Floss & Flip-Flops Podcast Episode 11 - Diabetes November 2022? Transcript Elizabeth Sanders, DPM 00:01? Hi, I'm Dr. Elizabeth Sanders, a foot and ankle surgeon and assistant professor at Boston University ? Medical Center.? Katrina Sanders, RDH 00:08? Hi, I'm Katrina Sanders. I'm a registered dental hygienist, consultant, international speaker from wine ? lover. And we're sisters.? Elizabeth Sanders, DPM 00:17? I grew up looking up to my big sister Katrina.? Katrina Sanders, RDH 00:20? And now I look up to my lady boss sister Elizabeth.? Elizabeth Sanders, DPM 00:23? Together, we are working to unite the dental and medical communities in unique and exciting ways.? Katrina Sanders, RDH 00:29? ? elcome to Floss & Flip Flops with the Sanders sisters, our monthly podcast Elizabeth Sanders, DPM 00:34? where we unpack all things health related from your mouth to your toes. ? Katrina Sanders, RDH 00:38? So grab your flossy floss ? Elizabeth Sanders, DPM 00:40? and slide on some flippy floppies Katrina Sanders, RDH 00:42? And then let's get on with the show. Hello, and welcome back to another fabulous episode of floss and ? flip flops with your favorite sisters. The ginger sisters. Hi Gingy How are you today?? Elizabeth Sanders, DPM 01:02? Oh, I'm so good. Because for the second time, actually, I get to record this with you in person in the ? same city on the same part of the world. So, so happy to see you in person,? Katrina Sanders, RDH 01:13? we're literally sitting next to each other having a glass of bubbles on champagne day, it is national ? champagne day. So cheers, cheers, cheers to you. And cheers to champagne. I'm so excited, we just ? finished delivering part one of a two part series on the oral systemic link together. And I just after we ? recorded or I'm sorry, after we presented today, I was like we just have to zip up to the hotel room. And ? we have to record our next episode for the month of November, because I think it just weaves so ? beautifully into the content that we were discussing today. So November is diabetes Health Month. And ? this, of course, we know is an overt opportunity for us to really serve, support and connect our patients. ? We know in the dental space that we see a lot of patients that do have diabetic complications. And I ? know that you, as a podiatric surgeon certainly see a lot in the way of diabetic complications as well. So ? I think you know, first and foremost, when we talk about diabetes, we're talking about three major types ? of diabetic conditions that our patients can experience. So type one diabetes, we'll start there, type one ? diabetes is oftentimes called the early onset or childhood diabetes. This is an insulin dependent form of ? diabetes for one reason or another, the individual is experiencing challenge, either in their isolates of ? Langerhans, something's going on with their pancreas where they're not necessarily producing insulin ? appropriate to be able to, of course, address the glucose that's going through their bodily system, etc. ? So individuals in a type one situation, oftentimes identified early on in their childhood, and oftentimes ? are placed on insulin, whether those are injections that are done or wonderful devices that a lot of type ? one diabetics have nowadays, to actively monitor their A1C, monitor their blood glucose levels, and to ? be able to deliver insulin as needed. Then we have a type two diabetics, which used to be called late ? onset or adult onset. Of course, the sad reality of an diabetic patient that is type two is that with the ? amount of childhood obesity that we are observing across the United States, particularly, we are seeing ? type two diabetes on the rise. And so of course, this leads into a lot of unique challenges that we're ? starting to see in our young people, which is impacting lifestyle choices. It used to be notated that a ? type two diabetic was considered a non-insulin dependent diabetic, but do you see patients that are ? type two diabetics that are now placed on insulin? ? Elizabeth Sanders, DPM 04:13? Yes, absolutely. ? Katrina Sanders, RDH 04:15? Yeah. And so I think one of our challenges in managing a lot of this really just comes down to we in the ? dental space are actively looking to the medical community to help give us identifiers as to how well this ? patient is controlling this disease process, etc. The third condition is what we call gestational diabetes. ? Gestational Diabetes is a diabetic condition that does form during pregnancy. Often times the delivery ? of the baby helps to eradicate gestational diabetes, but it certainly doesn't change the fact that these ? individuals during their pregnancy where their body is already going through so many changes, is going ? through another change on top of that, where they're experiencing gestation. Well, diabetes, we know ? that diabetes absolutely does impact a large portion of our population. So now when we talk about ? diabetes, I think it's important for us early on to create some parameters around how diabetes is ? managed. So, right out the gate before we even introduce medications for type two diabetics, as a ? doctor, what are some of the things that a type two diabetic could do to help manage their A1C?? Elizabeth Sanders, DPM 05:32? Yeah, and these are things that I think from a multidisciplinary approach really need to be addressed, ? as we as dental hygienists, and in the medical community, as we're seeing our patients. This is where ? we need to educate our patients, it's easy to give a patient a prescription, you know, to give them Oh, ? you need to be on insulin, or you need to be on Glipizide, or Metformin. But you also need to educate ? them about the long-term effects of those things. And this is where we're obviously going to talk to our ? patients about diet, an appropriate diet, exercise, and overall nutrition. And when you talk to your ? patients, you can't just say that this medication is going to be the end all be all, and help you for the rest ? of your life. There are patients who have gone off of medications, I've had patients before that very ? young patients who are diagnosed with diabetes type two, they were told that they needed to be on ? insulin because their hemoglobin A1C was very high 14%. And they refused it. They said I don't want to ? be on insulin, but I'll be on the pills, because I want my body to learn to produce insulin. And they with ? diet and exercise, manage that and get