Random blood glucose testing in dental practice

RESEARCH

Random blood glucose testing in dental practice A community-based feasibility study from The Dental Practice-Based Research Network Andrei Barasch, DMD, MDSc; Monika M. Safford, MD; Vibeke Qvist, DDS, PhD, DrOdont; Randall Palmore, DMD; David Gesko, DDS; Gregg H. Gilbert, DDS, MBA; for The Dental Practice-Based Research Network Collaborative Group A

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® Background. The prevalence of diabetes mellitus (DM) has been increasing. Instances of patients’ not having received a diagnosis have A been reported widely, as have instances of poor 2 RT I C LE 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. Key Words. Blood glucose testing; diabetes mellitus; dental practice; practice-based research; multicenter studies; clinical research; research methods. JADA 2012;143(3):262-269. T

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ype 2 diabetes mellitus (DM), both diagnosed and undiagnosed, has been increasing at epidemic rates. The prevalence of DM in the U.S. population is more than 12 percent, making this disease one of the most common and costly chronic conditions.1-4 According to the Centers for Disease Control and Prevention, DM is the seventh leading cause of death4 and is the chief cause of blindness, end-stage renal disease and nontraumatic limb amputation in the United States.1-5 An estimated 4 percent of the population may have the disease but have not received a diagnosis of DM, and, in about 65 percent of patients who have received a diagnosis, DM is not controlled optimally.4,5 Similarly, Scandinavian countries also have been experiencing a significant increase in the number of cases of type 2 DM, which affects approximately 6 to 8 percent of the population. It has been estimated that 3 to 4 percent of the Scandinavian population has undiagnosed DM.6-8 Hence, type 2 DM appears to be a problem both in the United States and in Scandinavian countries. DM typically develops after many years of metabolic derangements characterized by impaired fasting glucose metabolism and poor glu-

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Dr. Barasch was an associate professor, Department of General Dental Sciences, School of Dentistry, University of Alabama at Birmingham, when this article was written. He now is the chairman, Department of Dental Medicine, Winthrop University Hospital, Mineola, N.Y. Address reprint requests to Dr. Barasch at Department of Dental Medicine, Winthrop University Hospital, 222 Station Plaza N., Suite 408, Mineola, N.Y. 11501, e-mail “[email protected]”. Dr. Safford is an associate professor, Department of Medicine, School of Medicine, University of Alabama at Birmingham. Dr. Qvist is an associate professor, Department of Cariology and Endodontics, School of Dentistry, Faculty of Health Sciences, University of Copenhagen, Denmark. Dr. Palmore is in private practice of general dentistry, Pinson, Ala. Dr. Gesko is the dental director, HealthPartners Dental Group, Minneapolis. Dr. Gilbert is a professor and the chair, Department of General Dental Sciences, School of Dentistry, University of Alabama at Birmingham.

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RESEARCH

cose tolerance. Prediabetes affects about 54 million people in the United States, or 18 percent of the population.4,5 This finding means that approximately one-quarter of the U.S. population has impaired glucose metabolism.4,5 Prediabetes and DM have been associated with increased physical morbidity, including significant risk of developing cardiovascular, renal, periodontal, neuropathic and ocular diseases.9,10 Adequate glucose control significantly reduces vascular complications in patients with DM, and lifestyle interventions can prevent or delay the progression of prediabetes to DM.11 Therefore, detecting these conditions and treating them adequately are major public health objectives. Similarly, maintenance of good glycemic control is imperative in patients who have received a diagnosis of DM to preserve their health and to help ensure positive outcomes. DM control also is less than ideal in Scandinavia,12 although a nursing service for patients with DM has been implemented in some Swedish cities, and the results of this program have led to renewed calls for increased testing in and education for this population.13 The American Heart Association,14 Dallas, and American Diabetes Association,15 Alexandria, Va., have called for new strategies to improve screening and detection of DM and prediabetes. In Healthy People 2020, the U.S. Department of Health and Human Services rates screening for DM as one of the top measures that need to be implemented in the health care system.16 The dental office is a unique setting for screening patients for specific conditions, and study results have demonstrated that it can be used for preventive health interventions, such as smoking cessation.17,18 Most dental practitioners regard blood glucose testing (BGT) as outside their scope of practice, and only a few dental offices own and use a glucometer (A. Barasch, DMD, MDSc, unpublished data, 2009). It is our contention that measuring patients’ blood glucose levels in dental offices can provide valuable information to both patients and dentists and that the results could lead to patients’ being referred for medical services. Targeted populations should include people with risk factors but who have not received a diagnosis of DM, as well as people who have received a diagnosis of prediabetes and DM. These patients have the highest risk of having abnormal plasma glucose levels and can benefit the most from BGT. We conducted a study to test the feasibility of screening patients in community dental practices who are at risk or who have a diagnosis of

