LifeLong Learning

CE Course: Advances in Diagnosis and Monitoring By Stormy Li, RDH, MHEd, Kristen Stephens, RDH, MSDH, EdD, Michelle Hurlbutt, RDH, MSDH, DHSc

Diabetes mellitus, commonly referred to as diabetes, resulting in increased glycemic load, , is a group of chronic metabolic diseases characterized by and obesity.3 Increased morbidity and mortality is hyperglycemia resulting from defects in insulin secretion, associated with T2D. Diabetes remained the seventh insulin action, or both. It is one of the oldest diseases leading cause of death in the US in 2017, with 83,564 known to man and reported in Egyptian literature dating death certificates listing it as the underlying cause of back over 3000 years. Most cases of diabetes fall within death, and a total of 270,702 death certificates listing 1 two broad etiopathogenetic categories: Type 1 Diabetes diabetes as an underlying or contributing cause of death. (T1D), an autoimmune pathologic process and Type 2 Overall, the risk for death among people with diabetes is Diabetes (T2D), a combination of resistance to insulin twice that of people of similar age without diabetes. action and an inadequate compensatory insulin secretory Today, diabetes remains one of the most common diseases diagnosed by family physicians, and despite response. In a new report from the Centers for Disease scientific advances and discoveries in treating diabetes; Control and Prevention (CDC) on diabetes statistics, the population diagnosed and undiagnosed continues to 34.2 million people of all ages—or 10.5% of the US grow. Since the majority of cases of diabetes are T2D population—have diabetes—with an estimated 88 million and the diagnostic tests are considered reliable, screening 1 people aged 18 years and older having pre-diabetes. is recommended to identify asymptomatic people so This is one out of three American adults. Before people lifestyle changes and medications that reduce progression develop T2D, pre-diabetes is usually present. and adverse sequelae of the disease can be introduced.4,5 In the simplest of explanations, pre-diabetes is a However, there has been a recent shift in the medical condition characterized by slightly elevated glucose model away from the yearly physical exam. Some experts levels, but not high enough to be diagnosed as T2D. Pre- argue a yearly exam does not reduce illness or mortality diabetes can be present for years before symptoms develop. and think medical visits should be reserved for times of According to the CDC, of those with pre-diabetes, 90% illness.6 Therefore, as dental hygienists, the protocols were unaware. Pre-diabetes places patients at increased risk for diabetes screening to make the appropriate referrals of developing T2D, heart disease, and stroke.2 should be reviewed. It can also be argued that every is the most common form of diabetes dental professional should provide their patient with some type of in-office screening as part of the medical history. and according to the CDC, 90-95% of all diabetes One such tool can be found on the ADA website. This cases in the US are T2D.1 It is a chronic condition that brief screening questionnaire can be printed or completed affects the body’s ability to metabolize glucose. The online and is available in both English and Spanish pathogenesis of T2D initiates with inadequacy of the (https://diabetes.org/risk-test). pancreatic islet β-cells to respond to chronic fuel surplus

