Clinical implication of blood glucose monitoring in general dental offices: the Ehime Dental Diabetes Study

Association of Periodontitis with Mild Cognitive Impairment in Older Adults

Background

Early detection of cognitive decline, including mild cognitive impairment, is expected to provide a better prognosis. Several studies have suggested an association between periodontitis and mild cognitive impairment.

Objectives/Design

To test the hypothesis that there is an association between severe periodontitis and mild cognitive impairment in community residents who participated in a dental health check-up program.

Participants/Setting

Community residents who participated in our dental health checkup program were enrolled (age=67.5±9.9, 62.9% female).

Measurements

Mild cognitive impairment was tested using the MCI screening test. Periodontitis was diagnosed based on a widely used clinical periodontal parameter, the probing pocket depth. Statistical analysis was based on logistic regression models adjusted for potential confounders.

Results

Among 321 subjects, mild cognitive impairment was detected in 41. Severe periodontitis (probing pocket depth > 6mm) was detected in 123 cases, with a higher prevalence of mild cognitive impairment in the severe periodontitis group (65.9%) than in the unimpaired group (34.3%). The inclusion of four variables (age, education, functional teeth, and presence of severe periodontitis) in a multivariate logistic regression model revealed a statistically significant difference in the association between severe periodontitis and mild cognitive impairment (odds ratio = 4.024, p < 0.001).

Conclusions

A strong association was seen between severe periodontitis and mild cognitive impairment. Severe periodontitis appears to be a risk factor for mild cognitive impairment, and patients with severe periodontitis should be assessed for mild cognitive impairment.

Reliability and utility of blood glucose levels in the periodontal pockets of patients with type 2 diabetes mellitus: a cross-sectional study

Background

Several studies have measured gingival blood glucose (GBG) levels, but few have confirmed systematic bias using Bland-Altman analysis. This study compared the effectiveness of GBG levels with that of fingertip blood glucose (FTBG) levels using Bland-Altman and receiver operating characteristic (ROC) analyses.

Methods

A total of 15 healthy volunteers and 15 patients with type 2 diabetes were selected according to inclusion and exclusion criteria. Each group comprised eight male and seven female participants. The GBG and FTBG levels were measured using a self-monitoring blood glucose device after periodontal examination. Pearson's product‒moment correlation and simple linear regression analyses were performed. In addition, Bland‒Altman analysis was also performed to assess the degree of agreement between the two methods. ROC analysis was conducted to determine the sensitivity, specificity, and cutoff values for patients with diabetes. The area under the ROC curve (AUC) was used to identify significant differences.

Results

The mean GBG and FTBG levels were 120 ± 44.8 mg/dL and 137 ± 45.1, respectively, for the whole sample. The mean GBG and FTBG levels were 145 ± 47.2 mg/dL and 163 ± 49.1, respectively, in the diabetes group. The mean GBG and FTBG levels in the nondiabetes group were 95.3 ± 25.2 and 111 ± 18.8, respectively. Patients with diabetes were more likely to have a probing pocket depth (PPD) of ≥4 mm at the sampled site. Pearson's product‒moment correlation and simple linear regression analyses revealed a significant correlation between the GBG and FTBG measurements. Bland-Altman analysis revealed that GBG and FTBG measurements differed significantly among all participants; however, no significant differences were observed among the patients with diabetes (mean difference (MD) ± standard deviation (SD) = -18.1 ± 34.2, 95% confidence interval (CI) [-37.0 to 0.88]) or among the participants with a PPD of ≥4 mm (MD ± SD = -15.2 ± 30.4, 95% CI [-30.8 to 0.43]). The sensitivity, specificity, and cutoff values of the GBG measurements for detecting diabetes were 80%, 93%, and 123.5 mg/dL, respectively. The sensitivity, specificity, and cutoff values of the FTBG measurements for detecting diabetes were 73%, 87%, and 134.0 mg/dL, respectively. No significant differences were observed between the AUCs (0.078, 95% CI [-0.006 to 0.161]).

Conclusions

The GBG measurements aligned with the FTBG measurements in the patients with diabetes and among the participants with a PPD of ≥4 mm. Patients with diabetes were more likely to have a PPD of ≥4 mm at the sampled site, GBG levels can be used to screen for type 2 diabetes in dental clinics.

Pre-Procedure Blood Sugar Levels in Diabetic and High-Risk Patients Visiting King Abdulaziz University Dental Hospital: The Role of the Dentist in Diabetes Screening

AIM

Diabetes mellitus (DM) is a widespread problem. Satisfactory control of DM is essential for maintaining oral health and optimizing the outcomes of dental treatment; DM patients with poor glycaemic control have a high risk of dental treatment-related complications. Furthermore, the dentist and dental office can play an important role in DM screening. Therefore, this study aimed at measuring random blood glucose (RBG) levels in patients with established DM or high risk of DM seeking dental treatment at the King Abdulaziz University Dental Hospital to avoid treatment complications and execute an immediate physician referral.

