Periodontal Disease – The Overlooked Diabetes Complication


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Periodontal Disease – The Overlooked Diabetes Complication

  1. 1. Periodontal Disease – TheOverlooked Diabetes Complication Continuing Nursing EducationTrisha Dunning“He had one peculiar weakness, he had Periodontal diseases are infectious processes that occur in the presence of bacteria, whichfaced death in many forms but he had trigger an inflammatory response. Periodontal disease is associated with many medicalnever faced a dentist.” conditions, including diabetes mellitus and its complications (such as kidney disease). It – H.G. Wells (p. 75) has been described as the “sixth diabetes complication” but is often overlooked in rou- tine diabetes management and complication screening processes. Proactive, preventative iabetes mellitus is a chronic,D incurable modern epidemic that affects more than 171 mil- lion individuals globally (Wild,Roglic, Green, Sicree, & King, 2004).There are two main types of diabetes: dental and diabetes self care, as well as regular dental and diabetes assessment, are important management strategies because periodontal disease contributes to the progres- sion of impaired glucose tolerance to diabetes mellitus and to hyperglycemia in individ- uals with established diabetes. Copyright 2009 American Nephrology Nurses’ Associationtype 1, which usually occurs in youngpeople, but can occur at any age; and Dunning, T. (2009). Periodontal disease – The overlooked diabetes complication.type 2, which usually occurs in people Nephrology Nursing Journal, 36(5), 489-496.over age 40. However, there isincreasing prevalence of impaired Goalglucose tolerance (IGT) or pre-dia- To provide an overview of periodontal disease and its relationship to diabetes.betes and type 2 diabetes in childrenand adolescents (Zimmet et al., 2007). ObjectivesBoth type 1 and type 2 are associated 1. Identify various explanations for the association between diabetes and periodon-with significant, long-term complica- tal disease.tions, such as microvascular and 2. Discuss prevention strategies and management of periodontal disease.macrovascular disease, neuropathy,and depression, causing significantmorbidity and mortality. In addition,many individuals also have other tal disease (Southerland, Taylor, & This article focuses on the relation-comorbidities, such as arthritis. Offenbacher, 2005). Likewise, peri- ship between diabetes and periodon- The underlying pathophysiology odontal disease may contribute to the tal disease, possible underlying causalof diabetes-related long-term compli- progression of IGT to diabetes factors, and suggested managementcations largely arises from the effects (Andersen, Flyvbjerg, & Holmstrup, strategies.of chronic hyperglycemia, tissue gly- 2007). Löe (1993) described peri-cosylation, changes in collagen odontal disease as the “sixth diabetes Overview of Periodontal Diseasemetabolism, and oxidative stress complication” (p. 330). However, it(Brownlee 1995; Hammes et al., could also be described as the “over- The condition of the oral cavity1999; Nishimura, Soga, Iwamoto, looked complication” because it is not reflects and affects the overall health sta-Kudo, & Murayama, 2005). Diabetes included in most diabetes manage- tus of the individual. Between 60% tois recognized as a significant risk fac- ment strategies, education programs, 65% of the U.S. population has peri-tor for serious, progressive periodon- or complication screening processes. odontal disease; the prevalence increas- This offering for 1.1 contact hours is being provided by the American Nephrology Nurses’ Association (ANNA).Trisha Dunning, MEd, PhC, AM, RN, is a ANNA is accredited as a provider of continuing nursing education (CNE) by the AmericanProfessor and Chair in Nursing, Deakin University Nurses Credentialing Center’s Commission on Accreditation.and Barwon Health, Geelong, Australia. ANNA is a provider approved by the California Board of Registered Nursing, provider number CEP 00910.Statement of Disclosure: The author reported noactual or potential conflict of interest in relation to This CNE article meets the Nephrology Nursing Certification Commission’s (NNCC’s) continu-this continuing nursing education article. ing nursing education requirements for certification and recertification.NEPHROLOGY NURSING JOURNAL September-October 2009 Vol. 36, No. 5 489