their hemoglobin a one seemed much better controlled. So I ? think that this is where we need to really educate our patients. Because once you put patients on ? insulin, it is difficult to titrate them off. Wow. But it's it's certainly possible with type two diabetics to ? eventually be off of medications. Once you're diagnosed with diabetes, you're considered a diabetic for ? life, at least in some people's opinions. But you're at least managing it with diet and exercise.? Katrina Sanders, RDH 07:12? I think that's important because unfortunately, one of the things that we do see in the United States is ? that we are just so tethered and triggered right away to move into giving the patient a medication. And ? as a dental hygienist, we are focused on the preventive aspect, we are preventive specialists. So if ? there are things that we can do to change lifestyle choices, or to counsel the patient, I mean, that's ? really what we're focused on.? Elizabeth Sanders, DPM 07:38? Absolutely. And I think that's also with patient satisfaction. You think the patients coming to me, I must ? prescribe them something to help them correct when really, they're also coming to us for medical ? knowledge. So understand that we need to be teaching our patients as well. And they need to be ? accepting our knowledge, not just let's prescribe something,? Katrina Sanders, RDH 07:58? I think that's so powerful. The fact that you said patients come to us for knowledge, I think we ? oftentimes assume that the patient is coming to us because they want a pill, they want a prescription ? they want, you know, some sort of easy out. And the reality is, I can't remember where I heard this, but ? somebody the other day said, and I thought this was just so powerful. Medicine, health care, should ? make people feel better. Mm hmm. But how many times do we give somebody a medication? Or how ? many times do we give somebody a treatment or modality that does not make them feel better?? Elizabeth Sanders, DPM 08:36? Right, the consequences? Yeah, the side effects are worse than the actual underlying illness that ? you're prescribing it for? Yeah,? Katrina Sanders, RDH 08:42? I absolutely love that. So let's talk a little bit about prevalence. What is it that we know currently about ? the existing prevalence of diabetes?? Elizabeth Sanders, DPM 08:52? Yeah, so this certainly is a worldwide pandemic and a worldwide problem, we know that. But 20 million ? Americans have diabetes with upwards of 35 to 40% of those who remain undiagnosed. That's ? unbelievable. That's like 35 to 40% or, and undiagnosed. But one 1.5 million new cases are diagnosed ? each year.? Katrina Sanders, RDH 09:16? So okay, so let's dial this back. Because I love this. I don't love this. I don't love that a large portion of ? the individuals who have diabetes are undiagnosed. But I do want to talk about how that diagnosis ? happens. So I don't know why. Maybe it's just like me, like growing up in the Midwest, or am I due to do ? and I think everything is like hunky dory all the time. But I always picture that like people go in every six ? months or every year to their primary care physician, and they just get their vitals taken. And from there ? if Oh, the blood sugar looks a little funky, then the doctor manages that. But I think I'm living in a ? fantasy world right? Because the reality is, that's likely not how the vast majority of diabetic cases are. ? identified, right?? Elizabeth Sanders, DPM 10:01? Yeah, that's correct. And I would say only if there may be above 45 or 50. Would their primary care ? physician even consider ordering and even though the diagnostic tests would be a fasting glucose, but ? usually it's easier to use your to do a hemoglobin A1C, which is not diagnostic. But I've seen PCPs ? routinely order that Katrina Sanders, RDH 10:21? an HbA1c is not diagnostic?? Elizabeth Sanders, DPM 10:24? No, it's not diagnostic. Only fasting blood sugar is.? Katrina Sanders, RDH 10:27? So that would mean that the patient would have to come in prepared to take a fasting blood glucose. ? Elizabeth Sanders, DPM 10:33? That's correct exactly what your exam you say. You say go downstairs to the lab did you eat today? ? And that's probably why it is a difficult test to do. You have to tell each patients to go in the morning ? before they eat anything.? Katrina Sanders, RDH 10:48? Not only that, but like when you tell somebody did you eat today, you'll have some people that'll say no, ? but they've had like a Lunchable. Like on the way you know what I mean? So it's like, they're, they're ? even like loosey goosey terminologies and all of that, which is crazy. So you see a large portion of ? diabetics in your practice?? Elizabeth Sanders, DPM 11:04? Yeah, yeah, I would say 60 to 70% of the patients that I see 60 to 70%.? Katrina Sanders, RDH 11:09? Yeah. So what are some of the more common things that you see with a diabetic patient?? Elizabeth Sanders, DPM 11:17? Yeah, so a lot of our patients come in for routine, what we call diabetic foot care, where they'll come in ? every three to four months, usually to get their toenails cut, because there are multiple reasons why in ? patients with diabetes, they do have neuropathy. They also have skin changes, toenail changes, then ? think about the other systemic problems that happen with patients with diabetes. They have neuropathy ? of their hands as well, they have difficulty seeing with retinopathy. So how are they going to bend down ? and cut their toenails? Also, because these patients have neuropathy, they can't necessarily look at ? their feet to know if there's anything wrong. So we see routinely patients and we'll educate them on ? their diabetes. There are times where we'll see patients who come in with an ulcer, and we're the first ? eye on that ulcer. And we're the ones who ask like, are you diabetic? And they usually, they have no ? clue. A lot of patients have no clue. And why should they really, unless they're educated from our ? perspective,? Katrina Sanders, RDH 12:21? okay, so patient comes in, they have a problem with their foot. That's what they're complaining about. ? And you look at it, and I would imagine, like when you see a diabetic foot ulcer, like, you know, what ? you're looking at most of the time, right?? Elizabeth Sanders, DPM 12:38? A lot of ulcers do look the same. I would say that. So even if it's from a traumatic ulcer or simply a ? neuropathic goals or venous ulcer, and