The Association Between Oral Health Care and A1c Levels in Health Center Diabetic Patients

BACKGROUND: Poor oral health is a problem. A big problem. Some are calling it an emerging crisis in the United States (US) (Politico, 2019). There is strong evidence that a person cannot be truly healthy if they have poor oral health, yet the medical and dental professions are divided when it comes to the provision of care. For the most part the medical profession treats the patient as if they do not have a mouth, and the dental profession treats the patient as if they do not have a body. Research indicates this historical division must stop. This becomes very apparent when the guidelines for the care of patients with diabetes are examined. This project sought to focus on the association between oral health care received by patients with diabetes and glycemic control as measured by HbA1c, and policy implications for the medical/dental divide as they pertain specifically to the treatment and care of people living with diabetes. OBJECTIVES: The dissertation aims were to: 1) Document access to oral healthcare within a large FQHC in Southwestern US to determine whether there were disparities in access by specific demographic constructs; 2) Document the level of oral healthcare being delivered to medical/dental patients with diabetes to determine if there is an optimal level of oral health care for adult patients with Type II Diabetes; and, 3) Document whether access to oral hygiene services improved glycemic control of patients with diabetes who were enrolled in a Diabetes Self Management Education (DSME) program compared to those who did not. METHODS: This quantitative study was a retrospective record review of 3,144 randomly selected patients with diabetes who were medical and dental patients at a large Southwestern Federally Qualified Health Center. RESULTS: There was a greater disparity in access to oral health care services within the FQHC than what was reported for the Nation (Oral Health, 2000). Within patients who identified as Hispanic ethnicity, only 19.2% accessed oral health care services in 2017, while 46.2% at the National level did so in 1993 (Oral Health, 2000, pg. 80). Fewer than 10% of all adult medical patients accessed oral health care services. Patients who only access dental services make it appear like a greater percentage of medical patients are accessing oral health care. Fewer than 5% of adult patients with diabetes, seen for oral health care services, received dental prophylaxis at least two times per year. HbA1c was significantly lower for patients who had received dental prophylaxis at least two times per year or ever received dental prophylaxis, than patients who never received dental prophylaxis (F=16.13, df = 1,476, p<.000). Patients who had never received dental prophylaxis were 2.98 times more likely to have uncontrolled diabetes as measured by HbA1c than were patients who had received this level of care (z=2.74, se = 1.19, p=.006). The odds of patients having uncontrolled diabetes who have never received preventive oral hygiene services ranged from 2.60 to 3.34 times higher than patients who had received oral hygiene services. No significant difference in HbA1c was observed between patients who received medical care only and patients who received both medical and dental care but had not received dental hygiene services (t=-1.04, df=2,566, p=0.297). The majority of medical and dental patients with diabetes (68.2%) never received preventive dental services. Patients with diabetes who were enrolled in the Diabetes Self-Management Education (DSME) program who accessed oral health hygiene care at least two times per year have statistically significantly lower average HbA1c than DSME enrolled patients who did not access oral hygiene care (7.51 vs. 9.21 & 9.29). Fewer than one third (31.8%) of patients with diabetes enrolled in the DSME program who accessed oral health services received preventive dental services such as a dental prophylaxis or periodontal treatment. There were no statistically significant differences between average HbA1c for patients who only received a dental prophylaxis (teeth cleaning) versus those who had received at least one periodontal service (7.27 vs. 7.45 for all patients with diabetes; 8.47 vs. 8.63 for DSME enrolled patients). This finding was surprising as almost all prior research has been focused only on periodontal treatment such as scaling and root planing. CONCLUSIONS: The results of this study indicate more pronounced disparities in access to oral health care within a FQHC than what are found within the population. Patients who are being treated for diabetes medically are unlikely to access preventive dental services (68%), even when the services are available. Patients who do not access preventive dental services have a greater likelihood of uncontrolled diabetes than those patients who do access these services. Patients enrolled in an accredited DSME program and who access preventive dental services have statistically significantly lower HbA1c than those who do not. Medical guidelines for the treatment of diabetes do not include specific recommendations on the frequency or type of oral health care patients with diabetes should receive. The results of this study provide additional support to the hypothesis that access to preventive dental services every six months could play a major role in the control of diabetes. The lack of training of medical professionals to conduct oral exams as part of their regular protocol precludes their ability to incorporate the mouth into their regular practice routine. The lack of training of dental professionals to understand the impact of poor oral health on the systemic health of their patients precludes their ability to consider the impact of oral health beyond the mouth. While there are efforts on both the medical and dental sides to break down the divide, we have not reached a tipping point where the barriers to integration are completely removed. The parity in access to oral health care insurance is a major barrier to the ability of patients with diabetes who receive medical care in an FQHC to access preventive dental services. This lack of access precludes patients from the ability to achieve optimal health. RECOMMENDATIONS: Federal legislation should be sought to revise the Public Health Practice Act to include a definition of preventive dental services and a focus on preventing oral disease rather than the treatment of emergent dental issues in Federally Qualified Health Centers. The American Diabetes Association and the American Dental Association should convene a workgroup to determine specific guidelines for the oral health care of patients with diabetes. Medical schools should adopt the Head, Ears, Eyes, Nose, Oral cavity, and Throat (HEENOT) protocol as the standard protocol for the regular exam of the head and teach all medical students to conduct the HEENOT. Medical providers should be taught how to utilize non-invasive, nonrestorative, medicinal methods to prevent and arrest tooth decay, such as the application of Silver Diamine Fluoride and glass ionomer sealants. Dental school curriculum should be developed to teach dental students about the oral/systemic connection and how the dental professional can monitor the health of patients as well as to work interprofessionally with the medical profession. State legislation should be sought that requires the coverage of preventive dental services for all ages by all health insurance providers.Release after 12/10/202