RESEARCH A ND PR A C TIC E

The Potential for Glycemic Control Monitoring and

Screening for Diabetes at Dental Visits Using Oral Blood
| Shiela M. Strauss, PhD, Mary T. Rosedale, PhD, PMHNP-BC, NEA-BC, Michael A. Pesce, PhD, David M. Rindskopf, PhD, Navjot Kaur, RN, Caroline M.
Juterbock, RN, Mark S. Wolff, DDS, PhD, Dolores Malaspina, MD, MS, MSPH, and Ann Danoff, MD

Although diabetes has reached epidemic pro

portions in the United States,1 many diabetes
complications could be mitigated by early de
tection coupled with lifestyle modification and
therapeutic interventions to optimize glycemic
control.2 Unfortunately, 8.1 million of the 29.1
million persons in the United States who have
diabetes are undiagnosed,3 and among those
diagnosed with diabetes, many are not likely to
have received regular testing to monitor their
glycemic control.4 An additional 86 million US
adults have prediabetes, a condition that often
progresses to diabetes, but only 11.1% of these
persons have been told of their condition.3
Importantly, early identification and treatment
of prediabetes can interrupt its progression.5,6
Thus, more opportunities are needed to screen
for prediabetes and diabetes and to monitor
glycemic control in those already diagnosed.
Because many persons in the United States
visit a dental provider but not a primary care
provider (PCP) each year,7 the dental visit may
serve as an opportune site for diabetes screen
ing and monitoring blood glucose.8-10 How
ever, both dental patients and dental providers
are accustomed to having dental providers only
administer care in the mouth. In an earlier pilot
study, we therefore investigated and demon
strated the acceptability and feasibility of using
oral blood to screen for diabetes in persons
with bleeding on dental probing.11,12 Many
patients appreciated the use of oral blood for
this screening, indicating that its collection felt
like a routine dental cleaning, and most dental
providers felt that the oral blood collection was
fast and easy.12
In the current study, we refined our exam
ination of the use of oral blood to screen for
diabetes by implementing a laboratoiy-based
approach to diabetes testing that enabled de
finitive and accurate analysis of all of the
samples for which sufficient blood was
collected. We included a large sample of
patients (n = 408) at risk for diabetes or its

Objectives. We examined the potential for glycemic control monitoring and

screening for diabetes in a dental setting among adults (n = 408) with or at risk for
diabetes.
Methods. In 2013 and 2014, we performed hemoglobin A1c (HbA1c) tests on
dried blood samples of gingival crevicular blood and compared these with
paired "gold-standard" HbA1c tests with dried finger-stick blood samples in
New York City dental clinic patients. We examined differences in sociodemo
graphics and diabetes-related risk and health care characteristics for 3 groups of
at-risk patients.
Results. About half of the study sample had elevated HbA1c values in the
combined prediabetes and diabetes ranges, with approximately one fourth of
those in the diabetes range. With a correlation of 0.991 between gingival
crevicular and finger-stick blood HbA1c, measures of concurrence between the
tests were extremely high for both elevated HbA1c and diabetes-range HbA1c
levels. Persons already diagnosed with diabetes and undiagnosed persons
aged 45 years or older could especially benefit from HbA1c testing at dental
visits.
Conclusions. Gingival crevicular blood collected at the dental visit can be used
to screen for diabetes and monitor glycemic control for many at-risk patients.
(Am J Public Health. 2015;105:796-801. doi:10.2105/AJPH.2014.302357)

complications who presented for regular dental

visits at a dental colleges comprehensive care
clinics. We analyzed the sociodemographic and
diabetes risk-related characteristics of the
sample, and compared the results of diabetes
screening and glycemic control monitoring
with dried blood samples of gingival crevicular
blood (GCB) and gold-standard finger-stick
blood (FSB) to determine the validity of using
GCB for this purpose. This screening and
monitoring was performed by testing the sam
ples for hemoglobin A le (HbAlc), a test pro
moted by the American Diabetes Association
for diabetes diagnostic purposes and glycemic
control monitoring.2 By providing an average
measure of glycemic control over a 3-month
period, this test is especially advantageous
because fasting is not needed for HbAlc
assessment, and no acute perturbations (e.g.,
stress, diet, exercise) affect HbAlc.2 Finally, we
examined the potential benefits of this ap
proach to diabetes screening and glycemic
control monitoring according to whether study