  2. 2. Periodontal Disease – The Overlooked Diabetes Complicationes to 85% to 90% in individuals with Table 1diabetes (Iacopino, 2001). The chronic General Signs and Symptoms of Periodontal Diseaseeffect of hyperglycemia enhances theformation of biologically active glycosy- There are differences in the symptoms individuals experience. Some or all oflated proteins and lipids, which pro- the signs and symptoms may be present, depending on the severity of the dis-mote inflammation and potentiate the ease. Many symptoms are similar to those caused by other diseases and caneffects of periodontal infection (Lalla, be overlooked or misdiagnosed, and treatment can be delayed. All healthcare providers should ask relevant questions and perform an oral examination toLamster, Drury, Fu, & Schmidt, 2000). detect these signs and symptoms and refer the individual to a dentist.In addition, lipopolysaccharide (LPS), abacterial endotoxin, plays a role via the • Swollen, tender, red gumsactions of Toll-like protein receptors, • Bleeding while brushing the teeth or flossing, or when eating hard foodswhich stimulate the inflammatoryresponse and the immediate immune • Receding gums due to the destruction of ligaments and gingival tissues aroundresponse (Takeda & Akira, 2005). The the teeth and bone.immune response to infection is altered • Loose teeth or wide spaces between the teeth that develop over timein the presence of hyperglycemia; white • Persistent halitosiscell mobility and phagocytic capacity isreduced. • Ill-fitting dentures (can rub on the gums and lead to ulceration;.consequently, the individual may avoid wearing their dentures or avoid eating hard foods) Various explanations for the asso-ciation between diabetes and peri- • Worn or chipped teethodontal disease have been proposed, • Plaqueincluding:• Microvascular disease. • Caries• Changes in the composition of gin- • Pus around the teeth and gums gival cervicular fluid. • Changes in jaw alignment, which affect the bite• Altered collagen metabolism.• The formation of irreversible • Difficulty eating advanced glycated end products • Oral candida that are associated with oxidative stress, which in turn affects the structure and function of the base- pled with inadequate oral health • Persistent stress, which lowers ment membranes, particularly in care and none or irregular dental immunity and reduces resistance small blood vessels: therefore, it assessments. to infection. Stress also affects an contributes to microvascular dis- • Smoking. individual’s ability for self care. ease. • Hormone changes in girls and • Some medicines, such as antide-• Altered immune response and women. pressants and antihypertensive changed white cell function during • IGT and diabetes mellitus and agents, reduce saliva secretion hyperglycemia that contribute to their associated complications, and lead to xerostomia. Other delayed wound healing and infec- such as cardiovascular disease medicines, such as phenytoin, tion control. and kidney disease. Diabetes mel- cyclosporine, and nifedipine, may• Changes in the flora of the oral cav- litus is a primary cause of end cause gum enlargement, which ity and overgrowth of anerobes, stage renal disease (ESRD). increases plaque deposition. such as Porphyromonas gingivalis and ESRD is associated with severe • Systemic illnesses, such as osteo- Actinobacillus actinomycetemcomitans. stomatitis, and the majority of porosis, Alzheimer’s disease,• Over expression of inflammatory ESRD patients on dialysis devel- AIDS, and cancer. cytokines, such as interleukin-1β, op serious gingivitis and peri- Once periodontal disease and dia- tumor necrosis factor, and pro- odontal disease (Choudhury & betes occur together, a vicious cycle staglandin E2. Luna-Salazar, 2008). develops: diabetes predisposes the• Genetic predisposition (Iacopino, • Obesity. individual to periodontal disease, 2001). • Poor nutrition, which often has which in turn contributes to hyper-Risk Factors many inter-related causal factors, glycemia, which affects other tissues such as obesity, excess alcohol and organs, including the oral cavity. Risk factors that influence the intake, changed taste sensation, Preventing and/or effectively manag-development of periodontal disease eating disorders, gastrointestinal ing periodontal disease can reduceinclude: disease, cancer, increasing age, hyperglycemia, insulin requirements,• Inadequate knowledge about oral cognitive decline, depression, and and HbA1c (Danesh, Collins, Appleby, health and diabetes mellitus cou- socioeconomic factors (cost). & Peto, 1998). Periodontal infection is490 NEPHROLOGY NURSING JOURNAL September-October 2009 Vol. 36, No. 5
