Diabetes Screening In Dental Practice

Editor’s Note: Oral health professionals are urged to check all regulations and consult their state dental board for current requirements pertaining to diabetes screening in dental settings, including the chairside use of glucometers.

Interprofessional interaction among healthcare professionals is becoming more commonplace as the concept of One Health takes hold in the United States.¹ The U.S. Centers for Disease Control and Prevention (CDC) defines One Health as a collaborative and transdisciplinary approach at the local, national and global levels to achieve optimal health outcomes by recognizing the interconnection between people, animals, plants and the environment.¹ Oral health professionals are in a unique position to work with physicians and other providers to assist in recognizing chronic disease. One example is diabetes mellitus, which is thought to be associated with other chronic conditions, such as periodontal and cardiovascular disease. Dental teams often see patients on a more frequent basis than physicians, and this presents an opportunity to offer point-of-care (POC) screenings for diabetes mellitus. Screening in dental settings facilitates follow-up with medical professionals, allowing each provider to gain a better understanding of how chronic conditions may be interrelated. This could lead to the diagnosis of conditions that may otherwise go untreated.

For instance, in 2018 the Arizona State Board of Dental Examiners ruled to include diabetes testing and reporting in dental settings, which allows clinicians to determine appropriate dental treatment for patients who may be at high risk for diabetes or have experienced a recent change in diabetic condition.² In 2019, the American Dental Association (ADA) published an in-office guide for monitoring and documenting blood glucose and hemoglobin A1c (HbA1c) levels.³ The ADA asserts that through education, dental practitioners could enhance treatment by providing chairside POC assessments that would strengthen dental treatment plans and/or identify when a patient should be referred. In effect, these POC tests could begin the medical management of a patient’s undiagnosed chronic disease. As such, two new CDT codes were developed to allow for billing and tracking of these patient services: D0411 and D0412, which involve in-office testing for blood glucose and HbA1c levels. While the ADA does not expect dental teams to treat diabetes mellitus, it notes in-office monitoring of a patient’s glucose level on routine basis or immediately before treatment is appropriate because the results may cause practitioners to modify treatment plans. It therefore supports the POC prediabetes identification guide codeveloped by the CDC, American Medical Association and American Diabetes Association.⁴ The CDC also has a standalone prediabetes assessment,⁵ as does the American Diabetes Association.⁶ These self-tests focus on factors that are known to increase the risk of diabetes mellitus, including:³

• Weight status (specifically, being overweight or obese)
• Ethnic background (Latino, Asian, African American, Native American, Pacific Islanders or Alaska natives)
• Sedentary lifestyle
• Family history (parent or sibling)

It is important to note that if a dental provider chooses to perform chairside glucose testing, it is considered a laboratory test and certain regulatory requirements must be fulfilled. The Clinical Laboratory Improvement Amendments (CLIA) is the regulatory source that establishes standards for laboratory testing, which includes chairside use of glucometers. The ADA provides an excellent summary of the CLIA flowchart explaining that chairside glucose testing is considered a simple or waived test.³ Despite being a waived test, the dental office is still required to register with the state CLIA agency and apply for a CLIA certificate of waiver (CMS Form 116). Practitioners are strongly advised to consult with their respective state dental board for the most current list of regulations and requirements.

DISCUSSION

According to the National Diabetes Statistical Report 2020, more than 34.2 million Americans have diabetes mellitus, and another 88 million are prediabetic.⁷ In 2003, the independent U.S. Preventive Services Task Force published screening standards for diabetes mellitus, with updates issued in 2008⁸ and 2015.⁹ The task force recommends adults with treated or untreated hypertension (sustained blood pressure > 135/80 mmHg) be screened for diabetes mellitus because abnormal glucose metabolism is linked to cardiovascular risk factors. It also reported 2012 estimates showing that nearly 86 million Americans age 20 and older have impaired fasting glucose or impaired glucose tolerance, and that 15% to 30% of these individuals will subsequently develop type 2 diabetes within five years if lifestyle changes are not implemented. The task force also recommends diabetes screening for adults ages 40 to 70 who are overweight or obese. Patients found to have abnormal POC results should be referred for behavioral counseling to implement lifestyle interventions aimed at promoting a healthier lifestyle and diet.

