Abstract
Introduction
The prevalence of diabetes mellitus (DM) is increasing, and both undiagnosed patients and poor disease control among those already diagnosed are widely reported. We conducted a feasibility study of blood glucose screening in “The Dental Practice-Based Research Network” (DPBRN) as a potential strategy to detect undiagnosed DM, or poorly controlled DM among those with diagnosed disease.
Methods
Practitioners and staff were trained to use the glucose meter. Consecutive patients ≥19 years old were enrolled at each practice until 15 qualified and consented. Qualifying patients had at least one risk factor for DM according to American Diabetes Association criteria. Perceived barriers and benefits to testing were reported using patient and dentist/staff questionnaires.
Results
Twenty-eight practices enrolled 498 subjects. Glucose testing lasted <2min, 2–5min, or >5 min/patient in 29%, 64% and 7% of the practices, respectively. Twenty-six of 28 dentists (93%) considered testing necessary; 85% agreed it was beneficial; 75% agreed that testing may help identify patients at risk for periodontitis. Fifteen of 67 dental office personnel (22%) who returned questionnaires thought testing was time-consuming but 58% did not; 4% found the test too expensive (51% did not) and 4% thought that testing may open practices to liability (72% did not). Among subjects, 83% thought testing in dental practice was a good idea, 85% found it was easy and 62% said the test made them more likely to recommend their dentist to others.
Discussion
Glucose testing was well-received by patients and practitioners. These results should dispel the belief that glucose testing is time consuming, expensive and poorly accepted by patients.
Keywords: blood glucose, testing, diabetes mellitus, dental practice, practice-based research, multi-center studies, clinical research, research methods
Introduction
Type 2 diabetes mellitus (DM), both diagnosed and undiagnosed, has been increasing at epidemic rates. The current prevalence of DM in the United States is over 12%, making this disease one of the most common and costly chronic conditions.1–3 According to the Center for Disease Control and Prevention (CDC), DM is the seventh leading cause of death4 but also the chief cause of blindness, end-stage renal disease and non-traumatic limb amputation in this country.1–5 An estimated 4% of the population may have the disease but have not been diagnosed, and about 65% of diagnosed patients are not optimally controlled.,4,5 Similarly, Scandinavian countries have been experiencing a significant increase in the number of type 2 DM cases, which affects approximately 6–8% of the population. It has been estimated that 3–4% of the Scandinavian population has undiagnosed disease.6 Hence, type 2 DM appears to be a problem common to both the US and Scandinavian countries.
DM typically develops after many years of metabolic derangements characterized by impaired fasting glucose and poor glucose tolerance. Pre-DM affects about 54 million Americans, or 18% of the population. This means that fully one-quarter of Americans have impaired glucose metabolism.5 Both conditions have been associated with increased physical morbidity, including significant risk for cardiovascular, renal, periodontal, neuropathic and ocular disease.,7,8 Adequate glucose control significantly reduces vascular complications in both type 1 and type 2 DM, and lifestyle interventions can prevent or delay the progression of pre-DM to frank DM.9 Hence, detecting these conditions and treating them adequately are major public health objectives. Similarly, maintenance of good glycemic control is imperative in patients diagnosed with diabetes in order to preserve health and positive outcomes.
The American Heart Association and American Diabetes Association have both called for new strategies to improve screening and detection of DM and pre-DM. The newly released document “Healthy People 2020” (www.healthypeople.gov/2020) rates screening for DM as one of the top measures to be implemented in the healthcare system. DM control is also less than ideal in Scandinavia.10 While a nursing service for patients with diabetes has been implemented in some Swedish cities, results of this program have lead to renewed calls for increased testing and education in this vulnerable population.11
The dental office is a unique setting for screening, and studies have demonstrated that it can be a site for preventive health intervention, such as smoking cessation.12,13 Most dental practitioners regard glucose testing as outside their scope of practice and only a few dental offices own and use a glucometer. It is our contention that glucose measurement in dental practice can provide valuable information to both patients and doctors and that results obtained could inform patient referral to medical services as well as dental treatment plan decisions. Targeted populations should include those with risk factors but undiagnosed diseases as well as diagnosed (pre)-diabetics. These patients have the highest risk for abnormal glucose and also stand to benefit the most from testing.