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Screening for Type 2 Diabetes American, African American, Latino, Asian American or Pacific Islander as well as those with signs of insulin Several professional organizations have made resistance or conditions associated with insulin resistance recommendations regarding screening for T2D.7 The or a maternal history of GDM during gestation. Both the US Preventive Services Task Force’s (USPSTF) current ADA and American Academy of Pediatrics recommend recommendation is to screen for abnormal blood glucose screening for at-risk patients every two years starting at and T2D in non-pregnant adults 40 to 70 years of age age 10 years or at onset of puberty if before age 10.12 who are overweight or obese, and repeating testing Older adults. No organizations currently recommend every three years if results are normal. Individuals routine screening of older adults, 65 years of age and at higher risk should have earlier and more frequent older. It has been suggested that although statistics report screening. Risk factors for diabetes besides weight older adults are at higher risk for pre-diabetes and T2D are multifactorial and include those of African, Asian, than any other age group, the benefits of screening older Hispanic and Indian races and anyone regardless of race adults depends on whether or not the quality of life or over the age of 45. In addition, if a person has an history life expectancy would be improved with treatment.13 of low HDL cholesterol, high triglycerides, and familial The decision to screen or not screen should be made on history of diabetes or gestational diabetes they are at an an individualized basis between patient and primary increased risk.1 Dental hygienists are aware that patients care provider. When a diabetes diagnosis may lead to with are at an increased risk as complications causing functional impairment, a screening diabetes and periodontal diseases have a bi-directional should be more strongly considered in these older adults. relationship.8 The American Diabetes Association (ADA) currently recommends screening for T2D annually in Testing for Diabetes non-pregnant patients 45 years and older, or in patients According to the ADA, patients who are clinically younger than 45 years with major risk factors. The CDC diagnosed with diabetes based on classic symptoms such and the American Medical Association (AMA) joined polydipsia, polyuria, and sudden weight loss or those forces to create a program entitled, Prevent Diabetes having a hyperglycemic crisis, only a single diagnostic STAT, advocating for screening of high-risk patients. test is indicated for confirmation of diabetes diagnosis.9 Pregnant women. The ADA recommends screening However, those without clear symptoms of diabetes must pregnant women in their first trimester if risk factors such be diagnosed using two separate and deviant test results. as overweight, familial history and high These tests include plasma glucose tolerance and fasting 9 for developing T2D are present. The American Academy tests as well as the HbA1c test. Previously, these tests of Family Physicians and the USPSTF do not agree and were conducted on different days. The ADA guidelines recommend screening for gestational diabetes mellitus now accept two different abnormal tests on the same 10 (GDM) only after 24 weeks’ gestation. blood sample. If a single test is abnormal, the ADA Children and Adolescents. The ADA recommends recommends a second test for confirmation be conducted screening children and adolescents 18 years and younger as soon as possible. The second test can be the same for T2D and pre-diabetes who have a body mass index test repeated or a different diagnostic test altogether. (BMI) greater than the 85th percentile for age and sex, is detected using the same tests used for weight for height greater than 85th percentile and weight detecting T1D and T2D.9 11 for height greater than 120% of ideal. In addition, the Fasting Blood Glucose Test (FBG). Previously ADA recommends screening for children and adolescents considered the gold standard of glucose tests, patients belonging to high-risk ethnic groups such as Native

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may consume nothing but water within 8 hours of this levels of > 200 mg/dL in conjunction with the classic .9 The cut-off point for diagnosis with T2D is symptoms of diabetes mellitus.7 a blood glucose level of > 126mg/dL. A healthy person Special Tests. Because of the overlapping symptoms is considered to have a blood glucose level of < 100mg/ of the many types of diabetes mellitus, special tests may dL and between 100 mg/dL and 126mg/dL is considered be employed to specifically diagnose rare forms of the a diagnosis of prediabetes.9 It is not uncommon for this disease. These special tests may include autoantibody test to be conducted in conjunction with the Oral Glucose testing for any or all of the following: islets cells, insulin, Tolerance Test (OGTT) on the same day. glutamic acid decarboxylase, insulinoma-associated Oral Glucose Tolerance Test (OGTT). This test antigen -2, and zinc transport.7 Testing for connecting measures the ability of the patient to tolerate a 75g dose peptide insulin known as C-peptide may be used to of glucose after fasting. After an initial blood draw diagnose autoantibody negative type 1 diabetes and from a fasting state, the patient is given a syrupy drink latent autoimmune diabetes in the adult (LADA). Genetic containing 75g dose of anhydrous glucose. The blood testing may be used to identify one of the many forms glucose is measured after two hours. A diagnosis of T2D of monogenetic diabetes, to specify therapies to lower is considered > 200 mg/dL after 2 hours.7,9 the cost of treatment and possibly to recognize other Glycated hemoglobin (A1C) Test. First included in members of the family who may have the disease.7,9 the ADA guidelines as a diagnostic test for diabetes, this Salivary Diagnostics. One of the functions of test measures the attachment of glucose to hemoglobin is to protect the oral cavity. Saliva helps to maintain the molecules in circulation.7 Hemoglobin is a protein found pH of the mouth by eliminating carbohydrates that feed in our red blood cells that circulate oxygen. Hemoglobin the bacteria which in turn produce acids. Saliva buffers also binds or glycates with glucose. When there is a lot the acidity that does manage to form in the oral cavity.15-17 of glucose in circulation, it is easier for the hemoglobin Other functions include lubrication, maintenance of tooth to become glycated. The A1c test measures the glycation integrity, antibacterial activity, and taste and digestion.17 of hemoglobin over a two to three-month period and is Saliva-based diagnostic technology is an emerging field expressed as an average. There is no need for fasting. and its ability to be used in screening has grown. Saliva has It is recommended the test be performed in a lab using been reliably used to detect HIV 1 and 2, and viral method certified by the National Glycohemoglobin A, B and C. It can also be used to monitor a variety of Standardization Program (NGSP) utilizing testing drugs including marijuana, and alcohol.18,19 criteria developed during the Diabetes Complications In the past, a major drawback to the use of saliva as a and Control Trial.9 Diagnosis of T2D is made at > 6.5%. diagnostic fluid was the concern that analytes were present It should be noted many biological factors can alter in lower amounts in saliva than in serum. As the field the A1c results including sickle cell diseases, anemia, evolved, more sensitive techniques have been developed hemoglobinopathies, , HIV, and recent blood and the lower level of analytes in saliva is no longer a loss to name a few.9 The ADA does not recommend point- limitation. Some benefits of salivary diagnostics include its of-care A1C tests for screening or diagnosis. These types non-invasive nature which can decrease patient discomfort of chairside tests offer rapid turnaround of results, but and anxiety, its low cost compared to other diagnostic 16 there is a perceived inaccuracy and imprecision. A recent procedures, and it is easy to collect, store, and ship. study found these were as accurate as lab testing.14 It has also been found that glucose can appear in the Random Blood Glucose Test. This non-fasting, saliva of individuals with diabetes which could make salivary testing an ideal adjunctive diagnostic procedure unplanned test may diagnose diabetes with blood glucose for diabetes mellitus.20 The measurement of salivary

