Assessing patient acceptability of Type 2 diabetes risk-assessment in UK high‑street dental practices: a reflexive thematic analysis of 15 interviews

Assessing patient acceptability of Type 2 diabetes risk-assessment in UK high‑street dental practices: a reflexive thematic analysis of 15 interviews | Research Square Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Help Center Sign In Submit a Preprint Cite Share Download PDF Research Assessing patient acceptability of Type 2 diabetes risk-assessment in UK high‑street dental practices: a reflexive thematic analysis of 15 interviews Zehra Yonel, Antje Lindenmeyer This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9193426/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 9 You are reading this latest preprint version Abstract This qualitative study explored how patients perceive and experience Type 2 diabetes (T2D) risk assessment delivered within NHS high‑street dental practices. Fifteen adults who had completed a risk-assessment questionnaire and point‑of‑care HbA1c test participated in semi‑structured interviews analysed using inductive reflexive thematic analysis. Participants widely supported the concept of opportunistic diabetes risk assessment in dental settings, describing the process as convenient, acceptable and reassuring, particularly because it offered a single‑visit workflow and immediate results. Trust in familiar dental staff contributed strongly to perceptions of legitimacy and comfort. Many participants valued receiving a tangible HbA1c number and expressed a desire for a plain‑language printed explanation outlining the meaning of the result and recommended next steps. While weight‑ and waist‑circumference related questions were generally acceptable, several participants emphasised the importance of privacy and clear pre‑test communication to minimise discomfort. Preferences for follow‑up strongly favoured a dual‑communication approach: automatic GP notification complemented by a patient‑held copy to ensure understanding and encourage action. Views diverged regarding whether dental teams should directly refer into diabetes prevention programmes, but all participants agreed that strong integration with GP pathways was essential. Some also highlighted equity considerations, including the deterrent effect of patient fees and the need to ensure that screening does not compromise access to routine dental care. Overall, dental practices were seen as a credible, convenient and potentially impactful setting for early identification of T2D risk, provided pathways remain patient‑centred, well‑explained and integrated with broader primary care systems. Health sciences/Health care/Dentistry Health sciences/Diseases/Oral diseases Figures Figure 1 Figure 2 Key points • Patients value single‑visit convenience, immediate results and simple HbA1c ranges (printed at point‑of‑care). • Trust in known dental teams legitimises non‑oral screening; dual communication (patient copy + automatic GP notice) prompts follow‑through. • Implementation should ensure privacy for measurements, clear pre‑test explanation of outcomes, and equity safeguards. Introduction Diabetes is a major global concern. The consequences of diabetes can be severe with both macrovascular and microvascular complications resulting in significant economic and human cost. In the UK diabetes is one of the major causes of sight loss and amputation( 1 , 2 ). Due to the complex nature of diabetes, the care for people living with the condition often adopts a multi-disciplinary approach. Though in the UK oversight of care is primarily managed by family doctors, secondary care, podiatry, optometry, ophthalmology, dietetics, specialist nurses, pharmacy and others all play a role. However, Oral healthcare professionals (OHPs) are rarely included in this multi-disciplinary team as part of a holistic approach to support people living with diabetes. Early identification of hyperglycaemia can prevent or delay onset of type-2-diabetes (T2D) ( 3 , 4 ). In its early stages non-diabetic hyperglycaemia (NDH) may not yield any symptoms ( 5 , 6 ). Many adults do not access family doctors (GP) routinely for health checks when asymptomatic. OHPs, however, do routinely see asymptomatic patients ( 7 ) ( 8 ); we know that > 50% of the UK adult population continue to see their dentist at least once per year for routine check-ups. This may provide an opportunity for utilising OHPs for opportunistic risk-assessment and prevention of conditions such as diabetes, which have significant economic( 9 , 10 ), societal and individual impacts on both general health and oral health ( 11 , 12 ). The rationale for utilizing dental settings to provided targeted risk-based assessments goes beyond the different attendance patterns of patients to different healthcare providers. The idea of utilising dental settings for NDH/T2D risk-assessments is not a new phenomenon( 13 – 19 ). The association between diabetes and tooth-loss is long since established ( 20 – 23 ), as is the