ORAL CARE REPORT
Diabetes and Dental Practice:
The Dental Office and Point
of Care Assessment
The prevalence of type 2 diabetes
mellitus (DM) has reached over 12% in
the US, where it is the seventh leading
cause of death and a major cause of
blindness, kidney failure, and
nontraumatic lower-limb amputation.1
As the population ages, the prevalence
of DM is predicted to continue to
increase.2 Moreover, approximately 4%
of Americans may have undiagnosed
DM, and even among those with
diagnosed DM, an estimated 65% have
inadequate control of their condition.3
A similar epidemic increase in type 2
DM has been reported by Scandinavian
countries, where up to 8% of the
population is affected, half of which is
undiagnosed.3 In Scandinavia, the
results of a nursing program for DM
patients in certain Swedish cities have
prompted a renewed appeal for
improved screening and education of
this population.4
Impaired glucose metabolism,
present in an estimated 25% of the US
population,1 is a common precursor to
DM.5 Sufficient glucose control
substantially decreases cardiovascular
complications that may occur in DM
patients, and changes in lifestyle can
delay the onset of DM in those with
prediabetes.3 Therefore, early detection
and proper treatment are essential to
achieve optimal control of DM. Given
that morbidity and mortality associated
with DM constitute a major healthcare
burden in the US,2 the US Department
of Health and Human Services rates
DM screening among key measures to
be implemented in the healthcare
system.6
Diabetes and Dental Health
DM is a recognized risk factor for
periodontal disease;7 diabetic patients
Providing Continuing Education as a Service to Dentistry Worldwide
suffering from periodontitis have a
greater risk of morbidity and mortality
In This Issue
associated with cardiovascular and renal Diabetes and Dental Practice:
disorders.2 Further, DM has been The Dental Office and Point
associated with coronal and root caries, of Care Assessment 1
burning mouth syndrome, xerostomia,
Candida infection, altered tooth In Practice 3
eruption, and salivary gland
hypertrophy.2 In addition, abnormal Hygiene Page 5
serum glucose levels in diabetic patients
can negatively affect their ability to Clinical Practice 8
endure dental therapy.
Healthcare Trends 10
Implementation of blood
glucose testing in dental
practices is feasible; both Editor-in-Chief
patients and dental health Dominick P. DePaola, DDS, PhD; USA
providers have expressed President Emeritus
The Forsyth Institute
satisfaction with the screening
practice and obstacles seem to
be conquerable. Associate Editors
John J. Clarkson, BDS, PhD; Ireland
How Can Dental Offices Become Joan I. Gluch, RDH, PhD; USA
Involved in DM Management? Kevin Roach, BSc, DDS, FACD; Canada
Dental offices may serve as a Xing Wang, MD, PhD; China
beneficial setting for blood glucose
testing (BGT) among the target
population that includes patients
previously diagnosed or at risk of International Advisory Board
developing DM. Patients would be able
to get a referral from the dental office Mark Bartold, BDS, BScDent (Hons), PhD,
DDSc, FRACDS (Perio); Australia
for medical services required for proper
management of their condition. A
Thomas Van Dyke, DDS, PhD; USA
preliminary investigation in 2007
indicated that among 852 Dental
David T.W. Wong, DMD, DMSc
Practice-Based Research Network
(DPBRN) general practices and 268
specialty practices, dentists at less than
ten practices regularly screened for DM,
Volume 22, Number 3, 2012
2 ORAL CARE REPORT

even in high-risk patients, and more
than 98% of practices did not have on-
site glucose monitors. However, from a
survey of dentists in 2010, 77% of
respondents stated that DM screening
was essential.8
A recent study, published in 2012,
examined the feasibility of using BGT
(by means of glucose monitors and
finger-stick testing) to screen in the
dental office for patients at risk or who
are diagnosed with DM, and the
acceptability of administering or
receiving BGT among dental personnel
and patients, respectively.3 Eligible
patients selected for BGT had a body
mass index higher than 25 kg/m2 and
one or more of the following: a self-
reported history of hypertension,
hypercholesterolemia, diagnosed DM,
or prediabetes.3 After testing, patients
with blood glucose levels below 70
mg/dL or above 300 mg/dL were
retested, and those with confirmed
abnormal levels were informed about
the benefits of a more formal evaluation
by their physician.3 Two standardized
questionnaires employing five-point
Likert scales (1 indicating “strongly
agree” and 5 indicating “strongly
disagree”) were completed separately by
the patient and dental office personnel
to determine the obstacles and
advantages of BGT in private dental
practices.3
Findings
A total of 28 dental practices from
the five dental (DPBRN) regions (four
in the US and one in Sweden)
participated in this study. The results are
summarized in the table below. Among
the 67 dental office personnel who
completed the questionnaire, 42%
strongly agreed that BGT is
advantageous for patients, 25% strongly
agreed that BGT may result in improved
control of blood glucose levels if patients
were tested in dental offices, 36%
strongly agreed that BGT results can
help determine timing of invasive
procedures, 37% strongly agreed that
BGT results can help identify patients at
risk of developing periodontal disease,
and 43% strongly agreed that BGT
increased patients’ confidence as shown
in the table.3 In addition, among the 67
respondents, only 22% agreed or
strongly agreed that BGT is time
Continued on p. 9