The American Diabetes Association, CDC, U.S. Preventive Services Task Force and International Diabetes Federation also identified factors that place an individual at risk for diabetes, creating a tool that can be used for individual screening recommendations.¹⁰ In dental practice, the use of screening tools is critical to identify patients who have, or are at risk for, diabetes — particularly those with periodontal disease (which is exacerbated by uncontrolled diabetes mellitus).¹¹ In fact, glycemic control in patients with diabetes and periodontal disease is often poorer than in individuals with only diabetes,¹² reinforcing the importance of periodontal maintenance and blood glucose management to prevent progression of periodontal disease. Lack of glycemic control also fuels accelerated attachment loss and tooth loss.¹³ In short, the prevalence and severity of periodontal disease is higher in patients with diabetes mellitus than those without diabetes.¹⁴

Abundant research clearly suggests diabetes mellitus and periodontal disease — both chronic disease processes — are connected. Early diagnosis of diabetes may allow for effective intervention and risk reduction opportunities for factors such as smoking, hypertension, dyslipidemia, obesity, poor diet and inactivity. There appears to be an association between cardiovascular disease and diabetes mellitus, and early diagnosis of diabetes through POC dental screening would create opportunity to reduce risk for cardiovascular disease.

DIABETES AND DENTAL IMPLANTS

The literature connecting diabetes mellitus to the outcome of dental implant therapy is robust. The following review of the literature describes the impact of glycemic control on bone healing and dental implant outcomes. One of the major consequences of diabetes mellitus is microangiopathy, which can affect many organ systems. The appearance of microangiopathy in peri-implant tissues represents a significant risk to implant-adjacent hard and soft tissues.¹⁵ Poor glycemic control in patients with diabetes is associated with greater risk of peri-implantitis.¹⁶ Hyperglycemia has a negative effect on bone metabolism, leading to decreased density and poor bone architecture around the implant body.¹⁷ Poorly controlled diabetes has a negative effect on peri-implant bone formation and mineralization in animal models.¹⁸ For this reason, Aguilar-Salvatierra et al¹⁹ recommend that HbA1c levels be obtained for patients with diabetes mellitus who are being considered for dental implant therapy. There is little difference in implant success rates between patients with diabetes mellitus and those without — as long as diabetes is well controlled.¹⁹ Therefore, monitoring glycemic control in implant patients with diabetes is important at recall because issues can be identified early, allowing for appropriate interventions.³

As noted, implants can have high success rates if the patient’s diabetes is well controlled (HbA1c < 7.0); conversely, dental implant failure rates increase when glycemic control is poorly managed.¹⁵ Therefore, it appears HbA1c is indicated as a POC test to screen potential implant patients that would meet screening criteria based on diabetes risk factors alone. The provider could then consider blood glucose among other comorbidities when determining a patient’s eligibility for implant placement. While there is no clear line separating well controlled and poorly controlled diabetes, the authors recommend an HbA1c level below 7.0 as well controlled, per surgical protocol research by Tawil et al.²⁰

Screening for diabetes in a dental setting has been done successfully on numerous occasions.¹¹ In a cohort of 498 patients receiving blood glucose testing through finger sticks, Barasch et al²¹ assessed the feasibility of random blood glucose testing by dental teams. They found that 84% of dentists and 83% of patients supported this idea.

In a dental clinic population, Lalla et al²² predicted diabetes mellitus and prediabetes in 92% of patients with four or more missing teeth, periodontal pockets of 5 mm or greater at 26% of sites evaluated, and a POC HbA1c reading of 5.7 or greater. Borrell et al²³ found a 27% to 53% probability of undiagnosed diabetes mellitus in patients with self-reported family history of the disease, hypertension, high cholesterol and periodontal disease. Genco et al¹¹ screened 1022 patients using an HbA1c test after qualifying them for screening with the American Diabetes Association risk test, and those with a level of 5.7 or higher were referred to a physician for diagnosis. Of these, 416 (40.7%) had reported HbA1c levels exceeding 5.7, and, of these, 35.1% had a diabetes diagnosis within the following year.¹¹ Strauss et al²⁴ found that 93.4% of patients with periodontal disease met the American Diabetes Association guidelines for diabetes screening, and, of these, 60.4% had seen a dentist in the previous two years. The fact that more than half of these patients had seen a dentist in the previous two years underscores the opportunity and value of screening for diabetes in dental settings.

