Screening for diabetes during regular dental visits led to the diagnosis of diabetes and prediabetes in 12.3% and 23.3% of 1,022 patients enrolled in a recent study published in the Journal of the American Dental Association.
“More than 8 million US adults are currently undiagnosed with diabetes, and early identification is key to encourage lifestyle modification or treatment with medication to limit complications,” commented Shiela M. Strauss, PhD, Associate Professor and Co-Director of Statistics and Data Management Core, NYU Colleges of Dentistry and Nursing, New York, NY. “With so many US adults unaware that they have diabetes, the dental visit has the potential to be an important health care site for opportunistic diabetes screening,” said Dr. Strauss, who together with her colleagues, also conducted a related study to examine the feasibility and acceptability of screening for diabetes at dental visits, as described below.
Study Included More Than 1,000 Patients
The field trial by Dr. Genco and colleagues involved 1,022 patients age 45 years and older who presented at dental visits had not been tested for diabetes in the previous year. The patients underwent finger-prick blood testing for hemoglobin A1C (A1C).
Overall, 416 of the 1,022 patients (40.7%) had an elevated A1C (≥ 5.7%) and were referred to their physician for diagnostic workup. A total of 146 of those 416 patients referred to a physician received a confirmatory diagnosis during a 1-year follow-up period: 18 patients (12.3%) were diagnosed with diabetes, 34 patients (23.3%) were at high risk for diabetes, and 64.4% had neither condition. The most common reason for not following up with a physician was patient refusal or no response.
Poor Compliance With Physician Referrals Found in Private Dentist Offices
Patients who attended private dental offices and were referred to a physician’s care were less likely to receive follow-up compared with patients seen in a dental clinic within a community health center (21.5% vs 78.8%; P=0.001).
While the study was not designed to investigate the reasons for the high rates of poor compliance with follow-up in the private dental offices, Dr. Genco said that it appears to be a matter of patient choice as no resistance to follow-up was reported by physicians, dentists, and dental staff in the study. He speculated that denial may play a role in the low rates of follow-up among patients who have an elevated A1C but are asymptomatic.
In addition, cost may be an issue, Dr. Genco said. Even patients with medical health insurance may have a copay for follow-up testing, which may be viewed as wasted money if the patients are not diagnosed with diabetes or at high risk for diabetes, he noted.
“It was revealing that in the 1 community health system where the physicians and dentists are highly integrated, compliance was excellent (85%),” Dr. Genco said. This health system used shared electronic/dental records and every patient seen in the dental office had a physician in the community health system.
Dr. Genco emphasized that primary care physicians can do a great service to their adult patients with type 2 diabetes and public health by making clear recommendations to have routine dental examinations, including periodontal screening. He said that physicians should make this a part of the initial workup for diabetes complications, just like they would for eye, skin, and foot examinations. Periodontal disease is present in 60% to 70% of adults with type 2 diabetes and requires treatment as it places patients at increased risk for mortality from myocardial infarction, he said.
Gingival Crevicular Blood May Be Used to Screen for Diabetes
In the study by Dr. Strauss and colleagues, A1C levels obtained using gingival crevicular blood samples were highly correlated with finger-stick blood A1C levels. The study, which was published in the April 2015 issue of the American Journal of Public Health, involved 408 patients at risk for diabetes or its complications who presented for regular dental visits.
“Several studies, including the field trial conducted by Dr. Genco and colleagues, have demonstrated the feasibility and acceptability to dental patients and dental providers of screening for diabetes at dental visits,” Dr. Strauss said. “Although optimal in being able to provide patients with screening results at the time of the dental visit, some point-of-care tests may generate many false-positive results. Because such results may cause considerable concern and distress for patients, care must be taken to identify an optimal approach to collecting and testing blood for this screening,” Dr. Strauss said.
“In addition, as demonstrated in Dr. Genco and colleagues’ field trial involving patients receiving care in private dental practices, many patients with elevated screening results may not follow up with a primary care provider,” Dr. Strauss said. “This indicates the importance of increased communication by the dental provider with patients having positive screening results about the importance of follow up. It also indicates the importance of strong linkages and communication between the dentist and patients’ primary care providers, whenever possible,” Dr. Strauss noted.
“Many patients visit a dental provider on a yearly or more frequent basis, at which time this screening can occur,” Dr. Strauss said. “In fact, two-thirds of US adults see a dentist in a given year, and many patients see dentists but not primary care providers on an annual basis. For the dentist, knowledge of patients’ diabetes status is vital in order to optimize dental care, especially because elevated blood glucose may be related to increased risk for oral infections and delayed healing after dental surgery,” Dr. Strauss concluded.
Commentary by Courtney Kloberdanz, DDS
I agree with Dr. Genco in that clear recommendations should be made by primary care physicians for their patients to have periodontal screenings by their dentist. And it is the duty of dental practitioners to understand the importance of accurate diagnosis and treatment of periodontal disease, as we know that a strong correlation exists between periodontal disease and diabetes. Patients with uncontrolled diabetes are more susceptible to infections, and therefore, at greater risk for developing periodontal disease. Furthermore, research suggests that having active periodontal disease can make it more difficult for a patient to control their blood sugar, leading to uncontrolled diabetes. General dentists have a duty to recognize this correlation and take it seriously. Periodontal disease is often under diagnosed, and therefore, under treated. General dentists must make an effort to stay current with the criteria outlined by the American Academy of Periodontology, which provides guidelines on how to identify patients who have periodontal disease and, which stage of disease they are in.
One potential issue occurred to me regarding this article's suggestion of A1C screening at the dental office. I question the practicality of testing A1C at the dental office during routine examinations. This test will not only require more time for appointments but will also pose an increased cost of treatment, and it is undetermined who the party will be that absorbs this cost. It is unlikely that the patient would be willing to pay extra for this testing, as cost of medial treatment already appears to be a road block to patient's receiving follow-up care with their physician. Given what we know about insurance company's willingness to compensate providers, it seems unlikely that insurance companies will be footing the bill for this testing. This likely leaves the dentists themselves left to eat the cost of the test, or find a way to work the cost into other services they bill for. This could potentially be a significant problem that may cause dentists to be reluctant about adopting A1C/diabetes screening at biannual dental exams. It is my hope that the medical and dental community can brain storm, problem solve, and work together on resolving these issues, so we may, collectively, provide the best care to our patients.
June 29, 2015
Genco RJ, Schifferle RE, Dunford RG, Falkner KL, Hsu WC, Balukjian J. Screening for diabetes mellitus in dental practices: a field trial. J Am Dent Assoc. 2014;145(1):57-64.
Strauss SM, Rosedale MT, Pesce MA, et al. The potential for glycemic control monitoring and screening for diabetes at dental visits using oral blood. Am J Public Health. 2015;105(4):796-801.