Q. You discussed this in more detail in part one but to refresh, when do you recommend glucometer testing of dental patients?
A. In my opinion, patients who take insulin should test their blood sugar before treatment begins in the dental office. The risk of hypoglycemia is higher in any patient who takes insulin—always—so getting a baseline pretreatment glucose level is important. I even take a glucometer reading before routine procedures like prophylaxis in those patients who take insulin. If the patient is taking oral medications instead of insulin, the risk of low blood glucose is reduced. Risk is also affected by which drug class the patient is taking since some oral agents are more likely to cause hypoglycemia than others.
Q. Will the dental office know that a patient is taking insulin from his/her medical history?
A. Usually new medical history forms are done every 6 to 12 months in most practices. The dental hygienist should review the patient’s medical history before treatment is started each time. Patients should always be asked if they are taking any new medications.
Q How accurate is the glucometer test?
A. Glucometers are generally quite accurate in determining blood sugar levels, within 10% to 15% of a plasma laboratory test level. There is a difference between the glucometer test and an actual laboratory blood test. The results will be different because the glucometer test is done from capillary blood pricked from the finger and a blood test is from venous blood. The capillary blood results typically show lower levels of blood sugar than the plasma derived from whole-venous blood.
Q. How might elevated vs normal results influence dental treatment decisions?
A. If I have a long treatment planned and the patient’s glucose level is either below the average level or even at the lower end of normal, I will give the patient glucose before I start. I generally give about 4 ounces of juice, which raises most people’s glucose level by about 25 mg to 30 mg/dl.
If on the other hand, the person’s glucose level is above normal or at the higher end of normal, then I usually will not increase his or her glucose level. I will also pause mid-way through a long treatment to have the patient take his or her glucose level again just to make sure it has not decreased to a level that could cause hypoglycemia.
Q. Are there reasons that may inhibit dental offices from using the glucometer or asking their patients to bring one in?
A. If the dental office elects to purchase a glucometer to test patients’ blood glucose, the dental office is now classified by the government as a medical laboratory. This is a federal law that most dentists are completely unaware of.
The law is called the Clinical Laboratory Improvement Amendment (CLIA). It was originally passed in 1988 and has been modified several times since then. CLIA is a federal quality control law that monitors medical laboratories to make sure they are doing quality controls on their equipment. The government views in-office testing as needing quality control procedures in place to assess the data because treatment decisions are made based on the quality of data gathered with in-office testing. So a glucometer is considered a laboratory testing device. Because of this, medical and dental offices that use glucometers fall under CLIA. If a physician wants to check a patient’s cholesterol with an in-office finger stick test, his or her office is now a medical laboratory. Most physician offices actually are labs. CLIA covers almost 200,000 labs in the United States and most of those aren’t actually medical laboratories. So the dental offices that keep a glucometer in their office fall under CLIA, meaning they need to be essentially approved by the government. This sounds like an onerous burden but it is actually a simple process.
Dental offices need to visit the Centers for Medicare and Medicaid Services, Health and Human Services’ website—www.cms.hhs.gov/center/clinical.asp—to get a CLIA certificate. Click on “CLIA: Clinical Laboratory Improvement Amendments” under the heading “Policies/Regulations” to find the CMS Form 116. This form is used to apply for a CLIA certificate, which registers the dental practice as a laboratory. While the form looks intimidating, most of it does not apply to the dental office using a glucometer. The dental office notes on the form that it wants to perform glucometer testing in the office to check glucose levels before and during dental treatment. Glucometer testing is called a CLIA waived procedure. So the dental office is registered as a lab to do a procedure that is actually exempt from the act. While it seems confusing, it’s really not.
The dental office becomes a CLIA waived lab, which allows the office to use its glucometer to check patients. The glucometer has to be tested using the control solutions that come with all glucometers, to make sure that the results are accurate. The waived lab designation costs $150 every 2 years. The dental office does need to post the CLIA waiver certificate that Health and Human Services will send to the office, just like licenses have to be posted.
The number one barrier to dental offices doing glucometer testing in their office is CLIA. The CLIA is not a big burden but it is a paperwork exercise, which turns many dentists off.
Q. Can the patient just bring his or her own glucometer in?
A. Yes, but I think it’s good for dental offices to have their own, at least as a backup to the patients’.
Glucometer testing is a simple means of determining the glucose level in the bloodstream at the time the test is taken. After the discovery of insulin in the early 1900s, glucometer testing has probably done more to save lives than any other device in diabetes care. Because glucometer testing is so simple, people are willing to keep track of their glucose levels much more frequently and consistently. Some people with diabetes check their blood sugar five or six times a day, especially those taking insulin. Glucometer machines are also very inexpensive.
Q. What do you think the future holds for glucometer testing in the dental office?
A. Right now, glucometers are not accepted as a means of screening people for diabetes but this could change in the future. If the American Dental Association (ADA) decides that glucometers are a great screening tool and dental offices are a good health care setting to do it in, then that’s wonderful. There is some hope that the ADA will look at dental offices and decide that it might be a good place to screen patients, especially those who may have some oral sign or symptom of undiagnosed or poorly controlled diabetes. I do not think it’s appropriate to test every dental patient for diabetes with a glucometer because of the cost. Instead, dental offices should look for signs and symptoms of undiagnosed diabetes and refer the patient to a physician for formal evaluation and testing.
From Dimensions of Dental Hygiene. October 2007;5(10): 26-27.