7 9 6 I Research and Practice | Peer Reviewed | Strauss et al.

participants had previous-year tests for blood

glucose and previous-year visits to PCPs and
dental providers.
METHODS

Study recruitment, participation, and data

collection took place in the comprehensive care
clinics at the New York University College of
Dentistry from June 2013 to April 2014.
Study Participants

Persons were eligible for the research if they

indicated that their gums bled on brushing or
flossing and if they (1) were aged at least 18
years; (2) did not require antibiotics before
dental treatment; (3) did not have a history of
severe cardiovascular, hepatic, immunologic,
renal, hematologic, or other organ impairment;
and (4) had been told by a health care provider
that they had diabetes (group 1) or they were at
risk for diabetes according to American Di
abetes Association criteria (groups 2 and 3).2

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RESEARCH AND PRACTICE

These criteria included (1) being aged at least

45 years (group 2) or (2) being aged between
18 and 44 years, having a body mass index
(BMI; defined as weight in kilograms divided by
the square of height in meters [kg/m2]) of
25 kg/m 2 or greater, and having at least 1 of
the following additional diabetes risk factors:
little or no exercise on a given day; first-degree
relative (parent or sibling) with diabetes; Latino
ethnicity; Black, Native American, or Pacific
Islander race; or being a woman who gave birth
to a baby weighing 9 pounds or more (group 3).
Study Procedures
Research assistants recruited New York
University College of Dentistry patients when
the patients were seated in the clinics waiting
areas before their scheduled dental appoint
ments, where they were screened for study
eligibility. The research assistants oversaw the
eligible participants completion of a 30-minute
survey that assessed sociodemographic char
acteristics and health care utilization. W ith the
patient seated in the dental chair for the dental
procedure, the research assistants collected two
10-pm blood samples (FSB and GCB) with
micropipettes. The 2 samples were placed on
separate W hatm an 903 filter papers (GE
Healthcare, Bio-Sciences Corp, Westborough,
MA), labeled with separate identification
codes, and allowed to dry for 1 hour at room
temperature. They were then separately sealed
in plastic bags, stored at 4C, and transported to
the laboratory for H bA lc analysis. Only re
search team members knew the correspon
dence between FSB and GCB identification
codes; the laboratory was masked to this in
formation and analyzed the samples as unique
specimens for H bA lc testing.
The laboratory used a high-performance
liquid chromatography D-10 program (BioRad Laboratories Inc, Hercules, CA), which is
traceable to the reference methods of both the
National Glycohemoglobin Standardization
Program and the International Federation of
Clinical Chemistry and Laboratory Medicine, to
analyze the blood samples for H bAlc.
Statistical Methods
W e assessed the study sample in terms of its
sododemographic and diabetes-related risk char
acteristics according to the 3 diabetes-related risk
groups described in the studys eligibility criteria