DM or prediabetes for abnormal random blood glucose levels by means of glucose monitors (also called “glucometers” or “glucose meters”) and finger-stick testing. Specifically, we aimed to identify patients’ and providers’ attitudes toward BGT after it had been performed and determine specific barriers to BGT in dental practices. METHODS

We conducted this study as part of The Dental Practice-Based Research Network (DPBRN).19 Although practitioner-investigators from many U.S. states and Scandinavian countries participate in certain DPBRN studies, projects that require extensive training and interaction via face-to-face contact with practitioners have been focused on five regions: Alabama/Mississippi, Florida/Georgia, Minnesota, Permanente Dental Associates in Oregon and Washington state, and the Scandinavian countries of Denmark, Norway and Sweden.20-23 Participation in this study was open to all four DPBRN U.S. regions and the DPBRN in Sweden. We limited the Scandinavian recruitment for this study to Sweden because Danish dental practice regulations do not allow dentists to conduct glucose screenings, and we needed only a modest number of dentists in the Scandinavian region for the study. Dentists from all community dental practices (general dentistry or specialty practice) were eligible to enroll. The University of Alabama at Birmingham and all regional human research institutional review boards approved the study. All dentists who participated in the study completed research training at their practices before the study began. We informed practitioners in the DPBRN regions about the study by means of the mail, and those who were willing to participate notified the DPBRN regional coordinator. We selected five or six practices from each region at random from the pool of interested practitioners, and we trained the practitioners, their delegated staff members or both how to use a glucometer (FreeStyle Freedom Lite, Abbott Diabetes Care, Alameda, Calif.), which we provided to all participating offices along with test strips, lancets and calibration equipment. Dental practitioners screened eligible patients who had scheduled a routine dental examination by means of data they entered on a standard form. They used American Diabetes ABBREVIATION KEY. BGT: Blood glucose testing. BMI: Body mass index. DPBRN: Dental PracticeBased Research Network. DM: Diabetes mellitus. HbA1c: Glycosylated hemoglobin. JADA 143(3)

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Association24 and U.S. Preventive Services Task Force25 recommendations for patients who should have glucose screening in health care settings to select patients for BGT. The practitioners offered BGT to all patients with a body mass index (BMI) greater than 25 kilograms per square meter, who had a self-reported history of hypertension or hypercholesterolemia, or whose DM or prediabetes had been diagnosed. These patients were considered to have an elevated risk of having abnormal glucose levels. The DPBRN provided dentists and staff members with a chart so that they could determine patients’ BMIs quickly by using patientreported height and weight. They screened consecutive patients older than 19 years who had a nonemergency, scheduled dental examination, regardless of sex, race, ethnicity, medical history or dental status at each practice until a total of 15 patients qualified for the study and consented to undergo BGT. Staff members compiled patients’ reasons for declining the test if patients were willing to provide them. At the beginning of the dental visit, consenting patients underwent assessment of their random glucose levels by means of finger-stick testing and the use of the glucometer according to the manufacturer’s instructions. We repeated BGT if a patient’s blood glucose level was less than 70 milligrams per deciliter (dangerously low) or more than 300 mg/dL (dangerously high). Patients received a card with the results of their BGT and information on how to interpret the results. They also received literature designed for patients about DM and prediabetes from the American Diabetes Association or the Swedish Diabetes Association. If a patient’s blood glucose level was abnormal, the dentist informed the patient that he or she might benefit from a more formal evaluation and should discuss the results with his or her physician. Patients could show their cards, which also included a paragraph that briefly described the study and the context in which blood glucose levels were obtained, to their physicians. We collected data regarding the barriers to and benefits of BGT by means of two standardized survey instruments: a patient questionnaire completed by all patients at the end of the appointment and a dentist and staff member questionnaire that office personnel who performed the BGT completed at the end of the study. Dentists and patients were asked to choose the most important barriers to and benefits of BGT from the perspective of having completed the protocol. On both questionnaires, the questions were followed by five-point Likert 264 JADA 143(3)

