463 - Periodontitis and DM, Youth Suicide Prevention, Handle With Care

From the Cochrane Library

1)    Treatment of Periodontitis to Improve Diabetes Control

Diabetes mellitus is an important and prevalent health condition. Helping our patients control their diabetes is a common priority in primary care given. It takes multiple small interventions to improve diabetes control – medication adherence, healthy eating, increased physical activity. An updated Cochrane review adds another target for us to work on – periodontitis. While both type 1 and type 2 diabetes add to the risk of periodontitis, there is a reciprocal risk of poor diabetes control because of this condition, probably because of both local inflammation and a systemic inflammatory response.

The authors of this update looked for trials of periodontitis treatment in patients 16 years and older with either type 1 or type 2 diabetes mellitus. Periodontitis treatment usually included “subgingival instrumentation,” i.e., the usual dental hygiene treatments of scaling and other non-surgical treatment, but could include surgical approaches, antibiotic therapy, or dental hygiene education. Change in A1c after at least three months was the primary outcome. The actual review was done very well with a comprehensive search, critical appraisal of the included studies, and heterogeneity assessment with appropriate plans for subgroup and sensitivity analyses.

Thirty-five trials met inclusion criteria and 33 of them contributed to the meta-analysis. The studies occurred in a variety of settings, had follow up that ranged from 3 to 12 month, and included adults with a wide range of diabetes control and medication use. The studies were all at high or unclear risk of bias, even after excluding the topic of blinding (it is not possible to blind periodontal procedures).

The pooled effect of periodontal treatment in reducing HgbA1c level at 3-4 months was - 0.43% [-0.59% to -0.28%], with significant heterogeneity (I² = 71%). Subgroups of periodontal procedures alone vs. placebo, and periodontal procedures + antimicrobials vs. placebo each showed a similar magnitude decrease in A1c in this time frame.

Subgroup analyses did not explain the heterogeneity well, but the results were robust to several sensitivity analyses. Fewer studies contributed to the 6-month outcome, and only 1 contributed to a 12-month outcome, but those analyses also showed a similar magnitude of A1c reduction. Adverse events were not well-documented in the studies, but when the serious adverse events were enumerated in studies, they appeared to be unrelated to the periodontal treatment and more related to the underlying medical conditions. Cost analyses done retrospectively using claims data showed less cost (overall and diabetes-related) for patients undergoing periodontal treatment, though these data were simply associations, not proof of causation.

John’s Comments:

Just as we cannot forget the contribution of behavioral health to medical conditions, we should not write off dental health as unimportant to the work we do for our patients. Yes, the pooled effect seems small (0.43%), but few treatments have been individually shown to reduce A1c more than 1% on average. Unfortunately, insurance companies aren’t exactly helpful in this regard with both behavioral health and dental carve-outs in most plans. In addition to engaging in advocacy with payers and legislators about greater access to dental care, we should advocate the importance of basic dental care to our patients who are able to access it.

Reference:

·         Simpson TC, Clarkson JE, Worthington HV, et al. Treatment of periodontitis for glycaemic control in people with diabetes mellitus. Cochrane Database Syst Rev. 2022;4:CD004714. Link

From Multiple Sources

2)    Youth Suicide Awareness and Prevention

This past week (September 4-10) has been National Suicide Prevention Week. Statistically someone commits suicide in the US every 11 minutes. For youth, suicide is the second leading cause of death in persons age 14-18 after unintentional injuries.

Like other human behaviors, it has no single determining cause. Instead, suicide occurs in response to multiple biological, psychological, interpersonal, environmental and societal influences that interact with one another, often over time.

The social ecological model—encompassing multiple levels of focus from the individual, relationship, community, and societal—is a useful framework for viewing and understanding suicide risk and protective factors identified in the literature. Risk and protective factors for suicide exist at each level. Risk factors include:

·         Individual level: history of depression and other mental illnesses, hopelessness, substance abuse, certain health conditions, previous suicide attempt, violence victimization and perpetration, and genetic and biological determinants

·         Relationship level: high conflict or violent relationships, sense of isolation and lack of social support, family/loved one’s history of suicide, financial and work stress

·         Community level: inadequate community connectedness, barriers to health care (e.g., lack of access to clinicians and medications)

·         Societal level: availability of lethal means of suicide, unsafe media portrayals of suicide, stigma associated with help-seeking and mental illness.

Suicide is preventable and doing so requires a comprehensive public health approach to help create healthy individuals, families, and communities. Such an approach has been outlined by the CDC (see references). Details for each of these are provided in the 2017 CDC "Preventing Suicide" report. Additionally, the National Academies of Sciences, Engineering, and Medicine is launching an expansive research study analyzing the impact of social media on the health of teens and children. The research will examine social media companies' use of consumer data and how this breach of privacy impacts the health and safety of children and teens.