W e used x2 analysis to determine statistically

significant differences among these groups and
between pairs of these groups.
W e measured central tendency, dispersion,
and correlation of FSB H bA lc and GCB HbAl c;
regression of GCB H bA lc on FSB HbAlc; and
the proportion of the samples out-of-range FSB
H bA lc and GCB H bA lc values in the pre
diabetes and diabetes ranges. W e used these
data and analyses, as well as those from 2
Receiver Operating Characteristic Curve (ROC)
analyses, to determine GCB H bA lc values that
could serve as criteria for positive diabetes
screening and glycemic control monitoring re
sults. These GCB H bA lc values correspond to
elevated FSB FlbAlc readings (ie., in the pre
diabetes or diabetes ranges: > 5.7%) and
diabetes-range readings (i.e., > 6.5%) W e then
assessed the concurrence of elevated H bA lc in
FSB and GCB samples by using percent agree
ment and Cohens k .13 W e also examined the
specificity and sensitivity of elevated GCB
HbAlc readings relative to gold-standard FSB
HbAlc levels. In addition, we evaluated the
predictive power of both a positive GCB HbAlc
test (> 5.7%) and a negative GCB HbAlc test
(< 5.7%). W e similarly examined concurrence
of HbAlc in the diabetes range in FSB and GCB
samples. W e performed all statistical analyses
with IBM PASW version 21 (IBM, Somers, NY).
To determine whether H bA lc testing at the
dental visit could benefit persons with or at risk
for diabetes, we report the proportion of persons
diagnosed with diabetes and for whom glycemic
control monitoring would be especially helpful.
W e also used x2 analysis to determine the types
of persons at risk for diabetes who could most
benefit from diabetes screening based on
whether they had previous-year testing for
blood glucose and clinical visits to PCPs and
dental providers within the previous year.
RESULTS
A total of 518 individuals volunteered to
participate in the study, and 4 5 4 were eligible.
Of these 4 5 4 individuals, we collected and
measured an FSB sample for H bA lc from 441
participants. Paired H bA lc values from GCB
were unavailable for 33 of these 441 partici
pants: 17 were not collected because of in
sufficient bleeding on dental probing during
the dental visit and 16 had insufficient oral

April 2 0 1 5 , Vol 1 0 5 , No. 4 | American Journal o f Public Health

blood collected on filter paper for laboratory

analysis. Thus, there were 4 0 8 eligible indi
viduals in the study sample, all of whom had
paired FlbA lc values from FSB and GCB
specimens. On the basis of study eligibility
criteria, we divided the study sample into 3
diabetes risk groups: group 1 with 67 persons;
group 2 with 245 persons; and group 3 with
96 persons. It is notable that, like the persons in
group 3, 54.7% of those in group 2 had a BMI
of 25 kg/m 2 or greater, as well as at least 1
additional diabetes risk factor.
As shown in Table 1, 56.9% of study partic
ipants were female, and two thirds either had
some college education (23.4%) or had com
pleted technical school or college (43.1%).
Overall, 55.9% were aged between 45 and 64
years, and 18.9% were aged at least 65 years.
Their allocations to the diabetes risk groups were
dependent, in part, on both age and BMI. Thus,
there were statistically significant differences
between the groups in terms of age CP<.001),
including for all pairwise group comparisons
(P< .001). There were also statistically signifi
cant differences among the groups in terms of
BMI of 25 kg/m2 or greater (P<,001), with
groups 1 and 2 each differing significantly from
group 3 (P<.001). In all, 70% of the study
sample had a BMI of 25 kg/m2 or greater. The
majority (59.9%) had little or no daily exercise.
Although there were no statistically signifi
cant differences in the 3 study sample groups
regarding increased diabetes risk because of
race (36.7% were Black, Native American, or
Pacific Islander), there were statistically signif
icant differences regarding increased risk for
participants because of Latino ethnicity
(P< .001). Latinos constituted almost half
(46.9%) of the persons in group 3, compared
with 29.9% in group 1 (P= .029) and 24.7%
in group 2 (P< .001). The groups also differed
significantly regarding having a parent or sib
ling with diabetes (P = .003). Almost two thirds
(64.2%) of persons in group 1 had a firstdegree relative with diabetes, compared with
40.8% in group 2 (P < .0 0 1 ) and 44.8% in
group 3 (P= .015). There were also statistically
significant differences among the groups re
garding women who had a baby weighing at
least 9 pounds at birth (17.6%, 4.9%, and
10.7% in groups 1, 2, and 3, respectively;
P = .0 3 8 ), with women in group 1 differing
significantly from women in group 2 (P= .011).