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glucose can be difficult due to often low concentrations continuous glucose monitoring are being explored as an especially in patients who do not have diabetes. alternative to the finger prick test. Measurable glucose begins to appear in saliva when Continuous Self-Monitoring. Continuous glucose blood glucose levels exceed 84.6mg/dL.20 Moreover, monitoring has grown in popularity among those with when blood glucose values reach 100mg/dL, which can diabetes because it reveals short-term trends in glucose be indicative of pre-diabetes, salivary concentrations as they happen. Unlike conventional glucose meters, of glucose can be shown to exceed 1.13mg/dL.20,21 continuous monitoring provides semi-continuous A systematic review and meta-analysis conducted information about glucose level via extrapolating blood by Mascarenhas, Fatela, and Barahona confirmed a glucose levels from interstitial fluid glucose via an correlation between salivary glucose and glycemia algorithm.25 The patient can see the trend in their glucose (r=0.37), and salivary glucose and HbA1c (r=0.37) levels over the last 1, 3, 6, 9, 12, or 24 hours.25 Continuous supporting the use of salivary glucose as a diagnostic monitoring involves wearing a sensor placed under the for diabetes mellitus.22 skin of the abdomen or it can be adhered to the back Sucrose obtained from one’s diet is cleared from the of the arm. A transmitter on the sensor then sends the oral cavity in approximately 11 minutes whereas salivary information to a wireless-pager-like monitor that the glucose in patients with diabetes is present all day, so patient keeps nearby. The major players in the field are caution should be taken in procuring a salivary sample Dexcom (Figure 1), Medtronic, Freestyle Libre (Figure close to a meal as sucrose from the individual’s diet could 2), and Eversense. The ideal sensing technology would skew results.20 be portable, inexpensive, and able to selectively and sensitively detect glucose with painless touch and real- Monitoring of Diabetes time feedback. Just as early diabetes detection is critical, non- Tear-based Glucose monitoring. Tear glucose invasive methods for monitoring of diabetes are also key concentration has a positive correlation with in ensuring patient compliance and reduction of adverse that in blood.26 Researchers have developed a health outcomes. Those with diabetes have an increased risk of heart attack and stroke, as well as increased risk of microvascular problems such as retinopathy, neuropathy Figure 1: and kidney disfunction. These adverse health outcomes Dexom Continuous 23 are postponed or decreased with strict glycemic control. Monitoring Meter Blood Glucose Self-Monitoring. Blood glucose self-monitoring (BGSM) has been shown to lower a patient’s HbA1c. In a systematic review and meta- analysis of 15 clinical trials with individuals with T2D, results demonstrated that individuals who monitor their glucose compared to those who do not had a reduction in HbA1c.24 Currently, BGSM involves a patient pricking Figure 2: their finger with a lancet several times a day, applying Freestyle Libre Continuous this blood droplet to a reagent stick that is inserted into Monitoring System a meter to obtain the current blood glucose level. This method provides a snapshot of the blood glucose at the time of testing. Noninvasive BGSM techniques such as