Ratings of Dental Office Blood Glucose Testing

Strongly Disagree Neutral Agree Strongly
N Disagree (%) (%) (%) (%) Agree (%)

Dental Personnel
Patients will benefit from BGT 66 2 2 12 42 42
BGT may lead to better control of BG levels if patients
are tested in dental offices 67 3 5 24 43 25
BGT results can help determine timing of invasive procedures 67 3 5 33 24 36
BGT can help identify patients at risk of developing periodontal diseases 67 5 6 15 37 37
Patients’ confidence increased 67 0 2 10 45 43
BGT is time consuming 67 20 37 19 13 9
BGT is too expensive 67 24 27 45 5 0
BG levels are not relevant to dental practice 66 49 27 19 1 1
Patients were unhappy 67 72 21 3 3 2
BGT opens the practice to liability 67 45 27 24 5 0

Patients
BGT in the dental office is a good idea 498 2 1 15 35 48
BGT shows a high level of care 497 1 1 8 34 56
I am more likely to refer friends and family because BGT is offered 494 2 4 32 28 34
BGT was easy* 434 2 0 1 16 70
BGT gave me useful information* 434 2 0 6 21 58

BG: Blood Glucose; BGT: Blood glucose testing. * Asked only of patients who underwent BGT.
Adapted from Barasch, et al. 20123
 ORAL CARE REPORT
Childhood Caries
and Obesity: Common
Risk Factors
T he incidence of dental caries
among children aged 5–17 years is five-
fold that of asthma, and coincides with
an increased prevalence of childhood
obesity that has been reported in recent
years.1 Although earlier research on the
association between childhood caries
and obesity was inconclusive, recent
studies in women have shown significant
differences in the salivary bacterial
composition between overweight and
normal weight women, suggesting that
oral bacterial composition may link
obesity to oral disease. Spiegel and
Palmer1 reviewed the recent literature
on common dietary and environmental
factors that affect both childhood caries
and obesity.
Common Risk Factors
Modern lifestyle has imposed
changes in dietary and behavioral habits
that seem to increase the risk of
developing dental caries and obesity
among children.1
• Fewer homemade meals: Children
now eat fewer homemade meals,1 as
reflected by a 300% increase in fast
food and restaurant meal
consumption between 1970 and
1990. Because restaurants have also
increased portion size, children’s
caloric intake is higher (increased
from 20% to 32% between
1970–1990), which may result in
weight gain.1 Furthermore, food
options offered in schools tend to
be high in calories and poor in
essential nutrients.
• Frequent snacking on foods with
poor nutritional value: Almost all
children (98% in 2000; mostly those
2–6 years old) snack frequently
outside of regular mealtimes.1 Favorite
snacks (e.g., chips, crackers, candy)
have poor nutritional value, yet they
IN PRACTICE
provide more calories and fat (168
additional calories per day).1 In
addition to higher caloric intake,
consumption of foods low in
nutritious value may negatively impact
the intake of essential nutrients; it was
shown that fruit consumption
decreased by 11% for every vending
machine available in school.1
• High consumption of sugary drinks:
Excessive consumption of sugar-
sweetened beverages (e.g., soda,
juice) is associated with an increased
risk of obesity and caries in the
pediatric population.1 Frequent
consumption of sweetened
beverages is the primary dietary risk
factor for dental caries among
children.1 Drinking juice and soda,
especially by sipping, provides
prolonged tooth exposure to
fermentable carbohydrates and/or
acids, favoring the growth of caries-
causing oral bacteria.1
• Low physical activity levels:
Coupled to changes in dietary
habits, sedentary lifestyle, and
indoor activities (such as television
and video games, reduced physical
activity programs at school) result in
lower expenditure of calories and
increased risk of being overweight.
Prevention: The Dental
Professional’s Role
Initiatives have been taken by
professionals and lay groups to limit
exposure to unhealthy snacks. Many
Table 1: Body Mass Index Criteria for Weight Status
Percentile Range
• Less than the 5th percentile
• 5th percentile to less than the 85th percentile
• 85th to less than the 95th percentile
• Equal to or greater than the 95th percentile
From the Centers for Disease Control and Prevention, 20125
3
By providing simple
interventions to promote
healthy diet and behavior,
dental professionals help
prevent both childhood caries
and obesity.
schools have banned soda and sugary
sports drinks. The American Academy of
Pediatrics recommends limiting fruit
juice consumption to 4–6 ounces per
day for children 1–6 years old, and 8–12
ounces for 7- to 18-year-old children.2
The American Academy of Pediatric
Dentistry (AAPD) developed a Policy on
Dietary Recommendations for Infants,
Children, and Adolescents that
incorporated dietary recommendations
into dental visits and keeping track of a
child’s growth and weight during each
visit.3 Because dental visits are more
frequent than medical visits, dental
professionals are in an ideal position to
help prevent childhood obesity, as well
as caries, through simple interventions.1
In a pilot study, the implementation of a
healthy diet and behavior training by
dentists had a positive impact on dietary
and behavioral habits.1 Examples of
simple interventions that dental
personnel could adopt include:1
• Discussing the relationship between
dental caries and unhealthy body
weight;
• Determining a child’s weight status
based on the percentile in which his
or her Body Mass Index (BMI) falls
(Table 1). BMI can be calculated
Weight Status Category
Underweight
Healthy Weight
Overweight
Obese
4 ORAL CARE REPORT

