Identification of Diabetes Risk in Dental Settings: Implications for Physical and Mental Health.

The risk for diabetes risk is significantly elevated in persons who are older, overweight and have serious mental illness. However, primary care practitioners (PCP) tend to underestimate this risk. Although there are few opportunities for early detection of diabetes, blood exuded during routine oral exams in dental settings can be used to assess glycated hemoglobin (HbA1c) levels. The current study sought to understand how primary care practitioners would react to patients who screened positive for elevated HbA1c, how they estimated risk, and whether they provided treatment recommendations or counseling. Method: Semi-structured telephone interviews were conducted on 61 subjects three months after demonstrating elevated HbA1c levels from dental screenings. Data were transcribed and analyzed using content analysis. Results: Qualitative analyses revealed four themes according to patients: (1) "Being told I needed to make lifestyle changes" (41%); (2) Realizing I needed a new health care provider or medication change" (10%); (3) "Being told of the need for monitoring but no counseling/treatment change" (16%); and (4) "Being told everything is fine and there is nothing to worry about" (31%). Conclusions: Only half of the 61 cases reporting elevated HbA1C levels at screening experienced their PCP's as responding with counseling or medication changes. Almost a third of cases perceived that their PCP's dismissed the results, making no recommendations, and the rest perceived no counseling or interventions being proposed. Based on subjects' perceptions of their PCP's responses to their elevated HbA1c values, the impact of this intervention is substantially reduced over expectations.

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

UNLABELLED: 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.

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.

Original Research: Oral Health Concerns of Female Breast Cancer Survivors on Adjuvant Endocrine Therapy.

BACKGROUND: Oral complications from cancer treatments are among the adverse effects breast cancer survivors can face. Yet such complications are often overlooked in cancer survivorship care. Many breast cancer survivors are receiving adjuvant endocrine therapy, but there is limited understanding of potential oral complications from this therapy. PURPOSE: This study aimed to compare aspects of oral health in female breast cancer survivors who were taking adjuvant endocrine therapy with those of survivors not taking such therapy. METHODS: National Health and Nutrition Examination Survey data collected from January 2009 through March 2020 were used for the analysis. Female adults ages 20 years and older who had been diagnosed with breast cancer were included. Linear regression and χ 2 analyses were conducted to examine aspects of oral health, using IBM SPSS Complex Samples software, version 27. RESULTS: In our sample of 423 female breast cancer survivors, 7.1% were taking tamoxifen, 7.8% were taking anastrozole, 4.3% were taking letrozole, and 2.9% were taking exemestane. Compared with the survivors not taking such therapy, a greater proportion of those taking it had decayed teeth, gum disease/problems, and were recommended for imminent dental care after oral health examination by dentists. The survivors who were not taking adjuvant endocrine therapy had more coronal cavities. CONCLUSIONS: Data analysis showed that female breast cancer survivors taking adjuvant endocrine therapy appear more likely to have oral health issues than those not taking such therapy. Improved awareness of these issues is critical. Assessment and management guidelines to address these oral health issues are needed by health care providers.

Identifying unaddressed systemic health conditions at dental visits: patients who visited dental practices but not general health care providers in 2008.

We assessed the proportion and characteristics of patients who do not regularly visit general health care providers but do visit dentists and whose unaddressed systemic health conditions could therefore be identified by their dentist. Of the 26.0% of children and 24.1% of adults that did not access general outpatient health care in 2008, 34.7% and 23.1%, respectively, visited a dentist. They varied by census region, family income, and sociodemographics. Dental practices can serve as alternate sites of opportunity to identify health concerns among diverse groups of US patients.

Screening for elder mistreatment in a dental clinic population.

The purpose of this study was to establish the feasibility and utility of screening for elder mistreatment in a dental clinic population. We approached older adults in a busy dental clinic and enrolled 139 persons over the age of 65 who completed an Audio Computer Assisted Self Interview (ACASI), which included the Hwalek-Sengstock Elder Abuse Screening Test (HS-EAST). Overall, 48.4% of the participants scored 3 or greater on the HS-EAST, and 28.3% scored 4 or greater. Our study suggests that there is an opportunity to screen in busy dental clinics and to facilitate early detection for those patients who screen positive for elder mistreatment.

The dental office visit as a potential opportunity for diabetes screening: an analysis using NHANES 2003-2004 data.

OBJECTIVES: The bidirectional relationship between periodontitis and diabetes suggests that the dental visit may offer a largely untapped opportunity to screen for undiagnosed diabetes. To better examine this potential opportunity, data from the National Health and Nutrition Examination Survey (NHANES) 2003-2004 were used to determine if a larger proportion of patients with periodontal disease as compared with those without periodontitis would be recommended for screening according to American Diabetes Association (ADA) guidelines. The data were also used to determine whether at-risk individuals with periodontitis visited a dental professional recently, so that they could avail themselves of this opportunity for screening, if offered. METHODS: Data to perform these analyses were collected from 2,923 subjects aged 20 and older who reported that they were never told that they had diabetes, had a periodontal examination, and had sufficient data to compute body mass index. Descriptive statistics, t-tests, and chi-square analyses that compared those with and without periodontitis were extrapolated to the US population. RESULTS: A total of 62.9 percent of those without periodontitis and 93.4 percent of those with periodontal disease met ADA guidelines for diabetes screening. Of those at-risk with periodontal disease, 33.9 percent had seen a dentist in the past 6 months, 50 percent in the past year, and 60.4 percent in the past 2 years. CONCLUSIONS: As almost all individuals with periodontitis would have been recommended for diabetes screening, and many at-risk persons with periodontal disease recently visited a dentist, our data suggest that the dental visit provides an important potential venue for this screening.