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phenylboronic acid (PBA)-based HEMA contact lens onset of hypoglycemia that exhibits a reversible swelling/shrinking effect to can be regarded as a fast, change its thickness as it absorbs glucose from tears. versatile, reliable, and The difference in thickness can be detected in a picture cost-effective approach taken with a smartphone and analyzed using software for safeguarding the allowing the patient to monitor glucose levels (Figure health of those with 3).27 Researchers have also developed a hydrogel colloidal diabetes (Figure Figure 4: 31 Leia, a diabetes alert dog, crystal that can be integrated into contact lenses that 4). A recent review accompanies her partner to school. possess promising potential for noninvasive monitoring suggested that optimal Used with permission. of glucose in tears.28 performance of the dogs depended not only on good initial and ongoing training, but also careful selection of dogs for the conditions in which they will be working.32 Salivary pH. In an effort to investigate a relationship between salivary pH and diabetes, Goyal, Kaur, Jawanda, Verma, and Parhar examined the correlation between salivary pH and caries prevalence in patients without diabetes, patients with controlled diabetes, and patients with uncontrolled diabetes.33 Compared to those patients Figure 3: Phenylboronic acid (PBA)-Based HEMA Contact Lens 27 without diabetes, results indicated a statistically significant decrease in salivary pH among patients with controlled Exhaled Breath Condensate. As an alternative to diabetes (p<0.001) and those patients with uncontrolled blood sample collection, exhaled breath condensate diabetes (p<0.001), and a statistically significant increase (EBC) has emerged as a promising non-invasive in DMFT scores with patients with uncontrolled diabetes method to monitor glucose levels. EBC is the exhalate (p<0.002). Conversely, when comparing the DMFT score from breath, which has been condensed, typically via of healthy patients and patients whose glucose was in cooling using a collection device and then the glucose target range, there was a statistically significant decrease concentration is measured. Although most of the in dental caries (p<0.025). Lastly, upon comparing patients research with EBC has been conducted with lung , with controlled diabetes mellitus to those with uncontrolled emerging research has demonstrated that glucose can be diabetes mellitus, results demonstrated a statistically detected in the collected samples. Because of the rapid significant decrease in salivary pH (p<0.002) and an glucose exchange between lung fluid and blood, the increase in dental caries (p<0.001) in the uncontrolled glucose concentrations gathered via EBC are typically group. The authors concluded that a lower salivary pH can 3–20 times lower than that of plasma glucose.29 A recent be caused by changes in the metabolism of patients with study with a new collection device demonstrated a diabetes, however the reduction in the incidence of decay in higher concentration of glucose detected in the collected those with controlled diabetes compared to patients without sample that allowed for a repeatable and robust evaluation diabetes suggested that dietary control might be more between analytes in EBC and blood.30 significant in reducing caries than salivary pH. Glucose Sniffing Dogs. Emerging research suggests The buffering capacity of saliva in patients with and the use of diabetes alert dogs that are trained to detect the without diabetes was assessed by Reddy et al.17 When

