|Year : 2017 | Volume
| Issue : 3 | Page : 210-213
Screening for diabetic patients using gingival crevicular blood with a self-monitoring device in an dental outreach program: A cross-sectional study
Arshdeep Singh1, Nagesh Bhat1, Harkiranjot Kahlon2, Ramandeep Singh Gambhir3, Anmol Rattan Singh Sandhu3, Jogdeep Singh Jagpal3
1 Department of Public Health Dentistry, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
2 Department of Oral Pathology, Pacific Dental College and Hospital, Udaipur, Rajasthan, India
3 Department of Public Health Dentistry, Gian Sagar Dental College and Hospital, Rajpura, Punjab, India
|Date of Web Publication||18-Sep-2017|
Ramandeep Singh Gambhir
Department of Public Health Dentistry, Gian Sagar Dental College and Hospital, Rajpura - 140 401, Punjab
Source of Support: None, Conflict of Interest: None
Background: The number of people with diabetes is increasing globally. Undiagnosed diabetes may be present in number of people having periodontitis. Self-monitoring devices, although useful, require a needle puncture. Aim: The aim of this study was to establish whether gingival crevicular blood (GCB) can be used as a noninvasive diagnostic aid in screening for diabetes mellitus during routine periodontal examination. Materials and Methods: The study involved sixty patients based on convenient sampling methodology. Probing depth, bleeding on probing (BOP), gingival bleeding index, and periodontal disease index were recorded. The GCB oozing out of the sites with positive BOP was collected. The capillary finger blood was collected from the pad of the finger. Both the samples were analyzed using a readily available portable blood sugar monitoring device. The data were analyzed using Karl's Pearson's correlation and Student's t-test. Results: GCB glucose levels ranged from 66 to 216 mg/dl with a mean of 137.15 ± 18.36 mg/dl as compared to the finger-prick blood glucose levels which ranged from 86 to 248 mg/dl with a mean of 134.24 ± 16.45 mg/dl. A Pearson's correlation coefficient between the GCB glucose levels and the capillary finger-prick glucose levels showed a very strong correlation with an r = 0.94. Conclusion: The data from this study have shown that GCB collected during diagnostic periodontal examination could be an excellent source of blood for glucometric analysis.
Keywords: Blood glucose self-monitoring, diabetes mellitus, gingival hemorrhage, periodontal diseases
|How to cite this article:|
Singh A, Bhat N, Kahlon H, Gambhir RS, Singh Sandhu AR, Jagpal JS. Screening for diabetic patients using gingival crevicular blood with a self-monitoring device in an dental outreach program: A cross-sectional study. J Indian Assoc Public Health Dent 2017;15:210-3
|How to cite this URL:|
Singh A, Bhat N, Kahlon H, Gambhir RS, Singh Sandhu AR, Jagpal JS. Screening for diabetic patients using gingival crevicular blood with a self-monitoring device in an dental outreach program: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2017 [cited 2020 Nov 29];15:210-3. Available from: https://www.jiaphd.org/text.asp?2017/15/3/210/215067
| Introduction|| |
Diabetes mellitus (DM) represents one of the major chronic health problems faced by the society today. The incidence of DM worldwide, and especially in India, is on a steep rise. The National Urban Diabetes Survey reported that the prevalence of impaired glucose tolerance (IGT) in the Indian subcontinent is ~8.7% in urban and ~7.9% in rural areas. Because of the observation that ~35% of those with IGT will develop full blown diabetes in ≤5 years, the sheer numbers of those with diabetes seem overwhelming. Moreover, 50% of the diabetics go undiagnosed.
DM and chronic periodontitis are common chronic diseases in adults in the world population. Diabetes and periodontitis seem to interact in a bidirectional manner. The increased prevalence and severity of periodontitis seen in patients with diabetes, especially in those with poor metabolic control, have led to the designation of periodontal disease as the “sixth complication of diabetes,” and successful periodontal therapy in diabetic patients entails the stabilization of blood glucose to a normal range.
