Dentists' attitudes toward chairside screening for medical conditions

Diabetes screening at the periodontal visit: patient and provider experiences with two screening approaches

OBJECTIVES

This study examined patient and dental provider experiences during the periodontal visit of diabetes screening approaches involving the collection of gingival crevicular blood (GCB) and finger stick blood (FSB) for haemoglobin A1c (HbA1c) testing.

METHODS

At a large, urban, US periodontics and implant clinic, FSB samples from 120 patients and GCB samples from 102 of these patients were collected on special blood collection cards and sent to a laboratory for HbA1c testing, with test results sent to the patients from the laboratory. Quantitative and qualitative data from patients and qualitative data from providers were collected and analysed.

RESULTS

Quantitative and qualitative data support the feasibility and acceptability of the approaches described. Themes that arose from the interviews with providers and patients include 'a good chance to check', 'patient choice', 'FSB versus GCB testing' and 'a new way of interacting and viewing the dental visit'.

CONCLUSIONS

Periodontal patients and dental providers believe that the dental visit is an opportune site for diabetes screening and generally prefer GCB to FSB collection. HbA1c testing is well tolerated, convenient and acceptable to patients, and GCB testing reduces time and liability obstacles for dental providers to conduct diabetes screening.

Assessing systemic disease risk in a dental setting: a public health perspective

Screening and monitoring for systemic disease risk in a dental setting are valuable components for more effective disease prevention and control and health care delivery. This strategy can identify patients at increased risk of disease yet unaware of their increased risk and who may benefit from proven prevention/intervention strategies. The involvement of oral health care professionals in strategies to identify individuals at risk for coronary heart disease and diabetes will extend preventive and screening efforts necessary to slow the development of these diseases, and provide a portal for individuals who do not see a physician on a regular basis to enter into the general health care system.

Assessment and management of patients with diabetes mellitus in the dental office

Diabetes mellitus is a serious chronic disease that affects many dental patients. Dental professionals have the potential and responsibility to assume an active role in the early identification, assessment, and management of their patients who present with or are at risk of developing diabetes. Close maintenance, meticulous monitoring of individual patient needs, and close collaboration with other health care professionals involved in the care will enable better control of the oral complications of diabetes and contribute to the better management of the patient's overall health status.

Random blood glucose testing in dental practice: a community-based feasibility study from The Dental Practice-Based Research Network

BACKGROUND

The prevalence of diabetes mellitus (DM) has been increasing. Instances of patients' not having received a diagnosis have been reported widely, as have instances of poor control of DM or prediabetes among patient's who have the disease. These facts indicate that blood glucose screening is needed.

METHODS

As part of The Dental Practice-Based Research Network, the authors conducted a study in community dental practices to test the feasibility of screening patients for abnormal random blood glucose levels by means of glucometers and finger-stick testing. Practitioners and staff members were trained to use a glucometer, and they then screened consecutive patients older than 19 years at each practice until 15 patients qualified for the study and provided consent. Perceived barriers to and benefits of blood glucose testing (BGT) were reported by patients and dental office personnel on questionnaires.

RESULTS

Twenty-eight practices screened 498 patients. A majority of the respondents from the 67 participating dental offices considered BGT useful and worth routine implementation. They did not consider duration of BGT or its cost to be significant barriers. Among patients, more than 80 percent thought BGT in dental practice was a good idea and found it easy to withstand; 62 percent were more likely to recommend their dentists to others if BGT was offered.

CONCLUSION

BGT was well received by patients and practitioners. These results support the feasibility of implementation of BGT in community dental practices.

CLINICAL IMPLICATIONS

Improved diagnosis and control of DM may be achieved through implementation of BGT in community dental practices.

Salivary diagnostics

Saliva is a noninvasive and accessible biofluid that permits early detection of oral and systemic diseases. Recent scientific and technologic advances have uncovered specific salivary biomarkers for a number of clinical conditions, including cancers, autoimmune diseases, and cardiovascular disorders. The availability of highly sensitive and high-throughput assays such as microarray, mass spectrometry, reverse transcriptase quantitative polymerase chain reaction (RT-qPCR) and nano-scale sensors that can measure proteins and nucleic acids are poising saliva as an emerging biofluid for translational and clinical applications. This paper will discuss development of salivary biomarkers for the detection of oral and systemic diseases and the translational application of these markers for clinical applications.