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scales, with responses ranging from 1 (“strongly agree”) to 5 (“strongly disagree”). Space for additional comments was provided on the questionnaires. We developed the survey instruments on the basis of answers from DPBRN dentists to an informal survey that solicited their opinions on perceived barriers to and benefits of BGT in dental practice (data not shown). None of the questionnaires included information that could identify the participant, and participants placed the questionnaires in a locked box at each office. The DPBRN regional coordinators retrieved the locked boxes from each practice. All forms, questionnaires and patient literature used in this study are available at the DPBRN Web site.26 The screening forms and the questionnaires were reviewed by the study coordinator for completeness and then were transferred to the DPBRN Coordinating Center in Birmingham, Ala. We also conducted an end of study interview with each of the practices’ practitioner-investigators. We entered the data and analyzed them for distribution of responses and associations with demographic and medical characteristics. We also used descriptive statistics on each set of data and evaluated the distributions across the Likert scales. We used a statistical software package (SAS, SAS Institute, Cary, N.C.) to perform the analyses. RESULTS

Dentists and staff members from 28 dental practices (24 general practices, one practice specializing in oral surgery, one practice specializing in periodontics and two practices specializing in endodontics) from the five DPBRN regions participated in this study (Table 1). Of the dentists in the 28 practices, 23 (82 percent) were men and 23 were white. In addition, two (7 percent) were African American, two (7 percent) were Asian, and one (4 percent) was Pacific Islander. Dentist and staff member questionnaire. Questionnaires were distributed to all dental office personnel who performed the BGT. Twenty-eight dentists and 44 staff members in 28 practices participated in the study, and 67 (93 percent) returned completed questionnaires. We received at least one completed questionnaire from each practice; 22 of the 67 respondents (33 percent) were from the Alabama/Mississippi region, 31 percent were from the Florida/Georgia region, 17 percent were from Minnesota, 8 percent were from Permanente Dental Associates in Oregon and Washington state, and 11 percent were from Sweden. Among the 67 respondents, 56 (84 percent) agreed or strongly agreed that BGT benefits patients, and