The main objective of the current study was to test the feasibility of screening patients at risk for, or with a diagnosis of DM or pre-DM for abnormal random glucose levels in community dental practices, using glucose monitors (glucometers) and finger stick testing. Specifically, we aimed to identify patient and provider attitudes toward testing after such testing had been performed as well as determine specific barriers to glucose testing in dental practice.
Methods
This study was performed within The Dental Practice-Based Research Network (DPBRN). Although practitioner-investigators from many U.S. states and Scandinavia participate in certain DPBRN studies, projects that require extensive training and interaction via face-to-face contact with practitioners have been focused in five regions: Alabama/Mississippi, Florida/Georgia, Minnesota, Permanente Dental Associates (PDA) in Oregon and Washington states, and the Scandinavian countries of Denmark, Norway, and Sweden.14–17 A comprehensive description of DPBRN can be found at http://www.DentalPBRN.org. Participation in this study was open to all four DPBRN United States regions and Sweden (Danish dental practice regulations do not currently allow dentists to conduct glucose screening). Owing to the modest number of dentists in the Scandinavian region needed for the study, recruitment was limited to Sweden. All dental practice types in DPBRN, be they general dentistry or specialty, were eligible to enroll. The project was approved by the UAB and all regional human research review boards (IRBs). All dentists who participated in the study completed research training prior to study initiation at their practice.
Practitioners were informed about the study through mail and those willing to participate notified the DPBRN regional coordinator. Five or six practices from each geographic location were selected at random from the pool of interested practitioners and each enrolled practice participated in a training session. Practitioners and/or their delegated staff were trained in the use of the glucometer (FreeStyle Freedom Lite, Abbott Diabetes Care, Alameda, CA), which was provided to all participating offices along with test strips, lancets and calibration equipment.
Eligible patients scheduled for a routine dental examination were screened with data entered onto a standard form. We used the American Diabetes Association and the U.S. Preventive Services Task Force recommendations for patients who should have glucose screening in health care settings.18 All patients with body mass index (BMI) ≥ 25 kg/m2, or with a self-reported history of hypertension or hypercholesterolemia, or with a diagnosis of DM or pre-DM, were offered blood glucose testing. These patients were considered to have an elevated risk for abnormal glucose. The protocol included a BMI chart so that practices could quickly determine this value using patient-reported height and weight. Consecutive patients older than 19 years who presented for a non-emergency, scheduled dental visit, regardless of gender, race, ethnicity, medical history or dental status were enrolled at each practice until a total of 15 qualified and consented for blood glucose testing. Reasons for declining the test were also obtained by the dental office staff if the patient was willing to provide them. Consenting patients had their random glucose assessed with a finger stick and the Freestyle glucometer following the manufacturer’s instructions at the beginning of the dental visit. The test was repeated if the glucose value was below 70 mg/dl or above 300 mg/dl.
Subjects received a card with their glucose reading and information about how to interpret the reading, as well as literature designed for patients from the American Diabetes Association and the Swedish Diabetes Association about DM and pre-DM. If the glucose value was abnormal, the dentist advised patients that they may benefit from more formal evaluation, and to discuss the result with their physicians. The card included a paragraph that briefly described the study and what was done in the dental office and served as a referral to the physician.
Data regarding barriers and benefits to glucose testing were collected on two standardized forms: a patient questionnaire filled by all subjects at the end of the appointment and a dentist/staff questionnaire that office personnel who performed the testing filled at the end of the study. On both forms the responses to questions consisted of 5-point Likert scales ranging from “strongly agree” to “strongly disagree” where dentists and patients were asked to rate the most important barriers and/or benefits of glucose testing, from the perspective of having completed this protocol. Comment space was provided as well. These forms were designed based on answers by DPBRN dentists to an informal questionnaire querying opinions on perceived barriers and benefits of glucose testing in dental practice (data not shown).
All forms contained no identifying information and were placed in a locked box that was retrieved by the local study coordinator. All forms, questionnaires, and patient literature used in this study are publicly available at the DPBRN web site.19 Data forms were reviewed by the study coordinator for completeness and then transferred to the DPBRN Coordinating Center. Data were entered and analyzed for distribution of responses and associations with demographic and medical characteristics. We also used descriptive statistics on each item and evaluated the distributions across the Likert scales. Analyses were performed with the SAS statistical package (SAS Institute, Cary, NC).