METHODS AND MATERIAL

This cross-sectional study included patients presenting to our institution for dental treatment, who were categorized as diabetic (established diagnosis) or at high risk of DM according to the American Diabetes Association criteria. Participants' pre-procedure RBG level was assessed via a glucometer. High-risk participants were classified as per their blood glucose level into two groups (<200 mg/dL and >200 mg/dL), while the diabetic participants were placed into four groups (<140 mg/dL; 140 to <200 mg/dL; 200-300 mg/dL; and >300 mg/dL).

RESULTS

This study included 695 patients (361 females and 334 males), of which 354 (52%) had established DM and 341 (48%) were high-risk patients. Around 31% of patients in the high-risk group were potentially diabetic but unaware of it; 46% of the diabetic patients had RBG levels >200 mg/dL. For the high-risk participants, age had a statistically significant association (P-value 0.03) with the RBG level.

CONCLUSION

Pre-procedure RBG measurement in diabetic and high-risk patients undergoing dental treatment is crucial for the prevention of DM-related complications. Dental health-care professionals have a vital role in screening, early detection, and referral of these patients.

Screening of undiagnosed hyperglycaemia in the dental setting: The DiabetRisk study. A field trial

AIM

To evaluate the efficacy of different screening protocols for undiagnosed hyperglycaemia in a Research Network of Dental Clinics coordinated by the Spanish Society of Periodontology (SEPA).

MATERIAL AND METHODS

A total of 1143 patients were included in the study. Participants filled a questionnaire considering diabetes risk factors (FINDRISC) and received a periodontal screening examination. Patients with a slightly elevated score according to the Findrisc (≥7), received a point-of-care HbA1c and were eventually referred to their physician for confirmatory diagnosis. Receiver Operating Characteristic (ROC) curves were used to assess the performance of various predictive models with confirmed hyperglycaemia as outcome.

RESULTS

From this population, 97 (8.5%) were finally diagnosed of diabetes (n = 28; 2.5%) or prediabetes (n = 69; 6.0%). When only including the results from the FINDRISC questionnaire, the model reported an area under the curve (AUC) of 0.866 (95% confidence interval - CI [0.833; 0.900]). This model significantly improved when a basic periodontal examination (EPB Code; AUC = 0.876; 95% CI [0.845: 0.906]; p = .042) or a point-of-care HbA1c were added (AUC = 0.961; 95% CI [0.941; 0.980]; p < .001).

CONCLUSIONS

The tested protocol, combining the FINDRISC questionnaire and a point-of-care HbA1c, showed to be feasible when carried out in a dental clinic setting and was efficient to identify subjects with undiagnosed diabetes or prediabetes.

Evaluation of a questionnaire-based diabetes screening concept in German patients with Stage III or IV periodontitis: A practice-based study

BACKGROUND

This practice-based retrospective study evaluated a screening method for diabetes mellitus (DM) in patients with Stage III or IV periodontitis using the FINDRISC questionnaire.

METHODS

Patients with Stage III or IV periodontitis who received FINDRISC screening in a German private dental practice were recruited. Individuals with positive FINDRISC scores (≥12, FINDRISC+) were referred for diabetological examination. Several general and periodontal findings from the patients' documentation were recorded and analyzed.

RESULTS

A total of 179 patients (52.65 ± 11.49 years) were included. In DM screening, 24.6% (n = 44) patients were FINDRISC+, including all patients with currently known DM (21 of 21). Of the remaining FINDRISC+ patients, 82.6% (19 of 23) visited their general practitioner, and 63.2% (12 of 19, 7.6% of total cohort) had an HbA1c ≥5.7%. Accordingly, 75% of the FINDRISC+ patients were diabetologically conspicuous (HbA1c ≥ 5.7%), including those with already known DM. Patients with previously unknown DM showed higher mean age, more missing teeth, a higher periodontitis stage (more Stage IV) and more frequently teeth with suppuration compared with the diabetologically inconspicuous individuals (P <0.01).

CONCLUSION

The FINDRISC questionnaire is appropriate for patients with Stage III or IV periodontitis and can be recommended in dental practice setting.

Use of dental practices for the identification of adults with undiagnosed type 2 diabetes mellitus or non-diabetic hyperglycaemia: a systematic review

AIM

Type 2 diabetes is a growing global challenge. Evidence exists demonstrating the use of primary care (non-hospital based) dental practices to identify, through risk assessments, those who may be at increased risk of type 2 diabetes or who may already unknowingly have the condition. This review aimed to synthesize evidence associated with the use of primary care dental services for the identification of undiagnosed non-diabetic hyperglycaemia or type 2 diabetes in adults, with particular focus on the pick-up rate of new cases.

METHOD

Electronic databases were searched for studies reporting the identification of non-diabetic hyperglycaemia/type 2 diabetes in primary care dental settings. Returned articles were screened and two independent reviewers completed the data-extraction process. A descriptive synthesis of the included articles was undertaken due to the heterogeneity of the literature returned.