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RESEARCH AND PRACTICE

TABLE 1 S o ciodem ographic and D ia b e te s -R e la te d Risk C h ara c te ristic s o f a S a m p le o f D e n ta l C linic P a tie n ts , by D ia b e te s Risk Groups:
New York City, 2 0 1 3 - 2 0 1 4

C haracteristic

Group 1: Told H ad D iabetes

Group 2: N ot Told H ad D iabetes

Group 3: O ther3

Total

(n - 6 7 ), %

and Aged > 4 5 Years (n = 2 4 5 ), %

(n - 9 6 ), %

(n = 4 0 8 ), %

5 0 .7

5 8 .0

5 8 .3

5 6 .9

Fem ale
A g e ***
1 8 -4 4 y

1 0 .4

0 .0

1 0 0 .0

2 5 .2

4 5 -6 4 y

6 5 .7

7 5 .1

0 .0

5 5 .9

2 3 .9

2 4 .9

0 .0

1 8 .9

< high-school g raduate

3 7 .9

3 1 .7

3 4 .7

3 3 .4

S om e college

2 4 .2

2 0 .8

2 9 .5

2 3 .4

Technical school or college

3 7 .9

4 7 .5

3 5 .8

4 3 .1

>65 y
Highest education

graduate
BMI > 2 5 k g /m 2* * *

6 8 .7

5 8 .4

1 0 0 .0

7 0 .0

L ittle or no dally exercise

6 1 .2

5 8 .8

6 1 .5

5 9 .9

First-degree relative with

6 4 .2

4 0 .8

4 4 .8

4 5 .6

d ia b e te s **
Latino e th n ic ity * * *

2 9 .9

2 4 .7

4 6 .9

3 0 .8

Black, N ative A m erican, or Pacific

4 3 .1

3 6 .4

3 3 .3

3 6 .7

1 7 .6

4 .9

1 0 .7

8 .2

Islander race
Am ong w om en, had baby > 9
p ounds*

Note. BM I = body m ass index (defin ed as weight in kilogram s divided by th e square of height in m eters).
aN ot told he or she had d ia be tes , aged 1 8 - 4 4 y, BMI > 2 5 k g /m 2, and > 1 o f the follow ing ad d itio n a l d ia be tes risk factors: little or no exercise on a given day; first-degree relative (p a re n t, sibling)
with d iabetes; Latino ethnicity; Black, N ative Am erican, or Pacific Islander race; w om an who gave birth to a baby > 9 pounds.
* P < .0 5 ; * * P < .0 1 ; * * * P < . 0 0 1 .

C on cu rren ce of H em oglobin A l e Values

in P aired Blood S am p les

As shown in Figure 1, HbAl c values assessed

with FSB and GCB were nearly identical, with
a correlation of 0.991. Finger-stick blood
HbAlc ranged from 4.2% to 10.8% and GCB
HbAlc ranged from 4.1% to 10.9%. Each of
the 2 FlbAlc measures had a mean of 5.9%,
a median of 5.7%, a standard deviation of 0.93,
and a standard error of the mean of 0.046. A
regression analysis in which GCB FlbAlc was
regressed on FSB HbAlc yielded
(1) GCB FFbAlc = 0.060 + 0.987 * FSB
HbAlc.
We determined that 5.7% and 6.5% were
GCB HbAlc values that could serve as criteria
for elevated and diabetes-range H bA lc results
corresponding to elevated and diabetes-range
K B H bA lc readings, respectively. This de
termination was made because (1) the means,
medians, standard deviations, and standard

errors of the means were identical for the study

samples FSB FlbAlc and GCB HbAlc values;
(2) the correlation of the 2 HbAlc values was
0.991; (3) the regression of GCB HbAlc on
FSB HbAlc had an intercept close to 0 and
a slope of almost 1; and (4) in 2 ROC analyses,
the sum of (1-sensitivity)2 plus (1-specificity)2
for the GCB H bA lc value of 5.7% as a crite
rion for elevated HbAlc and 6.5% as a crite
rion for diabetes-range HbAlc were each close
to 0 (0.010 and 0.004, respectively). In the
ROC analysis for elevated FlbAlc, the area
under the ROC curve was 0.976, and in the
analysis for diabetes-range HbAlc, the area
under the ROC curve was 0.998.
C oncu rren ce of O ut-of-Range Hem oglobin
A l e V alu es in P aired Blood S am ples