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analyzing the initial pH versus the pH of saliva after the glucose, painless and easy monitoring needs to be addition of 1.5ml HCL, patients with diabetes were found available. The ease of salivary testing and ability of this to have a sharp decline in salivary pH (6.8 to 5.3) compared to be completed by the dental hygienist might make this a to patients without diabetes (7.2 to 6.9).17 The authors viable option for early detection, diagnosis and continued suggested that diabetes mellitus might alter the buffering monitoring of diabetes mellitus. capacity of saliva leading to an increase in dental caries in patients with diabetes. It might be timely to consider About the Authors the use of salivary pH as a disease biomarker for diabetes Stormy Li, RDH, MHEd mellitus considering the results of these studies. graduated from the Indiana University School of Dentistry’s Conclusion Dental Hygiene Program and As new advances in diabetes diagnostics and holds a Master of Arts degree in monitoring are being made available for use, dental Health Education from Columbia hygienists may encounter patients undergoing these University. As an Assistant tests and using new monitoring devices; therefore, it Professor at West Coast University, is important the dental professional be familiar with she teaches Dental Anatomy, the available technology. Patients often rely on dental Embryology and Histology along with Pain Management. hygienists for information and as conversations regarding She is a proud member of the California Dental Hygienists’ the patient’s diabetes diagnosis arise, these technologies Association, Tri-County Dental Hygienists’ Society, and might be part of the discussion. American Dental Hygienist’s Association. She became co- Some dental facilities have even begun to monitor chair of the CDHA Student Relations Council in 2019 their patient’s glucose levels prior to treatment. This and that same year was honored for her leadership and helps to identify patients who might be uncontrolled service with the CDHA President’s Recognition Award. She and might be more susceptible to complications during currently serves as a trustee. treatment and/or post operatively. Currently, neither Kristen Stephens, RDH, the American Dental Association or American Dental MSDH, EdD is an Assistant Hygienists’ Association make formal recommendations Professor and Senior Clinic on in office diagnostics and monitoring for diabetes, Coordinator at West Coast however, as research in salivary pH as a biomarker University in Anaheim, California for diabetes continues, recommendations might be and currently teaches Basic and made incorporating this as a standard of care in dental Applied Pharmacology. Kristen practices. As the incidence of diabetes mellitus in the received her Master of Science in population continues to rise, coupled with an increase Dental Hygiene degree from Idaho in morbidity and mortality, and costs associated with State University and her Doctor of Educational Leadership treatment, it is critical that early identification of diabetes degree from Concordia University. Kristen is a member mellitus takes place to allow for early intervention of the California Dental Hygienists’ Association, Long 34 measures. As some medical practitioner’s move away Beach Dental Hygienists’ Society, and American Dental from the yearly exam, dental hygienists are poised to Hygienist’s Association. She is past president and former become more involved with pre-screening to make the trustee for Long Beach Dental Hygienists’ Society. appropriate referrals. In addition, to avoid or delay the health complications associated with elevated blood

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Michelle Hurlbutt, RDH, MSDH, References DHSc is an Associate Professor and 1. Centers for Disease Control and Prevention. (2020). National Dean of Dental Hygiene at West Coast diabetes statistics report, 2020. Retrieved from https://www. University in Anaheim, California. cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statis- She has taught a variety of courses in tics-report.pdf her career as an educator including 2. Bansal, N. (2010). Prediabetes diagnosis and treatment: cariology, nutrition, pharmacology, A review. World Journal of Diabetes, 6(2), 296-303. doi: 10.4239/wjd.v6.i2.29 preventive dentistry, radiology, medically 3. Pandey, A., Chawla, S., & Guchhait, P. (2015). Type-2 diabetes: compromised care, and research. Michelle Current understanding and future perspectives. International received her Bachelor of Science in Dental Hygiene degree from the Union of Biochemistry and Molecular Biology 67(7), 506–513. University of Nebraska, her Master of Science in Dental Hygiene doi: 10.1002/iub.1396. from the University of Missouri, Kansas City and her Doctor 4. Selph S, Dana T, Blazina I, Bougatsos C, Patel H, Chou R. Screening for type 2 diabetes mellitus: a systematic review of Health Science degree from Nova Southeastern University. for the U.S. Preventive Services Task Force. Ann Intern Med. Michelle is a member of the California Dental Hygienists’ 2015;162(11):765–776. Association, Tri-County Dental Hygienists’ Society, and American 5. Siu AL. Screening for abnormal blood glucose and type 2 dia- Dental Hygienist’s Association. Michelle served on the Dental betes mellitus: U.S. Preventive Services Task Force recommen- Hygiene Board of California (DHBC) from 2009-2020 and is a dation statement. Ann Intern Med. 2015;163(11):861–86. past president of the California Dental Hygienists’ Association.