The potential use of gingival crevicular blood for measuring glucose to screen for diabetes: an examination based on characteristics of the blood collection site.

BACKGROUND: This study examined conditions under which gingival crevicular blood (GCB) could be used to obtain a useful glucose reading to screen for undiagnosed diabetes during routine dental visits. METHODS: GCB and capillary finger-stick blood (CFB) glucose readings obtained with a glucometer were compared for 46 patients recruited from an urban university dental clinic. Study participants were divided into two groups based on probing depth or bleeding on probing (BOP) at the site of collection of the GCB sample. Group 1 participants had blood collected from sites with adequate BOP to obtain a sample without touching the tooth or gingival margin, whereas group 2 participants had blood collected from sites with little or no bleeding. For each group, Pearson correlations were calculated for glucose readings obtained using GCB and CFB samples, and the limits of agreement between the two samples were examined. RESULTS: For group 1 participants, correlations between CFB and GCB glucose readings were high (0.89), and the limits of agreement were acceptable (-27.1 to 29.7). By contrast, for participants in group 2, correlations between the glucose readings were lower (0.78), and limits of agreement were much broader (-25.1 to 80.5). CONCLUSION: GCB samples were suitable to screen for diabetes in persons with sufficient BOP to obtain a sample without touching the tooth or gingival margin (i.e., in patients having the basic clinical signs of gingivitis or periodontal disease).

Illness perceptions among adults at risk for diabetes.

PURPOSE: The purpose of this study is to examine diabetes illness perceptions among a sample of at-risk adults according to specific characteristics that make them vulnerable to diabetes. METHODS: At-risk adults (N = 372) participated in a study investigating the potential to screen them for diabetes at a large urban dental college. Sociodemographic and individual-level diabetes risk-related characteristics, A1C measures, diabetes-related symptoms, diabetes knowledge, diabetes illness perceptions, and perceived causes of diabetes were collected and reported for the study sample; t tests were then used to determine whether there were statistically significant differences in each of 8 dimensions of diabetes illness perceptions according to the presence or absence of 6 diabetes risk factors. RESULTS: Average A1C values were 5.6% (38 mmol/mol), and 46% of the study sample had A1C values in the prediabetes or diabetes range. Participants had various diabetes knowledge gaps and misperceptions, and there were differences in dimensions of diabetes illness perceptions depending on specific diabetes-related risk factors. CONCLUSIONS: In view of differences in the diabetes-related illness perceptions of persons at risk for diabetes, it is important for diabetes educators and other health care providers to personalize their diabetes-related education, management, and support to the specific needs and vulnerabilities of at-risk patients.

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.

Point-of-Care HbA1c Testing with the A1cNow Test Kit in General Practice Dental Clinics: A Pilot Study Involving Its Accuracy and Practical Issues in Its Use.

With millions of at-risk people undiagnosed with pre-diabetes and diabetes, there is a need to identify alternate screening sites for out-of-range glucose values. We examined practical issues and accuracy (relative to High Performance Liquid Chromatography testing in a laboratory) in the use of the A1cNow point of care device for this screening in general practice dental clinics at a large University-based Dental College. Health care professionals obtained evaluable readings for only 70% of the subjects, even after two attempts, and its use according to manufacturer's instructions was often challenging in the busy environment of the dental clinic. At thresholds for pre-diabetes and diabetes established by the American Diabetes Association, sensitivities of the A1cNow kit relative to the HPLC method were 91.9% and 100%, respectively. However, specificities for pre-diabetes and diabetes were 66.7% and 82.4%, respectively, indicating many false positive results. A better strategy for diabetes screening may involve a laboratory-based analysis approach that is patient- and provider-friendly, with minimal burden to the dental team.

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.

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

BACKGROUND: This pilot study examines whether a novel diabetes screening approach using gingival crevicular blood (GCB) could be used to test for hemoglobin A1c (HbA1c) during periodontal visits. METHODS: Finger-stick blood (FSB) samples from 120 patients and GCB samples from those patients with adequate bleeding on probing (BOP) were collected on special blood collection cards and analyzed for HbA1c levels in a laboratory. The Pearson correlation coefficient was used to measure correlation between FSB and GCB HbA1c values for 75 paired FSB and GCB samples. A receiver-operator characteristic curve (ROC) analysis was performed to determine an optimal GCB HbA1c criterion value for a positive diabetes screen. RESULTS: For the 75 paired samples, the Pearson correlation coefficient was 0.842. The ROC analysis identified a criterion value of 6.3% for the GCB HbA1c test with high sensitivity (0.933) and high specificity (0.900), corresponding to FSB HbA1c values ≥6.5% (in the diabetes range). Using this GCB HbA1c criterion value for 27 additional paired samples, in which there was an unidentified component observed to coelute within the elution window of GCB HbA1c in the laboratory, there was agreement between FSB and GCB values for 24 of the pairs according to whether both were within or outside of the diabetes range. CONCLUSION: Using a criterion value of 6.3%, GCB samples are acceptable for HbA1c testing to screen for diabetes in most persons with BOP at the GCB collection site.