Periodontal examination as a rule comprises careful probing of periodontal pockets which result in some amount of bleeding from the gingival sulcus. Instead of swabbing and disposing the gingival crevicular blood (GCB), this can be employed to assess blood glucose by glucometer. The screening for disease should start early, especially in high-risk populations, and should be repeated every 3 years and more frequently in people with other associated risk factors. The early diagnosis of diabetes, however, might help prevent its long-term complications that are responsible for the high morbidity and mortality of diabetic patients. A lot of diabetic patients undergoing dental treatment needs to be first ascertained of their existing blood sugar level, so that appropriate treatment strategies can be provided to the individual patients.
Glucose self-monitoring systems have provided reliable, rapid blood glucose determinations in diabetes screening and in home monitoring. When utilized in a dental office, such a system could result in a more objective parameter for referral for diagnosis of DM. Development of an intraoral blood sampling technique as opposed to the typically used finger site could make such tests even more suitable for use by dental practitioners.
A large population with gingivitis or with periodontitis might not be screened elsewhere, the dental outreach programs may be an important setting for opportunistic screening for diabetes, with substantial advantage to patients who might not get better chances for screened. This will open a larger window of opportunity for prevention whereas considering the possible reduction in modifiable risk factors among such patients which is possible only when the prediabetic stage is identified at earlier stages, in which the dental team has a key role.
The purpose of the present study was to establish whether GCB can be used as a noninvasive diagnostic aid in screening for DM during routine periodontal examination in a dental outreach program.
| Materials and Methods|| |
The study was conducted over a period of 5 days from November 14 to 18, 2016. The study protocol (cross-sectional study) was reviewed by the Institutional Ethical Committee and was granted Ethical Clearance. Official permission to conduct the study was obtained from the Institutional authorities. After explaining the purpose and details of the study, a written informed consent was obtained from all the patients who were willing to participate in the study.
First examiner conducted all the examinations. The examiner was calibrated in the department itself. Intraexaminer calibration was undertaken by examining 25 patients followed by reexamination a week later which resulted in 82% of diagnostic acceptability with a kappa value of 0.84.
Sixty patients were recruited from patients attending the dental outreach programs organized by the Department of Public Health Dentistry in rural areas around the institution on the basis of convenient sampling methodology. The required sample size was determined using the formula for estimating sample size for single population proportion with 95% confidence level and 0.05° of accuracy required.
Patients with gingivitis and/or periodontitis and patients with at least one site with positive bleeding on probing (BOP) were included in the study. Patients having any indication for antibiotic prophylaxis, any bleeding disorder, severe systemic disease such as cardiovascular, renal, hepatic, immunologic or hematological disorders, and taking any medication interfering with the coagulation system were excluded from the study.
Data were recorded using the probing depth, BOP, gingival bleeding index, and periodontal disease index, all measured by the same examiner. A Williams probe was used to examine all sites for BOP. The sites where probing was done were then carefully observed to check for blood oozing out of the respective sites. One of these sites with profuse BOP was chosen for obtaining the blood sample for GCB glucose analysis. The sites most commonly selected were the interproximal area of the maxillary premolar and molar regions. These areas were properly isolated with cotton rolls to prevent saliva contamination, and the remaining fluid in the site was wiped out using a piece of gauze.
The GCB oozing out of the sites with positive BOP was collected and analyzed using a readily available portable blood sugar monitoring device (Freestyle Optimum H, Mediscence, Abott Healthcare, Oxon, UK) according to the manufacturer's instructions. The device was selected considering its compact design. Glucometer was standardized by known sugar solution after every fifth reading.
The glucometric device was kept ready with a test strip in place before the probing. The site with positive BOP was isolated using cotton rolls and the device was then introduced into the oral cavity and the blood oozing out of the respective crevice was allowed to flow onto its reactive area. Care was taken to prevent the strip from contacting the tooth and entering the sulcus to prevent contamination of blood.