there are characteristics for each type of ulcer, but yeah, I ? would say we pretty much know when a patient is diabetic or they come in with a diabetic foot infection. ? Yeah.? Katrina Sanders, RDH 12:56? So you call it a diabetic foot infection, but these individuals come in and they have, they have no clue ? they have diabetes, you ask them. So when they have, when they come in, they experienced this. And ? you ask them, Do you have diabetes? At any point? Are they like, no, but I have diabetes in my family? ? Like, are there any remarks from this patient? Or are they just like, No, I don't have it. And I would ? imagine from there, you're like, Okay, well, we're going to do some testing, right?? Elizabeth Sanders, DPM 13:22? That's correct. So where I work, though, I do see patients from kind of all over the world, though, they ? will come from other countries. And some of them don't necessarily know, their family medical history, ? I'll be at some do. And they say, yeah, it does right in my family, but some are just very unaware, and ? maybe uneducated about the process. So they'll come to me with an ulcer of some sort. But at the ? same time, we do have to get referrals from their PCP. So maybe this would be more from an ? emergency room perspective where patients will come into the emergency room with oh, I noticed ? bleeding. That's usually what they say. I noticed bleeding,? Katrina Sanders, RDH 13:59? Wait, they notice bleeding on their foot? like there's like my foot is bleeding, like on the floor, or Elizabeth Sanders, DPM 14:04? if they wear sandals, or shoes without socks, which gosh happens all the time. But they'll notice ? bleeding and it's usually after an ulcer has been present for quite some time.? Katrina Sanders, RDH 14:16? Wow. Okay, so let's pretend early on, this patient has an ulcer and they come in to see you. And as a ? diabetic, they are diabetics is diabetic foot ulcer, you then walk them through doing this initial testing, so ? you send them to the lab, you have them do ideally a fasting blood glucose, right? So oftentimes, you're ? the one that is bringing these patients to this diagnosis, right.? Elizabeth Sanders, DPM 14:42? Yeah, that's very true. And a lot of the times if they if it is a severe infection, we do have to admit them ? to the hospital, and that's when they're diagnosed with diabetes.? Katrina Sanders, RDH 14:51? Walk me through how you manage a diabetic foot foot ulcer on a patient, like what does that process Elizabeth Sanders, DPM 14:57? so obviously we want to manage certain things. We want to manage the infection. So in our way we do ? debridement. Similar to what you do, I mean, you guys debris teeth. To get rid of the infection, we do ? the same thing we did breed all non-viable tissue, whether it be a muscle, or if there's bone exposed, ? we call that osteomyelitis. So there's a bone infection, we're lucky because it's of the foot things, we ? can do certain things, the best thing, honestly, you know, would be an amputation of that portion that is ? infected the other Katrina Sanders, RDH 15:30? Okay, hold on a second. Wait, the best thing would be to amputate the foot because the foot now ? becomes a focal point of infection.? Elizabeth Sanders, DPM 15:38? Yeah. So you have your certain options. When you have a bone infection, you have one option would ? be an amputation of the infected bone and then closing the wound.? Katrina Sanders, RDH 15:47? So sometimes you can like slice the foot and half,? Elizabeth Sanders, DPM 15:50? right, hundred percent. Yeah, what's that called? It's called a transmetatarsal amputation. It's actually a ? very durable procedure. So and this is when we're talking about ulcers of the distal foot. So if the toes ? of Katrina Sanders, RDH 16:02? The distal foot means like the one that wee wee wee'd all the way home, is that the distal foot?? Elizabeth Sanders, DPM 16:07? That's that little piggy, that little Katrina Sanders, RDH 16:10? piggy that's not the one that went to the market. But the one that matters,? Elizabeth Sanders, DPM 16:12? the one that went home that lateral, but it's also distal, yeah, it's Katrina Sanders, RDH 16:16? distal, right? I'm pointing to my toe,? Elizabeth Sanders, DPM 16:19? all your toes are distal.? Katrina Sanders, RDH 16:22? Okay, well, okay, that's, that's a conversation for another day. Because this ginger is very confused ? about that. Now, in diabetic foot ulcers, they form on like the pad of the foot, the center of the foot kind ? of all over the place, where do they Elizabeth Sanders, DPM 16:33? they can't and this is great, because a lot of this is because of certain things with diabetics, diabetic ? neuropathy, you think, oh, you know, there are patients who have a significant amount of pain with ? neuropathy, like sharp shooting pains, and there are patients who also feel absolutely nothing. And ? what I tell patients is, it's almost like the high blood sugar is coding your nerves. And that's creating for ? this sense of pain or lack of sensation. And it also affects the sweat glands. So it makes very draining. It ? also affects the muscles, so you get contractures of your foot and you get hammertoes. And you get ? very prominent metatarsal heads, which is what you were pointing to before Katrina Sanders, RDH 17:16? Do I have a prominent metatarsal head?? Elizabeth Sanders, DPM 17:19? You do only because you have very high arches,? Katrina Sanders, RDH 17:23? but I don't have diabetes, but you don't. Okay, we can we can examine later to see if I have a diabetic ? foot ulcer, or not feeling anything, but apparently that's called a neuropathy.? Elizabeth Sanders, DPM 17:32? That's exactly right.? Katrina Sanders, RDH 17:33? This is what I want our listeners at home to pick up on it doesn't hurt them. Right? That's correct it you ? they show up in your practice because their foot is bleeding. Do you know what would be amazing in ? dentistry is if my patients because periodontal disease associated with diabetes does not hurt them. ? And their gums also bleed. The difference is for whatever reason, it's totally normal to bleed from the ? mouth. The moment they bleed from the foot. They're like, wait a second, and they come in and see ? you. Right.? Elizabeth Sanders, DPM 18:08? So that crazy. So on that though? What are besides bleeding gums? What are some things that you ? may see in patients with diabetes? Yeah, so,? Katrina Sanders, RDH 18:18? you