  3. 3. Table 2 Oral Complications Associated with Diabetes, Proposed Underlying Causal Mechanisms, Common Signs and Symptoms, and ManagementRegular dental examination is important to detect these complications early. Early referral to a dentist andthen regular assessment is recommended. Management should be collaborative to ensure the oral problemis treated effectively and the blood glucose is adequately controlled. Complication Causal Mechanisms Signs and Symptoms ManagementGingivitis or inflammation of • Infection as a • May be painless. • Good oral hygienethe gums affects about 90% consequence of plaque, • Bleeding may occur and is • Regular removal of plaqueof the population. If untreated, which harbors bacteria sometimes associated with • Antimicrobial mouthwashesit can progress to periodontitis. particularly anaerobes oral contraceptive use by if halitosis is present • Ulceration may be present, women, and during • In severe cases, gingivec- and in childhood, may be second pregnancies. It tomy and gingivoplasty due to Herpes simplex may be a sign of bleeding may be needed stomatitis disorders or be associated • Control hyperglycemia • Acute necrotising with anticlotting medicines, (initiate or adjust doses of ulcerative gingivitis which are frequently glucose lowering oral (Vincent’s disease) required by individuals with agents/insulin) mainly occurs in diabetes. • Manage pain immunocompromised • Red, swollen, gingival • Oral health and diabetes adults (HIV, chemothera- margins. education py), and individuals with • Halitosis, bleeding, and malnutrition and poor oral fever suggest acute hygiene necrotising gingivitis.Periodontitis is often • Accumulation of plaque is • Plaque and calculus • Improve oral health, whichpreceded by gingivitis and often associated with • Red, swollen, tender gum might require scaling andmay become chronic untreated gingivitis, which margins. polishing(pyorrhea). leads to destruction of the • Pockets of infection around • Diagnose bone involve- periodontal ligaments, the teeth and gums ment: X-ray tissues, and bone around • Bleeding gums • Control hyperglycemia the teeth • Loose teeth (initiate or adjust doses of • Kidney disease, especially • Halitosis – however, glucose lowering oral if inadequately treated or halitosis can also be agents/insulin) dialysis is required caused by food, smoking, • Treat the infection, which alcohol, some medicines, might require systemic diabetic ketoacidosis antibiotics, such as (acetone breath), and amoxicillin or clindamycin, if renal and hepatic disease the individual is allergic to • Bad taste in the mouth penicillin (some experts suggest antibiotics “have no place in routine treatment” (Coventry et al., 2000, p. 38) • Topical antimicrobial medicines in infected periodontal pockets • Bacterial mouth rinses (such as Listerine®) to reduce halitosis and promote tissue repair • In severe disease, oral surgery may be required to remove dead tissue • Manage pain • The individual should be carefully assessed for other foci of infection, such as the feet and urinary tract (continued on next page)NEPHROLOGY NURSING JOURNAL September-October 2009 Vol. 36, No. 5 491
  4. 4. Periodontal Disease – The Overlooked Diabetes Complication Table 2 (continued) Oral Complications Associated with Diabetes, Proposed Underlying Causal Mechanisms, Common Signs and Symptoms, and Management Complication Causal Mechanisms Signs and Symptoms ManagementPeriodontitis is often preced- • Ongoing managemented by gingivitis and may involves regular oralbecome chronic (pyorrhea) self-care (cleaning teeth at least BID and flossing, see Table 3) • Regular dental examination and teeth cleaning • Replacing toothbrushes every 3 to 4 months • Oral health and diabetes educationCandida is caused by the fun- • Side effect of • Glossitis • Manage the underlyinggus Candida albicans medicines, including • Secondary to stomatitis cause antibiotics, from ill-fitting dentures • Oral hygiene chemotherapy, and • Pain, if severe • Manage hyperglycemia by antihistamines commencing or adjusting • Other underlying glucose- causes include lowering medicines diabetes, illicit drug use, • Refit dentures, if malnutrition, low immunity necessary due to systemic disease, • Soak dentures in side effect of some antifungal medications medicines (such as antibi- • Local