A novel intraoral diabetes screening approach in periodontal patients: results of a pilot study

BACKGROUND

This pilot study examines whether a novel diabetes screening approach using gingival crevicular blood (GCB) could be used to test for hemoglobin A1c (HbA1c) during periodontal visits.

METHODS

Finger-stick blood (FSB) samples from 120 patients and GCB samples from those patients with adequate bleeding on probing (BOP) were collected on special blood collection cards and analyzed for HbA1c levels in a laboratory. The Pearson correlation coefficient was used to measure correlation between FSB and GCB HbA1c values for 75 paired FSB and GCB samples. A receiver-operator characteristic curve (ROC) analysis was performed to determine an optimal GCB HbA1c criterion value for a positive diabetes screen.

RESULTS

For the 75 paired samples, the Pearson correlation coefficient was 0.842. The ROC analysis identified a criterion value of 6.3% for the GCB HbA1c test with high sensitivity (0.933) and high specificity (0.900), corresponding to FSB HbA1c values ≥6.5% (in the diabetes range). Using this GCB HbA1c criterion value for 27 additional paired samples, in which there was an unidentified component observed to coelute within the elution window of GCB HbA1c in the laboratory, there was agreement between FSB and GCB values for 24 of the pairs according to whether both were within or outside of the diabetes range.

CONCLUSION

Using a criterion value of 6.3%, GCB samples are acceptable for HbA1c testing to screen for diabetes in most persons with BOP at the GCB collection site.

Feasibility of implementing rapid oral fluid HIV testing in an urban University Dental Clinic: a qualitative study

Background

More than 1 million individuals in the U.S. are infected with HIV; approximately 20% of whom do not know they are infected. Early diagnosis of HIV infection results in earlier access to treatment and reductions in HIV transmission. In 2006, the CDC recommended that health care providers offer routine HIV screening to all adolescent and adult patients, regardless of community seroprevalence or patient lifestyle. Dental providers are uniquely positioned to implement these recommendations using rapid oral fluid HIV screening technology. However, thus far, uptake into dental practice has been very limited.

Methods

The study utilized a qualitative descriptive approach with convenience samples of dental faculty and students. Six in-depth one-on-one interviews were conducted with dental faculty and three focus groups were conducted with fifteen dental students.

Results

Results were fairly consistent and indicated relatively high levels of acceptability. Barriers and facilitators of oral fluid HIV screening were identified in four primary areas: scope of practice/practice enhancement, skills/knowledge/training, patient service/patient reactions and logistical issues.

Conclusions

Oral fluid HIV screening was described as having benefits for patients, dental practitioners and the public good. Many of the barriers to implementation that were identified in the study could be addressed through training and interdisciplinary collaborations.

One-to-one dietary interventions undertaken in a dental setting to change dietary behaviour

BACKGROUND

The dental care setting is an appropriate place to deliver dietary assessment and advice as part of patient management. However, we do not know whether this is effective in changing dietary behaviour.

OBJECTIVES

To assess the effectiveness of one-to-one dietary interventions for all ages carried out in a dental care setting in changing dietary behaviour. The effectiveness of these interventions in the subsequent changing of oral and general health is also assessed.

SEARCH METHODS

The following electronic databases were searched: the Cochrane Oral Health Group Trials Register (to 24 January 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 1), MEDLINE via OVID (1950 to 24 January 2012), EMBASE via OVID (1980 to 24 January 2012), CINAHL via EBSCO (1982 to 24 January 2012), PsycINFO via OVID (1967 to 24 January 2012), and Web of Science (1945 to 12 April 2011). We also undertook an electronic search of key conference proceedings (IADR and ORCA between 2000 and 13 July 2011). Reference lists of relevant articles, thesis publications (Dissertations Abstracts Online 1861 to 2011) were searched. The authors of eligible trials were contacted to identify any unpublished work.

SELECTION CRITERIA

Randomised controlled trials assessing the effectiveness of one-to-one dietary interventions delivered in a dental care setting.