know, our diabetic patients, first and foremost, for a long time, I thought that one of the best ways ? to evaluate what diabetes looks like in the oral cavity is to do an exam like on tissue exam, because ? that's where we oftentimes see the ramifications of diabetes. And that is true, you can probe a patient ? and I actually asked this question today, did I not that you see diabetic foot ulcers, and you have to ? manage this patient? Because now you're telling the patient, they may not think that they have ? diabetes, but you see a diabetic foot ulcer, you know what it is? And you bring the patient to understand ? the big conversation we had today was, how often do we see disease in the oral cavity? And we're just ? conditioned to scale and debride and root playing the tooth. But we don't know. We don't know that that ? patient may be an undiagnosed diabetic, how do we identify if that patient has an undiagnosed ? diabetic? Well, you would debride the patient and you would see the patient back and you would ? evaluate them and they would have been non responsive in many cases, right? That's how you know, ? okay, something is wrong, they are not responding. The question being, how often do we in dentistry, ? we evaluate our work, so that becomes another layer, right?? Elizabeth Sanders, DPM 19:30? Because you see your patients every what, two times a year every six months,? Katrina Sanders, RDH 19:34? two times a year. However, if they do have periodontal disease associated with diabetes, for example, ? or of course the precursor to that irreversible disease process gingivitis, we should be treating them ? with a more advanced treatment, and we shouldn't be seeing them on a shorter week here. So the ? question becomes, are we actually reevaluating our patients? are we identifying if our patient has ? responded to our therapy or not?? Elizabeth Sanders, DPM 19:59? Do insurance plans cover more routine dental cleanings for patients with diabetes.? Katrina Sanders, RDH 20:05? Turns out, they do somewhat. So you have to submit a letter to the insurance company. And you let ? them know, you know, my patient is a type one type two gestational diabetic. So we want to shorten ? this free care for this patient. So there are insurance companies that will do that. They'll do that even for ? pregnant patients, which is really nice. But the idea being when we take a look at the oral cavity, one of ? one clear indicator of us being able to identify undiagnosed diabetes in the oral cavity would be a ? patient who is nonresponsive to our periodontal therapy, because we know that one of the conditions ? that we see with diabetes is a delayed wound healing, right? They're immunocompromised. We can ? also see pathologies in the oral cavity. So Lichen Planus is a big one. And we can see either the ? Wickham strike, which is that reticular form, that kind of white lace like observation of the tissue, or ? even into that erosive form of Lichen Planus. Um, so that oftentimes does accompany we know that a ? diabetic patient will have a higher concentration of glucose and their saliva. So we understand that they ? oftentimes have an elevated risk for decay. So we might start to see more cavities pop up in these ? individuals, we can also see opportunistic infection, as we oftentimes do see with diabetics, so in the ? oral cavity, that could look like Candida, these could be patients that are struggling to control fungal ? infections, particularly when patients were wearing masks, we saw that quite a bit like they're covering ? their mouth, right. So it's a warm, moist environment underneath that mask. And so we saw our diabetic ? patients, or undiagnosed diabetic patients experiencing fungal or yeast infections in the nares of their ? nose, or in their philtrum, which we used to call the booger, gutter, gutter that fit in there, or even in their ? chins, that they had kind of that anatomy that allowed for the collection of fungus or yeast, or, or ? angular cheilitis. So in the corners of the mouth, we could see fungus or yeast producing in there.? Elizabeth Sanders, DPM 22:08? ? I see yeast in between the toes,? Katrina Sanders, RDH 22:09? not crazy. So I mean, we see so many similarities. It's like, it's unbelievable. And so you know, it's ? interesting, as we look at this in dentistry, that I implore you to consider the statistic is over 25 million ? people will see a dentist this year, but will not see a primary care physician. I believe that there are ? millions of people that will not see a primary care physician, because I hate to say it, but we in the ? United States live in a country in a cultural society, where it's like you don't go to the doctor unless ? there's a problem. So the issue becomes Who's the one who sees the problem? We're, we're waiting ? for society for our patients to go. Well, that's where I shouldn't be bleeding from my foot, when the ? reality is, who's the advocate? Who's the one who's the preventive specialist who can identify these ? things and say, I'm concerned, I implore you to consider perhaps dental hygienists could be your true ? referral source. They could be your gatekeeper. They could be the ones that are triaging these patients. ? Right.? Elizabeth Sanders, DPM 23:19? And I feel the same way about podiatry. Sometimes that can be the gateway, especially to refer for ? vascular. So I have a question for you. And I've heard mixed answers even when we present this ? material. So let's say you a lot of the times, I'm sure you see patients who and we talked about the ? statistics probably are not diagnosed with diabetes, and you're doing major scaling and root planing on ? these patients. But then, I've heard some statistics of some dental practices who won't do scaling and ? root planing or any elective cases on patients with hemoglobin over whatever it it is because everyone ? has different standards, and there really hasn't been an approach. So what are your thoughts on that?? Katrina Sanders, RDH 24:04? Great question. So my first question, actually, I'm gonna, I'm gonna answer your question question. ? And that is, first of all, is scaling and root planing elective? For a diabetic patient?? Elizabeth Sanders, DPM 24:17? I would say no, I mean, so let's unpack that if my patient has an infection in their foot, they have an ? open ulcer, essentially, it needs to be cleaned out, it needs to be depleted. Likewise, if my patient has ? fungal toenails, I need to cut my