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RESEARCH TABLE 1 46 (68 percent) agreed or strongly Geographic distribution of study practices agreed that BGT may and patients. lead to better control of blood glucose levels DENTAL PRACTICEPRACTICES (N = 28), NO. PATIENTS (N = 498), NO. BASED RESEARCH if patients are tested General Specialty General Practice Specialty Practice NETWORK REGION in the dental office Alabama/Mississippi 5 1 84 15 (Table 2). Among the 67 respondents, 40 Florida/Georgia 5 1 88 17 (60 percent) thought Minnesota 4 1 69 15 that BGT results Permanente Dental 6 1 84 15 could help determine Associates in Oregon and Washington State the timing of invasive procedures, and five Sweden 4 0 111 0 (8 percent) did not. Among the 67 respondents, 50 (74 percent) practices (29 percent) reported it was less than agreed or strongly agreed that BGT results can two minutes, and respondents from two prachelp identify patients at risk of developing tices (7 percent) reported it was longer than five periodontal disease, and seven (11 percent) disminutes. Respondents from 17 (61 percent) of agreed or strongly disagreed. A total of 59 (88 the practices did not consider BGT to be disruppercent) respondents thought that BGT will protive, and respondents from 23 (82 percent) of mote the perception that dentists are interested the practices considered BGT to be beneficial to in patients’ general health and increase the practice; five (18 percent) respondents were patients’ confidence in the practice, and one indifferent. (2 percent) did not. Among barriers to implementation of routine Among the 67 respondents, 39 (57 percent) BGT, respondents from 16 of the 28 particidisagreed or strongly disagreed that BGT is pating practices (57 percent) named lack of time consuming, and 15 (22 percent) agreed or insurance coverage, respondents from seven strongly agreed. Thirty-four (51 percent) responpractices (25 percent) thought there was insuffidents disagreed or strongly disagreed that BGT cient patient demand, and a respondent from is too expensive, and three (5 percent) agreed. one practice (4 percent) thought the test needed Fifty-one (77 percent) respondents disagreed or to be easier. strongly disagreed that blood glucose levels are Respondents from 26 of the 28 practices (93 not relevant to dental practice, and two (2 perpercent) thought that routine BGT for at-risk cent) agreed or strongly agreed. Sixty-two (93 patients should be implemented in dental pracpercent) respondents disagreed or strongly distice, and respondents from all 28 practices (100 agreed that patients were unhappy that a percent) stated that BGT was well received by screening was performed, and three (5 percent) patients and was easy to perform by the end of agreed or strongly agreed. Three (5 percent) the study. respondents agreed that BGT opens the practice Patient questionnaire. We screened 498 to liability, and 48 (72 percent) disagreed or patients (222 were men; 22 were Hispanic or strongly disagreed. Latino; 419 were white, 49 were black, 10 were End-of-study interview with the Asian, one was Pacific Islander, 10 were other, practitioner-investigator. We conducted an and nine did not report their race or ethnicity; end-of-study interview with the practitioner111 were from Sweden; and 387 were from the investigator at each of the 28 participating United States). Among these 498 patients, 412 practices. The results of these interviews indi(83 percent) had dental insurance. Of the pacated that the BGT was performed only by dentients, 420 (84 percent) qualified for BGT. Seven tists in 19 practices, dentists and hygienists in of the 498 screened patients refused to fill out seven practices, and dentists and dental assisquestionnaires, six of them because they had tants in 17 practices. In 26 practices, providers undergone screening recently in a medical office performed finger-stick testing in the dental or at home. The average number of patients operatory, and in 11 practices, providers perscreened per practice was 19 (range, 15-28). All formed the testing in the hygiene operatory. 498 patients whom providers screened for the Respondents from 18 (64 percent) of the 28 study either completed a questionnaire or told practices reported the average duration of BGT us how they felt about the idea of being tested was two to five minutes, respondents from eight in the dental office. Patients’ blood glucose JADA 143(3)

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RESEARCH TABLE 2

Dental personnel’s ratings of blood glucose testing. ITEM (NO. OF RESPONDENTS)

STRONGLY DISAGREE, NO. (%)

DISAGREE, NO. (%)

1 (2) 2 (3)

1 (2) 3 (5)

8 (12) 16 (24)

28 (42) 29 (43)

28 (42) 17 (25)

BGT results can help determine timing of invasive procedures (67)

2 (3)

3 (5)

22 (33)

16 (24)

24 (36)

BGT results can help identify patients at risk of developing periodontal disease (67)

3 (5)

4 (6)

10 (15)

25 (37)

25 (37)

Patients’ confidence increased (67)

7 (10)

30 (45)

29 (43)

Potential Positive Aspect Patients will benefit from BGT* (66†) BGT may lead to better control of blood glucose levels if patients are tested in the dental office (67)