antifungal medicines otics), inadequate diet, (such as pastilles, lozenges, increasing age, oral sex rinses, or troches [nystatin, with an infected partner clotrimazole, and fluconazole]) • Manage pain • Undertake a medicine review to determine the need for medicines that contribute to candida • Oral health and diabetes educationBurning mouth syndrome, • The causes are largely • Burning sensation in the • Manage the symptomswhich is a chronic pain syn- idiopathic, but burning tongue, lips, and oral • Manage hyperglycemia bydrome mouth syndrome is cavity commencing or adjusting associated with chronic glucose lowering medicines hyperglycemia, hormone • Review medicine regimen therapy, neuropathy, • Medicines, such as xeostomia, and candidiasis, benzodiazepenes, tricyclic and can have a antidepressants, and psychological component anticonvulsants, often effectively relieve pain; these medicines are also used to manage diabetic peripheral neuropathy and are not necessarily prescribed for depression • They can predispose the individual to xerostomia (continued on next page)492 NEPHROLOGY NURSING JOURNAL September-October 2009 Vol. 36, No. 5
  5. 5. Table 2 (continued) Oral Complications Associated with Diabetes, Proposed Underlying Causal Mechanisms, Common Signs and Symptoms, and Management Complication Causal Mechanisms Signs and Symptoms Management Lichen planus is a chronic • The cause is largely • White striations, plaques • Topical or systemic steroid inflammatory disease. It might unknown and/or papules on the oral medicines to control predispose people to oral • There is some evidence mucosa, tongue and gums redness, ulceration, and cancer that it is a T-cell-mediated • Redness pain autoimmune response, • Blisters • If systemic steroids are which triggers apoptosis of • Superinfection with used, glucose-lowering the oral epithelial cells Candida albicans can medicines/insulin may (Thornhill, 2001) occur need to be increased because steroids cause hyperglycemia • Manage pain • Oral health and diabetes education Xerostomia – Reduction in • Xerostomia is associated • Difficulty eating, speaking, • Preventative dental care the amount or quality of with hyperglycemia and swallowing • Saliva substitutes, such as saliva; it can lead to high-sugar diets • Wearing dentures xerolube, or prescription significant dental caries, • It is a common complica- • Denture-induced mouth medicines, such as pilo- inflamed and cracked lips, tion of systemic diseases, ulcers carpine enlarged parotid glands, head and neck radiation, • Tongue sticks to the palate • Avoiding hyperventilation, mouth ulcers, oral candida, and some medications or tongue depressor when smoking, and excess infection in the salivary glands • Dental caries can occur examining the oral cavity |alcohol intake, which (sialadenitis), halitosis, and when the proportion of • Dysgeusia (taste exacerbate xerostomia tooth abscesses Streptococci mutans is disorders) • X-ray to determine bone high compared to other • Glossodynia (painful status may be indicated in oral flora because tongue) severe, long-standing dis- Streptococci mutans • Increased need to drink ease adheres to the surface of water especially at night • Treat dental caries the teeth and produces a • Signs of Candida albicans • Manage hyperglycemia by greater amount of sugar and/or dental caries commencing or adjusting acids than other oral glucose lowering medi- bacteria cines • The combination of high • Manage pain levels of Streptococci • Oral health and diabetes mutans, xerostomia, education hyperglycemia, and high- sugar intake significantly increases the risk of dental cariesassociated with long-term diabetes Management nutritional and immune status, bloodcomplications, such as atherosclerosis Primary prevention is an essential glucose and lipid management, and a(Nichols, Fischer, Deliargyris, & management strategy. Effective pre- healthy oral cavity. Self care alsoBaldwin, 2001) and nephropathy vention and management depends on involves typical diabetes-related self-(Choudhury & Luna-Salazar, 2008). patient self-care, which is facilitated by care tasks, which are shown in Table 4. Research is currently underway to education about appropriate oral self- Regular dental assessment anddetermine the strength of the associa- care in a language and teaching style teeth cleaning is vital. Tooth brushingtion among periodontal disease, hyper- relevant to the individual. Key educa- does not remove plaque that