point-of-care gluoose testing in dentistry · looking beyond the tonsils: point‐of‐care glucose...

Looking Beyond the Tonsils: Point‐of‐Care Glucose Testing in Dentistry June 3, 2020; Colgate Oral Health Network

© 2020 Casey Hein BSDH, RDH, MBA. All Rights Reserved 1

Looking Beyond the Tonsils: Point-of-Care Glucose

Testing in DentistryCasey Hein BSDH, RDH, MBA

Assistant Professor, School of Dental HygieneDr. Gerald Niznick College of DentistryRady Faculty of Health SciencesUniversity of Manitoba, Winnipeg, Manitoba, Canada

President, Casey Hein & Associates, LLCPO Box 4637Hagerstown, Maryland 21742

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Dentistry

Med

icin

e

Dentistry

Med

icin

e

Oral-Systemic

Health

Look Beyond

the Tonsils

Look in the

Mouth

• Whether entry through medicine or dentistry, all disciplines share responsibility for patient outcomes

• Medical-dental collaboration• Improves communication • Decreases fragmented care• Facilitates continuity of care• Better patient outcomes• Increases efficiency and eventually

cost of care

Practicing at Top - of - Licensure

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Strauss, SM, et al. Identifying Unaddressed Systemic Health Conditions at Dental Visits: Patients Who Visited Dental Practices but Not General Health Care Providers in 2008. Am J Public Health. 2012

CDC. Dental visits in the past year, by selected characteristics: United States, selected years 1997-2016; https://www.cdc.gov/nchs/data/hus/2017/078.pdf; accessed May 18, 2019CDC. Age-adjusted percent distribution (with standard errors) of length of time since last contact with doctor or other health care professional among adults aged 18 and over, by selected characteristics: United States, 2017; https://ftp.cdc.gov/pub/Health_Statistics/NCHS/NHIS/SHS/2017_SHS_Table_A-18.pdf; accessed May 19, 2019.

Explosion in baby-boomer population

Advent of personalized medicine in dentistry

Recognition of oral-systemic interrelationships

Rising costs of healthcare

Emphasis on role of patient

New technologies, e.g. POC testing

Accountability for healthcare outcomes

Shortage of primary care providers

Oral health education in medicine, nursing, etc.

Call for interprofessional collaboration Cost-benefit of treating oral diseases

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Not treated but aware

Treated and controlled

Not treated and undiagnosed

Treated and uncontrolled

Heart Disease and Stroke Statistics—2019 Update: A Report From the American Heart Association; Circulation; https://www.ahajournals.org/doi/10.1161/CIR.000000000; Accessed May 27, 20190000659

• Average general dental practice consists of 2,000 patients; 1,400 adults

• 189 may have diabetes• 51 may not know they

have diabetes• 526 may have

prediabetes• Does not include young

children and adolescents

Projections of the Prevalence of Diabetes within the Average Dental Practice

American Diabetes Association Position Statement: Standards in Medical Care in Diabetes – 2020. Diabetes Care 2020

For all people, regardless of BMI, testing should begin at age 45 years

American Diabetes Association Position Statement: Standards in Medical Care in Diabetes –2020. Diabetes Care 2020

American Diabetes Association Position Statement: Standards in Medical Care in Diabetes – 2020- Diabetes Care 2020



If screening is normal, repeat at a minimum of 3-year intervals, or more frequently in BMI is increasing

FPG OGTT HbA1c (%)

Diabetes ≥ 126 mg/dL(7.0 mmol/dL)

≥ 200 mg/dL(11.1 mmol/dL)

≥ 6.5%(48 mmol/mol)

Prediabetes100-125

mg/dL (5.6-6.9 mmol/L)

IFG

140-199 mg/dL(7.8-11.0 mmol/L)

IGT

5.7-6.4%(39-47

mmol/mol)American Diabetes Association Position Statement: Standards in Medical Care in Diabetes –2020. Diabetes Care 2020

In the absence of unequivocal hyperglycemia, diagnosis requires two abnormal test results from the same sample or in two separate test samples.