DATA COLLECTION AND ANALYSIS

Abstract screening, eligibility screening and data extraction decisions were all carried out independently and in duplicate by two review authors. Consensus between the two opinions was achieved by discussion, or involvement of a third review author.

MAIN RESULTS

Five studies met the criteria for inclusion in the review. Two of these were multi-intervention studies where the dietary intervention was one component of a wider programme of prevention, but where data on dietary behaviour change were reported. One of the single intervention studies was concerned with dental caries prevention. The other two concerned general health outcomes. There were no studies concerned with dietary change aimed at preventing tooth erosion. In four out of the five included studies a significant change in dietary behaviour was found for at least one of the primary outcome variables.

AUTHORS' CONCLUSIONS

There is some evidence that one-to-one dietary interventions in the dental setting can change behaviour, although the evidence is greater for interventions aiming to change fruit/vegetable and alcohol consumption than for those aiming to change dietary sugar consumption. There is a need for more studies, particularly in the dental practice setting, as well as greater methodological rigour in the design, statistical analysis and reporting of such studies.

Rapid HIV testing in dental practices

Despite increasing discussion about the dental care setting as a logical, potentially fruitful venue for rapid HIV testing, dentists' willingness to take on this task is unclear. Semistructured interviews with 40 private practice dentists revealed their principal concerns regarding offering patients HIV testing were false results, offending patients, viewing HIV testing as outside the scope of licensure, anticipating low patient acceptance of HIV testing in a dental setting, expecting inadequate reimbursement, and potential negative impact on the practice. Dentists were typically not concerned about transmission risks, staff opposition to testing, or making referrals for follow-up after a positive result. A larger cultural change may be required to engage dentists more actively in primary prevention and population-based HIV screening.

Patients' attitudes toward screening for medical conditions in a dental setting

OBJECTIVES

Previous studies demonstrated the efficacy of chairside medical screening by dentists to identify patients who are at increased risk for developing cardiovascular-associated events and the favorable attitude of dentists toward chairside medical screening. This study assessed patient attitudes toward chairside medical screening in a dental setting.

METHODS

A self-administered questionnaire of eight five-point response scale questions was given to a convenience sample of adult patients attending an inner-city dental school clinic and two private practice settings. Wilcoxon-Mann-Whitney tests and t-tests were used to compare responses between study groups. Friedman nonparametric analysis of variance was used to compare response items within each question.

RESULTS

Regardless of setting, the majority of respondents was willing to have a dentist conduct screening for heart disease, high blood pressure, diabetes, human immunodeficiency virus infection, and hepatitis infection (55-90 percent); discuss results immediately (79 percent and 89 percent); provide oral fluids, finger-stick blood, blood pressure measurements, and height and weight (60-94 percent); and pay up to $20 (50-67 percent). Respondents reported that their opinion of the dentist would improve regarding the dentist's professionalism, knowledge, competence, and compassion (48-77 percent). The fact that the test was not done by a physician was ranked as the least important potential barrier. While all respondents expressed a favorable attitude toward chairside screening, the mean score was significantly lower among clinic patients across most questions/items. The priority rankings within an item were similar for both groups.

CONCLUSIONS

Acceptance by patients of chairside medical screening in a dental setting is a critical element for successful implementation of this strategy.

Saliva, Diagnostics, and Dentistry

Saliva, a scientific and clinical entity familiar to every oral health researcher and dental practitioner, has emerged as a translational and clinical commodity that has reached national visibility at the National Institutes of Health and the President’s Office of Science and Technology. “Detecting dozens of diseases in a sample of saliva” was issued by President Obama as one of the 14 Grand Challenges for biomedical research in the 21st Century ( National Economic Council, 2010 ). In addition, NIH’s 2011 Government Performance Report Act (GPRA) listed 10 initiatives in the high-risk long-term category ( Collins, 2011 ). The mandate is to determine the efficacy of using salivary diagnostics to monitor health and diagnose at least one systemic disease by 2013. The stage is set for the scientific community to capture these national and global opportunities to advance and substantiate the scientific foundation of salivary diagnostics to meet these goals. A specific calling is to the oral, dental, and craniofacial health community. Three areas will be highlighted in this paper: the concept of high-impact diagnostics, the role of dentists in diagnostics, and, finally, an infrastructure currently being developed in the United Kingdom—The UK Biobank—which will have an impact on the translational and clinical utilizations of saliva.