association between diabetes and periodontitis ( 24 ). Periodontitis is considered the sixth complication of diabetes( 25 ), and those living with T2D have a three-fold increased risk of also living with periodontitis( 26 ). Furthermore, the association between oral health and diabetes is now understood to go beyond shared risk-factors (smoking, diet, obesity, alcohol consumption), with a recognised bi-directional association between the conditions and plausible mechanisms published for the association between diabetes and periodontitis ( 27 , 28 ). Thus, there is now growing momentum for patients living with both conditions to be managed more holistically. This would be of direct benefit to patients and would also be in the interest of OHPs to develop a relationship with other healthcare providers via the diagnostic pathway. Importantly we now also have several key guidelines advocating and advising closer integrated working between healthcare professionals including the: International Diabetes Federation (IDF) and European Federation of Periodontology (EFP) consensus statement ( 24 ). the Consensus report of the Joint Workshop by the European Federation of Periodontology (EFP) and the European arm of the World Organization of Family Doctors (WONCA Europe)( 29 , 30 ). National Institute of Health and Care Excellence (NICE) Guidelines – recognising periodontitis as a complication of diabetes and advising medical teams to sign-post patients newly diagnosed with diabetes to OHPs ( 31 ). Commissioning Standard, “Dental care for those living with Diabetes” which went through Government Gateway in 2019 and was subsequently updated in 2024. This outlined a care-pathway to be implemented ( 32 ). Uptake, awareness and implementation of the above guidelines have been variable. But given that there is growing momentum for improving the integration of high-street dental and medical services and a degree of “task-shifting” with OHPs and GPs expanding what was once seen as their traditional roles into a more collaborative approaches to patient care, it is important to understand the views of patients regarding this potential expansion of OHPs roles. This study aimed to understand those patient views through qualitative interviews. Several studies have assessed stakeholder opinion including those from the USA, Europe and Asia, they were all broadly in support of task-shifting and utilising OHPs to risk-assess for NDH/T2D ( 33 – 36 ). Our group undertook a pilot study within UK high-street dental settings, the “INDICATE” studies (Award ID: NIHR300171). INDICATE aimed to determine the most appropriate risk-assessment process( 31 , 37 ), determine identification rate of new cases of NDH/T2D within NHS high street dental practices and examine patients’ experiences and preferences regarding a dental‑based NDH/T2D risk assessment pathway. [Manuscript under submission with BDJ]. A further aim of INDICATE was a qualitative work-package to understand the barriers and facilitators to utilizing OHPs within primary care (high street) dental practices risk assessing for NDH/ T2D in addition to the views of stakeholders. To address these uncertainties and to build upon existing feasibility and stakeholder work, we adopted a qualitative, interview-based approach using inductive reflexive thematic analysis. This analytic orientation supports a rich exploration of both semantic and latent meaning, enabling us to examine how patients construct the acceptability and perceived legitimacy of dental-based diabetes risk assessment. Methods Design and methodological orientation A topic guide was designed and piloted. A purposive sample was drawn from those participants who had taken part in the “INDICATE” study (38) and consented to be contacted for interview. We then conducted semi‑structured interviews and analysed data using inductive, reflexive thematic analysis with semantic and latent coding. Theme development prioritised iterative, reflexive engagement with the data rather than the use of consensus‑based metrics (such as coder agreement or inter‑rater reliability), in line with contemporary guidance on reflexive thematic analysis(39-41). Participants, recruitment and setting Adults who completed a chairside T2D risk assessment (questionnaire + finger‑prick HbA1c) in participating NHS dental practices were invited via staff, posters or email/phone to participate in an interview. Interviews were offered to be conducted via Zoom or in private rooms at practices, according to participant preference. All participants requested online interviews. We did not recruit individuals who declined the risk‑assessment itself. This was due to ethical and practical constraints within participating practices. We acknowledge that the perspectives of those who declined may have provided valuable insights into additional barriers to acceptability. Table 1: Participant characteristics (pseudonymised, n=15) Ethnicity Sex Age Risk flag White Male 66 Low risk White Female 77 Low Risk White Female 54 High risk