NEUTRAL, NO. AGREE, NO. STRONGLY (%) (%) AGREE, NO. (%)

0 (0)

1 (2)

Potential Negative Aspect BGT is time consuming (67) BGT is too expensive (67) Blood glucose levels are not relevant to dental practice (66†)

14 (20) 16 (24) 33 (49)

25 (37) 18 (27) 18 (27)

13 (19) 30 (45) 13 (19)

9 (13) 3 (5) 1 (1)

6 (9) 0 (0) 1 (1)

Patients were unhappy (67) BGT opens the practice to liability (67)

48 (72) 30 (45)

14 (21) 18 (27)

2 (3) 16 (24)

2 (3) 3 (5)

1 (2) 0 (0)

* BGT: Blood glucose testing. † One respondent did not answer the question.

levels and characteristics are presented in a separate report (A. Barasch, DMD, MDSc, unpublished data, 2010). Specific ratings of BGT as reported by patients are shown in Table 3. Among the 498 patients who were screened, 413 (83 percent) thought that BGT in dental office was a good idea, and 13 (3 percent) disagreed or strongly disagreed. A total of 449 (90 percent) patients felt that BGT in the dental office showed a high level of care, and 10 (2 percent) patients disagreed or strongly disagreed. A total of 307 (62 percent) patients reported that they would be more likely to refer friends and family to the practice because BGT was offered, and 28 (6 percent) patients disagreed or strongly disagreed. When we excluded patients who had received a diagnosis of DM or prediabetes, the results were similar. We asked the 64 (13 percent) patients who did not qualify to undergo BGT to not respond to the latter two items on the questionnaire: ease of undergoing BGT and whether BGT results provided useful information. Among the 498 patients, 422 (86 percent) thought that BGT was easy, and nine (2 percent) strongly disagreed. Among the 498 patients, 397 (79 percent) found that the BGT results provided them with useful information, and eight (2 percent) strongly disagreed. DISCUSSION

Despite the known morbidity of DM, detection remains suboptimal. An estimated 30 percent of people who meet the criteria for having this dis266

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ease are unaware of their condition, and it remains unclear what strategies would be able to detect patients with diabetes most efficiently.27-29 Because of the cost of and the lack of robust evidence in support of earlier treatment, neither the U.S. Preventive Services Task Force nor the American Diabetes Association support community screening. Rather, the American Diabetes Association recommends opportunistic screening in the health care setting.29,30 Dental offices are health care settings, and, therefore, the feasibility of obtaining blood glucose measurements in dental offices is worthy of scrutiny. Most patients who have received a diagnosis of DM or prediabetes tend to have poorly controlled DM or prediabetes, and, hence, benefit from frequent BGT. Elevated blood glucose levels in people with DM and prediabetes may trigger dentists’ referral of patients to their physicians for evaluation of their treatment and to help dentists determine the correct timing for these patients to undergo invasive dental procedures. In addition, the bidirectional relationship of DM with periodontal disease suggests a potential benefit of screening for DM and prediabetes for both patients and dental practitioners.1 The proposal to conduct BGT of patients visiting the dental office is not new. In 2002, a German group of investigators reported that screening for DM in patients with periodontitis could be accomplished by using blood from gingival tissues collected during a routine perio-

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RESEARCH TABLE 3

Patients’ ratings of BGT* (N = 498). ITEM

BGT in the dental office is a good idea BGT shows a high level of

care†

STRONGLY DISAGREE, NO. (%)

DISAGREE, NO. (%)

NEUTRAL, NO. (%)

AGREE, NO. (%)

STRONGLY AGREE, NO. (%)

NO RESPONSE, NO. (%)

9 (2)

4 (1)

72 (15)

176 (35)

237 (48)

0 (0)

6 (1)

4 (1)

38 (8)

170 (34)

279 (56)

1 (1)

I am more likely to refer friends and family because BGT was offered†

9 (2)

19 (4)

159 (32)

139 (28)

168 (34)

4 (1)