In April of 2022, the USPSTF issued draft recommendations for screening for major depressive disorder (MDD) and suicide risk in children and adolescents. They include:

·         For asymptomatic adolescents ages 12-18, recommends screening for major depressive disorder (MDD) (B Recommendation)

·         For asymptomatic children < 11, concludes the evidence is insufficient to assess the balance of benefits and harms for screening for MDD (I Recommendation)

·         For asymptomatic children and adolescents, concludes the evidence is insufficient to assess the balance of benefits and harms for screening for suicide risk (I Recommendation)

Mark’s Comments:

Youth emotional health was a significant concern prior to the COVID pandemic and social media appears to have played a significant, though far from exclusive, role in this. The additional negative impact of the pandemic is still unclear but preliminary research indicates it is quite concerning and far-reaching. Be sure both in your professional work and in your personal life to be checking in on teens, assessing for needs, and forming relationships with them. Those relationships, as we know, matter (see Pointer 3).

Though the USPSTF didn’t specifically address anxiety, have a low threshold for screening for this as well in at risk youth.

In 2020, Congress designated the new 988 dialing code to be operated through the existing National Suicide Prevention Lifeline in an attempt to make it easier for those in distress to reach out for help. We have a part to play in making sure all those we care for are aware of this and other resources should they or a loved one need them.

References:

·         CDC. Suicide Prevention – Facts About Suicide. Last Reviewed 22 July 2022. Link . Comprehensive Report 2017: Link

·         CDC Newsroom: New CDC data illuminate youth mental health threats during the COVID-19 pandemic. March 31, 2022. Link

·         USPSTF: Depression and Suicide Risk in Children and Adolescents – Screening. Draft recommendations April 12, 2022. Link.

·         Stephenson A, et al. Suicidal Ideation and Behaviors Among High School Students

— Youth Risk Behavior Survey, United States, 2019. CDC MMWR. August 21, 2020 / 69(1);47–55. Link

From PeerRxMed ( www.PeerRxMed.org )

   3)    Handling Each Other With Care

“We need to be better at helping each other.” Physician colleague who came within minutes of committing suicide

A conversation this week with a colleague who reached out due to some ongoing emotional distress and past suicidal thoughts brought to mind another colleague who 5 years ago came within minutes of choosing to take her life through suicide. Over the years since she has shared details with me of that painful time in her life and the healing journey she has taken.

When we last spoke, she was far enough away from that intensely dark and emotionally raw time to have gained deeper insight. One of the things she told me (and has given me permission to share) speaks directly to why it is so essential to have a buddy (or buddies) who understand what it is like to travel this professional journey called healthcare: “I’m not the kind of person who would ever consider something like suicide–  so I thought. But I broke, and the level of emotional pain I was feeling is difficult to describe. It had to be quite obvious to others that something was wrong. I believe they wanted to help, but none of them seemed comfortable in reaching out to me and when they did, it was easy to push them away.” She concluded, “We need to be better at helping each other.”

National Physician Suicide Awareness (NPSA) Day will be on Saturday, September 17th this year. Started in 2018, the vision for this initiative is that this day will serve as a call to action for all of us to re-commit to breaking down stigma, opening the conversation, decreasing the fear of consequences, recognizing warning signs and learning to approach our colleagues who may be at risk for suicide. Of course, it is a tragedy to think that we even need a day to raise awareness of physician suicide, but the statistics indicate that on average, one of our physician colleagues choses to take their life every day, and these statistics do not account for our NP, PA, PhD, PharmD, Allied health, and nursing teammates, all of whom, as we know, are struggling mightily as well.

Additionally, the 2022 Medscape Physician Suicide Report indicates almost 1 in 10 physicians have had thoughts of suicide, but more than 1/3 told no one about them.

According to Psychiatrist Michael Meyers, MD, author of the book The Physician as Patient, when a colleague shares that they are having suicidal thoughts, the first step is to thank them for sharing the information; “I’m sure that wasn’t easy, but I appreciate that you respect me enough to share with me.  Let’s talk more.” Then ask what you can do to help. If, on the other hand, you note that someone isn’t doing well, reach out and compassionately let them know of your concern and that you’d like to help, and don’t hesitate to ask directly if they’ve considered suicide.

The pressures we face with the work we do are extraordinary. Given this, the entire purpose of the PeerRxMed process is to ensure that “no one cares alone.” It is vital that every one of us has someone we are certain we can reach out to in good times and bad and we know they will be there for us. This is a person who knows us well enough that they would recognize when were weren’t doing well and would feel very comfortable and even insistent on helping to be sure we received the help we needed.  The stakes are too high to do otherwise.   Let’s all commit to becoming better at helping each other. If you’re not signed up for PeerRx, get a buddy and do so (if you’re not sure how, e-mail me). If you are, encourage others to sign up as well. This is too important to leave to chance. The life that we save could be someone close to us, or even our own.

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Mark and John

Carilion Clinic Department of Family and Community Medicine

Feel free to forward Take 3 to your colleagues. Glad to add them to the distribution list.

Email: mhgreenawald@carilionclinic.org