White Female 66 Low Risk White Male 55 Low Risk White Male 65 Low Risk White Male 52 Low Risk White Female 48 Low Risk White Male 11 High risk Asian Male 56 Low risk White Female 11 Low risk Black Female 74 Intermediate risk Black Male 48 Intermediate Risk White Male 55 Low Risk White Female 59 High risk Summary counts: • Sex: Male = 8, Female = 7 • Ethnicity: White = 12, Asian = 1, Black = 2 • Risk: High risk = 3, Low risk = 10, Intermediate risk = 2 Data collection A flexible topic guide (patient‑tested) covered motivations, setting perceptions (how the participants felt about such risk-assessments being undertaken specifically in the dental setting), questionnaire experience (patients views on content and completion of questionnaires utilised for risk-assessments), finger‑prick testing, result delivery and aftercare. Interviews were audio‑recorded and transcribed verbatim by an external service; identifiers were removed. Analytic memos were maintained throughout. Analysis The lead analyst (ZY) coded line‑by‑line and developed themes inductively, iterating coding and memoing across the dataset. Analytic memos were used throughout data collection and analysis as contemporaneous notes capturing early impressions, contextual observations, and developing analytical insights. These memos supported reflexivity and informed subsequent iterations of coding and theme development. Themes were refined to capture patterned meaning while attending to negative cases and equity considerations. Reflexivity The interviewer is a clinician‑researcher in dentistry (oral–systemic focus). Positionality and assumptions were logged in reflexive memos. All interviews were conducted and analysed by a single interviewer (ZY) who was also the chief investigator of the study. The interviewer had no prior relationship with the participants being interviewed and had not been directly involved with their inclusion into the research study nor their risk-assessment process within their dental practices. Table 2: Example of reflexive memos Example of Reflexive Memo. Legitimacy is relational ; numbers matter (patients remember and trust the HbA1c figure); pre‑test briefing reduces anxiety (including clarity on UK 6.0% vs US 5.7% thresholds); privacy optics around measurements; dual communication consistently valued; watch equity risks (fees/space). • Memo 1 – Legitimacy is relational: participants anchor confidence in trusted dental teams; rapport built over years normalises screening in that space. • Memo 2 – Numbers and artefacts: the HbA1c “number”, printed with simple ranges and next‑steps, is a key credibility artefact patients keep. • Memo 3 – Pre‑test explanation: quick briefing about possible outcomes (including UK 6.0% vs US 5.7% thresholds) reduces anxiety and confusion. • Memo 4 – Privacy optics: participants value private spaces for weighing/waist; screens or side rooms improve acceptability. • Memo 5 – Pathway preference: “dual communication” is favoured; views split on dentists referring directly to DPP, but consensus that GPs must be informed. • Memo 6 – Digital pragmatism: explicit “Now submit” messages and fewer email hops are needed; provide paper/in‑practice option. • Memo 7 – Equity & capacity: nominal co‑pays are acceptable to some, but risk deterring priority groups; don’t displace core dental care. Ethics Ethical approval for this study was granted (REC reference: 21/LO/0654). This study complies with the Declaration of Helsinki. Results Across 15 interviews, participants generally regarded dental‑setting T2D risk assessment as acceptable, convenient, and credible, with preferences for single‑visit testing, tangible test artefacts (i.e. clear results and a printout they could keep for reference), privacy for measurement, and dual communication to general practice (GP) and the patient. Seven interconnected patterns were determined. 1. Trust, relationship and role legitimacy . Longstanding rapport with the dental team underpinned acceptance. Participants described dentists as “professionals” operating in a “safe” clinical environment, which normalised non‑oral screening. The importance of the close professional relationship between patients and OHPs was evident. Several participants talked about their experience of being with the same dental practice for many years. There was a focus on building strong professional relationships and rapports with the OHP over that timeframe which resulted in trust of the professional and the messages that they deliver: “I’ve been with the dental practice for quite a long while and I had a lot of faith in them.” (Int 7) “I’ve known them years… I just have trust in them.” (Int 8) Convenience and single‑visit preference. Patients valued having the diabetes check incorporated within their routine dental assessment. It was deemed convenient and meant they could “kill two birds with one stone” – “have multiple checks undertaken at the same time in the same place”.  