BGT was easy‡

9 (2)

0 (0)

3 (1)

77 (16)

345 (70)

64 (13)

BGT gave me useful information‡

8 (2)

0 (0)

29 (6)

106 (21)

291 (58)

64 (13)

* BGT: Blood glucose testing. † Some patients left specific questions unanswered. ‡ Asked only of patients who underwent BGT; 64 patients did not undergo BGT.

dontal examination.31 The correlation between the oozing gingival blood and that obtained from finger-stick testing was high (r = 0.98). Other investigators have proposed screening for DM3234 or have recommended that BGT equipment be available for emergency medical management in dental offices.35-37 In a study similar to ours that was aimed at screening dental patients for cardiovascular disease risk factors, the investigators obtained glycosylated hemoglobin (HbA1c), a marker for DM, from 100 dental school patients.38 In 2007, however, as the result of an informal preliminary investigation for our study, we found that among the 852 DPBRN general practices and 268 specialty practices, dentists at fewer than 10 practices routinely screened for DM even in patients at high risk of developing the disease, and most (> 98 percent) practices did not have on-site glucose monitors. Therefore, testing blood glucose levels does not seem to be a widespread practice in dental offices. We surveyed dental office personnel after they experimented with conducting BGT, which allowed them to use their own practical experiences to answer the questionnaire. Our findings suggest that most providers and their patients regard BGT as beneficial and easy after becoming familiar with the process. These results coincide in large measure with those of a recent survey of general dentists by Greenberg and colleagues,39 in which screening for DM was considered necessary by 77 percent of the respondents. However, the post facto acceptance of performing finger-stick testing by dental office personnel in our study (84 percent) was significantly larger than the 56 percent who reported they were willing to collect blood samples via finger-stick testing in Greenberg and colleagues’39 article. This difference suggests that dental health workers may find this type of

testing easier after practical application. The DPBRN encompasses a broad variety of dental practices and practitioners located mainly in five geographic regions. These practices have much in common with dental practices at large and may be representative of general dental practice in the United States and Scandinavia.20,21 We tested for potential differences between the countries involved in this study and analyzed the data for Sweden and the United States separately. The results showed no significant difference among any of the variables. The data from the United States alone were no different from the data from the United States and Sweden combined. Recruitment of practices was limited to those whose dentists expressed an interest in participating in the study, so a bias toward positive results is possible. Our study may have other limitations, including the relatively small number of patients who underwent BGT in each practice and the uneven distribution of dentist and staff member questionnaires that were returned. To our knowledge, this is the largest study conducted regarding DM screening in dental offices. In addition, the geographic distribution of the study was broad. Nevertheless, the results of this study should be interpreted as a step toward implementation of screening for DM in dental practices, and future investigations should address issues that we identified in our study (for example, patients’ attitudes, dental personnel’s attitudes, ease of test administration). An additional possible limitation of our study was the use of random blood glucose testing instead of other, more precise tests. Measuring HbA1c, which reflects glucose control across months, is significantly more expensive and, thus, not the most appropriate test for a feasibility study. Whether the more consistent HbA1c JADA 143(3)

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or random glucose testing is the most appropriate test to be used in patients seen in the dental office was beyond the scope of our study. The answer to this issue may depend on dental providers’ ability to recoup the investment for the more expensive HbA1c testing. Similarly, testing fasting glucose or glucose tolerance is impractical for dental patients and could not be implemented easily in the dental setting. Nevertheless, the objective of our study was to test the feasibility of screening for glucose abnormalities, not to diagnose the disease. Random glucose testing proved adequate for that purpose. Patients with abnormal blood glucose levels were referred to their physicians for further testing, diagnosis and disease management. Since past propositions for BGT in dental patients appear to have gained little traction with practicing dentists, an analysis of the barriers to implementing BGT can point the way toward strategies for implementation. In addition to opening the door to opportunistic screening among appropriate patients, BGT in the dental office may enable practice-based research on such topics as postoperative infectious complications and preoperative hyperglycemia. CONCLUSIONS