Table 2: Recommended Portion Sizes Based on Food Groups

for Children Aged 1–5 Years
Servings Food Serving size
Food Daily types 1- to 3-year-olds 4- to 5-year-olds
Grains ≥6 Bread / – 1/2 slice
1 4 1 slice
Buns/ bagels/ muffins / – 1/2 slice
1 4 / slice
1 2

Cooked cereal / – / cup

1 4 1 3 / cup
1 2

Dry cereal / – / cup

1 4 1 3 / – 1/3 cup
1 4

Crackers 2 to 3 each 4 to 6 each

Vegetables 2 to 3 Any ~ 2 tbsp ~ 2 tbsp
Fruits* 2 to 3 Any / piece or 1/2 cup
1 2 / piece or 1/2 cup
1 2

Dairy ≥3 Milk and yogurt / – 1/2 cup

1 4 / to 3/4 cup
1 2

(total 2 cups/day) (total 2 cups/day)

Cheese 1 2 / ounce / ounce
3 4

(1-inch cube)
Protein group: 2 Meat 1 ounce 1 ounce
meat, fish, poultry, (equal to two 1-inch cubes of solid
tofu, and eggs meat or 2 tbsp. of ground meat)
Egg 1, any size 1, any size
(yolk and white)
Legumes: 2 Soaked and cooked 2 – 4 tbsp. 4 – 5 tbsp.
dried beans, peas, lentils (1/4 cup)
Fat group 3 – 4* 1 tsp 1 tsp

* depending on total calorie needs

Source: American Dietetic Association Pediatric Manual of Clinical Dietetics, second edition
and Manual of Pediatric Nutrition recommendations,6,7 adapted from Spiegel and Palmer, 20121

easily by measuring a child’s weight
and height to input into an online
BMI calculator, such as the one
found at About.com
(http://pediatrics.about.com/cs/us
efultools/l/bl_bmi_calc.htm);
• Providing the basics of a healthy diet
using MyPlate Food Guide,1,4
available online, and the Manual of
Pediatric Nutrition
recommendations (Table 2);
• Promoting physical activity over
sedentary behaviors.
The dental team has a key role in
the prevention of both childhood caries
and obesity through the promotion of a
healthy lifestyle and diet. Simple but
meaningful interventions may help
reduce the growing burden of these
conditions. O C
References
1. Spiegel KA, Palmer CA. Childhood dental
caries and childhood obesity. Different
problems with overlapping causes. Am J Dent
2012;25(1):59-64.
2. American Academy of Pediatric Dentistry
Council on Clinical Affairs. Policy on dietary
recommendations for infants, children, and
adolescents. Pediatr Dent 2005;27(7 Suppl):36-7.
3. Tseng R, Vann WF, Jr., Perrin EM.
Addressing childhood overweight and obesity
in the dental office: rationale and practical
guidelines. Pediatr Dent 2010;32(5):417-23.
4. U.S. Department of Agriculture. My plate.
2012. http://www.choosemyplate.gov.
5. Centers for Disease Control and Prevention.
About BMI for children and teens. 2012.
http://www.cdc.gov/healthyweight/assessing/b
mi/childrens_bmi/about_childrens_bmi.html.
6. Hendricks KM, Duggan C. Manual of
Pediatric Nutrition, 4th ed. BC Decker, Valley
Stream, NY, 2005.
7. U.S. Department of Health and Human
Services and Office of Disease Prevention and
Health Promotion. Healthy People 2020:
Diabetes – find evidence-based information and
recommendations related to diabetes. 2011.
http://healthypeople.gov/2020/topicsobjectiv
es2020/. (Accessed 6 Jul 2012.)
 ORAL CARE REPORT 5