By recognizing risk factors, dental teams can assist in the early detection, diagnosis and treatment of diabetes and, secondarily, other chronic conditions, such as cardiovascular disease. The U.S. Preventive Services Task Force determined there is sufficient evidence that lifestyle interventions can prevent or delay progression to type 2 diabetes. In terms of dental therapy, POC screening for diabetes will aid patient selection when planning dental implants. Stronger consideration for implant therapy should be given to patients with lower HbA1c values, indicating better glycemic control, as these individuals may have higher implant success rates.²⁰ As a long-term follow-up with implant patients, obtaining an HbA1c reading twice a year may allow dental teams to better monitor the patient’s glycemic control. If a dental implant patient’s HbA1c rises above acceptable levels, intervention could be initiated prior to the onset of peri-implant disease or other complications. The blood glucose test should be limited to use just prior to rendering treatment, as the proposed treatment may be altered based on the findings.

In order to assist the dental community in implementing this service, the authors propose this protocol for POC screening for diabetes mellitus in dental settings.

IMPLEMENTING HbA1c AND BLOOD GLUCOSE SCREENING

It is proposed that patients should be screened for diabetes mellitus if they meet the following criteria:

• Adults who are overweight or obese, and who have one or more of the following risk factors:
  • – Physical inactivity
  • – Hypertension greater than 135/80 mmHg, treated or untreated
  • – First-degree relative with diabetes mellitus
  • – High-risk race/ethnicity
  • – History of coronary artery disease
  • – Asian American with body mass index ≥ 23
  • – Women who experienced gestational diabetes
  • – Hyperlipidemia
  • – Periodontal disease

• Adults who are potential dental implant patients

Blood glucose level testing should be obtained on any patient who:

• Displays signs and symptoms of hypoglycemia
• Has diabetes and is scheduled for a procedure in which healing outcomes could be compromised by poor glycemic control
• Is believed by clinicians to have poorly controlled blood glucose at that point in time, and for patients whose glucose test results could alter treatment plans

The HbA1c test will provide summary of the patient’s circulating blood glucose for the last two to three months. Though this result may show good control, blood glucose will change throughout the day based on when the patient has eaten or taken medications. It is important to obtain a blood glucose level at the time of treatment for an accurate measurement at that point in time. This will allow the dentist to make an informed decision on how to proceed with treatment. According to the ADA Quick Reference Guide, blood glucose levels that would alter treatment at the time the POC test was performed are as follows:³

• Blood glucose below 70 mg/dl is hypoglycemia. Therefore, the procedure should not be carried out, as the patient is at risk for a hypoglycemic episode.
• Blood glucose over 300 mg/dl could cause delayed healing of surgical sites or lead to infection, especially in patients with high HbA1c levels that indicate poor glycemic control has been present over an extended period. Elective surgical procedures should be delayed until blood glucose is in an acceptable range.

Each dental office should establish how these POC tests will be carried out, and all staff members should be calibrated on the technique. The calibration should be repeated on regular intervals, as directed by the dentist. The ADA Quick Reference Guide recommends the following steps:³

• • • Selection of the appropriate finger
    • Site massage
    • Clean the site appropriately
    • Puncture the skin with a lancet
    • Discard the first sample of blood
    • No finger milking after stick
    • Place blood drop on analyzing strip and insert into test device
    • Read and interpret the results

Practitioners should also recognize the test result continuum of both POC tests.

CONCLUSIONS

Based on the findings of our literature review, patients with undiagnosed or uncontrolled diabetes mellitus should be educated about the disease process. Involving other medical providers — such as physicians, physician assistants and pharmacists — in patient education will yield true multidisciplinary care. Upon obtaining a positive screening result in the dental setting, referral to a physician for formal diagnosis and management of diabetes is indicated. This further emphasizes the concept of One Health through the synergistic effects of POC screening and multidisciplinary care.¹