Opportunistic BGT in dental practices appears to have acceptance from both patients and practitioners who underwent such a screening. Barriers to BGT appear to be surmountable, and the information gathered may have significant health care implications. Further study of these two topics is warranted. ■ Disclosure. None of the authors reported any disclosures. The Dental Practice-Based Research Network (DPBRN) Collaborative Group comprises practitioner-investigators, faculty investigators and staff investigators who contributed to this DPBRN study, titled “Blood Sugar Testing in Dental Practice.” A list of these people is available at “www.dentalpbrn.org/uploadeddocs/Blood%20sugar% 20testing%20in%20dental%20practice_041311.pdf”. The investigation described in this article was funded by grants U01-DE-16746 and U01-DE-16747 from the National Institutes of Health, Bethesda, Md. Opinions and assertions contained herein are those of the authors and are not to be construed as necessarily representing the views of the respective organizations or the National Institutes of Health. The informed consent of all human participants who participated in this investigation was obtained after the nature of the procedures had been explained fully. 1. Ship J. Diabetes and oral health: an overview. JADA 2003; 134(10 suppl):4S-10S. 2. Koro CE, Bowlin SJ, Bourgeois N, Fedder DO. Glycemic control from 1988 to 2000 among U.S. adults diagnosed with type 2 diabetes: a preliminary report. Diabetes Care 2004;27(1):17-20. 3. Nguyen NT, Nguyen XM, Lane J, Wang P. Relationship between obesity and diabetes in a US adult population: findings from the National Health and Nutrition Examination Survey, 1999-2006. Obes Surg 2010;21(3):351-355.