RESULTS

Nine studies were identified, the majority of which utilized a two-stage risk-assessment process with risk score followed by a point-of-care capillary blood test. The main barriers cited were cost, lack of adequate insurance cover and people having previously been tested elsewhere. The pick-up rate of new cases of type 2 diabetes and non-diabetic hyperglycaemia varied greatly between studies, ranging from 1.7% to 24% for type 2 diabetes and from 23% to 45% for non-diabetic hyperglycaemia, where reported.

CONCLUSION

This review demonstrates that although it appears there may be benefit in using the dental workforce to identify undiagnosed cases of non-diabetic hyperglycaemia and type 2 diabetes, further high-quality research in the field is required assessing both the clinical and cost effectiveness of such practice. (Prospero Registration ID: PROSPERO 2018 CRD42018098750).

Prevalence of Undiagnosed Diabetes and Prediabetes in the Dental Setting: A Systematic Review and Meta-Analysis

Background

With the close link between diabetes mellitus (DM) and periodontal disease (PD), dentists have an unrealized opportunity to make a chance discovery of a patient's medical condition. Unlike in the medical setting, information on the point of care (PoC) and opportunistic screening for DM in the dental setting is limited. To make a reliable estimate on the prevalence of undiagnosed type 2 diabetes mellitus (T2DM) and prediabetes among dental patients in the dental setting and to assist healthcare planners in making an informed decision, information on the disease frequency and strategies employed to address this issue is of paramount importance.

Objectives

To summarize the data on the prevalence of undiagnosed T2DM and prediabetes amongst dental patients and further explore the effectiveness of the PoC screening and its implication for use in the dental setting.

Methods

A MEDLINE-PubMed, EMBASE, Web of Science, and Cochrane Library search was conducted with no time specification. Information on study characteristics and diagnostic parameters was retrieved for meta-analysis. All the studies were assessed for methodological quality using the QUADAS-2 tool. Proportions were presented in tables and forest plots. All statistical analysis was performed using the MedCalc software.

Results

Nine studies met the inclusion criteria. The proportion of dental patients identified to be at a risk of hyperglycaemia with the PoC screening using random blood glucose (RBG) and HbA1 was 32.47% and 40.10%, whilst the estimated proportion with undiagnosed T2DM and prediabetes was identified as 11.23% and 47.38%.

Conclusion

A significant proportion of dental patients can be identified as undiagnosed T2DM and prediabetes. Targeted opportunistic screening is a feasible approach and can help reduce the prevalence of undiagnosed T2DM and prediabetes.

IDF Diabetes Atlas: Diabetes and oral health - A two-way relationship of clinical importance

The current scientific evidence for the bi-directional associations between oral health and diabetes is summarized. The universal biologic mechanisms and demographic and behavioral risk drivers underlying these associations in both directions are also described. Dysglycemia, even slightly elevated blood sugar levels, adversely affects oral health, manifesting itself in several oral diseases and conditions. In the opposite direction, any oral infection with its subsequent local and systemic inflammatory responses adversely affects blood glucose levels. Moreover, painful, mobile, or missing teeth may lead to intake of soft food items representing a sub-optimal diet and hence poor nutrition, and thereby contribute to incident type 2 diabetes or to poorer glucose control in existing diabetes. Treatment of inflammation related oral conditions, such as non-surgical periodontal treatment and extraction of infected teeth, can lead to a clinically significant decrease in blood glucose levels. Attention to infectious oral diseases and referral to dental care professionals for treatment can therefore be an important novel tool for medical care professionals in preventing and managing diabetes mellitus. Dental professionals can detect unrecognized potential dysglycemia and refer for medical examination. Such interprofessional, patient centered care may contribute to improved health, wellbeing, and quality of life in people with diabetes.

Screening for dysglycaemia in dental primary care practice settings: systematic review of the evidence

INTRODUCTION

Increasing prevalence of diabetes and periodontal disease is prompting identification of additional clinical settings to identify patients at risk for dysglycaemia. A systematic review of studies that have examined feasibility of screening for at-risk patients in general dentistry settings at point-of-care (POC) was undertaken.

MATERIALS AND METHODS

Systematic review of pragmatic clinical field trials piloting POC screening for dysglycaemia risk in dental settings was undertaken in studies whose primary objective was to explore rates of dysglycaemia among undiagnosed patient populations.

RESULTS

Among 17 dental clinical field trials identified, 10 were systematically reviewed. High rates of undiagnosed dysglycaemia were detected among dental patients by biological screening in all trials. Notably, substantive differences in study design and population characteristics were identified, precluding meta-analysis.

CONCLUSION

Screening for dysglycaemia in dental offices effectively identified high-risk patients requiring triage for glycaemic management. Considerations for future clinical trial design were advanced to establish an evidence base amenable to meta-analysis of the relative translational value of glycaemic screening in dental settings.