A novel intraoral diabetes screening approach in periodontal patients: results of a pilot study

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.

Can gingival crevicular blood effectively screen for diabetes in Chinese patients with moderate to severe periodontitis? A pilot study

Background/purpose

The early diagnosis of diabetes is essential for the prevention of complications. Periodontitis has been identified as the sixth complication of diabetes and chair-side screening may improve diagnosis of diabetes. This study evaluated whether gingival crevicular blood (GCB) available during routine periodontal examination can be used to screen for diabetes in Chinese patients with moderate to severe periodontitis.

Materials and methods

Finger-stick blood (FSB) and GCB were collected from patients (18 with diabetes and 42 without diabetes) during routine periodontal probing and analyzed for glucose and hemoglobin A1c (HbA1c) levels.

Results

In the diabetic group, the mean glucose levels in GCB and FSB were 12.21 ± 3.86 and 12.61 ± 4.19 mmol/L respectively, while those of the non-diabetic group were 6.14 ± 0.85 and 6.15 ± 0.87 mmol/L, respectively. The average HbA1c values of the diabetic group were 7.72% ± 1.71% and 7.89% ± 1.78% in GCB and FSB, respectively, while those of the non-diabetic group were 5.28% ± 0.31% and 5.23% ± 0.32%, respectively. Highly significant correlations were found between GCB and FSB glucose levels (r = 0.993 for the diabetic group, and r = 0.977 for the non-diabetic group) and between GCB and FSB HbA1c levels (r = 0.977 for the diabetic group, and r = 0.829 for the non-diabetic group).

Conclusion

Our study results indicate that GCB available during routine periodontal examination may be acceptable for the analyses of blood glucose and HbA1c levels. The approach is suitable for screening undiagnosed diabetes in a dental setting.

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.

Patient perceptions of healthy weight promotion in dental settings

INTRODUCTION

Excess weight is a risk factor for systemic and oral diseases. Since dental professionals are already involved in imparting overall health messages when certain conditions impact oral health, it should make sense that they also deliver related health messages such as promoting the maintenance of healthy weight for patients.

OBJECTIVES

This study evaluated the perceptions of adult patients attending private dental clinics on healthy weight promotion by dental professionals.

METHODS

A cross-sectional multicenter survey was designed and set in four private dental clinics (London/Hampshire) between April and July 2015. All eligible patients (≥ 18 years) completed a questionnaire. Body Mass Index (BMI; kg/m²) was calculated from height and weight measurements. Questionnaire content was centred on patient perceptions of 6 domains with the primary domain as to whether patients would accept healthy weight promotion by dental professionals.

RESULTS

213 adults (aged 20-85 years) participated in this study and 58.2% were females. Although the overwhelming majority endorsed healthy weight promotion by the dental team, the overweight/obese were significantly more sensitive (BMI screening χ2 trend = 6.840, p = 0.009; healthy weight information χ2 trend = 6.231, p = 0.013). Awareness of risk of periodontitis, carcinoma and overall adverse health outcomes associated with overweight or obesity was low.

CONCLUSION

The study cohort was well primed for healthy weight advice. Routine healthy weight promotion and BMI screening should be considered in the private dental clinic settings.

CLINICAL SIGNIFICANCE

This is an opportunity to collaborate with other health care professionals to support overall health monitoring/advice; a common risk factor strategy as recommended by the WHO. Future research is merited for this new initiative particularly perceptions of: dental teams' on healthy weight management, longitudinal interventions, NHS, children/parents and separate obese groups.

The Oral Health Care Manager in a Patient-Centered Health Facility

The dental hygienist team member has an opportunity to coordinate care within an interprofessional practice as an oral health care manager.

BACKGROUND AND PURPOSE

Although dental hygienists are currently practicing within interprofessional teams in settings such as pediatric offices, hospitals, nursing homes, schools, and federally qualified health centers, they often still assume traditional responsibilities rather than practicing to the full extent of their training and licenses. This article explains the opportunity for the dental hygiene professional to embrace patient-centered care as an oral health care manager who can facilitate integration of oral and primary care in a variety of health care settings.