Results
Twenty-eight dental practices (24 general, 1 Oral Surgery, 1 Periodontics and 2 Endodontics) from the five geographic areas of DPBRN participated in this study (Table 1). Of the practitioners, 23 (82%) were male and the same number were Caucasian, with 2 (7%) and 3 (10%) being African-American and Asian/Pacific Islander, respectively.
Table 1.
Practices and patients enrolled in the study
| DPBRN Region | Practices | Patients Enrolled |
|---|---|---|
| General | ||
| Alabama/Mississippi | 5 | 84 |
| Florida/Georgia | 5 | 88 |
| Minnesota | 4 | 69 |
| PDA | 6 | 84 |
| Sweden | 4 | 111 |
| Specialty | ||
| Alabama/Mississippi | 1 | 15 |
| Florida/Georgia | 1 | 17 |
| Minnesota | 1 | 15 |
| PDA | 1 | 15 |
| Sweden | 0 | 0 |
| Total | 28 | 498 |
Dentist/Staff Questionnaire
Questionnaires were distributed to all dental personnel who performed the testing at participating offices. A total of 28 dentists and 44 staff members in 28 practices (Table 2) participated in the study and 67 (93.1%) returned completed forms. All offices returned at least one completed questionnaire, with 30.6% of the total coming from AL/MS region, 33.3% from FL/GA, 16.7% from MN, 8.3% from WA/OR and 11.1% from Sweden. Among the 67 responders, 56 (85%) agreed that testing benefits patients, 46 (69%) agreed that patients may get better glucose control if tested in the dental office; 40 (60%) thought glucose reading can help determine timing of invasive procedures; 5 responders (7%) were in disagreement; 50 (75%) agreed that testing may help identify patients at risk for periodontal disease (7 disagreed) and 59 (88%) thought that testing will promote the perception that dentists are interested in patients’ general health and increase confidence in the practice (1 disagreed).
Table 2.
Dental personnel rating of glucose testing N=72 (missing N)
| Item | Strongly Disagree N (%) |
Disagree N (%) |
Neutral N (%) |
Agree N (%) |
Strongly Agree N (%) |
|---|---|---|---|---|---|
|
Potential Positive Patients will benefit (missing 6) |
1 (1.5) |
1 (1.5) |
8 (12.1) |
28 (42.4) |
28 (42.4) |
| May get better glucose control (5) |
2 (3) | 3 (4.5) | 16 (24) | 29 (43.3) | 17 (25.4) |
| BST determine invasive procedure(5) |
2 (3) | 3 (4.5) | 22 (32.8) | 16 (23.9) | 24 (35.8) |
| BST identify risk for periodontitis (5) |
3 (4.5) | 4 (6) | 10 (14.9) | 25 (37.3) | 25 (37.3) |
| Patients increase confidence |
0 | 1 (1.5) | 7 (10.5) | 30 44.8) | 29 (43.3) |
| Potential Negative | |||||
| BST time consuming (5) | 14 (20.1) | 25 (37.3) | 13 (19.4) | 9 (13.4) | 6 (9) |
| BST too expensive (5) | 16 (23.9) | 18 (26.9) | 30 (44.8) | 3 (4.5) | 0 |
| Glucose not relevant to dental practice(6) |
33 (50) | 18 (27.3) | 13 (19.7) | 1 (1.5) | 1 (1.5) |
| Patients unhappy (5) | 48 (71.6) | 14 (20.9) | 2 (3) | 2 (3) | 1 (1.5) |
| BST opens to Liability (5) |
30 (44.8) | 18 (26.9) | 16 (23.9) | 3 4.5) | 0 |
BST: Blood sugar testing
On the statement that glucose testing is time consuming, 39 (58%) disagreed and 15 (22%) agreed; 34 (51%) disagreed that the test is too expensive while 3 (4%) agreed and 51 (77%) disagreed that glucose levels are not relevant to dental practice, while 2 (3%) agreed. Regarding whether patients were unhappy that the practice was doing glucose screening, 62 (93%) disagreed, and 3 (4%) agreed or strongly agreed. Similarly, 3 (4%) of the responders agreed that glucose testing will open practices to liability suits while 48 (72%) disagreed with that statement.