We measured the concurrence of HbAlc

values in the FSB and GCB samples for both
elevated HbAlc levels and for HbAlc levels
in the diabetes range. As shown in Table 2,

7 9 8 | Research and Practice | Peer Reviewed | Strauss et at.

53.2% of the study sample had FSB HbAlc

values in the prediabetes or diabetes (elevated)
ranges, including 13.0% in the diabetes range.
When we measured HbAl c with GCB, 51.5%
had elevated H bAlc values, including 13.7%
in the diabetes range.
When we considered agreement between
K B HbAlc and GCB HbAlc for elevated
values in either prediabetes or diabetes ranges,
the percent agreement was 92.9, remaining
high at 85.8 when corrected for chance
agreement as measured by k . Only 11 in
dividuals had a normal FSB HbA 1c reading but
an elevated GCB HbAlc reading, and 18 had
an elevated K B HbAlc reading but a normal
GCB HbAlc reading. Although differences in
these 29 individuals FSB and GCB sample
level readings were small (mean = -0.03;
SD = 0.23), a person whose HbAlc level was
close to 5.7% could have 1 samples HbAlc
level in the normal range (< 5.7%) and the
other samples level in the elevated range

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RESEARCH AND PRACTICE

P o te n tia l B e n e fic ia r ie s o f H e m o g lo b in
A l e T e s tin g a t D e n ta l V is its

Although all adults with diabetes can po

tentially benefit from additional opportunities
for glycemic control monitoring, these oppor
tunities are especially advantageous for those

N ote. The diagonal line represents equal paired hem oglobin A le fin g er stick blood and gingival crevicular blood values.
FIG UR E 1 -P a ir e d hem oglobin A l e (H b A lc ) fin g e r s tic k blood and gingival c re v ic u la r blood
values in a s a m p le o f d e n ta l c lin ic p atie n ts : New York City, 2 0 1 3 - 2 0 1 4 .

(> 5.7%). Other measures of concurrence in

cluded (1) specificity of the GCB H bA lc of 94.2
and the predictive power of a negative GCB
H bA lc test (< 5.7%) of 90.9; and (2) sensitivity
of the GCB H bA lc of 91.7 and the predictive
power of a positive HbA 1c test (> 5.7%) of 94.8.
W e also considered agreement between FSB
H bA lc and GCB H bA lc for values in the
diabetes range (Table 2). The percent agree
ment was 97.8 and the k statistic was 0.905.
Only 6 individuals had a FSB H bA lc reading
in the prediabetes range but a diabetes-range

GCB H b A lc reading, and 3 had a diabetesrange FSB H b A lc reading but a GCB FlbA lc
reading in the prediabetes range. Differ
ences in these 9 individuals FSB and GCB
sample level readings had a m ean of 0 .1 0
(SD = 0.24). Other measures of concurrence
included (1) specificity of the GCB H bA lc of
98.3 and the predictive power of a negative
GCB H bA lc test (< 6.5%) of 99.1; and (2)
sensitivity of the GCB H bA lc of 94.3 and the
predictive power of a positive H bA lc test
(>6.5%) of 89.3.

