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The July 2011 issue of the Journal of Dental Research (JDR) features a study from Columbia University on a simple algorithm that could identify nearly 3 out of 4 cases of unrecognized diabetes or pre-diabetes.1 The screening algorithm evaluated only two dental parameters: number of missing teeth, and percentage of deep periodontal pockets (at least 5 millimeters in depth). Adding a point-of-care glycohemoglobin (HbA1c) test significantly improved identification of diabetic and pre-diabetic individuals, raising screening accuracy to 92 percent sensitivity. The study received national news coverage from United Press International2 and other news agencies.

In the study, researchers from the Columbia University College of Dental Medicine recruited 601 new dental patients from a clinic in northern Manhattan to test several predictive models for identifying dental patients with previously unrecognized diabetes (fasting plasma glucose greater than or equal to 126 mg/dL) or pre-diabetes (fasting plasma glucose of 100-125 mg/dL). The study evaluated 535 individuals who were primarily Hispanic, a higher-risk population for type 2 diabetes, and who reported at least one diabetes risk factor (e.g., family history of diabetes, hypertension, high cholesterol, or being overweight/obese). Study participants were 40 years or older (if non-Hispanic white) or over age 30 (if Hispanic or non-white), and none were previously told by a health care provider that they had diabetes or pre-diabetes. Each participant received a periodontal exam and a point-of-care HbA1C test as part of the study protocol, plus a fasting glucose test in a second appointment to identify potential diabetes or pre-diabetes.

Overall, 182 individuals were found to have an abnormal fasting plasma glucose test, and the majority (161 patients, or 31.8% of the study sample) was categorized as potentially pre-diabetic. In evaluating predictive models for detecting diabetes/pre-diabetes, the researchers found that the presence of 4 or more missing teeth, or at least 26% deep periodontal pockets (i.e., probing depth of at least 5 millimeters), enabled identification of 73% of true cases of diabetes or pre-diabetes. Adding the HbA1C test to the identification protocol raised accuracy of the screening algorithm to 92 percent.

While acknowledging that the test algorithm requires further validation in “diverse dental patient populations,” the authors note that their findings underscore the need for the dental profession to take a wider role in identifying patients with unrecognized diabetes and pre-diabetes, and to direct those individuals for appropriate medical care. Impaired fasting glucose or impaired glucose tolerance commonly precede the development of type 2 diabetes, and interventions can be taken to delay or prevent the onset of type 2 diabetes (e.g., exercise, dietary measures, weight loss).

Diabetes is a well-established risk factor for periodontal disease, and dentists commonly treat patients who either have diabetes or are at increased diabetes risk due to obesity, family history of diabetes, hypertension, sedentary lifestyle and other factors. The JDR study presents a practical identification protocol that should be validated further in diverse patient populations for improved identification of dental patients with unrecognized diabetes or pre-diabetes. Dentists should also remain aware that specific oral health conditions, such as missing teeth or deep periodontal pockets, could suggest that the patient has one or more potential risk factors for diabetes or pre-diabetes. Oral complications are commonly found in individuals with uncontrolled diabetes, making the dental office an ideal location for early identification and appropriate referral for medical evaluation.
 
Dentists are encouraged to query patients about known signs and symptoms of diabetes (e.g., polydipsia, polyuria, weight loss), and to consider the individual’s family disease history and other risk factors (e.g., ethnicity, hypertension, obesity) as part of a complete medical/dental history. Based on recent estimates, over 50 million Americans have pre-diabetes, which includes individuals with impaired fasting glucose or impaired glucose tolerance. The risks of diabetes and pre-diabetes are also increased among Hispanics, African-Americans and other ethnic groups, as witnessed in the new JDR study.

Dentists can provide a valuable public health service by informing at-risk individuals of their potential risk factors for diabetes, the oral and systemic health complications associated with the disease, and by educating patients that the incidence of type 2 diabetes increases with age, obesity and lack of physical activity. Patients with diabetes are at least two to three times more likely to develop periodontal disease than non-diabetics, and should be advised to visit their dentist regularly for full evaluation of their dental and periodontal condition.

References

1. Lalla E, Kunzel C, Burket S, Cheng B, Lamster IB. Identification of unrecognized diabetes and pre-diabetes in a dental setting. J Dent Res. 2011 Jul;90(7):855-60. Available at: http://jdr.sagepub.com/content/90/7/855. Accessed July 16, 2011.

2. Dentists can identify undiagnosed diabetes. United Press International.  July 15, 2011. Available at: http://www.upi.com/Health_News/2011/07/15/Dentists-can-identify-undiagnosed-diabetes/UPI-18401310787312/. Accessed July 17, 2011.

Additional Resources

Working Together to Manage Diabetes: A Guide for Pharmacy, Podiatry, Optometry and Dental Professionals (National Diabetes Education Program)

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Science in the News is a service by the American Dental Association (ADA) to its members to present current information about science topics in the news. The ADA is a professional association of dentists committed to the public’s oral health, ethics, science and professional advancement; leading a unified profession through initiatives in advocacy, education, research and the development of standards. As a science-based organization, the ADA’s evaluation of the scientific evidence may change as more information becomes available. Your thoughts would be greatly appreciated.

Document posted July 2011