End-of-study interview with the dentist
An end-of-study interview was conducted with the practitioner-investigator at each participating practice. Results of this interview showed that the glucose test was performed only by dentists in 19 practices, dentists and hygienists in 7 and dentists and dental assistants in 17. In 26 practices the finger stick was performed in the dental operatory; 11 used the hygiene operatory. The majority of practices (n=18, 64%) reported the average duration of glucose testing to be 2–5 min, while in 29% (n=8) and 7% (n=2) it was less than 2 min or longer than 5 min, respectively. Seventeen (65%) of the responders did not consider the testing disruptive and 23 (82%) considered it beneficial to the practice, with the remaining 5 (18%) being indifferent.
Among barriers to implementation of routine testing, 16 (59%) responders named lack of insurance coverage, 7 (26%) thought there was insufficient patient demand and 1 (4%) thought the test needed to be easier.
A total of 26 (93%) of the responding practitioners thought that routine blood sugar testing for at-risk patients should be implemented in dental practice and 100% stated that testing was well-received by patients and was easy to perform by the end of the study.
Patient Questionnaire
There were 498 patients screened (222 males, 22 Hispanic or Latino, 419 Caucasian, 49 African-American, 10 Asian, 1 Pacific Islander, 10 other, 9 not reported, 111 from Sweden and 387 from the US). Among these, 412 (83%) had dental insurance. From the screened patients, 418 (85.1%) qualified for testing. Only 7 patients refused participation, six of them because they had it done recently in a medical office or at home. The average number of patients screened per practice was 19 (range 15–28). All subjects completing the study provided a filled questionnaire. Plasma glucose values and patient characteristics are presented in a separate report. Specific ratings of glucose testing as reported by subjects are presented in Table 3.
Table 3.
Patient rating of glucose testing (N=498)
| Item | Strongly Disagree N (%) |
Disagree | Neutral | Agree | Strongly Agree |
No response |
|---|---|---|---|---|---|---|
| BST in dental office is good idea |
9 (1.8) | 4 (0.8) | 72 (14.5) | 176 (35.3) | 237 (47.6) | 0 |
| BST shows high level of care |
6 (1.2) | 4 (0.8) | 38 (7.6) | 170 (34.1) | 279 (56) | 1 (0.2) |
| More likely to refer friends, family |
9 (1.8) | 19 (3.8) | 159 (31.9) | 139 (27.9) | 168 (33.7) | 4 (0.8) |
| BST was easy* | 9 (1.8) | 0 | 3 (0.6) | 77 (15.5) | 345 (69.3) | 64 (12.9) |
| BST gave me useful information * |
8 (1.6) | 0 | 29 (5.8) | 106 (21.3) | 291 (58.4) | 64 (12.9) |
BST: Blood sugar testing
asked only of persons who received testing
Among enrolled subjects, 413 (83%) thought glucose testing in dental office was a good idea while 13 (3%) disagreed; 422 (85%) thought testing was easy and 9 (2%) disagreed; and 397 (80%) found that information from testing was useful while 8 (2%) disagreed. Sixty-four subjects (13%) who did not qualify for plasma glucose testing were not asked to respond to the latter two items. A total of 449 (90%) of subjects felt that glucose testing showed a high level of care in this setting. Of note, 307 (62%) of subjects said they would be more likely to refer others to the practice because of the glucose test. When patients with a diagnosis of diabetes or pre-diabetes were excluded, results were similar.
Discussion
Despite the well-known morbidity of DM, detection remains suboptimal. An estimated 30% of individuals who meet criteria for this disease remain unaware of their condition, and optimal screening strategies remain a matter of scientific inquiry.20–22 Because of cost and the lack of robust evidence of the benefits of earlier treatment, neither the U.S. Preventive Services Task Force nor the American Diabetes Association (ADA) support community screening; rather, the ADA recommends opportunistic screening in the health care setting. 22,23 The dental practice is a health care setting, and therefore the feasibility of glucose measurement in the dental office is worthy of scrutiny.