with elevated HbA 1c levels. As shown in Table

3, 92.5% of group 1 participants had GCB
H bA lc readings of 5.7% of greater. Hemo
globin A le monitoring at the dental visit may
be particularly helpful for the 71.6% of per
sons in group 1 who visited dental providers on
a yearly or more frequent basis, especially
because almost all of these individuals (93.8%)
had elevated GCB H bA lc readings. Such op
portunities may also be of great benefit to the
12.3% of persons in group 1 who did not visit
(or did not have) a PCP in the previous year. All
of these individuals had elevated GCB H bA lc
values. W hether they saw a PCP in the pre
vious year, 9.4% of group 1 participants noted
that their glucose test was conducted more than
1 year ago and all had elevated GCB H bA lc
values. As shown in Table 3, results for persons
in group 1 with elevated FSB H bA lc readings
were very similar.
All at-risk persons who were never told they
had diabetes can potentially benefit from ad
ditional opportunities for diabetes screening,
but these opportunities may be more advanta
geous for one group of at-risk persons com
pared with another. As shown in Table 3,
participants in group 2 (at risk because they
were > 45 years) might especially reap great
benefit from diabetes screening at dental visits.
They were significantly more likely than those

TABLE 2 -C o n c u r r e n c e o f Elevated and D ia betes-R an ge H em oglobin A l e V alues From Finger S tic k and Gingival C revicu lar Blood Testing of
a S a m p le o f D e n ta l C lin ic P a tie n ts : New York City, 2 0 1 3 - 2 0 1 4
O ut-of-R ange
Values Based on

Out-of-R ange

O ut-of-R ange

Finger Stick

Values Based on

Percent

Values

B lood, %

Oral Blood, %

A greem ent

5 3 .2

5 1 .5

9 2 .9

1 3 .0

1 3 .7

9 7 .8

P rediabetes or

Predictive Power

Predictive Power

o f N egative Oral

of Positive Oral

Specificity

Test

Test

Sensitivity

0 .8 5 8

9 4 .2

9 0 .9

9 4 .8

9 1 .7

0 .9 0 5

9 8 .3

9 9 .1

8 9 .3

9 4 .3

d ia be tes range
(H b A lc > 5 .7 % )
D ia be tes range
(H b A lc > 6 .5 % )
N ote. H b A lc = hem oglobin A le .

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RESEARCH AND PRACTICE

TABLE 3 At-Risk Adults Who Could Especially Benefit From Glycemic Control Monitoring and Diabetes Screening at Dental Visits:
New York City, 2 0 1 3 -2 0 1 4
Group 2: N o t Told Had

