Page 9 - GP Spring 2018

Diabetes and the Dentist’s new role in Recognition and Screening:

A1c in-office testing as a new ADA procedure code (D0411)

By Daniel G. Pompa, DDS

Introduction treatment can be initiated. Dentists see RBC turnover such as in hemolysis, recent-
Diabetes Mellitus (DM) is a chronic hor- more people today than physicians. The ly treated iron, B12 or folate deficiencies,
monal metabolic disorder characterized by many complications associated during this with hemodialysis, and with RBC transfu-
chronic hyperglycemia. This results from pre-diabetic stage may possibly be avoid- sions.
deficiencies in insulin secretion and/or the ed leading to a greater quality of life and
inability of receptor cells to utilize the insu- longevity for these patients that were un- The test is limited to a three-month look
lin that is secreted by the pancreas. 1 aware of their pre-diabetic or diabetic sta- back because the lifespan of a RBC is ap-
tus. This could result in significant savings proximately 4 months (117 days for men
Insulin is required for the metabolism of to our healthcare system where we are now and 106 days for women). Since RBC’s
carbohydrates, fats, and proteins. When spending over 250 billion dollars in Medi- do not undergo lysis at the same time, the
there is a deficiency of insulin or its in- care costs for patients with diabetes. 7 HBA1c is taken as a limited measure of
ability to function, there are multiple target three months. It is formed as a non-enzy-
organs that are damaged leading to their Delta Dental has done studies where they matic glycation pathway of hemoglobin’s
dysfunction and potential failure. Diabetes reimbursed for the A1c testing in dental exposure to plasma glucose. The glucose
affects more than 10% of the U.S. popu- offices in NJ and may be considering cov- levels on days nearer to the test contribute
lation and is rising at a dramatic rate. Of ering this in the future. Other dental insur- substantially more to the test than glucose
these 30 million people, one-third are not ance companies have not as of yet approved levels days further from the test date. Since
diagnosed. Presently, there are almost 100 a reimbursement for this ADA procedure pre-diabetes has no consistent signs and
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million people in the U.S. that are pre-di- code, but hopefully will do so in the future. symptoms, the A1c test is the most reliable
abetic and most are unaware of this diag- Before starting a A1c in-office point of care test that is easily available today. In addi-
nosis. 3 program, be sure to consult with regulatory tion, A1c testing does not require a fasting
experts and your local dental society. state.
Insulin Resistance is a term used for the
pre-diabetic state defined by an Impaired D0411: HbA1c: In - office point of service People without diabetes usually have an
Fasting Glucose (over 100 mg/dl) plus Im- testing A1C level of between 4.5% to 5.6%. For
paired Glucose Tolerance (over 140 mg/dl). every 1% decrease in A1c levels, the inci-
Fifteen percent of adults in the U.S. have As of January 1, 2018, dentists will be able dence of complications from diabetes de-
insulin resistance with the pre-diabetic to test A1c levels in their office, by offering creases up to 40%. Ideally, a diabetic pa-
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state defined as A1c levels between 5.7% a simple in-office test. tient with an A1c level of 8.5% who can get
and 6.4% on two separate occasions. The to 6.5% can reduce their complication rate
early diagnosis of pre-diabetes is essential CDT 2018 marked the addition of “D0411 by up to 80%. 7
for the prevention of diabetes complica- HbA1c in-office point of service testing”
tions. On average, diabetes will lower life – a chair-side screening procedure that, The American Diabetes Association now
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expectancy by 13 years. This is especially along with appropriate referral, aids in suggests that all adults who are overweight
true when both pre-diabetes and diabetes the diagnosis of pre-diabetes and diabetes. or obese be tested, along with anyone who
are not diagnosed early. This procedure, also known as finger-stick has one or more risk factors for diabetes,
random capillary HbA1c glucose testing, is such as high blood pressure or close family
Diabetes is more prevalent today than in relevant to dentists as diabetes is a risk fac- members who have diabetes. At age 45, all
the past. It is now considered a pandem- tor related to periodontal disease. adults should be screened for pre-diabetes
ic throughout the world. Two-thirds of all or diabetes.
adults in the U.S. are overweight and half Hb1Ac testing enables a dentist to amend
of those are considered obese. In the near the patient’s treatment planning depend- Dentists can often be at the forefront of
future, almost half of all Americans will be ing on whether the results are the first in- detecting the early signs of the disease just
pre-diabetic. “Sugar is now considered to dicator of a new diabetic condition, or if by observing how patients heal after a sur-
be the tobacco of the New Millennium.” 6 the results indicate a change in the existing gical procedure. Poor or delayed healing
diabetic condition. is a first sign of diabetes or pre-diabetes.
More people have died from diabetes since This, along with early periodontal disease
1900 than in all the wars and conflicts in D0411 – ADA Guide to Point of Care Di- in a young patient, is another red flag that
the same time period. Because diabetes abetes Testing and Reporting is avail- should heighten your index of suspicion to
takes ten or more years to discover and the able at no cost for you to view or down- rule out pre-diabetes and diabetes.
complications develop so slowly, it is not load.
addressed with the level of commitment Other possible dental manifestations of
and interest it should be given. 6 • Guide to Reporting D0411 (PDF) DM include:
Granulomatous polyps on the gingiva
Dentists will now be able, with a simple A1c levels can be falsely elevated when Candidiasis
in-office screening test, to detect diabetes there is low red blood cell (RBC) turnover, Parotid gland enlargement
as well as pre-diabetes. With a medical as in untreated iron deficiency or anemia Taste impairment
referral, a full workup, an evaluation for and can be falsely depressed with increased Xerostomia
continued on next page
www.nysagd.org l Spring 2018 l GP 9