Journal of Public Health Dentistry . ISSN 0022-4006 Screening for prediabetes and type 2 diabetes in dental offices William H. Herman, MD, MPH1,2; George W. Taylor, DMD, MPH, DrPH3; Jed J. Jacobson, DDS, MS, MPH4; Ray Burke, MA1; Morton B. Brown, PhD5 1 Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA 2 Department of Epidemiology, University of Michigan, Ann Arbor, MI, USA 3 School of Dentistry, University of Michigan, Ann Arbor, MI, USA 4 Delta Dental of Michigan, Ohio, and Indiana, Lansing, MI, USA 5 Department of Biostatistics, University of Michigan, Ann Arbor, MI, USA Keywords Abstract screening; dental office; prediabetes; diabetes; periodontal disease; epidemiology. Objectives: Most Americans see dentists at least once a year. Chair-side screening and referral may improve diagnosis of prediabetes and diabetes. In this study, we Correspondence developed a multivariate model to screen for dysglycemia (prediabetes and diabetes Dr. William H. Herman, University of Michigan, defined as HbA1c ≥5.7 percent) using information readily available to dentists and 1000 Wall Street, Room 6108 / SPC 5714, Ann Arbor, MI 48105-1912. Tel.: 734-936-8279; assessed the prevalence of dysglycemia in general dental practices. Fax: 734-647-2307; e-mail: Methods: We recruited 1,033 adults ≥30 years of age without histories of diabetes [email protected]. William H. Herman from 13 general dental practices.A sample of 181 participants selected on the basis of and Ray Burke are with the Department random capillary glucose levels and periodontal status underwent definitive diag- of Internal Medicine, University of Michigan. nostic testing with hemoglobin A1c. Logistic models were fit to identify risk factors William H. Herman is with the Department for dysglycemia, and sample weights were applied to estimate the prevalence of of Epidemiology, University of Michigan. dysglycemia in the population ≥30 years of age. George W. Taylor is with the School of Dentistry, University of Michigan. Jed J. Results: Individuals at high risk for dysglycemia could be identified using a ques- Jacobson is with the Delta Dental of Michigan, tionnaire that assessed sex, history of hypertension, history of dyslipidemia, history Ohio, and Indiana. Morton B. Brown is with of lost teeth, and either self-reported body mass index ≥35 kg/m2 (severe obesity) or the Department of Biostatistics, University of random capillary glucose ≥110 mg/dl. We estimate that 30 percent of patients ≥30 Michigan. years of age seen in these general dental practices had dysglycemia. Conclusions: There is a substantial burden of dysglycemia in patients seen in general Received: 5/29/2014; accepted: 12/10/2014. dental practices. Simple chair-side screening for dysglycemia that includes or does doi: 10.1111/jphd.12082 not include fingerstick random capillary glucose testing can be used to rapidly iden- tify high-risk patients. Journal of Public Health Dentistry 75 (2015) 175–182 Practical implications: Further studies are needed to demonstrate the acceptability, feasibility, effectiveness, and cost-effectiveness of chair-side screening. Introduction Approximately 70 percent of Americans see dentists at least once a year for check-ups and cleanings (4). The concept of Diabetes mellitus affects 25.8 million Americans or 8.3 prevention is fundamental to dentistry, and many dental percent of the population (1). Another 79 million Americans healthcare professionals have built relationships with their are estimated to have prediabetes (1), the vast majority of patients focused on prevention. The American Dental Asso- whom are undiagnosed. The US Preventive Services Task ciation has recognized that its members may wish to take Force has recommended screening for type 2 diabetes in advantage of this relationship to monitor cardiovascular risk asymptomatic adults with sustained blood pressure >135/ factors (5). There may also be an opportunity to screen for 80 mmHg (2). The American Diabetes Association has rec- prediabetes and diabetes during routine dental checkups. ommended screening for diabetes every 3 years in persons Screening for a disease is appropriate if the disease is ≥45 years of age and in those <45 years of age with body mass serious; its natural history is understood; it is detectable in its index (BMI) ≥25 kg/m2 and one or more risk factors for preclinical stage; the screening test is inexpensive, safe, diabetes (3). acceptable, and valid; early treatment of the disease is more © 2015 The Authors. Journal of Public Health Dentistry published by Wiley Periodicals, Inc. on behalf of American Association of Public Health Dentistry. 