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4. Centers for Disease Control and Prevention. Diabetes Public Health Resource. “www.cdc.gov/diabetes/”. Accessed Dec. 5, 2011. 5. Ong KL, Cheung BM, Man YB, et al. Treatment and control of diabetes mellitus in the United States National Health and Nutrition Examination Survey, 1999-2002. J Cardiometab Syndr 2006; 1(5):301-307. 6. diabetes foreningen. Diabetes i Danmark. “www.diabetes.dk/ Rundt_om_diabetes/Diabetes_i_tal/Diabetes_i_Danmark.aspx”. Accessed Jan. 31, 2012. 7. diabetesforbundet. Type 2-diabetes. “www.diabetes.no/ Type+2-diabetes.9UFRnQ4P.ips”. Accessed Jan. 30, 2012. 8. Svenska Diabetesförbundet. “www.diabetes.se/Templates/ Extension____309.aspx”. Accessed Jan. 30, 2012. 9. Narayan KM, Boyle JP, Geiss LS, Saaddine JB, Thompson TJ. Impact of recent increase in incidence on future diabetes burden: U.S., 2005-2050. Diabetes Care 2006;29(9):2114-2116. 10. Nathan DM, Davidson MB, DeFronzo RA, et al. Impaired fasting glucose and impaired glucose tolerance: implications for care. Diabetes Care 2007;30(3):753-759. 11. The 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(14):977-986. 12. Gudbjörnsdottir S, Cederholm J, Nilsson PM, Eliasson B. The National Diabetes Register in Sweden: an implementation of the St. Vincent Declaration for Quality Improvement in Diabetes Care. Diabetes Care 2003;26(4):1270-1276. 13. Gershater MA, Pilhammar E, Roijer CA. Documentation of diabetes care in home nursing service in a Swedish municipality: a cross-sectional study on nurses’ documentation (published online ahead of print Sept. 17, 2010). Scand J Caring Sci 2010;25(2): 220226. doi:10.1111/j.1471-6712.2010.00812.x. 14. Grundy SM, Benjamin IJ, Burke GL, et al. Diabetes and cardiovascular disease: a statement for healthcare professionals from the American Heart Association (published correction appears in Circulation 2000;101[13]:1629-1631). Circulation 1999;100(10):1134-1146. 15. American Diabetes Association. Screening for diabetes highly cost effective, study finds. “www.diabetes.org/for-media/2010/ screening-for-diabetes-highly-cost-effective.html”. Accessed Jan. 31, 2012. 16. U.S. Department of Health and Human Services; Office of Disease Prevention and Health Promotion. Healthy People 2020: diabetes—find evidence-based information and recommendations related to diabetes. “http://healthypeople.gov/2020/topicsobjectives2020/ ebr.aspx?topicId=8”. Accessed Jan. 31, 2011. 17. Houston TK, Richman JS, Ray MN, et al; for The DPBRN Collaborative Group. Internet delivered support for tobacco control in dental practice: randomized controlled trial. J Med Internet Res 2008;10(5):e38. 18. Houston TK, Richman JS, Coley HL, et al; DPBRN Collaborative Group. Does delayed measurement affect patient reports of provider performance? Implications for performance measurement of medical assistance with tobacco cessation—a Dental PBRN study. BMC Health Serv Res 2008;8:100. 19. Dental Practice-Based Research Network. “www.DentalPBRN. org”. Accessed Jan. 12, 2012. 20. Gilbert GH, Williams OD, Rindal DB, Pihlstrom DJ, Benjamin PL, Wallace MC; DPBRN Collaborative Group. The creation and development of The Dental Practice-Based Research Network. JADA 2008;139(1):74-81. 21. Gilbert GH, Qvist V, Moore SD, et al; DPBRN Collaborative Group. Institutional review board and regulatory solutions in The Dental PBRN. J Public Health Dent 2010;70(1):19-27. 22. Makhija SK, Gilbert GH, Rindal DB, Benjamin PL, Richman JS, Pihlstrom DJ; DPBRN Collaborative Group. Dentists in practicebased research networks have much in common with dentists at large: evidence from The Dental Practice-Based Research Network. Gen Dent 2009;57(3):270-275. 23. Makhija SK, Gilbert GH, Rindal DB, et al; DPBRN Collaborative Group. Practices participating in a dental PBRN have substantial and advantageous diversity even though as a group they have much in common with dentists at large. BMC Oral Health 2009;9:26. 24. American Diabetes Association. Screening for type 2 diabetes. Diabetes Care 2004;27(suppl 1):S11-S14. 25. U.S. Preventive Services Task Force. Screening for Type 2 Diabetes Mellitus in Adults. “www.uspreventiveservicestaskforce.org/ uspstf/uspsdiab.htm#summary”. Accessed Jan. 27, 2012. 26. Dental Practice-Based Research Network. Supplements to spe-

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RESEARCH cific DPBRN publications: DPBRN Study 15—“Blood glucose testing in dental practice.” “www.dentalpbrn.org/users/publications/ Supplement.aspx”. Accessed Dec. 5, 2011. 27. Mealey BL, Oates TW. Diabetes mellitus and periodontal diseases. J Periodontol 2006;77(8):1289-1303. 28. National Diabetes Information Clearinghouse; National Institute of Diabetes and Digestive and Kidney Diseases; U.S. Department of Health and Human Services. National Diabetes Statistics, 2011. “http://diabetes.niddk.nih.gov/dm/pubs/statistics”. Accessed Dec. 5, 2011. 29. Waugh N, Scotland G, McNamee P, et al. Screening for type 2 diabetes: literature review and economic modelling. Health Technol Assess 2007;11(17):iii-iv, ix-xi, 1-125. 30. Resnick HE, Foster GL, Bardsley J, Ratner RE. Achievement of American Diabetes Association clinical practice recommendations among U.S. adults with diabetes, 1999-2002: the National Health and Nutrition Examination Survey. Diabetes Care 2006;29(3):531-537. 31. Beikler T, Kuczek A, Petersilka G, Flemmig TF. In-dental-office screening for diabetes mellitus using gingival crevicular blood. J Clin Periodontol 2002;29(3):216-218.

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