This convenience, and the ability to have a health check that fitted into people’s busy schedules was cited as a highlight and key benefit. Furthermore, having results delivered immediately was also considered to be a factor that patients valued. “Everyone is so busy nowadays, if it is there and just done when I am scheduled to be at the dentist anyway, that’s just convenient isn’t it. And it’s great that there is no hanging around or chasing up results. It’s just get in, have the test and you know, you get the result” (Int 9). Participants valued the ability to “get it all done together” during routine care. The dental appointment provided an opportunistic moment to act: “You’re there anyway… for a few minutes and a finger prick—why not?” (Int 9) “Have it all done together.” (Int 4) Tangible testing and documentation. Though people were happy to complete the questionnaire, more faith was placed in the finger-prick test. Having the blood spot reading and immediate result gave people greater belief that that the result was accurate. Having a documented number/ printout of the result was important to patients. Finger‑prick HbA1c was perceived as a concrete, here‑and‑now indicator that prompted action; printed results and simple ranges were repeatedly requested: “Definitely the prick test… that’s in the here and now.” (Int 7) “Nice to actually have a printout… you can’t always remember these figures.” (Int 6) Privacy and measurement sensitivities. Patients reported a willingness to share measurements and health data with OHPs, even where that data may be considered sensitive (e.g. weight / BMI/ waist circumference). They were also willing to have the data recorded within dental practices provided it was done in a private location. While most were comfortable sharing height/weight/waist, participants asked for discreet weighing and clearer guidance on where/how to measure waist circumference: “Not sure I’d stand on [scales] in a waiting room… private is better.” (Int 4) “It took me a little while to realise exactly where… to measure your waist.” (Int 6) Aftercare and GP linkage. A further key consideration is how care is joined up between OHPs and family doctors, ensuring all relevant parties have access to patient results. This was considered important to avoid duplication of testing and to ensure patients get the correct and efficient onward care. Participants wanted an integrated pathway: an immediate explanation of “what the number means”, plus automatic notification to the GP and a copy for themselves. Several reported subsequent GP follow‑up and lifestyle changes: “Prefer GP notified immediately—and I get a copy.” (Int 6) “Reading was higher than I thought… GP confirmed and advised lifestyle change.” (Int 3) Digital access and interface. Some of those interviewed found having questionnaires emailed in advance added friction. Several patients stated they would have preferred paper forms to complete in the practice. “Had to do the questionnaire three or four times… not as user‑friendly.” (Int 7) “Online was quick and straightforward.” (Int 6) Equity and capacity. Views diverged on patient fees: some would pay a nominal amount for convenience; others warned that charges could deter those most at risk. Participants also recognised wider system pressures on dental access. When talking about cost of testing, it was apparent that most patients felt that the cost of case-finding by OHPs should not be a barrier to understanding your diabetes risk.  They also felt that if case-finding as part of the NHS health check was not paid out of pocked at the GP it should not incur additional cost when undertaken in dental setting. Table 3: This table shows the key themes and provides examples which helped establishment of them Trust, relationship and role legitimacy Long‑standing rapport with dental teams fostered confidence in non‑oral (NDH/T2D) screening; legitimacy increased after experiencing the process. Familiar dental teams and clinical setting legitimise non‑oral screening. “ I’ve been with the dental practice for quite a long while and I had a lot of faith in them. ” (Int 7) “ I’ve known them years… I just have trust in them. ” (Int 8) “ Trust them completely… practice like family. ” (Int 2) Convenience and single‑visit preference Participants endorsed one‑stop workflows with immediate results; opportunistic offers (posters, staff invitations) were effective. Opportunistic, one‑stop appointment with quick feedback drives uptake. “ Doing it in the dental setting was great for me… really easy and convenient. ” (Int 8) “ You’re there anyway… for a few minutes and a finger prick… why not? ” (Int 9) “ So much easier just going to one place to get everything done. ” (Int 5) Tangible testing and documentation Finger‑prick HbA1c and a printed number felt credible; participants wanted a one‑page results explainer with reference ranges and next steps. HbA1c number + printed ranges boost credibility and actionability. “ Definitely the prick test… that’s in the here and now. ” (Int 7) “ Results came through in a matter of minutes. ” (Int 8) “ Nice to