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Students learn to screen for diabetes

Nation's epidemic drives University of Maryland School of Dentistry to focus on prevention, monitoring

June 19, 2019

By Jennifer Garvin


Experiment: Dr. Hack presents student Desire Renggli with a Coke to show her how the beverage can raise blood sugar levels.
Editor's note: In November 2017, the ADA News launched Becoming a Dentist, a series of stories that follows three dental students at the University of Maryland School of Dentistry — Dan Yang, LaShonda Shepherd and Ben Horn — during their journey to becoming dentists. See all the stories in the series at ADA.org/BeADentist.

Baltimore — Class was just underway and already the dental students were thinking about numbers.

Photo of LaShonda demonstrating how to test and read blood glucose levels
Watch me: LaShonda demonstrates to the class how to test and read blood glucose levels.
LaShonda was surprised to get 86 — she thought she'd be higher.

Ben and Dan were certain they'd be in the 100s.

Were they wondering about their latest lab grades?

Not this time. As students in Dr. Gary Hack's diabetes class, they were challenged with guessing their blood glucose levels.

Learning about the importance of blood glucose levels is part of the University of Maryland School of Dentistry's diabetes block. Each year, all second-year dental students learn how to measure the blood glucose levels of university dental clinic patients. The program, which is supported by an ongoing grant from the Maryland Office of Oral Health, helps the future dentists understand the relationship between oral health and diabetes so that they can better treat their future patients.

Diabetes continues to be a growing problem in the U.S. and worldwide. According to the Centers for Disease Control and Prevention, more than 100 million U.S. adults have diabetes (over 30 million) or prediabetes (over 86 million). Many don't realize they have the chronic disease, which can affect their oral health. Oral manifestations of diabetes can include gingivitis, periodontitis, xerostomia, thrush, impaired or delayed wound healing, increased incidence and severity of infections and parotid salivary gland enlargement.

"Twenty-seven million people will see a dentist in a year, and not see a physician," said Dr. Hack, a professor in the school's department of advanced oral sciences and therapeutics. "Since periodontal disease is one of the first signs of diabetes, dentists should begin to monitor their patients with diabetes and screen at-risk patients for diabetes and prediabetes."

Image of Becoming A Dentist graphicToday's class begins with students testing their own blood glucose levels using a glucometer. Before arriving, they were encouraged to eat breakfast but not everyone had time for a meal. High blood sugar, known as hyperglycemia, is defined as a value of more than 140.

With his love of gummy bears and soda, Dan said he was a little surprised to learn his blood glucose reading was only 107. He was worried it would be higher.

"I have a family history of diabetes — both grandparents on my dad's side have diabetes," said Dan.

Ben, who skipped breakfast that morning, was surprised to find his number was 93.

"Knowing my score was a little high (for me) that day is enough motivation for me to tweak my lifestyle," Ben said.

LaShonda, who ate eggs before coming to class, guessed her reading would be around 110 instead of the 86 she measured.

Photo of Dan and Ben checking their blood sugar levels
Test time: Dan and Ben test their blood sugar levels.
Testing themselves and learning how to use the glucose meters is a key part in preparing for their upcoming work in UMSOD's dental clinic. In the clinic, a blood glucose test is offered to patients who have diabetes risk factors. According to the CDC, those risk factors include being overweight, being over 45, having a parent or sibling with type 2 diabetes and not being physically active. Students refer patients found to have high blood glucose levels to medical colleagues at the university or to their primary care providers. The clinic makes glucometers and A1C blood test point-of-care instruments available to do this.

"Diabetes is a systemic disease that is a risk factor for gum disease," Dr. Hack told the class. "People with poor glucose control are more prone to periodontal disease and that makes it more difficult to control blood sugar levels.
There is a bidirectional relationship between oral health and diabetes.

"Some people even think that chronic, severe periodontal disease can actually initiate diabetes," he continued, "so there is a huge relationship."

When it comes to diabetes and dentistry, it's personal for Dr. Hack, who has been living with the disease for more than 30 years and wears a continuous glucose monitor and insulin pump. He launched the diabetes course at UMSOD in 2014.

During his lecture, Dr. Hack broke down some typical scenarios that could occur when a person with diabetes comes in for treatment.

"There was a patient who came into the clinic and was asked what his blood sugar was and he said, 'It's perfect,' " Dr. Hack recalled. "However, the student had taken this course and when she took his blood sugar, she found it was extremely high. The student was then able to refer the patient back to his physician."

In another, he described a patient testing with a low blood sugar reading. That patient might be given orange juice and tested again 15 minutes later before proceeding with treatment.

Photo of Dr. Hack giving a lecture
Oral-systemic connection: Dr. Hack gives a lecture on diabetes at the University of Maryland School of Dentistry on April 25.
For the future practitioners, Dr. Hack advised keeping glucose tablets or juice on hand for these situations — both of which the university clinic currently does.

"People do not generally go to a physician without symptoms, but we see otherwise healthy people every day," Dan said. "Our role in health care puts us in the perfect position to screen for these types of illnesses. Given the fact that a majority of people in the U.S. with prediabetes do not even know, it makes sense that we should offer these routine tests for each of our patients."

"At this point in time, dentists can't diagnose diabetes, but because diabetes is such an epidemic, I believe dentists will one day be able to. I've talked to endocrinologists about this, and they're overwhelmed. They would welcome the help," Dr. Hack said.

LaShonda said she's up for the responsibility.

"I absolutely plan to use glucose meters in the future. If they will give me a more comprehensive view of my patient's health status, they're worth the effort," she said.

The ADA currently has no policy on dentists screening for diabetes but the ADA Code on Dental Procedures and Nomenclature approved codes in 2018 and 2019 for reporting HbA1c in-office testing and blood glucose level tests using a glucose meter. Dr. Hack attended the Code Maintenance Committee meetings to support both of these codes.