patients toenails, you are dealing with something that is the gateway to ? the rest of the body. So many things happen through the mouth. I believe that you should be cleaning ? any infection in the teeth, and I guess I'm wondering where the hesitancy is that if a hemoglobin a one ? C is above a certain level, why is that considered elective and why would you be hesitant? Maybe ? infective endocarditis is there, you know, like what would be the reason that you'd be so I'm nervous.? Katrina Sanders, RDH 25:00? I do. And I'll tell you what I think the answer is, and this is just the world according to Katrina Sanders, ? this is no, there's no research on this that like hygienist won't blah, blah, blah, blah, blah, I really think ? this is the world according to Katrina Sanders, we were told in hygiene school that an agency of 7.0 or ? under is optimal, meaning the patient will have a better chance of wound healing. If you can get them or ? treat them at 7.0, or under from an agency perspective, we were told, most of us were trained that over ? ?7%, that the patient is now struggling to control their diabetes. And so they will not respond us favorably ? toward treatment, which I want to dive into. But they will not respond as favorably to our treatment if ? they are over 7.0%. So I want to ask you to share the statistic that you shared today, during our ? program, about what we know about treating patients with periodontal disease,? Elizabeth Sanders, DPM 26:03? there have been multiple documentations. But one that I kind of quoted was one was that was done in ? Spain on 90 patients, where they performed scaling and root planing on these 90 patients. Sorry, half of ? the study was done on scaling and root planing patients, and half of the study was done via ultrasound. ? And what they found was is that those patients who had scaling and root planing within six months and ? they're all diabetics in this study, correct, but that they had lowered their hemoglobin a one c by 1%, in ? six months. And I want to tell you that if my percentage if my patient came in, and in six months, their ? hemoglobin valency was down by 1%. I'm like dancing. I'm ecstatic. Wait,? Katrina Sanders, RDH 26:47? so Okay, so let's pause for a second. So you see a patient who has a diabetic foot ulcer, you treat that ? diabetic foot ulcer, and you're tracking their A1C, A1C is not a diagnostic, it can be a screening tool, but ? it's non diagnostic, you've already said right, so you take your fasting blood glucose, but the A1C tells ? you over 90 days, how well because that's how long it takes a red blood cell to die, right? So over 90 ? days, you're taking this A1C on this patient and you're tracking how well the patient is able to control ? their blood glucose, etc over a spectrum of time. And you're saying that with a diabetic foot ulcer, in you ? treat these a lot that you would still say that if a patient can drop in six months 1% That that is that is? ? That's amazing. Yeah, that is something that you'd want to see.? Elizabeth Sanders, DPM 27:36? That's fantastic. And then there are times where the these patients come in with we and we talked ? about with a Charcot foot is there are times that they are in have such a crazy deformity that they do ? require a surgical reconstruction, however,? Katrina Sanders, RDH 27:50? so this is like their the diabetic foot ulcer has not been treated at the ulcer level and it's gotten Elizabeth Sanders, DPM 27:56? worse. So not all patients with what's called Charcot neuropathy, not all of them have ulcers, most of ? them do because of the deformity and most of them, a lot of them do require reconstructive surgery.? Katrina Sanders, RDH 28:10? Okay, so what does Charcot mean? What what is that Elizabeth Sanders, DPM 28:13? Charcot is a deformity mainly in patients with neuropathy, any type of neuropathy, not necessarily ? diabetic, but most commonly in diabetics where there's essentially increased blood flow and ? neuropathy. So that lack of sensation,? Katrina Sanders, RDH 28:30? so the increased blood flow comes because the body is now in a state of inflammation. The host is now ? in a state of panic. So it's sending blood to the area. I'm gonna take a pause, because we know in ? gingivitis, one of the key indicators early on in stage, and we're talking about the the stages of gingival ? diseases, by the way, the early histological signs that we see in gingival. Inflammation is an increase in ? vasculature changes and increase in blood flow. Why do we say that because the body is in a state of ? distress, and it's sending inflammatory components to the area, we see a vasodilation we see ? permeability of the blood vessels. So we see that in the oral cavity, so you're seeing the same thing in ? the foot. Absolutely. So you see, I'm sorry, vasodilation, or an increase in vasculature in that area. What ? else? And neuropathy so the body starts shutting down those nerve endings. What is the body doing? ? It's literally saying, I'm preparing to amputate this myself, because it's so infected, right?? Elizabeth Sanders, DPM 29:32? Yeah. And patients will have this red hot, swollen foot and they don't know about they just think, oh, it's ? red, hot, swollen, and because they don't feel anything. They just keep walking, walking, walking, and ? you're getting these fractures throughout all of the foot. Same thing as the you're describing to me in ? the mind Katrina Sanders, RDH 29:49? the oral cavity, the oral cavity, the same thing happens. They get gum tissue inflammation, as they ? continue chewing on that because occlusion plays a role in this the way that their teeth bite together. ? That As they continue to chew on this inflammatory period on Chimp, they start to experience over ? time, bone loss. What does bone loss mean? Boneless means the same thing as the body. Because ? again, your your patients experienced neuropathy fancy term for neuropathy is they cannot feel or they ? got pins and needles feeling. Remember we got neuropathy when we were hiking Mount Kilimanjaro, it ? was a side effect of our altitude pills was neuropathy and our fingers or toes and our lips work it was ? like, like pins and needles, so you couldn't feel the pain. So patients experienced that in their feet. They ? experienced that in their mouth when it comes to periodontal disease, because most of the time it's ? asymptomatic early on in the process. So they experience an engagement of their blood