actually have a printout of the result… a permanent record. ” (Int 6) → prioritise printed result + reference ranges. Privacy and measurement sensitivities Weight/waist items were acceptable when handled privately; public weighing was disliked by some; clear guidance was requested. Height/weight/waist acceptable when discreet and well‑explained. “ She came and sat down… there was nobody else in the room. ” (Int 9) — sensitive delivery in a separate area. “ Weight would’ve been a guess… machine/tape would give an accurate reading. ” (Int 8) — tools help accuracy. “ Screens or a cubicle would help with weighing/waist. ” (Int 3) Aftercare and GP linkage Strong preference for dual communication: automatic GP notification plus a patient copy. Views varied on direct referral to prevention programmes; consistent support for GP linkage. Clear signposting; strong preference for dual communication (patient copy + GP notice). “ I’d 100% have consulted my GP if it was high. ” (Int 7) — strong intention to act. “ Just as easy… dental surgery can keep the doctor in the loop and refer patients direct. ” (Int 9) — support for direct DPP referral with GP informed “ Reading was higher than I thought… GP confirmed and advised lifestyle change. ” (Interview 3) Digital access and interface Email hand‑offs and unclear “submit” steps hindered some; paper or in‑practice completion reduced friction. Email/online steps can add friction; paper/in‑practice completion often preferred. Equity and capacity Concerns included the deterrent effect of fees and the need to avoid displacing core dental care. Avoid fees that deter; ensure adequate space so screening doesn’t displace core care. “ Fees could put off those most at risk; dentists are already stretched. ” (Int 2) Discussion Statement of principal findings This qualitative analysis indicates that adult dental patients perceived chairside T2D risk assessment as acceptable and useful when it (i) leverages trusted relationships with dental teams, (ii) offers single‑visit convenience , (iii) provides tangible outputs (e.g., printed HbA1c with interpretive ranges), (iv) ensures privacy‑sensitive anthropometry , and (v) embeds dual communication (automatic GP notification + patient copy). Participants generally viewed a finger‑prick HbA1c as a credible catalyst for action—consistent with emerging evidence that dental settings can feasibly identify previously unrecognised hyperglycaemia and prompt follow‑up in primary care. Strengths and weaknesses of the study Strengths include a reflexive thematic approach attentive to both semantic and latent meaning, with analytic transparency aligned to Braun and Clarke’s contemporary guidance on reflexive TA (39). This enabled us to move beyond “what was said” to how participants positioned acceptability, burden, and perceived effectiveness in context. The dataset spans 15 interviews across varied experiences (including those who received low, medium, and high results), enhancing thematic richness. Given the stage of integrating NDH/T2D risk‑assessment into routine dental workflows, a qualitative design was necessary to explore how patients made sense of the process, how they interpreted its legitimacy within dentistry, and what shaped their comfort or discomfort at different stages of the pathway. Interviews, rather than focus groups, were chosen because they enable participants to discuss personal experiences—such as weight measurement, health anxieties, perceptions of risk, or previous encounters in dental care—in a private and non‑judgemental space. These individual interviews were particularly important for capturing the relational aspects of trust in dental teams and the subtle practical or emotional considerations that would likely be suppressed in a group environment. Reflexive thematic analysis (TA) was selected as it offers an analytically flexible yet rigorous approach suited to examining experiential meaning-making. TA allowed us to attend to both what participants said (semantic content) and the underlying assumptions, expectations and social norms shaping those accounts (latent content). This approach aligned with our aim to understand not only whether dental‑based risk assessment was acceptable, but how and why participants constructed it as acceptable, convenient, legitimate or, in some instances, sensitive or potentially inequitable. Reflexive TA further supports a theoretically and reflexively informed reading of participant narratives, rather than seeking consensus or coding reliability, making it particularly appropriate for a study focused on exploring nuanced patient perspectives and shaping future pathway design. The purposive sample was congruent with that of similar such studies and the findings broadly aligned with similar studies reported both in the UK and abroad (7, 11). Several studies have explored patients’ perceptions of risk assessing for systemic diseases within the dental setting. But given, the cultural differences as well as differences in healthcare systems and