,” rewarding patient interventions are just

Equally exciting is that some insurers are starting to look around the corner, as are new opportunities for collabo-
at chronic conditions associated with periodontal disease. ration in transdisciplinary care.

One recently reported study sought to quantify the effect
of periodontal treatment on the reduction of overall risk Note from Co-Author Doreen Small, RN, MA, CDE: As a clinical
and medical expenditures for diabetes, coronary artery nurse specialist in diabetes for more than 31 years, I have had
disease, and cerebrovascular disease (CVD) in a large the opportunity to observe the evolution of both the profession of
population of patients with both dental and medical ben- nursing and the management of diabetes. Nursing has evolved
efits from one company. ⁵⁰ The conclusions were that ear- into a diversified profession with nurses not only providing bed-
lier periodontal treatment resulted in lower medical costs side but ambulatory care. Nurses in private practice settings,
for diabetes, CAD, and CVD. ⁵⁰ those in education, and those in research are eager to solve the
many still-unanswered questions about diabetes and its man-

Consider the case of an obese, 57-year-old white male agement. Nurses also have expanded their focus to include pre- with type 2 diabetes, with his last three HbA1c values vention. I see the role of the dental hygienist undergoing a simi- over 8.0%, advancing retinopathy, and recently diagnosed lar transformation, with both nurses and hygienists expanding periodontal disease. This patient just experienced his first their focus and practicing in a more holistic, syndemic manner.