vessels, they ? experienced neuropathy. And then for you, the body starts to like try to amputate itself it starts to get ? infected. And in the oral cavity, the same thing starts to happen, the body starts to you know, create ? bone loss in that area osteoclastic activity starts to happen. And the body's trying to amputate a body ? part, a tooth structure, right? That you see the same thing in the foot that we see in the mouth. So ? Charcot foot continues to happen because the patient is walking out and it creates these micro ? fractures, right that over time you have to do major reconstructive. So by reconstructive what are we ? talking about? You're having to amputate you're having to put like pins in rods in like, what would that ? look like for a patient?? Elizabeth Sanders, DPM 31:28? Yeah, very good question. So amputation, unfortunately is an option. But our goal would be limb ? salvage, and that really depends on a lot of things, the patient, their nutritional status, the patient's ? compliance, and our skills. So a lot of the time Katrina Sanders, RDH 31:45? weight limb salvage is the skill set, you have your ability to either treat this patient the equipment that ? you have, in your practice, the nutritional status of the patient, the patient's ability to control their own ? disease process. dental professionals out there does that not sound exactly like how we manage ? periodontal disease? We look at how advanced that case is. We look at the vertical and angular ? defects. We look at the patient's ability to control biofilm, we look at the stage and grade of the disease ? process and we identify from there. Does it make sense to extract this tooth? Does it make sense to try ? to salvage this tooth? How involved is the furcation? In this area? What is the prognosis of this case? ? So we're looking at the same thing on the dental side.? Elizabeth Sanders, DPM 32:31? Wow. And when you talk about is it okay to salvage this tooth, I think of the same thing in terms of toes ? because really your options are like long term IV antibiotics versus an amputation and sometimes ? amputation is better. And this is where you weigh the consequences. And you talk about talk to the ? patient about their options. And we all need to be on the same board. And I think losing a toe. While it ? seems more traumatic losing a tooth is also very traumatic. And it's a huge implication overall in your ? oral systemic health.? Katrina Sanders, RDH 33:05? It's really incredible what losing a tooth does as far as the rest of the dentition trying to move into that ? spot. So we start to create and when that tooth moves into that spot, I I always say to my patients, and ? this is again, just the world according to Katrina Sanders, but one of the worst teeth to lose is your ? mandibular first molar, because the second molars on the mandible, try to move into that gap, they tip ? inward. And then the upper tooth from above tries to super erupt down into that space. And so it ? creates these gaps where now you remove one, and the others now have to work that much harder. ? Mm hmm. And so do you not see that? Of course. Yeah, how a patient walks and bounces. So it's like ? you see a lot of the synergies which is absolutely incredible. So when we talk about performing for you, ? you know you're doing, you know, management of the patient's a one c by maybe removing the source ? of the infection, depriving the patient putting the patient on IV antibiotics. We in the dental space can ? also impact the patient's a one scene by performing periodontal scaling if the patient has active ? periodontal disease. What does that mean systemically for the patient? So I've heard statistics notating, ? that for a patient who has an A one C reduced of 1%, that they experience an improvement in their ? systemic health.? Elizabeth Sanders, DPM 34:34? That's exactly right. So when we talked about how lowering someone's hemoglobin a one c by 1%, ? although it seems very minimal, it actually is a huge impact on the patient overall. In fact, lowering ? someone's hemoglobin a one c by 1%, can lower their risk of having a cardiovascular event by 14%? Katrina Sanders, RDH 34:55? by 14%. And we haven't talked about this yet, but the vast majority of time diabetic patients that I see in ? perio. It's not just diabetes. It's a comorbidity that oftentimes is woven into other comorbidities like how ? often do we see. And we see this quite a bit with our patients that do have diabetes, that there are other ? systemic complications. So we do see, you know, things like the elevated risk of stroke, heart attack, ? peripheral artery disease, how often do you see that as a pediatric surgeon, we see cataracts, ? glaucoma. And we see, of course, diabetic nephropathy. So we're seeing additional complications in ? these individuals where uncontrolled diabetes can eventually become life threatening. In fact, diabetes ? is considered the seventh leading cause of death in the United States. So what you're saying is, if we ? can drop their agency by 1%, we could reduce their risk of having a cardiovascular event by 14%.? Elizabeth Sanders, DPM 35:58? That's right, and their risk of death by 21%, just by lowering your hemoglobin A1C by 1%.? Katrina Sanders, RDH 36:06? So I don't mean to be extra about this. But I'm just gonna say in a different way. Oh, yes, you do. It's my ? pickle bears in the corner, like baby, you're extra. So like, just be extra about it. So what I mean to say ? is dental hygienists out there who see a patient who's a diabetic who has periodontal disease. And that ? hygienist says to that patient, whether they're diagnosed or undiagnosed diabetic, if that hygienist says ? to that patient, I want to perform active scaling and root planing, I want to do periodontal debridement, ? that hygienist with the skills that she or he have in their hands, could reduce the risk of that individual ? dying by 21%.? Elizabeth Sanders, DPM 36:49? That's exactly right. And then when I talk about doing shortcode reconstructions, essentially saving ? someone's limb, and I'll talk about the statistics of saving someone's limb, when I want to do that ? particular procedure, I need their hemoglobin valency, to be under 8%. So if you come in to me with a ? terrible shortcode foot and you need a reconstruction, and you're telling me you're in so much pain, ? blah, blah, blah, if your hemoglobin a one C is 11, I can't help you unless you can get it lower, which ? means doing multiple things. And I do think that using your specialty, and having scaling and root ? planing done on the patients, it will tremendously help because once a patient loses a limb, their ? possibility of having the contralateral limb amputated is 50%. Within five years, not only that their ? chance of death, after having the contralateral limb amputated is 50 to 100%. Actually, in some study,? Katrina Sanders, RDH 37:50? so 50% the time I'm sorry, if you if you were told 50 to one 100%, you will lose your life Elizabeth Sanders, DPM 37:57? in some studies. Yeah, it's shown if you'd like I said, yeah. So and to lose one leg,? Katrina Sanders, RDH 38:02? it's a huge one leg, there's a 50% impacted risk that you're going to lose the other foot, leg, below the ? knee, whatever that may be. Right. So dentistry, do we not see that though? Like, we see that where ? it's like, okay, you lose the bowler over here, then then it adds additional pressure over here, it creates ? an imbalance in the body. And so now you're having to to over here because people want people to it's ? what happens, right? It's what they do. So of course, we see that move in tandem. So when we talk ? about management of a onesie, we talked about diet, you mentioned that diet is a critical component to ? that consuming a low glycemic index diet. low glycemic index is going to be foods that don't create ? inflammation. So now we're talking about the reduction of fermentable carbohydrates, we're talking ? about the pivot away from bread and potatoes and things like that into more nutrient dense ? carbohydrates. Things like cauliflower and broccoli, you know, encouraging our patients to shift away ? from high sugar fermentable carbohydrate diets. So diets a critical component to that. I also Elizabeth Sanders, DPM 39:06? must mention that nowadays vegetables are reasonably priced. You know, it's easy to say Katrina Sanders, RDH 39:13? so weird. I know what I'm you're saying that with like such a such a, you know, point. I just want to know ? is that Trader Joe's was a great price.? Elizabeth Sanders, DPM 39:26? And how many times do patients say Oh, I can't afford the healthy foods that you eat,? Katrina Sanders, RDH 39:31? unfortunately. And if you look at the price comparison between what it would be to purchase ? vegetables, versus what it would be to purchase a bag of chips to get you full because we're talking ? about staity now. Right?? Elizabeth Sanders, DPM 39:48? But a bag of chips doesn't necessarily make you full, it's not nutrient dense.? Katrina Sanders, RDH 39:55? Correct. So what it does is it changes your hypothalamus your hypothalamus now was told because ? you just consumed a bunch of carbohydrates that you're full, but those are empty carbs. So those ? empty carbs tell you that you're full. And then a few hours later, you're hungry again, I have another bag ? of chips. Now on the other hand, to your point, we can use nutrients to turn off the brain. This turned ? into a nutrition program, which I love. But you can use nutrients to turn off the brain, so your body can ? consume those nutrients. And then your body can say, Hey, I've had enough. What are your water ? solubles, your B and your C vitamins. So I've had enough B and C vitamins. So I'm good for today. And ? we can turn off we can trigger that hypothalamus to turn off and say no longer say that I'm hungry. If we ? can give the brain we can give the body enough nutrients. So part of that nutritional counseling to your ? point is consuming nutrient dense fruits and vegetables. That if you can consume a smoothie that has ? enough vitamins and minerals, and yeah, give yourself 10 minutes have a glass of water chill out, ? you're going to be full, you will be so diets a critical component to that exercise is a critical component ? to that it encourages the body to metabolize to you know, break up glycogen in the body, which we ? know is that stored glucose in the liver, so breaks up that glycogen. So exercise is a critical component. ? We know medications are so Dr. E mentioned know your Metformin, which does a beautiful job of ? increasing the body's own sensitivity to insulin, which we know is critical for our type two diabetics ? where maybe we are trying to move them away from taking insulin for your glide. Brian's glide rights do ? a great job of stimulating the release of insulin from our beta cells of our pancreatic components. So we ? know that medications can help to control a lot of that but I implore you to consider that a dental ? hygienist or a periodontal specialist performing active Periodontal Therapy is another way to help ? address diabetic complications. I couldn't agree more, which I think is just like amazing. So I just want ? to kind of wrap up with this really interesting piece that has come down in dentistry. So for a long time, ? we were not able to screen a patient for diabetes, the best that we could do was if the patient was non ? responsive to our active therapy, we would send the patient to the primary care physician, we would ? say I don't know there's something weird going on with the patient's not responding to treatment. And ? quite frankly, most of that's a giant question mark, because it's not as closed loop of a referral system ? as it should be. So we would send the patient to the PCP, and then the PCP would never send us a ? letter back. Oh my gosh, never. So we would ask the patient like, did you talk to your primary care? And ? the patient be like, yeah, they looked at it, they said everything was fine. And it's like what we want is a ? CBC, what we want as a nutritional panel, what we want is for you to test our patient for diabetes, for ? rheumatoid arthritis for an autoimmune disorder.? Elizabeth Sanders, DPM 42:52? So can you as a dental professional order any of these labs?? Katrina Sanders, RDH 42:56? We can order some of them but then we are responsible for them? Well, yes and no. So we can do ? them in our office. So we now have CPT codes to do point of service HbA1c, and blood glucose ? readings in our practices. So depending on what the State Dental Practice Act is, we can, as a dental ? practice, have our own lab equipment, small pieces of equipment that allow us to gather a small blood ? collection sample from the patient of finger prick test, and then utilize that information to be analyzed to ? identify an agency or blood glucose. To be very clear, these are screening