expectations of patients related to healthcare delivery it is interesting to see how similar the global results are. A study based in India (42) reported 84.5% of patients in a university clinic and 77.5% in a private practice were willing to be tested for diabetes. With the vast majority willing to participate in chair-side screening that yielded immediate results (84.6% clinic and 86.1% private)(42). A study in the USA which surveyed 264 participants found that >83% were willing to be tested for diabetes in a university dental clinic (35). Furthermore, a systematic review published in 2020 reported that patient support for such testing ranged from 73-87% with most patients reporting they were willing to undergo chairside testing that yielded immediate results(33). Limitations include: (1) self‑selection—participants willing to be interviewed may already be positively disposed to research or prevention; (2) interviews occurred post‑intervention, so recollection of pre‑test concerns could be muted; (3) the analysis was conducted within one programme and may not capture operational variations (e.g., in practices without private weighing facilities); and (4) the study did not link qualitative accounts to clinical outcomes or GP records. Strengths and weaknesses in relation to other studies Our findings align with feasibility work showing that chairside HbA1c in dental settings can reveal substantial proportions of previously unrecognised prediabetes/diabetes and is well‑accepted by patients. For example, a 2025 JADA feasibility study in a safety‑net setting reported 34.2% prediabetes and 6.6% diabetes, with ~65% follow‑up at six months, paralleling our participants’ readiness to consult GPs after receiving concrete results. Earlier work likewise found that POCT HbA1c at the dental chair can reasonably predict laboratory classification and surface hidden hyperglycaemia. Recent analyses in secondary‑care dental cohorts (KCL) also suggest that dental visits are an opportunity for hyperglycaemia detection, reinforcing the salience of opportunistic screening perceived by interviewees(43, 44). Where our data extend prior evidence is in the granular texture of acceptability—mapping closely to Sekhon et al.’s Theoretical Framework of Acceptability (TFA). Participants emphasised affective attitude (comfort/trust in dental teams), burden (minimal added time), perceived effectiveness (a concrete number), intervention coherence (clarity on why dentistry is involved), and ethicality/opportunity costs (privacy; equity). Such constructs can inform implementation fidelity and patient‑centred refinements—issues also highlighted in NHS DPP evaluations (e.g., equity of access, local adaptation, and digital options) (45-47). A point of departure concerns charging models. Some participants accepted fees for convenience; others cautioned about deterring those at risk. The NHS DPP DIPLOMA evaluation similarly highlighted inequalities in engagement and the need for tailored pathways, suggesting that fee‑based dental screening could exacerbate disparities unless carefully designed(46). Meaning of the study: possible explanations and implications for clinicians and policymakers Why dentistry? Many adults see dentists more frequently than their GP; a dental visit can therefore act as a preventive touchpoint for non‑communicable diseases (NCDs), consistent with calls to integrate screening for diabetes and cardiovascular risk into dental care. The bidirectional diabetes–oral health relationship (periodontitis ↔ hyperglycaemia) provides a clinical rationale for dental‑based risk assessment and integrated aftercare(7, 29). Implications for clinicians. Standardise a pre‑test briefing (60–90 seconds) that clarifies the oral–diabetes link and what the number means . Our participants’ uncertainty about “which way the link runs” underscores this need. Ensure privacy by design for anthropometry (screened weighing area; clear waist‑measurement guidance), which participants perceived as integral to dignity. Provide tangible artefacts : a printed HbA1c ticket with UK thresholds (e.g., <42 mmol/mol normal; 42–47 mmol/mol at‑risk; ≥48 mmol/mol diabetes) to aid recall and action. Embed dual communication : routine, auditable electronic GP notification plus a patient‑facing result sheet with signposts (e.g., NHS DPP/“Know Your Risk”) (48). Refine digital questionnaires (clearer “submit” affordances; in‑practice paper option) to mitigate usability issues noted by participants. (Int 7; Int 6) Implications for policymakers Commissioning & integration. Our findings support integrated primary‑care models that reduce handoffs between dentistry and medicine, consistent with NHS moves toward prevention and ICS‑level collaboration (49). Pathway alignment with NHS DPP. Dental screening can act as an upstream feeder into the Healthier You programme; DIPLOMA shows the DPP can reduce diabetes incidence but faces equity and fidelity challenges—precisely the areas where dentistry’s frequent contact could help target