Following the collection of GCB, the capillary finger blood (CFB) was collected. The pad of the finger was wiped with laboratory spirit and allowed to dry. A sterile lancet was used to puncture the prepared pad of finger. A CFB sample was drawn onto the test strip preloaded in the same glucometric device. While loading the blood into the blood strip, care was taken not to squeeze the finger to remove the blood and the prick was made deep enough for free blood flow. The GCB and CFB glucose readings were recorded. These CFB readings were viewed as “casual” readings because they were taken without regard to the time of meals. Study patients with elevated casual readings were referred to primary care providers for a more detailed medical evaluation.
The data obtained were subjected to statistical analysis which was performed using Statistical Package for Social Science Version 16.0 for Windows (SPSS Inc., Chicago, IL, USA, version 16.0 for Windows). The categorical measurements were represented as number (%) and the results of continuous readings are presented as mean ± standard deviation, i.e., S.D. The Karl Pearson's correlation value has been used to find the correlation between the different variables, unpaired Student's t-test was used to find the differences between the GCB and CFB glucose measures. The level of significance was set at P < 0.05.
| Results|| |
The present study was conducted on sixty patients which included 64% (38) males and 36% (22) females with a mean age of 42.9 ± 12.56 years. The total study population of the sixty patients was categorized into two groups: patients with gingivitis (26%) and the other group comprised the patients with periodontitis (74%). Blood glucose levels were assessed successfully in all the sixty patients, of which four cases revealed elevated blood glucose levels. The prevalence of undiagnosed cases of DM has been observed at 6% in the present study.
In the present study, the GCB glucose levels ranged from 66 to 216 mg/dl with a mean of 137.15 ± 18.36 mg/dl as compared to the finger-prick blood glucose levels which ranged from 86 to 248 mg/dl with a mean of 134.24 ± 16.45 mg/dl [Table 1].
|Table 1: Blood glucose levels obtained by gingival crevicular blood and capillary finger-prick blood methods|
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A Pearson's correlation coefficient between the GCB glucose levels and the capillary finger-prick glucose levels showed a very strong correlation with an r = 0.94 and it was statistically highly significant at P < 0.0001 [Table 2].
|Table 2: Pearson's correlation between capillary finger-prick blood and gingival crevicular blood glucose|
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| Discussion|| |
The long-term morbidity and mortality associated with the disease can be effectively reduced with detection and treatment at earlier stages. The prevalence of undiagnosed cases of DM has been observed at 6% in the present study, whereas the prevalence of undiagnosed cases of DM is estimated to be 7.2% with known to unknown diabetic population ratio is 1.8:1 according to the epidemiological data on DM in urban India. It has also been documented in recent literature that more than 50% of the diabetic patients in India are unaware that they are suffering from the disease, which further complicates the situation. The screening for diabetic patients in outreach programs and mass awareness is therefore of utmost importance to lower the disease burden.
DM is a complex metabolic disorder. Periodontitis can occur in patients with DM as their sixth complication. According to some previous data, the prevalence of the DM is greater among individuals with periodontitis than healthy individuals. During routine oral examination in dental clinics, adequate blood is extravasated from the gingival crevice. With regard to the significance of early detection of DM and the need for an easy and quick method for screening for DM, a self-monitoring device was used to estimate blood glucose level from this blood in the present study. In addition, if the dentist is also aware of the patients' diabetic status, it can augment the dentists' treatment planning for optimization of the patients' health.
Similar studies, have reported that GCB samples are suitable to screen for diabetes patients with sufficient BOP. Findings of some other studies revealed that GCB is useful for measuring blood glucose during routine periodontal examination in diabetics with periodontitis, but not in nondiabetics., The results of the present study are in accordance with the results of two studies, who reported a strong correlation between blood glucose measured in GCB and CFB on examination of diabetic and nondiabetic patients with moderate to advanced periodontitis, whereas another study did not obtain any correlation between GCB and CFB.