Early Childhood
Caries: Screening
Tools for Risk
Assessment
A lthough early childhood caries
(ECC) is a preventable disease, it
continues to be a public health threat.1
In the US, national surveys reported that
only less than half (42%) of children
under the age of 18 had a dental
consultation or general exam annually.2
Around 16.25% of preschool children
(2–4 years) had untreated dental caries,
according to the Third National Health
and Nutrition Examination Survey
(NHANES III; 1988–1994).3 It is
estimated that 80% of dental disease is
found among those with limited access
to professional dental care, accounting
for 25% of the US population.4
HYGIENE PAGE
Identification of children at risk of
developing dental caries is an essential
step toward the implementation of
preventive measures.4 In these high-risk
children, early intervention would
hinder disease progression and avoid
the need for complex treatment
interventions.4 In addition to tooth
brushing and flossing, key preventive
interventions include fluoride exposure,
and pit and fissure sealants.4,5
A number of caries risk assessment
approaches are available. The Caries-risk
Assessment Tool (CAT) was introduced
by the American Association of Pediatric
Dentistry.6 This tool estimates a child’s
caries risk by combining information on
dental health history (i.e., history of
caries and dental care, etc.),
socioeconomic status, and clinical
evaluation (i.e., presence of visible
plaque, gingivitis, etc.).6 Saliva screening
for Streptococcus mutans (MS), a pathogen
highly associated with dental caries, is
also used to assess caries risk.5 MS
culturing may be added to the CAT as an
optional screening component.5,6 Most
recently, acid production detection in
the biofilm was developed in Japan and
may become a potentially useful test to
predict caries risk.4
Comparison of Caries-Risk
Assessment Approaches
Caries-risk assessment tools are not
equally accurate and clinically useful.
Several criteria define a tool’s usefulness;
these include reliability and the ability to
identify the presence of caries without
producing false results (sensitivity and
specificity criteria), ease of use,
affordability, and rapid results.5 For
example, it was suggested that the
sensitivity and specificity of MS decrease
with age, therefore its predictive value
(or clinical usefulness) would be highest
in younger children.5 No reports on the

ORAL CARE REPORT

THE

Educational Objectives
After reading this issue of the Colgate Oral Care Report and correctly answering the
questions in the quiz, you will:
1. learn how an easy-to-use, patient-acceptable in-office test can uncover the presence
of diabetes mellitus;

2. see how simple interventions to promote healthy diet and behavior can help
prevent both childhood caries and obesity;

3. discover the latest approaches for identifying children at risk of developing dental
caries; and