accumu-tension, heart disease, cerebrovascular tion messages are shown in Table 3. In lates below the gum line; therefore,disease, and low birth weight. Signs addition, educating diabetes health scaling and polishing may be neededand symptoms of periodontal disease professionals may also be needed to (Coventry, Griffiths, Scully, & Tonetti,are shown in Table 1, and oral compli- highlight the association between peri- 2000). Currently, dental assessment iscations of diabetes and the relevant odontal disease and diabetes. not included in most diabetes compli-management strategies are shown in Prevention involves eating a healthy cation screening guidelines, but itTable 2. diet, which is essential to a healthy should be.NEPHROLOGY NURSING JOURNAL September-October 2009 Vol. 36, No. 5 493
  6. 6. Periodontal Disease – The Overlooked Diabetes Complication Table 3 Health professionals can incorpo-Core Information about Oral Health Care for Individuals with Diabetes rate the following strategies into rou- tine health care to highlight theThis information should be part of comprehensive diabetes self-care educa- importance of oral health. Theytion and general health care. General information about the importance of oral should ask individuals with diabeteshealth care and diabetes self care should be offered to put the following infor- the following:mation into context. • When they last visited a dentist orGeneral Advice had their teeth and oral cavity examined by a dentist.1. Bacteria can cause mouth infections and damage teeth and gums if plaque • About their oral health, such as builds up.You can prevent plaque deposits and prevent mouth and gum disease by keeping diabetes under control and brushing your teeth and flossing every the presence of any signs and day. Infections in the mouth and gums can cause blood glucose to go high, and symptoms presented in Table 1, diabetes medicine doses may need to be increased until the infection settles and their oral self-care practices, down. such as brushing and flossing.2. Ensure you have regular dental checks so any problems with your teeth can be • About the medicines they are tak- detected early and treated. ing and provide education about3. Keep your blood glucose under control and visit your diabetes health profes- managing medicines that affect sionals regularly. If your blood glucose level is persistently high, you are more oral health. likely to develop mouth and gum infections. • Ensure the person is referred toSpecific Advice about Dental Care their family doctor and diabetes specialist for a review of their dia-Brushing betes management regimen and1. Choose a good quality toothbrush with soft nylon bristles with rounded ends on medications, especially if they the bristles. have HbA1c greater than 7%2. Change your toothbrush regularly (every 3 to 4 months). Consider using an and/or hyperlipidemia, or are electric or battery-operated toothbrush to help prevent gums from shrinking using medicines that affect oral away from the teeth. health. Regular assessment, such3. Gently brush your teeth at least twice a day and after food consumption.4. Use small, circular motions, as well as moving the toothbrush up and down, and as retinal examination and blood clean all your teeth. Make sure you clean the front and the back surfaces of your pressure, and laboratory tests, teeth. Try not to scrub your teeth because it can damage the enamel and gums. such as HbA1c, lipids, and renal5. Gently brush your tongue. function, are essential.6. Choose a good quality toothpaste that contains fluoride to help protect against • Perform an oral examination tooth decay. Choose a specially formulated toothpaste if you have sensitive within their competence and teeth. scope of practice, and/or refer to a dentist if indicated.Flossing • Provide the individual with rele-1. Choose a good quality dental floss. vant education, such as the need2. Break off a piece of floss about 18 inches long. for regular dental assessment and3. Floss after brushing your teeth at least once a day. diabetes self-care education, and4. Insert the dental floss between each pair of teeth in turn. Gently move the floss involve family and caregivers backward and forward from the bottom to the top of the tooth. Try not to snap the dental floss against the gums. when relevant.5. Rinse your mouth after flossing with an antibacterial mouth rinse (such as • Include oral health assessment in Listerine®). routine complication screening procedures. These should beSeek a Dentist’s Advice if You Notice: undertaken at least annually but may be needed more frequently• Persistent bad breath. for some individuals (for example• Bleeding. individuals with ESRD and• Pain. retinopathy).