Variables

Group 1: Told Had

D ia be tes and Aged > 4 5

Group 3: Other3

P C om paring Group

D ia be tes (n = 6 7 ), %

Years (n = 2 4 5 ), %

(n = 9 6 ), %

2 and Group 3

GCB H b A lc > 5 .7 %

9 2 .5

5 1 .4

2 2 .9

< .0 0 1

FSB H b A lc > 5 .7 %

8 9 .6

5 4 .7

2 4 .0

< .0 0 1

Have regular visits with dental

7 1 .6

6 1 .7

5 4 .2

.2 0 6

provider
GCB H b A lc > 5 .7 %

9 3 .8

5 0 .7

1 7 .3

< .0 0 1

FSB H b A lc > 5 .7 %

9 1 .7

5 2 .0

1 7 .3

< .0 0 1

1 2 .3

2 0 .2

3 3 .3

.0 1 2

GCB H b A lc > 5 .7 %

1 0 0 .0

5 1 .1

2 5 .8

.0 2 6

FSB H b A lc > 5 .7 %

8 7 .5

5 5 .3

2 9 .0

.0 2 2

9 .4

4 2 .2

7 0 .1

< .0 0 1

1 0 0 .0

5 1 .6

1 6 .4

< .0 0 1

5 3 .7

1 8 .0

< .0 0 1

Did not see prim ary care provider in

past y

N ever tested or tested > 1 y ago for

blood glucose
GCB H b A lc > 5 .7 %
FSB H b A lc > 5 .7 %

1 0 0 .0

N o te. BMI = body m ass index (defined as weight in kilogram s divided by th e s qu are o f height in m eters); FSB - finger-stick blood; GCB - gingival crevicular blood; H b A lc * hem oglobin A le .
N ot told he o r she had d iabetes, aged 1 8 - 4 4 y, BMI > 2 5 k g /m 2, and had > 1 o f the follow ing ad d itio n a l d ia be tes risk factors: little or no exercise on a given day; first-degree relative (pa re n t,
sibling) with diabetes; Latino ethnicity; Black, N ative A m erican, o r Pacific Islan d er race; w om an who gave birth to a baby > 9 pounds.

in group 3 (at risk because they were aged 1844 years, had a BMI >25 kg/m2, and had > 1
additional diabetes risk factor) to have elevated
GCB H bA lc readings (51.4% vs 22.9%;
P<.001). This may especially be the case
because, in addition to older age being a major
risk factor for diabetes,2 the majority of persons
in group 2 also had a BMI of 25 kg/m2 or
greater and had at least 1 additional diabetes
risk factor possessed by persons in group 3.
Significantly higher GCB HbAlc readings for
subgroups of persons in group 2 compared
with group 3 were also the case for those who
had regular visits with a dental provider
(50.7% vs 17.3%; P< .001), those who did not
see a PCP in the previous year (51.1% vs
25.8%; P=.026), and those who were never
tested or were tested more than 1 year ago for
blood glucose (51.6% vs 16.4%; P< .001). As
shown in Table 3, results for persons in groups
2 and 3 with elevated FSB HbAlc readings
were very similar.

DISCUSSION
Approximately 46% of all US adults have
prediabetes or diabetes.'5 Whether measured

by using GCB or FSB, about half of our at-risk

sample of adults appearing for dental care
(51.5% vs 53.2%, respectively) had HbAlc
values in prediabetes or diabetes ranges. In
addition, 12.3% of all US adults have diabe
tes3; of our study sample, 13.7% had GCB
HbAlc readings in the diabetes range and
13.0% had FSB HbAlc readings in this range.
We acknowledge that there were some differ
ences in classification according to prediabetes
and diabetes-range HbAlc results with use of
FSB and GCB. However, percent agreement,
k, sensitivity, specificity, and the predictive
powers of both positive and negative tests of
GCB HbAlc relative to FSB HbAlc were
extremely high for both elevated HbAlc and
HbAlc levels in the diabetes range. Lack of
concurrence between FSB HbAlc and GCB
HbAlc regarding elevated and diabetes-range
HbAlc values was the case for only 29 and 9
of 408 individuals, respectively. This supports
the value of diabetes screening and glycemic
control monitoring with the approach we
employed.
Among persons who had been told that they
had diabetes, three quarters had regular visits
with dental providers at which time their

8 0 0 | Research and Practice | Peer Reviewed | Strauss et at.

HbAlc could have been measured. Although

only a small proportion of those with a pre
vious diabetes diagnosis did not see a PCP or
have a blood glucose test in the previous year,
all of these individuals had elevated readings
on the GCB HbAlc test, and all but 1 of these
individuals had an elevated FSB HbAlc read
ing. Therefore, patients may benefit from ad
ditional glycemic control monitoring in the
dental settings that they already use. For those
who have a PCP but had not visited that
provider in the previous year, the dental pro
vider might encourage such a visit. For those
without a regular PCP, the dental provider
might emphasize the importance of identifying
a PCP and make a referral, when appropriate.
Our findings indicate that at-risk adults aged
at least 45 years who had never been told that
they had diabetes could especially benefit from
HbAlc testing at dental visits. Close to two
thirds saw a dental provider on a regular basis,
and about half of these persons had elevated
HbAlc. Similarly, 1 in 5 did not see a PCP in
the previous year, and about half of these
individuals had H bA lc levels in the prediabe
tes or diabetes ranges. In addition, 2 in 5 did
not have a blood glucose test in the past 12

