Title: INtroducing DIabetes Checks in A denTal practice Environment: INDICATE
Funder: Department of Health and Social Care

Abstract: Research questions Could dental teams identify and clinically refer people with non-diabetic hyperglycaemia (NDH) or Type 2 Diabetes Mellitus (T2DM)? What are the facilitators/barriers to introducing such a care pathway? Background NDH and T2DM represent significant health and economic burdens. Glycaemic control is important to dental patients due to the established bi-directional co-morbid relationship between periodontitis and T2DM(2). Dental teams see patients regularly for 'check-ups', whereas patients typically visit their GP when symptomatic(3, 4). Hence it is possible that dental teams could detect NDH or pre-symptomatic T2DM among a population not normally assessed by GPs. US-based research suggests that dental teams can be effective in identifying those with NDH or T2DM (5-8). NICE recommends healthcare professionals including dentists should assess individual risk of T2DM(9) using the Leicester Risk Assessment (LRA) tool, and to refer anybody with assessment scores above a threshold for confirmatory tests. The UK National Screening Committee (NSC) does not currently advocate population-based screening for T2DM, but guidelines are under review and the Committee has acknowledged that earlier identification of NDH/T2DM by targeted risk assessment (RA) could confer benefit. Thus, dental care offers an opportunity to detect NDH/T2DM, to improve patient outcomes and to bring health economic savings. The feasibility of such a model in the UK remains unknown, but given the high prevalence of periodontitis in T2DM, addition of dental risk-factors to the LRA may enhance positive/negative predictive values. PPI has revealed strong support of a role for dental teams in the identification of T2DM. Aims To explore if routinely collected dental data could improve the accuracy of the LRA algorithm to predict risk of undiagnosed NDH/T2DM. To determine key stakeholder opinions about RA and the possible contributions of NHS dental practices to the diabetes care pathway.Objectives Evaluate if routinely collected records of periodontitis and tooth loss could contribute and improve the diagnostic accuracy of the LRA. Understand opinions about the possible role of dental teams in the identification of NDH/T2DM. Understand facilitators and barriers to dental RA and risk-targeted early detection of NDH/T2DM, to inform the design of these potential care pathways.Methods I propose 3 work-packages (WP): WP1 - Secondary analysis of large datasets to determine whether dental outcomes as additional inputs could improve the precision of the LRA. WP2 - Observation, Interviews and focus groups with patients and staff undertaking RA in five UK dental practices. WP3 - Interviews with key stakeholders to understand potential pathways from dental settings to diabetes care.Timelines See Gantt chart. Impact This project will elucidate the feasibility and acceptability of a new approach to diabetes case identification, that could: (A) enable detection of NDH/T2DM in people who do not visit their GP frequently; (B) lead to earlier identification, diagnosis, risk reduction and management; (C) achieve more cost-effective patient care; and (D) improve patient outcomes. The work proposed here will inform a definitive trial evaluating the effectiveness of the approach.

Lay abstract: Aims To determine the feasibility and acceptability of using UK dental practices to identify patients at high risk of diabetes or with undiagnosed type 2 diabetes, by seeking the opinions of people affected by the research including patients, dental and medical teams.Background Type 2 diabetes is a growing problem, predicted to account for 17% of money spent in the NHS by 2035(10). Almost 4 million people in the UK are currently diagnosed with diabetes, but it is thought another 1 million have undiagnosed diabetes(11) and another 12 million are at high risk of developing it(12). People may remain undiagnosed for years because diabetes often has no symptoms in its early stages(13). The UK National Screening Committee (NSC) recognises benefits to earlier identification of people at high risk of developing diabetes or with undiagnosed diabetes(3) including reducing the risk of complications like heart-attacks, stroke and blindness(14, 15). It is suggested that 1-in-5 diabetes patients already have developed complications at the time they are diagnosed (16). Evidence also shows that diabetes is preventable in those at high risk(17). The NHS has developed the Diabetes Prevention Programme, a service to which GPs (general practitioners) can refer patients and which help patients reduce their risk. New approaches to identify people with undiagnosed diabetes or who are at high-risk of developing diabetes may result in better health, improved quality of life for patients, and reduced NHS costs. In the UK, most people only see their GP when they feel unwell. However, most people visit a dentist for regular check-ups, even when they think themselves healthy(18). Using dental visits to identify diabetes provides a unique opportunity to check large proportions of the population for the condition. Importantly, diabetes can lead to problems with teeth and gums; dentists therefore also need to be aware if their patients have diabetes. Some UK pharmacists already test patients for diabetes(19). Opticians routinely refer patients to their GP if they show signs of diabetes. In dental hospitals, if a patient is not responding to periodontal (gum-disease) treatment and shows signs of risk-factors for diabetes, they may be tested for the condition. However, this is not the case in UK high-street dental practices. Consequently the NHS is currently missing an opportunity to identify people at risk. Research from America suggests dental practices can be effective in identifying people at high-risk of diabetes(20) although it is acknowledged that the American healthcare system is different to the NHS. I hope for my future research to determine whether UK dentists should help identify patients who have undiagnosed diabetes or who are at high-risk. But before the larger study can be started, further work is needed to decide if this will be possible and what is the best way of carrying out the research. Method This research aims to: Determine if oral health information easily available to the dentist can help to identify patients with undiagnosed diabetes or at high-risk of diabetes. Conduct interviews and focus groups with stakeholders, such as patients, GPs and dental teams, to gain a deeper understanding of their views on finding such patients in dental practices.PPI I have a panel of advisors including patients and members of the public who will assist me throughout my research, to ensure my work remains patient-focused and relevant to current practice. They will also help with the production of patient information leaflets and have already helped me to refine the design of my study. Dissemination I will share my results via scientific journals, presentations at conferences and at public-engagement events such as the annual AGEWELL event held in Birmingham.

Research activity codes: 2.5 RESEARCH DESIGN AND METHODOLOGIES (AETIOLOGY);4.2 EVALUATION OF MARKERS AND TECHNOLOGIES
Health categories: METABOLIC AND ENDOCRINE