• Red and/or swollen gums.• Your dentures do not fit properly.• You have difficulty eating. Take Home PointsPay particular attention to your teeth if you are pregnant. Eat a healthy diet that Dental disease is associated withcontains adequate amounts of calcium and vitamin D, as well as care for your teeth impaired glucose tolerance and dia-and gums. betes mellitus. In turn, chronic hyper- glycemia predisposes the individual to dental disease. Controlling blood494 NEPHROLOGY NURSING JOURNAL September-October 2009 Vol. 36, No. 5
  7. 7. Table 4 Southerland, J., Taylor, G., & Diabetes-Related Self-Care Tasks Offenbacher, S. (2005). Diabetes and periodontal infection: Making the These tasks need to be undertaken at appropriate times, often three or more connection. Clinical Diabetes, 23(4), times per day, and be maintained for a lifetime. Self care is hard, constant work. 171-178. Takeda, K., & Akira, S. (2005). Toll-like • Eat a healthy, balanced diet. receptors in innate immunity. • Undertake regular physical activity. International Immunology, 17(1), 1-14. Thornhill, M. (2001). Immune mecha- • Manage stress. nisms in oral lichen planus. Acta • Monitor blood glucose levels, usually several times a day, interpreting the results Odontology of Scandinavia, 59(3),174- and using the information to maintain the blood glucose level in the target range. 177. Wells, H.G. (1915). Bealby – Part VIII: How • Monitor ketones during periods of hyperglycemia, which is often associated with Bealby explained. As cited in Gaither, illnesses, especially in those with type 1 diabetes. C., & Cavazox-Gaither, A. (Eds.), • Manage medicines. Many people with type 2 diabetes are on more than 12 dif- Medically speaking: A dictionary of quo- ferent medicines and multiple doses per day, and sometimes complex dose inter- tations on dentistry, medicine and nursing vals. Thus, any extra medicines, such as antibiotics, complicate the regimen and (p. 75). Philadelphia: Institute of increase the chances of interactions and medicine mismanagement. Physics Publishing. Wild, S., Roglic, G., Green, A., Sicree, R., • Manage illnesses. Diabetes self care can be an added burden during illness. & King, H. (2004). Global preva- • Prevent and manage hypoglycemic events. lence of diabetes: Estimates for the year 2000 and projections for 2030. • Perform foot care. Diabetes Care, 27(5),1047-1053. • Attend appointments with health professionals. Zimmet, P., Alberti, G., Kaufman, E. Tajima, N., Silink, M., Arslanian, S., et al. (2007) The metabolic syndrome in children and adolescents – IDF con-glucose reduces the risk of dental dis- Journal of the American Medical sensus report. Paediatric Diabetes, 8, Association, 79, 1477-1482. 299-306.ease. Individuals with diabetes andhealth professionals have a key role in Hammes, H-P., Alt, A., Niwa, T., Clausen,effective prevention and management J., Bretzel, R., Brownlee, M., et al. (1999). Differential accumulation ofof dental disease. Diabetes education advanced glycation and products inand oral health education are essen- the course of diabetic retinopathy.tial to effective prevention and man- Diabetologia, 42(6), 728-736.agement. They are a holistic integrat- Iacopino, A. (2001). Periodontitis and dia-ed approach to care and effective betes interrelationships: Role ofcommunication among health profes- inflammation. Annals of Periodontology,sionals and patients. 6(1), 125-137. Lalla, E., Lamster, I., Drury, S., Fu, C., &References Schmidt, A. (2000). Hyperglycaemia,Andersen, C., Flyvbjerg, K., & Holmstrup, glycoxidation and receptor for P. (2007). Periodonitis is associated advanced glycation endproducts: with aggravation of prediabetes in Potential mechanisms underlying Zucker rats. Journal of Periodontology, diabetic complications, including 78(3), 559-565. diabetes-associated periodontitis.Brownlee, M. (1995). The pathological Periodontology, 23, 50-62. implications of protein glycation. Löe, H. (1993). Periodontal disease: The Clinical Investigation in Medicine, 18(4), sixth complication of diabetes melli- 275-281. tus. Diabetes Care, 16(1), 329-344.Choudhury, D., & Luna-Salazar C. Nashimura, F., Soga, Y., Iwamoto, Y., (2008). Preventative healthcare in