REFERENCES

1. U.S. Centers for Disease Control and Prevention. One Health. Available at: https:/​/​www.cdc.gov/​onehealth/​index.html. Accessed January 11, 2021
2. Arizona State Board of Dental Examiners. Agency Substantive Policy Statement 25. Available at: https:/​/​dentalboard.az.gov/​sites/​default/​files/​ALL.pdf. Accessed January 11, 2021
3. American Dental Association. D0411 and D0412 — ADA Quick Guide to In-Office Monitoring and Documenting Patient Blood Glucose and HbA1C Level. Available at: https:/​/​www.ada.org/​~/​media/​ADA/​Publications/​Files/​CDT_​D0411_​D0412_​Guide_​v1_​2019Jan02.pdf?la=en. Accessed January 11, 2021.
4. U.S. Centers for Disease Control and Prevention. Point-of-care prediabetes identification. Available at: https:/​/​www.cdc.gov/​diabetes/​prevention/​pdf/​point-of-care-prediabetes-identification-algorithm_​tag508.pdf. Accessed January 11, 2021.
5. U.S. Centers for Disease Control and Prevention. The Prediabetes Risk Test. Available at: https:/​/​www.cdc.gov/​diabetes/​takethetest/​. Accessed January 11, 2021.
6. American Diabetes Association. Type 2 Diabetes Risk Test. Available at: https:/​/​www.diabetes.org/​risk-test. Accessed January 11, 2021.
7. U.S. Centers for Disease Control and Prevention. National Diabetes Statistical Report 2020. Available at: https:/​/​www.cdc.gov/​diabetes/​pdfs/​data/​statistics/​national-diabetes-statistics-report.pdf. Accessed January 11, 2021.
8. U.S. Preventive Services Task Force. Screening for type 2 diabetes mellitus. Ann Intern Med. 2008;148:846–854.
9. Siu AL, U.S. Preventive Services Task Force. Screening for abnormal blood glucose and type 2 diabetes mellitus. U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2015;163:861–868.
10. Abid A, Ahmad S, Waheed A. Screening for type II diabetes mellitus in the United States: the present and the future. Clin Med Insights Endocrinol Diabetes. 2016;9:19–22.
11. Genco RJ, Schifferle RE, Dunford RG, Falkner KL, Hsu WC, Balukjian J. Screening for diabetes mellitus in dental practice: a field trial. J Am Dent Assoc. 2014;145:57–64.
12. Chang PC, Lim LP. Interrelationships of periodontitis and diabetes: A review of the current literature. J Dent Sci. 2012;7:272–282.
13. Demmer RT, Holtfreter B, Desvarieux M, et al. The influence of type 1 and type 2 diabetes on periodontal disease progression. Diabetes Care. 2012;35:2036–2042.
14. Apoorva SM, Sridhar N, Suchetha A. Prevelence and severity of periodontal disease in the type 2 diabetes mellitus (non-insulin-dependent diabetes mellitus) patients in Bangalore City: An epidemiological study. J Indian Soc Periodontol. 2013;17:25–29.
15. Javed F, Romanos GE. Impact of diabetes mellitus and glycemic control on the osseointegration dental implants: a systematic literature review. J Periodontol. 2009;80:1719–1730.
16. Monje A, Cantena A, Borgnakke WS. Association between diabetes mellitus/​hyperglycaemia and peri-implant diseases: Systemic review and meta-analysis. J Clin Periodontol. 2017;44:636–648.
17. Retzepi M, Donos N. The effect of diabetes mellitus on osseous healing. Clin Oral Implants Res. 2010;21:673–681.
18. Von Wilmowsky C, Stockmann P, Harsch I, et al. Diabetes mellitus negatively affects peri-implant bone formation in the diabetic domestic pig. J Clin Periodontol. 2011;38:771–779.
19. Aguilar-Salvatierra A, Calvo-Guirado JL, González-Jaranay M, Moreu G, Delgado-Ruiz RA, Gómez-Moreno G. Peri-implant evaluation of immediately loaded implants placed in esthetic zone in patients with diabetes mellitus type 2: a two-year study. Clin Oral Implants Res. 2016;27:156–161.
20. Tawil G, Younan R, Azar P, Sleilati G. Conventional and advanced implant treatment in the type II diabetic patient: Surgical protocol and long‐term clinical results. Int J Oral Maxillofac Implants. 2008;23:744–752.
21. Barasch A, Safford MM, Qvist V, et al. Random blood glucose testing in dental practice: a community-based feasibility study from The Dental Practice-Based Research Network. J Am Dent Assoc. 2012;143:262–269.
22. Lalla E, Kunzel C, Burkett S, Cheng B, Lamster I. Identification of unrecognized diabetes and pre-diabetes in a dental setting. J Dent Res. 2011;90:855–860.
23. Borrel LN, Kunzel C, Lamster I, Lalla E. Diabetes in the dental office: using NHANES III to estimate the probability of undiagnosed disease. J Periodontal Res. 2007;42:559–565.
24. Strauss SM, Russell S, Wheeler AJ, Norman R, Borrell LN, Rindskopf D. The periodontal office visit as a potential opportunity for diabetes screening: an analysis using NHANES 2003–2004 data. J Public Health Dent. 2010;70:156–162.

From Decisions in Dentistry. February 2021;7(2):26–28,31.