METHODS

Based on an innovative model of collaboration between a college of dentistry and a college of nursing, an idea emerged among several faculty members for a new management method for realizing continuity and coordination of comprehensive patient care. Involved faculty members began working on the development of an approach to interprofessional practice with the dental hygienist serving as an oral health care manager who would address both oral health care and a patient's related primary care issues through appropriate referrals and follow-up. This approach is explained in this article, along with the results of several pilot studies that begin to evaluate the feasibility of a dental hygienist as an oral health care manager.

CONCLUSION

A health care provider with management skills and leadership qualities is required to coordinate the interprofessional provision of comprehensive health care. The dental hygienist has the opportunity to lead closer integration of oral and primary care as an oral health care manager, by coordinating the team of providers needed to implement comprehensive, patient-centered care.

Follow-up with primary care providers for elevated glycated haemoglobin identified at the dental visit

OBJECTIVES

This study examined patient experiences after receiving elevated diabetes screening values using blood collected at a dental clinic. It explores patients' reactions to screening, whether or not they sought recommended medical follow-up, and facilitating factors and barriers to obtaining follow-up care.

METHODS

At the comprehensive care clinics at a large, urban College of Dentistry in the United States, haemoglobin A1C (HbA1C) values were obtained from 379 study participants who had not been previously diagnosed with diabetes. In all, 169 (44.6%) had elevated HbA1C values. We analysed quantitative and qualitative data concerning these patients' follow-up with primary care providers (PCPs).

RESULTS

We were able to contact 112 (66.3%) of the 169 study participants who had an elevated HbA1C reading. Of that group, 61 (54.5%) received recommended follow-up care from a PCP within 3 months, and an additional 28 (25.0%) said they intended to seek such care. Qualitative themes included the following: the screening letter - opportunity or burden, appreciation for the 3-month follow-up call and barriers to medical follow-up that included the following: lack of knowledge about diabetes, not understanding the importance of follow-up, busyness, financial concerns, fear and denial.

CONCLUSIONS

Quantitative and qualitative data demonstrate that dentists, dental hygienists and nurses are well poised to discover and translate new models of patient-centred, comprehensive care to patients with oral and systemic illness.

Measurement of HbA1c in Gingival Crevicular Blood Using a High-Pressure Liquid Chromatography Procedure

OBJECTIVE

To validate an ion exchange high-pressure liquid chromatography (HPLC) method for measuring glycated hemoglobin (HbA1c) in gingival crevicular blood (GCB) spotted on filter paper, for use in screening dental patients for diabetes.

METHODS

We collected the GCB specimens for this study from the oral cavities of patients during dental visits, using rigorous strategies to obtain GCB that was as free of debris as possible. The analytical performance of the HPLC method was determined by measuring the precision, linearity, carryover, stability of HbA1c in GCB, and correlation of HbA1c results in GCB specimens with finger-stick blood (FSB) specimens spotted on filter paper.

RESULTS

The coefficients of variation (CVs) for the inter- and intrarun precision of the method were less than 2.0%. Linearity ranged between 4.2% and 12.4%; carryover was less than 2.0%, and the stability of the specimen was 6 days at 4°C and as many as 14 days at -70°C. Linear regression analysis comparing the HbA1c results in GCB with FSB yielded a correlation coefficient of 0.993, a slope of 0.981, and an intercept of 0.13. The Bland-Altman plot showed no difference in the HbA1c results from the GCB and FSB specimens at normal, prediabetes, and diabetes HbA1c levels.

CONCLUSION

We validated an HPLC method for measuring HbA1c in GCB; this method can be used to screen dental patients for diabetes.

Awareness of Prediabetes and Diabetes among Persons with Clinical Depression

Background. Major depressive disorder (MDD) is highly comorbid with diabetes, a relationship underappreciated by clinicians. Purpose. Examine the proportion of nonpregnant individuals ≥20 years with MDD and elevated glucose and the demographic and clinical characteristics associated with unrecognized elevated glucose. Methods. 14,373 subjects who participated in the National Health and Nutrition Examination Survey (2007-2012) completed the PHQ-9 depression screen and had hemoglobin A1C (HbA1c) measured. PHQ-9 scores ≥10 and HbA1c scores ≥5.7% were defined as MDD and elevated HbA1c, respectively. Data were analyzed using complex survey sampling software. Results. 38.4% of the sample with MDD had elevated HbA1c readings. Compared with nondepressed subjects, they were significantly more likely to have elevated glucose readings (P = 0.003) and to be aware of their elevated glucose levels if they had a higher body mass index, family history of diabetes, more doctor visits in the past year, a usual care source, health insurance, or were taking hypertension or hypercholesterolemia medications. Conclusions. Many adults with MDD have elevated HbA1c levels, have never been advised of elevated HbA1c, have not received diabetes screening, and have minimal contact with a healthcare provider. Additional opportunities for diabetes risk screening in people with MDD are needed.