American Journal o f Public Health ] April 2 0 1 5 , Vol 10 5, No. 4

RESEARCH AND PRACTICE

months, and about half had elevated HbAlc

readings. Many persons aged at least 45 years
with elevated HbAlc levels have never been
told that they have prediabetes or diabetes, and
may remain unaware of their diabetes risk.
Therefore, screening for prediabetes and di
abetes at alternate sites, such as at the dental
visits that patients already attend, offers a key
window of opportunity for health assessment
and monitoring.
Several limitations to the study are ac
knowledged. The sample was nonrandom,
composed of persons who were at risk for
diabetes and its complications, self-selected to
participate in the study, and whose gums bled
on probing. Although bleeding on probing is
widespread among all American adults (ap
proximately half of US adults have periodontal
disease and an additional proportion has gin
givitis,14 most of whom bleed on probing), and
bleeding on probing is especially common
among persons with prediabetes and diabe
tes,1516 some patients do not bleed on gentle
dental probing. For such patients, HbAlc test
ing could still be performed at dental visits by
using blood collected from the finger.12 In
addition, although HbAlc values were
obtained through laboratory testing, another
study limitation involves the use of other data
in the analyses that were provided through
participant self-report, some of which may have
been subject to social desirability or inaccurate
recall.
Despite these limitations, our study has
considerable public health significance because
we identify the value and importance of capi
talizing on an opportunity at the dental visit (1)
to screen at-risk, but as yet undiagnosed,
patients for diabetes (especially those aged > 45
years) and (2) to monitor glycemic control in
those already diagnosed so as to enable them to
maintain their health to the greatest extent
possible.

About the Authors

A t the time of this study, Shield M. Strauss, Mary T.
Rosedale, and Navjot Kaur were with the College of
Nursing, New York University, New York, NY. Michael A.
Pesce was with the Columbia University Medical Center,
New York. David M. Rindskopf was with the Graduate
School and University Center of the City of New York.
Caroline M. futerbock, Dolores Malaspina, andAnnDanoff
were with the NYU Langone Medical Center, New York
University. Mark S. Wolff was with the College of Dentistry,
New York University.

Correspondence should be sent to Shield M. Strauss, PhD,

Associate Professor, New York University College of Nurs
ing, 433 First Avenue, 6th Floor, New York, N Y 10010
(e-mail: shiela.strauss@nyu.edu). Reprints can be ordered
at http://www.ajph.org by clicking the Reprints link.
This article was accepted September 22, 2014.

Contributors
S. M. Strauss and M. T. Rosedale conceptualized the
study and S. M. Strauss led the analyses with the support
of D. M. Rindskopf. S. M. Strauss led the writing,
with contributions from M. T. Rosedale, M. A. Pesce,
D. M. Rindskopf, N. Kaur, C. M. Juterbock, M. S. Wolff,
D. Malaspina, and A. Danoff. All authors contributed
to the editing of the artide and collaborated on the
interpretation of study results and their implications.

Acknowledgments
Funding for this study was provided by the National
Institute of Dental and Craniofacial Research (grant
1R15DE023201). Portions of the salaries of S. M.
Strauss., M. T. Rosedale, N. Kaur, C. M. Juterbock, M. S.
Wolff, and D. Malaspina were covered by this grant.
We wish to thank the many nursing students, dentists,
dental hygienists, and dental and dental hygiene students
who assisted with subject recruitment, blood sample
collection, and survey collection support. We also thank
the study participants, whose willingness to respond to
our questions and allow the collection of finger stick and
oral blood samples enabled us to perform the research.

Human Participant Protection

The study was approved by the institutional review
board at the New York University School of Medicine.

8. Lalla E, Kunzel C, Burkett S, Cheng B, Lamster IB.

Identification of unrecognized diabetes and pre-diabetes
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Effectiveness of screening for diabetes mellitus in dental
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Strauss et al.

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