175 This is an open access article under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs License, which permits use and distribution in any medium, provided the original work is properly cited, the use is non-commercial and no modifications or adaptations are made. Screening for prediabetes and type 2 diabetes W.H. Herman et al. effective than late treatment; and screening programs ethnicity, education, income, self-reported height and improve outcomes (6). Type 2 diabetes meets many of these weight, self-reported physical activity, history of hyperten- criteria (7). Screening for diabetes also provides an opportu- sion and hypertension treatment, history of dyslipidemia and nity to identify people with prediabetes who are at increased lipid treatment, history of cigarette smoking, history of car- risk for both type 2 diabetes and cardiovascular disease. diovascular disease, history of gestational diabetes, family Randomized controlled clinical trials have conclusively dem- history of diabetes, medical insurance coverage, and access to onstrated that lifestyle and medication interventions are medical care. The questionnaire also assessed symptoms and effective in delaying or preventing the development of type 2 signs of periodontal disease including teeth that hurt, painful diabetes in high-risk individuals with prediabetes (8-12). The gums, teeth that became loose by themselves without injury, failure to translate proven-effective interventions for diabetes and teeth that were lost from the upper or lower jaw other prevention into widespread clinical practice is due in large than wisdom teeth or teeth extracted to get braces. For pur- part to the difficulty in identifying high-risk individuals. To poses of this analysis, answers to the question about lost teeth help address this problem, investigators have developed and were dichotomized as none versus one or more teeth. There- validated multivariate risk factor models (13-18) and imple- after, the research assistant performed a random capillary mented them in a variety of settings including primary care. glucose measurement from each participant’s finger with a In an analysis of data from the Third National Health and portable blood glucose testing system (FreeStyle Lite blood Nutrition Examination Survey (NHANES), Eklund et al. glucose meters and test strips, Abbott Diabetes Care Inc., described prediabetes and diabetes among patients who Alameda, CA, USA). We have previously assessed the perfor- reported that they had at least one dental visit during the past mance of random capillary glucose as a screening test and year (Eklund, unpublished observations). At least 10 percent found a cutpoint of ≥110 mg/dl to be very sensitive in identi- of patients ≥50 years of age had diabetes and approximately fying people with previously undiagnosed diabetes regardless 40 percent had impaired fasting glucose. Perhaps even more of age and time since last food or drink (19). The hygienist or startling and troubling was the fact that one-third to one-half dentist then performed a brief periodontal evaluation based of those with diabetes and more than 90 percent of those with on their usual office practice and indicated the absence or impaired fasting glucose reported that they had never been presence of periodontal disease and its severity. Periodontal told by a doctor that they had diabetes or prediabetes. As a status was initially classified into one of five categories result, they remained undiagnosed and untreated. This may (Appendix 1). For the purpose of this analysis, periodontal ultimately increase the risk of diabetes and its complications status was dichotomized as none or gingivitis only versus and comorbidities, negatively impact oral health, and pre- early/slight, moderate, or advanced/severe periodontitis. clude appropriate dental care. Because we wished to rigorously evaluate the sensitivity The purpose of this study was to develop and validate a tool and specificity of the newly developed screening tool, we per- to screen for prediabetes and previously undiagnosed diabe- formed definitive diagnostic tests on a systematic sample of tes in dental practices using information readily available to the entire study population. All respondents at higher risk for dental practitioners and to assess the prevalence of prediabe- previously undiagnosed diabetes (random capillary glucose tes and previously undiagnosed diabetes in general dental ≥110 mg/dl) and a 50 percent random sample of those at practices. Because we wanted to develop a tool specifically for lower risk for undiagnosed diabetes (random capillary dental practitioners, we assessed essentially all of the risk glucose <110 mg/dl) and all patients with any degree of factors previously associated with dysglycemia as well as hygienist- or dentist-reported periodontitis were invited to symptoms and signs of periodontal disease