α-2-macroglobulin in saliva is associated with glycemic control in patients with type 2 diabetes mellitus

Background. Subjects with type 2 diabetes mellitus (DM2) require an adequate glycemic control to avoid diabetic complications. Currently, saliva biomarkers are used as a diagnostic tool and can be indicative of the degree of progression and control of various diseases. Several studies indicate that α-2-macroglobulin levels are elevated in diabetic patients. Methods. 120 subjects with DM2 were enrolled and classified into two groups according to their glycemic control (percentage of glycated hemoglobin-A1c (HbA1c), <7% adequate glycemic control group; >7% inadequate glycemic control group). The relationship between α-2-macroglobulin levels from saliva samples and HbA1c was subsequently evaluated. Results. We found a positive correlation between α-2-macroglobulin and HbA1c (r = 0.778 and P < 0.0001). Area under the receivers operating characteristic (ROC) curve of α-2-macroglobulin indicated a positive discrimination threshold of α-2-macroglobulin (AUC = 0.903, CI 95%: 0.847–0.959, P < 0.0001) to diagnose glycemic control. Conclusions. Our data strongly suggest that the level of saliva α-2-macroglobulin is an indicator for the degree of glycemic control in diabetic patients and represents a promising alternative method to evaluate this parameter.

The potential for glycemic control monitoring and screening for diabetes at dental visits using oral blood

OBJECTIVES

We examined the potential for glycemic control monitoring and screening for diabetes in a dental setting among adults (n = 408) with or at risk for diabetes.

METHODS

In 2013 and 2014, we performed hemoglobin A1c (HbA1c) tests on dried blood samples of gingival crevicular blood and compared these with paired "gold-standard" HbA1c tests with dried finger-stick blood samples in New York City dental clinic patients. We examined differences in sociodemographics and diabetes-related risk and health care characteristics for 3 groups of at-risk patients.

RESULTS

About half of the study sample had elevated HbA1c values in the combined prediabetes and diabetes ranges, with approximately one fourth of those in the diabetes range. With a correlation of 0.991 between gingival crevicular and finger-stick blood HbA1c, measures of concurrence between the tests were extremely high for both elevated HbA1c and diabetes-range HbA1c levels. Persons already diagnosed with diabetes and undiagnosed persons aged 45 years or older could especially benefit from HbA1c testing at dental visits.

CONCLUSIONS

Gingival crevicular blood collected at the dental visit can be used to screen for diabetes and monitor glycemic control for many at-risk patients.

Screening for prediabetes and type 2 diabetes in dental offices

Objectives

Most Americans see dentists at least once a year. Chair‐side screening and referral may improve diagnosis of prediabetes and diabetes. In this study, we developed a multivariate model to screen for dysglycemia (prediabetes and diabetes defined as HbA1c ≥5.7 percent) using information readily available to dentists and assessed the prevalence of dysglycemia in general dental practices.

Methods

We recruited 1,033 adults ≥30 years of age without histories of diabetes from 13 general dental practices. A sample of 181 participants selected on the basis of random capillary glucose levels and periodontal status underwent definitive diagnostic testing with hemoglobin A1c. Logistic models were fit to identify risk factors for dysglycemia, and sample weights were applied to estimate the prevalence of dysglycemia in the population ≥30 years of age.

Results

Individuals at high risk for dysglycemia could be identified using a questionnaire that assessed sex, history of hypertension, history of dyslipidemia, history of lost teeth, and either self‐reported body mass index ≥35 kg/m² (severe obesity) or random capillary glucose ≥110 mg/dl. We estimate that 30 percent of patients ≥30 years of age seen in these general dental practices had dysglycemia.

Conclusions

There is a substantial burden of dysglycemia in patients seen in general dental practices. Simple chair‐side screening for dysglycemia that includes or does not include fingerstick random capillary glucose testing can be used to rapidly identify high‐risk patients.