Identification of Unrecognized Diabetes and Pre-diabetes in a Dental Setting

Many diabetic patients remain undiagnosed, and oral findings may offer an unrealized opportunity for the identification of affected individuals unaware of their condition. We recruited 601 individuals who presented for care at a dental clinic, were ≥ 40 years old, if non-Hispanic white, and ≥ 30 years old, if Hispanic or non-white, and had never been told they have pre-diabetes or diabetes. Those with at least one self-reported diabetes risk factor (N = 535) received a periodontal examination and a point-of-care hemoglobin A1c (HbA1c) test. A fasting plasma glucose (FPG) test was used as the study outcome, signifying potential diabetes or pre-diabetes. Performance characteristics of simple models of dysglycemia (FPG ≥ 100 mg/dL) identification were evaluated and optimal cut-offs identified. A model including only two dental variables had an estimated area under the receiver operating characteristic curve (AUC) of 0.65. The addition of a point-of-care HbA1c test improved the AUC to 0.79 (p < 0.001). The presence of ≥ 26% deep pockets or ≥ 4 missing teeth correctly identified 73% of true cases; the addition of an HbA1c ≥ 5.7% increased correct identification to 92%. Analysis of our data suggests that oral healthcare professionals have the opportunity to identify unrecognized diabetes and pre-diabetes in dental patients and refer them to a physician for further evaluation and care.

Saliva as a diagnostic fluid

Salivary diagnostics is a dynamic and emerging field utilizing nanotechnology and molecular diagnostics to aid in the diagnosis of oral and systemic diseases. In this article the author critically reviews the latest advances using oral biomarkers for disease detection. The use of oral fluids is broadening perspectives in clinical diagnosis, disease monitoring, and decision making for patient care. Important elements determining the future possibilities and challenges in this field are also discussed.

Need for an Ethical Framework for Testing for Systemic Diseases in Dental Clinics

Testing for systemic diseases in dental clinics is a potentially attractive avenue for oral health professionals and may be viewed as an opportunity to increase professional reach, expand practice, and improve financial returns. However, several ethical questions arise that must be addressed before such activities are adopted. (1) What should be the level of training dentists must acquire to deal with challenges associated with testing? (2) How well are dental practices aware of and compliant with the Health Insurance Portability and Accountability Act and procedures related to informed consent? (3) What is the evidence regarding acceptability and effectiveness of testing? (4) What should be the acceptable standard of practice for conduct of invasive and noninvasive tests? (5) What is the boundary delineating "testing" and "reporting" vis-à-vis counseling? (6) What is the value of testing without counseling? (7) What assurances need to be in place to ensure voluntariness of testing? (8) How would data from testing be used in "research," especially with the growth of practice based research networks? and (9) Does the American Dental Association Code of Ethics need to incorporate guidance for practicing dentists? We discuss how ethical principles can be used to develop a framework of guidelines for potential testing for systemic diseases in dental clinics..

General health screening as part of a periodontal examination

Cardiovascular disease (CVD) and type 2 diabetes are common systemic illnesses with reliable, predictive risk factors. CVD is the number one killer worldwide accounting for nearly 30% of deaths and type 2 diabetes has reached epidemic proportions in many western industrialized countries. Both of these illnesses can go undiagnosed in an alarming number of people for significant periods of time. The relationship between oral health and systemic health has become the focus of much discussion and research in recent times. It is now widely accepted that periodontal disease is associated with systemic illnesses such as CVD and type 2 diabetes. Cigarette smoking and obesity are major risk factors accounting for a large portion of the global disease burden. Many periodontal patients may be at risk of systemic conditions but be asymptomatic and undiagnosed. With an aging population who are mostly retaining their natural dentition, the need for periodontal management will continue to rise in the future. Dental professionals are well placed to perform general health screening for their patients. Therefore, risk assessment during the periodontal examination may facilitate the early identification of the large proportion of people who are unaware of their risk status. As identification and intervention of patients with increased risk factors is key to lowering the systemic disease burden, general health screening during periodontal examinations may present an important opportunity for many patients.