4. become aware of the reasons for oral healthcare disparities among some ethnic
and cultural groups in the US.
6 ORAL CARE REPORT
Accuracy and Clinical Usefulness of Caries Risk Assessment Approaches
MS alone
CAT
CAT minus SES risk factors
CAT minus SES risk factors plus MS
CAT: Caries-risk Assessment Tool; MS: Streptococcus mutans; NPV: Negative Predictive
Value; PPV: Positive Predictive Value; SES: Socioeconomic Status
From Yoon, et al., 20125
CAT usefulness have been published.
Profile comparison of these tools is
warranted to help identify the optimal
screening approach for a given patient
population.
Recently, Yoon and colleagues
conducted a prospective study to
compare four approaches involving CAT
and MS in a pediatric population in
Manhattan, NY, USA.5 Recruited
participants were new pediatric dental
patients, aged three years or younger,
who were never seen by a dentist
previously. Overall, 229 children with
ECC (caries prevalence: 48.6%),
predominantly low-income Hispanic,
and 242 children without ECC were
screened.5 Compared tools were MS
alone, CAT alone, CAT without the
socioeconomic status (SES) risk factor,
and CAT without SES but with MS.
Comparison was based on accuracy
(sensitivity and specificity) and clinical
usefulness (positive and negative
predictive value; see Table). MS had the
highest clinical usefulness (> 85%);
these results were robust to variations of
the prevalence of severe ECC (between
5% and 75%).5 CAT was highly sensitive
(100%) but lacked specificity (2.9%).5
Excluding the SES component
improved CAT specificity (68.6%) and
positive predictive value (71.0% vs.
49.4%). However, adding MS to CAT
had minimal effect on its accuracy and
usefulness.5 CAT components with the
highest diagnostic performance were
Sensitivity Specificity
(%) (%)
86.5 93.4
100.0 2.9
85.6 68.6
95.2 65.7
gingivitis or visible plaque, and
moderate to high MS levels.5
MS is the best screening tool for
caries in a low-income
pediatric population.
Overall, MS was identified as the
best screening tool for caries in a low-
income pediatric population,5 although
accessibility to culturing facilities to
measure MS may prove to be a
hindrance to using this risk assessor in
underserved populations globally.
Because low socioeconomic status
classifies patients at high risk for caries
when using the CAT, it is not an
appropriate tool to use for this
population.5 O C
References
1. American Academy of Pediatric Dentistry.
Policy on early childhood caries(ECC):
Classifications, consequences, and
preventive strategies. Oral Health Policies
2011;33(6):47-9.
2. National Institute of Dental And Craniofacial
Research (NIDCR). Agency for Healthcare
Research and Quality. Table 5.0. Percentage
of children aged 18 years and younger who
received preventive dental services during
2000 by type of service. On National Institute
of Dental And Craniofacial Research
PPV NPV
(%) (%)
92.5 87.9
49.4 100.0
71.0 83.4
72.4 93.5
(NIDCR) website [updated 2000; cited 2012
Oct 19]. Available from: http://drc.hhs.gov/
report/dqs_tables/5.htm.
3. National Institute of Dental And Craniofacial
Research (NIDCR). The Third National
Health and Nutrition Examination Survey
(NHANES III) 1988-1994. Table 1.1.1
Untreated dental caries prevalence among
children (aged 2-4 and 6-8 years), adolescents
(aged 12-15 years), and adults (aged 35-44
years) by selected demographic
characteristics. On National Institute of
Dental And Craniofacial Research (NIDCR)
website [updated 2009; cited 2012 Oct 19].
Available from: http://drc.hhs.gov/report/
dqs_tables/pdf/Table1_1_1.pdf.
4. Berg J. Addressing the silent epidemic.
Dimensions Dent Hyg 2012;10(9):42-5.
5. Yoon RK, Smaldone AM, Edelstein BL. Early
childhood caries screening tools: a
comparison of four approaches. J Am Dent
Assoc 2012;143(7):756-63.
6. American Academy of Pediatric Dentistry.
Policy on use of a Caries-risk Assessment Tool
(CAT) for infants, children and adolescents.
Oral Health Policies 2006;31(6):25-33.
8 ORAL CARE REPORT
CLINICAL PRACTICE
Insurance-Related
Barriers to Dental
Care Access
D espite substantial improvements
in oral health for the overall US
population, racial and ethnic variation in
the utilization of dental care services
remains a persistent issue.1,2 Dental
insurance inequalities contribute to these
oral health disparities.1 However, insurance
status alone may not wholly account for
disparities in dental care, as a range of
sociodemographic factors and the type of
insurance held may also be relevant.3
A disproportionate number of
African American adults in the US face
dental health problems, reporting more
tooth loss, active dental disease, and dental
pain than Caucasian adults. Compared
with Caucasian adults, African Americans
also possess fewer teeth overall and suffer
worse oral health-related quality of life.4
They are less likely to have visited a dentist
within the past year, yet they generally
perceive themselves to be more in need of
dental care.1
While the factors that influence
dental care access are not fully
understood, African Americans are
generally more likely to be unable to
afford dental care out-of-pocket costs or
lack insurance for dental health.1,3 In
particular, more African Americans have
access to public insurance (Medicaid) than
those who hold private dental insurance.5
Notably, Medicaid covers a limited range
of dental services and level of care,6 and is
associated with lower utilization of dental
services.7
African American Adults with
Oral Health Symptoms in
New York City
To investigate barriers to accessing
dental care, a recent qualitative study
examined insurance-related factors in
obtaining dental care experienced by
African Americans living in the Central
Harlem neighborhood of New York City.8
In this population, dental symptoms were