tools, we are not using these ? to diagnose the patient, we take that information every time. And then we would send that to an ? endocrinologist or PCP, etc. ? Elizabeth Sanders, DPM 43:47? For the patient Isn't that perfect, especially for those patients who only see their dentist or their dental ? hygienist every six months?? Katrina Sanders, RDH 43:54? Precisely. So the idea being when we started to look early on as to what the appropriate patient ? selection would be like. So if we can do this in dentistry, how do we select the correct patient to receive ? this kind of testing? We started to look at things like number one, I think a current diabetic is a great ? patient. Because, you know, we talked about this during our program today, how often do you ask a ? patient about their agency as a diabetic patient and either they don't know? Or they're like, Oh, this is ? my agency, but that was taken, you know, three years ago, and it's like, you take an agency every 90 ? days because that's a cellular turnover of the red blood cells. So we look at current diabetics, we also ? could look at patients that have comorbidities that could indicate that the patient might also have ? diabetes. So think about your high blood pressure, high cholesterol, or even patients that maybe you ? know, indicate risk factors. You know, patients that have an elevated BMI, obesity, have a family history ? of diabetes, which if you're not asking your patients about their fate Only history. This is a critical ? component, I think, to identifying. And then of course, you know, looking even at how the patient ? responds to treatment, if these are non responsive patients, you're seeing new decay rates, could these ? be potential patients that present with elevated risk for diabetes, then we look at things in the oral ? cavity. So yes, we're looking for things like xerostomia, Angular colitis, sometimes they can experience ? ramifications like burning mouth syndrome, and altered taste perception. We talked about those ? lichenoid reactions either, you know, we're talking about the Wickham Striae, that lace like lesion or ? erosive Lichen Planus. We can also see, by the way, benign migratory glass, itis or fancy term for ? geographic tongue or oral ulcers. Think also about your patients that have elevated vital signs already, ? your elevated blood pressure, maybe your patients that have geldt, right, because we know that gout ? impacts insulin resistance as well. And so this is where we have the opportunity to integrate the use of ? point of service, either blood glucose or HbA1c testing, to identify patients that may indicate that they ? are an undiagnosed diabetic. Most of the time, if we're performing these procedures in office, we're able ? to receive these assessments back within six to seven minutes from the equipment. And this, of course, ? is going to give us a really terrific survey about if the patient is able to control their A1C or not,? Elizabeth Sanders, DPM 46:31? that's much faster than our lab. Really.? Katrina Sanders, RDH 46:34? Well, there you go. So when we take a look at this, of course, this gives us a lot of information about of ? course, how we in a dental practice can manage these patients, if we're able to identify oral conditions. ? If we're able to identify lifestyle behaviors, risk factors, comorbidity is showing up in the medical history. ? If the patient is non responsive to our treatment, if we're seeing overt inflammation, the oral cavity ? decay, pathological lesions, that these are terrific patients, where we could be partners in the oral ? systemic link, where we could identify individuals and perform early assessments on these patients and ? refer them before because what's the other option? You know, I mentioned earlier, one of the reasons ? why we were told to hold back and not do scaling and root planing is because if the patient's a one ? sees over 7%, they may not respond as favorably. But what does that mean? Their pocket depth won't ? he'll get there a one C could drop by 1%. So what are we really doing in dentistry, if we're not ? concerned about the whole of the patient, if all we're concerned about is the healing of those pockets, ? that there's more that's out there. And I think that is the opportunity for us to really critically look at what ? it is that we're doing when we're treating these patients, to counsel them appropriately, to look at those ? clear triggers. If the body's not responding, something's wrong. And we have the opportunity to do ? something about it. What a wonderful conversation we had today about the ABCs of HbA1c, Assessing ? the patient, collecting blood. And then of course, consulting with the patient afterwards, which I ? absolutely love.? Elizabeth Sanders, DPM 48:18? I think we created more questions than answers. But Katrina Sanders, RDH 48:23? we always do that. Well, with that, my hope, if nothing else is that our providers listening today ? understand the critical role that they have in managing our patients and mitigating the risk or the ? observation of disease for our patients. As we clink our glasses of champagne to National Diabetes ? Awareness Month in the month of November. My hope is that we are creating awareness not only in ? our profession, but for our patient population, and helping them understand the why. So with that, I ? want to thank all of you for joining us today. Thank you for joining the Sanders sisters on floss and flip ? flops as we continue to unpack fabulous oral systemic content. Stay tuned next month, as we will help ? you brush up on more fantastic oral systemic content.? Elizabeth Sanders, DPM 49:17? We promise to keep you on your toes.? Katrina Sanders, RDH 49:21? Cheers. Thank you for joining us for another monthly episode of floss and flip flops with the Sanders ? sisters.? Elizabeth Sanders, DPM 49:30? Thank you for being part of the change we need to see in the medical and dental profession.? Katrina Sanders, RDH 49:36? Join us next month for another Sister to Sister chat about other unique, interesting and perhaps ? provocative and disruptive health topics.? Elizabeth Sanders, DPM 49:45? Don't forget to like and subscribe and maybe even leave a fabulous Katrina Sanders, RDH 49:49? review and we'll catch you next month for another episode of Floss and Flip Flops with the Sanders ? sisters.? Elizabeth Sanders, DPM 49:55? I love you Kinka Katrina Sanders, RDH 49:57? ? I love you Izzy ?- 1 -? ?- 1 -?