To test for prediabetes and type 2 diabetes, fasting plasma glucose, 2-h plasma glucose during 75-g oral glucose tolerance test, and A1C are equally appropriate

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Koro CE, et al. Diabetes Care 2004; Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-986; Standards of Medical Care in Diabetes 2011; Diabetes Care ; January 2011; Vol 34; supplement 1 http://care.diabetesjournals.org/content/34/Supplement_1 ; Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada; Stratton, IM., et al. BMJ 2000 ; Khaw, KT., et al. Ann Intern Med 2004

Koro CE, et al. Diabetes Care 2004; Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. N Engl J Med 1993;329:977-986; Standards of Medical Care in Diabetes 2011; Diabetes Care ; January 2011; Vol 34; supplement 1 http://care.diabetesjournals.org/content/34/Supplement_1 ; Canadian Diabetes Association 2008 Clinical Practice Guidelines for the Prevention and Management of Diabetes in Canada; Stratton, IM., et al. BMJ 2000 ; Khaw, KT., et al. Ann Intern Med 2004

Impaired host response causes increased susceptibility to infection in tissues through out the body

Hypoglycemia≤ 70 mg/dl

Likely Acceptable80 ≥ mg/dl ≤ 180

Hyperglycemia≥ 200 mg/dl

D0411 and D0412 – ADA Quick Guide to In-Office Monitoring andDocumenting Patient Blood Glucose and HbA1C Level:https://www.ada.org/~/media/ADA/Publications/Files/CDT_D0411_D0412_Guide_v1_2019Jan02.pdf?la=en

Glucose sensing bio-implantsNon-invasive technologies

Blood glucose meters

Continuous glucose

monitoring (Dexcom G)

Excellent Good Poor

HbA1c Percentage 4.0 5.0 6.0 7.0 8.0 9.0 10.0 11.0 12.0 13.0 14.0

Mean Blood mg/dL 50 80 115 150 180 215 250 280 315 350 380

Glucose mmol/L 2.0 4.7 6.3 8.2 10.0 11.9 13.7 15.6 17.4 19.3 21.1

Measurement of Glycemic Control

DO411https://www.ada.org/en/publications/ada-news/2017-archive/july/cdt-coding-guides-educate-dentists-on-new-revised-codes; Accessed June 20, 2019

PTS Diagnostics

Excellent Good Poor

< 5.7 5.7 – 6.4 6.5 or higher

Alere Afinion

DO411https://www.ada.org/en/publications/ada-news/2017-archive/july/cdt-coding-guides-educate-dentists-on-new-revised-codes; Accessed June 20, 2019

Hypoglycemia≤ 70 mg/dl

Likely Acceptable80 – 180 mg/dl

Hyperglycemia≥ 200 mg/dl

Rose LF, et al. Periodontics, Medicine , Surgery and Implants. First Ed.

Mild

Severe

More common in patients using insulin; most common when blood glucose drops

to < 60 mg/dl

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Diabetes and the 2017 Classification System for Periodontitis

Clinical Presentation Diagnosis

> 30% teeth with bone loss Generalized Periodontitis

CAL at site of greatest loss = 11 mmStage IIIRadiographic bone loss > 33%

Tooth loss due to periodontitis = ≤ 4

% Bone Loss/Age = .74 (RBL of 40% /Age 54) Grade C

(Rapid Rate of Disease Progression)

Grade Modifiers: HbA1c: 9.5%; BMI 29.8 (borderline obesity); stage 1 hypertension, familial history of

hypertension, obesity, serious complications of DM; immunocompromised from Hep C, poor compliance to physician

recommendationsBOP at 4 mm PD Sites = 83% Unstable

Dentist

PeriodontistPrimary

Care Provider

EndocrinologistOral

Surgeon

Diabetes Educator

Cardiologist

Modifiable Risk Factors Controlled

Modifiable Risk Factors Uncontrolled

Periodontal Parameters

Decline

Periodontal Parameters

Improve

Remission

Stable

Unstable

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This patient questionnaire can be found in the product section of www.caseyhein.com

Siegel K, et al. Rapid HIV Testing in Dental Practices. Am J Pub Health, 2012Greenberg B, et al. Physicians’ attitudes toward medical screening in a dental setting. J Pub Health Dent 2015Feinstein-Winitzer RT, et al. Insurer views on reimbursement of preventive services in the dental setting: Results from a qualitative study. Am J Pub Health 2014



Siegel K, et al. Rapid HIV Testing in Dental Practices. Am J Pub Health, 2012Greenberg BL, et al. Dentists consider medical screening important and are willing to incorporate screening procedures into dental practice. J Evid Base Dent Pract2010Glick M et al. The potential role of dentists in identifying patients’ risk of experiencing coronary heart disease events. J Am Dent Assoc 2005Greenberg BL, etr al. Patients’ attitudes toward screening for medical conditions in a dental setting. J Public Health Dent 2012Greenberg BL, et al. Dentists’ attitudes toward chairside screening for medical conditions. J Sam Dental Assoc2010

Greenberg B, et al. Physicians’ attitudes toward medical screening in a dental setting. J Pub Health Dent 2015Feinstein-Winitzer RT, et al. Insurer views on reimbursement of preventive services in the dental setting: Results from a qualitative study. Am J Pub Health 2014

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point-of-care gluoose testing in dentistry · looking beyond the tonsils: point‐of‐care glucose...

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