previously found to be the most frequently
reported health complaint.7 Interviews
were conducted among a sample of 188
African American adults who had lived in
Central Harlem for a minimum of five
years. All recruited individuals were
required to have had at least one oral
symptom or problem in the preceding six
months that lasted two or more days. A
large proportion of study participants were
of low socioeconomic status: only 24%
worked full-time, 64% reported high
school education or lower, and 41%
reported personal income of less than
$10,000 per year.
The majority of study participants
reported characteristics indicative of poor
dental health. In particular, 84% had one
or more missing teeth and a large
proportion had lost several teeth (mean =
9.3 teeth lost, SD = 9.9). Despite this,
comparatively few had any type of tooth
replacement, such as fixed or partial
bridgework or dental implants (31% of
patients on the upper arch and 23% on
Self-reported Oral Symptoms Among a Sample of African American
Adults in Central Harlem, New York City, 2004-2005
Oral Symptoma
Have you had a ...
Tooth sensitive to cold
Toothache
Tooth sensitive to sweets
Difficulty biting or chewing
Bleeding gums
Tooth sensitive to pressure
Pain or irritation of the gums
Tooth sensitive to heat
Sore or irritation from a denture
Pain or irritation of the roof of the mouth
Pain or irritation of the inside of your cheeks
Pain or irritation of the floor of the mouth
Pain or irritation of the tongue
Experienced = all the symptoms participants self-reported in the past 6 months that lasted for 2 days or more in a row.
a
Total number of symptoms experienced: mean = 3.1; DS = 2.1; range = 1-11 (n = 118).
From: Schrimshaw et al., 20118
the lower arch). Respondents self-reported
an average 3.1 symptoms during the six
preceding months (SD = 2.1, range 1–11;
refer to table below).
Qualitative patient interviews
identified potential barriers to dental
healthcare utilization among African
American adults. While most interviewees
reported possession of some form of dental
coverage (50% had access to Medicaid and
21% had private or dental maintenance
coverage), 25% lacked dental insurance.
Uninsured and underinsured patients
described seeking only emergency dental
care or delaying dental treatment until they
could access more affordable options. Even
for those who had some form of dental
coverage, out-of-pocket costs were cited as a
barrier to seeking dental care. Accessing
care also represented a major difficulty for
insured individuals who noted restrictions
imposed by their coverage to accessing
prompt treatment, as well as a lack of
dentists in their area who accepted their
specific dental plan. Poor perceptions of
dental providers represented a barrier to
Experienced, No. (%)
56 (48)
44 (38)
43 (36)
40 (34)
37 (31)
33 (28)
33 (28)
25 (21)
15 (13)
14 (12)
12 (10)
6 (5)
5 (4)
 ORAL CARE REPORT
Underinsured patients described
seeking only emergency dental
care or delaying necessary
dental treatment until they could
access more affordable
treatment options.
seeking care for some respondents, who
expressed concerns that financial
considerations would limit the quality of
dental care offered.
Moving Toward
Overcoming Barriers
Consistent with previous studies,3,7
these findings highlight the importance
of insurance in determining access to
dental care. Additionally, the results
indicate that dental coverage, whether
Medicaid or private insurance, did not
fully overcome barriers to dental care in
the study population. To address these
issues, an increase in Medicaid-covered
services, improved community outreach
efforts, and access to midlevel dental
practitioners are suggested.9-11 Further,
recruitment of more African American
dental students and a raise in
reimbursement rates for treatment of
adult Medicaid patients are also
suggested to encourage better provision
of dental services for underinsured
populations.12,13 OC
References
1. Brown TT, Finlayson TL, Fulton BD,
Jahedi S. The demand for dental care and
financial barriers in accessing care among
adults in California. J Calif Dent Assoc
2009;37(8):539-47.
2. Kiyak HA, Reichmuth M. Barriers to and
enablers of older adults’ use of dental
services. J Dent Educ 2005;69(9):975-86.
3. Manski RJ, Cooper PF. Dental care use:
does dental insurance truly make a
difference in the US? Community Dent Health
2007;24(4):205-12.
4. Gilbert GH, Duncan RP, Shelton BJ.
Social determinants of tooth loss. Health Serv
Res 2003;38(6 Pt 2):1843-62.
5. Okunseri C, Bajorunaite R, Matthew R,
Iacopino AM. Racial and ethnic variation in
the provision of dental procedures. J Public
Health Dent. 2007;67(1):20-7.
6. Boykin MJ, Gilbert GH, Tilashalski KR,
Litaker MS. Racial differences in baseline
treatment preference as predictors of
receiving a dental extraction versus root
canal therapy during 48 months of follow-up.
J Public Health Dent 2009;69(1):41-7.
7. Zabos GP, Northridge ME, Ro MJ, Trinh
C, Vaughan R, Moon HJ, et al. Lack of oral
health care for adults in Harlem: a hidden
crisis. Am J Public Health 2002;92(1):49-52.
8. Schrimshaw EW, Siegel K, Wolfson NH,
Mitchell DA, Kunzel C. Insurance-related
barriers to accessing dental care among
African American adults with oral health
symptoms in Harlem, New York City.
Am J Public Health 2011;101(8):1420-8.
9. American Academy of Pediatric Dentistry
analysis and policy recommendations
concerning mid-level dental providers.
Pediatr Dent 2010;32(1):21-6.
10. Nash DA, Nagel RJ. Confronting oral
health disparities among American
Indian/Alaska Native children: the pediatric
oral health therapist. Am J Public Health
2005;95(8):1325-9.
11. Greenberg BJ, Kumar JV, Stevenson H.
Dental case management: increasing access
to oral health care for families and children