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6. Mehrotra, A., & Prochazka, A. (2015). Improving value in health 22. Mascarenhas, P., Fatela, B., & Barahona, I. (2014). Effect of diabetes care: Against the annual physical. New England Journal of Medicine, mellitus type II on salivary glucose – A systematic review and me- 373,1485-1487.doi: 10.1056/NEJMp1507485 ta-analysis of observational studied. PLOS One, 9(7), 1-15. 7. Pippitt, K., Li, M., & Gurgle, H. E. (2016). Diabetes mellitus: Diag- 23. Colayco, D. C., Niu, F., McCombs, J. S., & Cheetham, T. C. (2011). nosis and screening. American Family Physician, 93(2), 103-109. A1C and cardiovascular outcomes in type 2 diabetes. Diabetes Care, 8. Preshaw, P.M. & Bissett, S.M. (2013). Periodontitis oral complication 34(1), 77-83. doi.org/10.2337/dc10-1318. of diabetes. Endocrinology Metabolism Clinics of North America, 24. Alleman, S., Houriet, C., Diem, P., Stettler, D. (2009). Self-monitor- 42(4), 849-867. doi:10.1016/j.ecl.2013.05.012 ing of blood glucose in non-insulin treated patients with type 2 dia- 9. American Diabetes Association (2019). Classification and diagnosis betes: A systemic review and meta-analysis. Current Medical Research of diabetes. In standards of medical care in diabetes - 2019 Diabetes and Opinion, 25(12), doi.org/10.1185/03007990903364665. Care,42(Suppl. 1), S13–S28. doi.org/10.2337/dc19-S002 25. Mariani, H. S., Layden, B. T., Aleppo, G. (2017). Continuous 10. Garrison, A. (2015). Screening, diagnosis and management of gesta- glucose monitoring: A perspective on its past, present and future ap- tional diabetes mellitus. American Family Physician, 91(7), 460-467. plications for diabetes management. Clinical Diabetes, 35(1), 60-65. doi: 10.2337/cd16-0008. 11. American Diabetes Association. (2004). Position statement- Screen- ing for type 2 diabetes. Diabetes Care, 27(suppl 1), s11-s14. doi: 26. Lane, J. D., Krumholz, D. M., Sack, R. A., Morris, C. (2006). Tear 10.2337/diacare.27.2007.S11 glucose dynamics in diabetes mellitus. Current Eye Research 31,(11), 895-901. doi.org/10.1080/02713680600976552 12. Copeland, K.C., Silverstein, J., Moore, K.R., Prazar, G. E., Raymer, T., Shiffman, R. N., . . . Flinn, S. K. (2013). Management of newly 27. Lin, Y-R., Hung, C-C., Chiu, H-Y., Chang, P-H., Li, B-R., Cheng, diagnosed type 2 diabetes mellitus (T2DM) in children and adoles- S-J., Yang, J-W., Lin S-F., & Chen, G-Y. (2018). Noninvasive glucose cents Pediatrics, 131(2), 364-382. doi:10.1542/peds.2012-3494 monitoring with a contact lens and smartphone. Sensors,18, 3208. doi.org/10.3390/s18103208 13. Kirkman, M.S., Briscoe, V.J., Clark N., Florez, H., Haas, L. B., Hal- ter, J. B., . . .Swift, C. S. (2012). Diabetes in older adults. Diabetes 28. Ruan, J-L., Chen, C., Shen, J-H., Zhao, X-L., Qian, S-H., & Zhu, Care, 35(12), 2650-2664. doi: 10.2337/dc12-1801 Z-G. (2017). A gelated colloidal crystal attached lens for noninvasive continuous monitoring of tear glucose. Polymers Basel, 9(4), 125. 14. Szablowski, C. J., Sucha, E., Davis, K., Xie, C. Z., Moskowitz, K., doi: 10.3390/polym9040125 Anderson Jr, J. H., Mechley, A. (2018). Point of care HbA1c: A case for diabetes screening and diagnosis. Diabetes, 67(Suppl. 1), doi. 29. Baker, E. H., Clark, N., Brennan, A. L., Fisher, D. A., Gyi, K. M., org/10.2337/db18-1518-P. Hodson, M.E., Philips, B. J., Baines, D. L., & Wood, D. M. Hyper- glycemia and cystic fibrosis alter respiratory fluid glucose concen- 15. Seethalakshmi, C., Reddy, R. C. J., Asifa, N., & Prabhu, S. (2016). trations estimated by breath condensate analysis. Journal of Applied Correlation of salivary pH, incidence of dental caries and periodontal Physiology,102(5), 1969-1975. status in diabetes mellitus patients: A cross-sectional study. Journal of Clinical and Diagnostic Research, 10(3), 12-14. 30. Tankasala, D., Ng, G. P., Smith, M/ S., Bendell, J. R., & Linnes, J. C. (2019). Selective collection and condensation of exhaled breath 16. Baliga, S., Muglikar, S., & Kale, R. (2013). Salivary pH: A diagnostic for glucose detection. 40th Annual International Conference of the biomarker. Journal of Indian Society of Periodontology, 17(4): 461-465. IEEE Engineering in Medicine and Biology Society (EMBC), Hono- 17. Reddy, J. M., Gayathri, R., & Priya, V. V. (2018). Variation in lulu, HI, pp. 3890-3893, doi: 10.1109/EMBC.2018.8513393 salivary pH and buffering capacity of saliva in normal and diabetes 31. Lippi, G., Cervellin, G., Dondi, M., & Targher, G. (2016). Hypoglyce- mellitus patients – A pilot study. Drug Intervention Today, 10(6), mia alert dogs: A novel, cost-effective approach for diabetes monitor- 895-898. ing? Alternative Therapies in Health and Medicine,22(6), 14-18. 18. Mandel, I. D. (1993). Salivary diagnosis: More than a lick and a 32. Rooney, N. J., Guest, C. M., Swanson, L. C. M., & Morant, S. V. promise. Journal of the American Dental Association, 124, 85–87. (2019). How effective are trained dogs at alerting their owners to 19. Miller, S. M. (1994). Saliva testing: A nontraditional diagnostic tool. changes in blood glycaemiac levels? Variations in performance of Clinical Laboratory Science,7(1), 39–44. glycaemic alert dogs. PLOS ONE, 22(6), 1-16. 20. Goodson, J. M. (2017). Salivary glucose: A metabolic disease marker 33. Goyal, D., Kaur, H., Jawanda, M. K., Verma, S., & Parhar, S. (2012). and a risk factor for oral disease development. Advances in Dentistry Salivary pH and dental caries in diabetes mellitus. International and Oral Health, 4(3), 1-4. Journal of Oral & Maxillofacial Pathology, 3(4), 13-16. 21. Goodson, J. M., Hartman, M., Shi, P., Hasturk, H., Yaskell, T., Var- 34. Centers for Disease Control and Prevention. (2018). Prediabetes: gas, J., …Behbehani, K. (2017). The salivary microbiome is altered Your chance to prevent type 2 diabetes. Retrieved from https://www. in the presence of high salivary glucose concentration. PLOS One, cdc.gov/diabetes/basics/prediabetes.html 12(3), 1-13.