Kudo, C., & Murayama, Y. (2005). chronic kidney disease and end-stage Periodontal disease as part of insulin renal disease. Nature Clinical Practice resistance syndrome in diabetic Nephrology, 4(4), 194-206. patients. Journal of the InternationalCoventry, J., Griffiths, G., Scully, C., & Academy of Periodontology, 7(1), 16-20. Tonetti, M. (2000). Periodontal dis- Nichols, T., Fischer, T., Deliargyris, E., & ease. British Medical Journal, 321(7252), Baldwin, A. (2001). Role of nuclear 36-39. factor-kappa B (NF-kappa B) inDanesh, J., Collins, R., Appleby, P., & inflammation, periodontitis and Peto, R. (1998). Factor in periodontal atherogenesis. Annals of Periodontology, disease and oral health problems. 6(1), 20-29.NEPHROLOGY NURSING JOURNAL September-October 2009 Vol. 36, No. 5 495
  8. 8. Periodontal Disease – The Overlooked Diabetes Complication ANNJ0912 ANSWER/EVALUATION FORM Periodontal Disease – The Overlooked Diabetes Complication Trisha Dunning, MEd, PhC, AM, RN 1.1 Contact Hours Complete the Following: Expires: October 31, 2011 Name: ____________________________________________________________ ANNA Member Price: $15 Regular Price: $25 Address: __________________________________________________________Posttest Instructions __________________________________________________________________• Select the best answer and circle the appropriate letter on the answer grid Telephone: ______________________ Email: _____________________________ below.• Complete the evaluation. CNN: ___ Yes ___ No CDN: ___ Yes ___ No CCHT: ___ Yes ___ No• Send only the answer form to the ANNA National Office; East Holly Payment: Avenue Box 56; Pitman, NJ 08071- ANNA Member: ____ Yes ____ No Member #___________________________ 0056; or fax this form to (856) 589- 7463. Check Enclosed American Express Visa MasterCard• Enclose a check or money order Total Amount Submitted: _________________ payable to ANNA. Fees listed in pay- ment section. Credit Card Number: _______________________________ Exp. Date: _______• If you receive a passing score of 70% or better, a certificate for the contact Name as it Appears on the Card: ______________________________________ hours will be awarded by ANNA.• Please allow 2-3 weeks for processing. You may submit multiple answer forms in one mailing, however, because of Special Note various processing procedures for Your posttest can be processed in 1 week for an additional rush charge of $5.00. each answer form, you may not receive ■ Yes, I would like this posttest rush processed. I have included an additional fee all of your certificates returned in one of $5.00 for rush processing. mailing. Online submissions through a partnership with are accepted on this posttest at $20 for ANNA members and $30 regular price. CNE certificates will be available immediately upon successful completion of the posttest. Note: If you wish to keep the journal intact, you may photocopy the answer sheet or access this posttest at What would be different in your practice if you applied what you have learned from this activity? To provide an overview of periodontal dis- ease and its relationship to diabetes.________________________________________________________________________________________________________________________ Please note that this continuing nursing education activity does not____________________________________________________________ contain multiple-choice questions. This posttest substitutes the mul- tiple-choice questions with an open-ended question. Simply answer____________________________________________________________ the open-ended question(s) directly above the evaluation portion of____________________________________________________________ the Answer/Evaluation Form and return the form, with payment, to the National Office as usual. Strongly StronglyEvaluation disagree agree2. By completing this offering, I was able to meet the stated objectives a. Identify various explanations for the association between diabetes and periodontal disease. 1 2 3 4 5 b. Discuss the prevention strategies and management of periodontal disease. 1 2 3 4 53. The content was current and relevant. 1 2 3 4 54. This was an effective method to learn this content. 1 2 3 4 55. Time required to complete reading assignment: _________ minutes.I verify that I have completed this activity ________________________________________________________________________________ (Signature)496 NEPHROLOGY NURSING JOURNAL September-October 2009 Vol. 36, No. 5