with low incomes. J Am Dent Assoc
2008;139(8):1114-21.
12. Ramos-Rodriguez C, Schwartz MD,
Rogers V, Alos V. Institutional barriers to
providing oral health services for
underserved populations in New York City.
J Public Health Dent 2004;64(1):55-7.
13. Mitchell DA, Lassiter SL. Addressing
health care disparities and increasing
workforce diversity: the next step for the
dental, medical, and public health
professions. Am J Public Health
2006;96(12):2093-7.
9
Continued from p. 2
consuming, 5% agreed that BGT is too
expensive and opens the practice to
liability, 2% agreed or strongly agreed that
blood glucose levels are not important to
dental practice, and 5% agreed or strongly
agreed that patients were unhappy.3
Results from end-of-study interviews
with the practitioner-investigator at each
of the participating dental practices
indicated that 64% reported the average
duration of BGT was between two to five
minutes, 61% did not find BGT to be
disruptive, and 82% thought BGT was
beneficial to the practice.3 Moreover, 93%
stated that routine BGT for patients at risk
should be implemented in dental offices
and 100% considered BGT to be well
received by patients and easy to conduct
by study’s end.3 Lack of insurance
coverage was determined to be an
obstacle to implementing routine BGT
according to 57% of respondents.3
Among the 498 patients screened,
83% had dental insurance and 84%
qualified for BGT.3 According to the
patient questionnaires, 48% strongly
agreed that BGT in the dental office is a
good idea, 56% strongly agreed that BGT
shows a high level of care, 34% strongly
agreed that they were more likely to refer
friends and family to their dental practice
because BGT was offered, 70% strongly
agreed that BGT was easy, and 58%
strongly agreed that BGT gave them
useful information.3
Study Limitations
Despite this study being the largest
performed regarding DM in dental
offices, there were certain limitations.
Only dentists who expressed an interest
in participating in the study were
recruited, which may introduce a bias
towards positive results.3 In addition,
relatively few patients underwent BGT
in each practice and the distribution of
returned dental personnel
questionnaires was geographically
skewed.3 Although random blood
glucose testing was used in place of
Continued on p. 11
10
HEALTHCARE TRENDS
Editor-in-Chief Dominick P. DePaola,
DDS, PhD; USA
President Emeritus
The Forsyth Instiute
© 2012 Colgate-Palmolive Company.
All rights reserved.
The Oral Care Report
(ISSN 1520-0167) is supported by
the Colgate-Palmolive Company
for oral care professionals. Medical
writing by BioMedCom Consultants, inc.,
Montréal, QC (Canada).
Published by Professional Audience
Communications, Inc., Yardley, PA
(USA).
ORAL CARE REPORT
Education and Collaborative Practice
Across Borders and Professions
Dominick P. DePaola, DDS, PhD
Editor-in-Chief, the Colgate Oral Care Report
The articles selected for review in sufficiency and primary care/preventive
medicine have fueled the push for IPE/CP
this issue of the Oral Care Report (OCR)
in a changing healthcare system.
have a common theme: the growing
Interestingly, the article in this issue of the
evidence for the oral healthcare
OCR on common risk factors for
community to work together with other
childhood obesity and dental caries also
members of the health professions in
bears witness to the importance of
collaborative practice. The 2012 Dental
integrating oral health knowledge and
Deans Institute agenda was built entirely
skills with the patient’s overall health
around the notion of interprofessional
needs. Obesity and malnutrition are
education and collaborative practice
almost perfect examples of risk factors that
(IPE/CP).1 It may seem intuitive that
transcend borders and populations, and
IPE/CP should be the basis for future
illustrate the necessity of interprofessional
practice, but it has not been until recently
communication. If the essence of the
that the associations relating oral
changing healthcare system puts the
infections to a host of chronic systemic
patient front and center, then the oral
diseases, like cardiovascular disease, stroke,
healthcare provider’s role is even more
adverse pregnancy outcomes, and
compelling because, at least in the US,
diabetes, among others, have been
patients visit dentists more often than they
developed sufficiently to warrant careful
visit physicians.
consideration by the range of health
To be sure, there is much work to do
professionals. In addition, the potential for
in matching professional competencies to
dental healthcare professionals to be an
patient and population priorities,2 and in
important potential entry point for
developing the science base to
patients into the healthcare system has
demonstrate that health outcomes, cost
taken center stage in evidence-based
and quality of care, and patient safety
dental medicine—witness the Diabetes
would improve with the IPE/CP. The
and Dental Practice article in this issue.
Lancet Commission in its very thoughtful
The emerging role of saliva as a non-
review states unequivocally that there is,
invasive health surveillance tool is also
and must be, a fundamental linkage
testimony to the key position oral
between professional education and health
healthcare providers could play in the
conditions, and they have developed a
changing healthcare system. The
framework for understanding the complex
complexities of addressing chronic
interactions between two seemingly
diseases of the elderly, as well as
disparate systems; education and health.2
socioeconomic and ethnic health
The Commission further illustrated the
disparities speak volumes to the necessity
shift that must occur from a traditional
for health professions teamwork. Indeed, a