The present study has some limitations also. First, the present study used a convenient sampling methodology as it was easier and less time-consuming. However, this type of methodology has its own inherent limitations. Second, venous blood samples were not collected in our study which is considered as gold standards for measuring glucose in the laboratory. Finally, the study patients were not fasting and results were not adjusted on the basis of time since the patients had their last meal. The present study found a high correlation between GCB and CFB with a relatively smaller sample size. However, a large study sample is required for a better demonstration of the correlation between GCB and CFB.
| Conclusion|| |
It can be concluded that GCB can be an important tool in blood glucose analysis in screening for diabetic patients. As seen from the viewpoint of public health importance, diabetes screening at such outreach programs will limit the growing number of undiagnosed prediabetics and early diabetic patients leading to a better prognosis and treatment of such patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Wild S, Roglic G, Green A, Sicree R, King H. Global prevalence of diabetes: Estimates for the year 2000 and projections for 2030. Diabetes Care 2004;27:1047-53.
Shetty N, Shankarapillai R, Mathur LK, Manohar B, Mathur A, Jain M. Gingival crevicular blood: As a non-invasive screening tool for diabetes mellitus in dental clinics. J Indian Soc Periodontol 2013;17:472-7.
] [Full text]
Stanko P, Izakovicova Holla L. Bidirectional association between diabetes mellitus and inflammatory periodontal disease. A review. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2014;158:35-8.
Kandwal A, Batra M. Gingival crevicular blood as a screening tool for diabetic patient: A randomized clinical trial. Ann Dent Speciality 2014;2:6-8.
Chatterjee R, Narayan KM, Lipscomb J, Jackson SL, Long Q, Zhu M, et al.
Screening for diabetes and prediabetes should be cost-saving in patients at high risk. Diabetes Care 2013;36:1981-7.
Matteucci E, Giampietro O. Point-of-care testing in diabetes care. Mini Rev Med Chem 2011;11:178-84.
Freckmann G, Schmid C, Ruhland K, Baumstark A, Haug C. Integrated self-monitoring of blood glucose system: Handling step analysis. J Diabetes Sci Technol 2012;6:938-46.
Kaur H, Singh B, Sharma A. Assessment of blood glucose using gingival crevicular blood in diabetic and non-diabetic patients: A chair side method. J Clin Diagn Res 2013;7:3066-9.
Gaikwad S, Jadhav V, Gurav A, Shete AR, Dearda HM. Screening for diabetes mellitus using gingival crevicular blood with the help of a self-monitoring device. J Periodontal Implant Sci 2013;43:37-40.
Diabetes India. The Indian Task Force on Diabetes Care in India. Diabetes India. Available from: http://www.diabetesindia
. com/diabetes/itfdci.htm. [Cited on 2016 Apr 15].
Koneru S, Tanikonda R. Reliability of gingival blood sample to screen diabetes in dental hospital. Int J Prev Med 2015;6:23.
] [Full text]
Strauss SM, Tuthill J, Singh G, Rindskopf D, Maggiore JA, Schoor R, et al.
A novel intraoral diabetes screening approach in periodontal patients: Results of a pilot study. J Periodontol 2012;83:699-706.
Sarlati F, Pakmehr E, Khoshru K, Akhondi N. Gingival crevicular blood for assessment of blood glucose levels. J Periodontol Implant Dent 2011;2:17-24.
Dwivedi S, Verma SJ, Shah M, Jain K. Can gingival crevicular blood be relied upon for assessment of blood glucose level? N
Y State Dent J 2014;80:38-42.
Müller HP, Behbehani E. Methods for measuring agreement: Glucose levels in gingival crevice blood. Clin Oral Investig 2005;9:65-9.
Beikler T, Kuczek A, Petersilka G, Flemmig TF. In-dental-office screening for diabetes mellitus using gingival crevicular blood. J Clin Periodontol 2002;29:216-8.
[Table 1], [Table 2]