Practical implications

Further studies are needed to demonstrate the acceptability, feasibility, effectiveness, and cost‐effectiveness of chair‐side screening.

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

OBJECTIVE

We examined whether general dentists can contribute to the detection of patients with undiagnosed diabetes and prediabetes by monitoring blood glucose in dental clinics.

RESEARCH DESIGN AND METHODS

A total of 716 patients who visited clinics for dental treatment were enrolled and classified into 3 groups (mild, moderate, and severe) according to Kornman's criteria for periodontitis. The correlations between the casual blood glucose level, presence or absence of the history of diabetes, and/or severity of periodontitis were evaluated.

RESULTS

68 patients (9.5%) had hyperglycemia (blood glucose ≥200 mg/dL). Of these patients, 20 (29.4%) did not have a history of diabetes. Blood glucose tended to be higher with greater periodontitis severity. Of the 3 groups, the severe periodontitis group had the highest proportion of patients with hyperglycemia (p<0.0001).

CONCLUSIONS

Patients with dental problems could be screened for diabetes, especially undiagnosed diabetes. General dentists could function as practitioners to screen for diabetes.

TRIAL REGISTRATION NUMBER

UMIN-CTR 000014877.

Maintaining oral health across the life span

Oral health is directly related to systemic health, yet many Americans have limited to no access to dental health professionals. Nurse practitioners are in an excellent position to fill this void by providing caries risk assessments, chemical therapy to prevent progression of caries, and appropriate patient education to prevent caries.

Diabetes-related knowledge and sources of information among periodontal patients: is there a role for dental hygienists?

PURPOSE

Although there is a bidirectional relationship between periodontal disease and diabetes, little is known about the diabetes-related knowledge of periodontal patients. This study examines what patients with periodontal disease know about diabetes and its association with periodontitis. It also examines their sources of diabetes-related information.

METHODS

Patients (n=111) with or at risk for diabetes who were receiving care at a university-based periodontics and implant clinic completed a written survey assessing their socio-demographic characteristics, health-related activities, diabetes knowledge and sources of diabetes-related information. Survey results were summarized using descriptive statistics. Fisher's exact tests were used to compare patients who had and had not been diagnosed with diabetes according to responses on diabetes-related knowledge items and sources of diabetes information.

RESULTS

Although respondents endorsed various diabetes-related information sources, including family and friends and health care providers, respondents demonstrated very limited knowledge about the diabetes and periodontal disease association. There were no statistically significant differences between patients who had, and had not been diagnosed with diabetes regarding their diabetes-related knowledge. As compared with patients not diagnosed with diabetes, patients with diabetes were significantly more likely to have learned about diabetes from a health care provider (p=0.05) and significantly less likely to have learned about it from friends or family (p=0.05).

CONCLUSION

Periodontal patients need education about the periodontitis-diabetes relationship. Dental hygienists' regular and ongoing involvement with these patients and their primary role in the patients' periodontal care places them in an optimal position to provide this education.

Diabetes screening at the periodontal visit: patient and provider experiences with two screening approaches

OBJECTIVES

This study examined patient and dental provider experiences during the periodontal visit of diabetes screening approaches involving the collection of gingival crevicular blood (GCB) and finger stick blood (FSB) for haemoglobin A1c (HbA1c) testing.

METHODS

At a large, urban, US periodontics and implant clinic, FSB samples from 120 patients and GCB samples from 102 of these patients were collected on special blood collection cards and sent to a laboratory for HbA1c testing, with test results sent to the patients from the laboratory. Quantitative and qualitative data from patients and qualitative data from providers were collected and analysed.

RESULTS

Quantitative and qualitative data support the feasibility and acceptability of the approaches described. Themes that arose from the interviews with providers and patients include 'a good chance to check', 'patient choice', 'FSB versus GCB testing' and 'a new way of interacting and viewing the dental visit'.

CONCLUSIONS

Periodontal patients and dental providers believe that the dental visit is an opportune site for diabetes screening and generally prefer GCB to FSB collection. HbA1c testing is well tolerated, convenient and acceptable to patients, and GCB testing reduces time and liability obstacles for dental providers to conduct diabetes screening.