CDHA Journal – Winter 2021 27 3 CE Units (Category I) CDHA Member $25, Home Study Non-member $35 Correspondence Course “Advances in Diabetes Diagnosis and Monitoring” Stormy Li, RDH, MHEd, Kristen Stephens, RDH, MSDH, EdD, Michelle Hurlbutt, RDH, MSDH, DHSc Circle the correct answer for questions 1-10

1. Diabetes is a chronic ______disease. 6. Which glucose range is considered healthy? a) Renal a) 1mg/dL – 50mg/dL b) Muscular b) 70mg/dL – 100mg/dL c) Metabolic c) 100mg/dL – 126mg/dL d) Lung d) 126mg/dL – 200mg/dL 2. One out of three adult Americans has pre-diabetes. 7. Which of the following non-invasive glucose monitoring began a) True in lung cancer research? b) False a) Trained dog glucose monitoring b) Tear-based glucose monitoring 3. Which of the following tests measures average blood c) Exhaled breath glucose monitoring glucose over a two to three-month span? d) Continuous glucose monitoring a) Oral glucose tolerance test (OGTT) b) Hemoglobin A1c test (HbA1c) 8. Measurable glucose begins to appear in saliva when blood c) Fasting blood glucose test (FBG) glucose levels exceed what level? d) Random glucose testing a) Around 25mg/dL b) Around 55mg/dL 4. According to the American Diabetes Association, how c) Around 85 mg/dL often should non-pregnant adults over the age of 45 be d) Around 165 mg/dL screened for diabetes? a) Once a year 9. In the past, a major drawback to the use of saliva in diagnostic b) Twice a year was: c) Every five years a) The invasive nature of collection d) Every three years b) The inability to store and ship samples c) The low amounts of analytes 5. A person with no signs or symptoms of diabetes will be diagnosed using a single test. 10. Changes in metabolism in those with diabetes lowers salivary pH. a) True a) True b) False b) False

The following information is needed to process your CE certificate. Please allow 4 - 6 weeks to receive your certificate. Please print clearly: CDHA Membership ID#: ______❑ I am not a member Name: ______License #: ______Mailing Address: ______Phone: ______Email: ______Fax: ______Signature: ______Please mail the completed Post-test and information with your CE voucher or check payable to CDHA: 1415 L Street, Suite 1000, Sacramento, CA 95814 Keep a copy of your test for your records.

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