model of “siloed” care to a health systems,
recent Lancet Commission on Health
competency-based model where
Professions for a New Century2 notes that
healthcare results from a team approach of
the huge shift in population demographics
multidisciplinary professionals — social
and the global movements of people,
workers, nurses, therapists, doctors,
pathogens, technologies, financing,
counselors, and others — who must work
information, and knowledge across borders
together to provide a seamless web of
underlie the accelerating international
health services.2 One example from the
transfer of health risks and opportunities.3
oral healthcare profession is the
The global issues and movements
craniofacial anomalies team, a hospital-
related to access to care, workforce
 ORAL CARE REPORT
based team of a plethora of professionals
and caregivers to provide for the needs of
the complex craniofacial patient.
What is abundantly clear is that
incremental modifications to global
healthcare will not work! There are both
countries and states that are taking on the
challenge. For example, after many years
Mexico4 is providing universal healthcare
to all its citizens and the state of Vermont
has issued a Vermont Blueprint for
Health,5 which is centered on the
advancement of primary care, community
health teams, and specialized targeted
services. In a brilliant address at the Deans
Institute, Marsha Pyle made the case that
IPE/CP can be sustained as a curricula
model for the future because it is the
future with the emphasis on population
health, patient safety, and evolving science
to look critically at what works and what
Continued from p. 9
more precise tests, it proved adequate to
determine the feasibility of screening for
abnormal glucose levels.3
Conclusion
The study concluded that BGT is
considered beneficial and easy to
administer by dental personnel, and that it
is supported by patients. Study results
indicate that there is a high level of
satisfaction with BGT in dental offices
among both patients and dental personnel
which advocates implementing DM
screening in dental practices once issues
such as regulatory concerns, liability, and
reimbursement have been properly
addressed.2 In a 2011 study, researchers
were able to correctly identify 73% of all
cases of diabetes and prediabetes based on
dental examinations.9 The identification
rate improved to 92% with the
introduction of finger-stick testing,
attesting to the effectiveness of DM
screening in dental offices. In 2008, the
CDC reported that over 70% of US adults
had a dental visit in the preceding year,
does not work.6 Transformative change
and leadership in education and practice
is what is necessary for IPE/CP to be
sustained. The question remains as to
whether or not dental practice will either
lead or be a part of the changing global
health and education system and who will
galvanize the change? The ultimate benefit
is better health outcomes for the patient,
community, population, and families. Are
we willing to lead? O C
References
1. Dental Dean’s Institute. Leading change
through inter-professional education: The
Dean’s role. Newberg, Oregon, 2012.
2. Frenk J, Chen L, Bhutta ZA, Cohen J, Crisp
N, Evans T, et al. Health professionals for a new
century: transforming education to strengthen
health systems in an interdependent world.
suggesting that dental offices can be a
practical connection to the healthcare
system. Further, the bidirectional
relationship between DM and periodontal
diseases is another incentive to establish
BGT in dental practices and improve the
health of millions of patients who routinely
visit their dental providers. O
C
References
1. Centers for Disease Control and Prevention.
Diabetes public health resource. 2012.
http://www.cdc.gov/diabetes/. (Accessed 21
Jun 2012.)
2. Lamster IB, Kunzel C, Lalla E. Diabetes
mellitus and oral health care: time for the next
step. J Am Dent Assoc 2012;143(3):208-10.
3. Barasch A, Safford MM, Qvist V, Palmore R,
Gesko D, Gilbert GH. Random blood glucose
testing in dental practice: a community-based
feasibility study from The Dental Practice-Based
Research Network. J Am Dent Assoc
2012;143(3):262-9.
4. Gershater MA, Pilhammar E, Roijer CA.
Documentation of diabetes care in home
nursing service in a Swedish municipality: a
11
Lancet 2010;376(9756):1923-58.
3. Garcia PJ, Curioso WH, Lazo-Escalante M,
Gilman RH, Gotuzzo E. Global health training
is not only a developed-country duty.
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5. Department of Vermont Health Access.
Vermont blueprint for health implementation
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http://www.hcr.vermont.gov/blueprint.
(Accessed 18 Aug 2012.)
6. Pyle M. IPE in the context of evolving
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Scand J Caring Sci 2011;25(2):220-6.
5. Narayan KM, Boyle JP, Geiss LS, Saaddine JB,
Thompson TJ. Impact of recent increase in
incidence on future diabetes burden: U.S.,
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6. U.S.Department of Health and Human
Services and Office of Disease Prevention and
Health Promotion. Healthy People 2020:
Diabetes – find evidence-based information and
recommendations related to diabetes. 2011.
http://healthypeople.gov/2020/topics
objectives2020/. (Accessed 6 Jul 2012.)
7. Lalla E, Papapanou PN. Diabetes mellitus
and periodontitis: a tale of two common
interrelated diseases. Nat Rev Endocrinol
2011;7(12):738-48.
8. Greenberg BL, Glick M, Frantsve-Hawley J,
Kantor ML. Dentists’ attitudes toward chairside
screening for medical conditions. J Am Dent
Assoc 2010;141(1):52-62.
9. Lalla E, Kunzel C, Burkett S, Cheng B,
Lamster IB. Identification of unrecognized
diabetes and pre-diabetes in a dental setting.
J Dent Res 2011;90(7):855-60.