A majority of patients with a diagnosis of diabetes or pre-diabetes tend to be poorly controlled and hence, benefit from frequent glucose testing. Elevated values in this population may trigger referral of patients for treatment adjustment as well as inform decisions for timing of invasive dental procedures. Additionally, the bi-directional relationship of DM with periodontal disease suggests the potential benefit of screening to both the patient and the dental practitioner.1
The proposal to test glucose in the dental office is not new. In 2002, a German group reported that DM screening of periodontitis patients can be accomplished using blood from gingival tissues during routine periodontal examination.24 The correlation between the oozing blood and a capillary finger stick was very high (r=.98). Others have proposed screening for DM,25–27 or have recommended that glucose testing equipment be available for emergency medical management in the dental office.28–30 In a similar study aimed at screening for cardiovascular disease risk factors, the investigators obtained chairside glycosilated hemoglobin, (Hb A1c, a marker for DM), in 100 dental school patients.31 Nevertheless, in 2007, among the 852 DPBRN general practices and 268 specialty practices, fewer than 10 routinely screened for DM even in high-risk patients, and the vast majority (>98%) did not have on-site glucose monitors (unpublished preliminary data acquired for this study). Therefore, glucose or any other DM measure testing does not seem to be a widespread practice in dental offices.
We surveyed dental office personnel after they experimented with plasma glucose testing, which allowed responders to use their own practical experience in their answers. Our findings suggest that the vast majority of oral health providers and their patients regard glucose testing as beneficial and easy after becoming familiar with the process. These results coincide in large measure with those of a recent survey of general dentists by Greenberg et al,32 in which screening for diabetes was considered necessary by 77% of the responders. However, the post facto acceptance of finger stick testing in our study was significantly larger than the theoretical 56% shown in the Greenberg article. This difference suggests that dental health workers may find this type of testing easier after practical application.
The DPBRN encompasses a broad diversity of dental practices and practitioners located mainly in five distinct geographic areas. These practices have much in common with dental practices at large and may be representative of general dental practice in both the US and Scandinavia.33,34 We also tested for potential differences between these two countries and analyzed the data for Sweden and US separately. The results showed no significant difference in any of the variables. The data from the US alone were no different from the data sets combined
Recruitment of practices was limited to those who expressed an interest in participating in the study, so a bias toward positive results is possible. This study may have other limitations, including the relatively small number of patients tested in each practice and the uneven distribution of Dentist/Staff Questionnaire returns. To our knowledge this is the largest DM screening study in dental offices. Additionally, the geographic distribution of the study was broad. Nevertheless, this study should be interpreted as a step toward implementation of DM screening in dental practice and future projects should address issues that were identified here.
An additional possible limitation of the current study is the use of random plasma glucose measurement instead of other, more precise tests. Measuring HbA1c, which reflects glucose control over a period of months, is significantly more expensive and thus not the most appropriate test for a feasibility study. Whether the more consistent HbA1c or random glucose are the most appropriate test to be implemented in the dental office was beyond the purpose of the current study. The answer to this issue may well depend on dental providers’ ability to recoup the investment for the more expensive A1c. Similarly, testing fasting glucose or glucose tolerance is impractical for dental patients and would not be easily implemented in the dental setting. Nevertheless, the objective of the current study was to test the feasibility of screening for glucose abnormalities, not to diagnose the disease, and random glucose proved adequate for that purpose. Patients with abnormal values were referred to a medical office for further testing, diagnosis and management.
Since past propositions for glucose testing appear to have gained little traction with practicing dentists, an analysis of the barriers to implementing such testing can point the way to strategies for implementation. In addition to opening the door to opportunistic screening among appropriate candidates, glucose testing in the dental office may enable practice-based research on such important topics as post-operative infectious complications and pre-operative hyperglycemia.
In conclusion, opportunistic glucose testing in dental practice appears to have excellent acceptance from both patients and practitioners who experienced such screening. Barriers to testing appear to be surmountable and the information gathered may have significant healthcare implications. Further study of both these topics is warranted.
ACKNOWLEDGMENTS
This work was supported by National Institutes of Health grants U01-DE-16746 and U01-DE-16747. Opinions and assertions contained herein are those of the authors and are not to be construed as necessarily representing the views of the respective organizations or the National Institutes of Health. The informed consent of all human subjects who participated in this investigation was obtained after the nature of the procedures had been explained fully.
Supported by NIH-NIDCR Grants # U01DE016746 and U01DE016747
Footnotes
The DPBRN Collaborative Group includes practitioner-investigators, faculty investigators and staff investigators who contributed to this DPBRN activity. A list is at www.dpbrn.org/users/publications/Default.aspx.
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