underserved groups (46). Targeting thresholds and triage. Given evidence that higher HbA1c within the “at‑risk” band predicts substantially higher 5‑year progression, commissioners may consider risk‑stratified referral rules (e.g., prioritising ≥44 mmol/mol for expedited GP follow‑up), balancing sensitivity with capacity(50). Equity safeguards. Any consideration of patient co‑payment should be coupled with remission policies or targeted free screening to avoid widening inequalities flagged in DPP evaluations(46). Unanswered questions and future research Further work is required to determine the cost‑effectiveness and potential contract levers. Controlled studies should estimate incremental cost‑effectiveness of dental‑based screening (including staff time, consumables, and GP follow‑up) and test commissioning levers (e.g., outcome‑based contracts) that incentivise prevention without crowding out core dental access(51). This will further support existing evidence and help to underpin appropriately funded integrated care-pathways between high street dentistry and family doctors. A further area where additional research is required relates to pathway effectiveness & equity. Mixed‑methods implementation research should be undertaken to examine which combinations of dental‑based screening, patient facing information, and dual communication optimise attendance throughout the pathway in particular at GP/DPP—and for whom. Stratified analyses are needed to assess impacts across socioeconomic and ethnic groups, given DPP engagement disparities(45, 46). Additionally, specific pathways at optimal clinical thresholds need to be developed and “what next.” Trials comparing risk‑stratified thresholds (e.g., ≥42 vs ≥44 mmol/mol) could test trade‑offs between reach and positive predictive value in UK dentistry, and determine the optimal content of the immediate “aftercare” sheet for comprehension and behaviour change(50). Interprofessional data flows could also support ease of implementation. Work is needed on interoperable records and secure e‑notification pipelines that deliver the dual‑communication model at scale, aligning with the broader policy agenda on managing major conditions through integrated systems. Taken together, these findings help explain why dental settings were perceived as both appropriate and valuable places for diabetes risk assessment. Participants connected the process to their existing relationships with dental teams, the practicality of single‑visit testing, and the clarity of receiving an immediate numerical result. These experiential insights offer a coherent explanation for the consistently high levels of acceptability reported and help situate the study within wider discussions about the role of dentistry in preventive care. Conclusion This study demonstrates that patients within NHS dental practices are in broad support of utilising OHPs to case-find NDH/T2D.  Several key themes emerged from the interviews including: the relationship patients have with OHPs being key to success, the convenience of single visit testing, tangible testing and documentation, privacy and sensitivity around specific measures, aftercare and GP linkage, digital interface and clearer communication pathways with IT system linkage and improved IT infrastructure, Equity and measures to tackle health inequalities. The findings of this study may help support further work into the exploration of improved integrate care-pathways between primary care medicine and dentistry. Commissioners should consider equity safeguards and protect core dental capacity should they consider scaling this for national adoption. Declarations Funding : NIHR and Diabetes UK Doctoral Research Fellowship Ethics approval: Complies with Declaration of Helsinki. Ethical approval for this study was granted (REC reference: 21/LO/0654) Competing interests: Nil References 1. UK D. Early identification of people with, and at high risk of Type 2 diabetes and interventions for those at high risk.: Diabetes UK; 2015 [Available from: https://www.diabetes.org.uk/Documents/About%20Us/What%20we%20say/Position%20Statement%20-%20Early%20identification%20of%20people%20with%20Type%202%20diabetes%20(Nov%202015).pdf. 2. UK D. key facts and stats. 2015 [Accessed 15/09/15]. Available from: https://www.diabetes.org.uk/About_us/What-we-say/Statistics/. 3. Disease NIoDaDaK. Why Screen for & Treat Prediabetes. In: NIH, editor. NIH: NIH; 2015. 4. Duan D, Kengne AP, Echouffo-Tcheugui JB. Screening for Diabetes and Prediabetes. Endocrinology and metabolism clinics of North America. 2021;50(3):369-85. 5. Reduction in the Incidence of Type 2 Diabetes with Lifestyle Intervention or Metformin. N Engl J Med. 2002;346(6):393-403. 6. Tuso P. Prediabetes and lifestyle modification: time to prevent a preventable disease. Perm J. 2014;18(3):88-93. 7. Yonel Z, Sharma P, Yahyouche A, Jalal Z, Dietrich T, Chapple IL. Patients' attendance patterns to different healthcare settings and perceptions of stakeholders regarding screening for chronic, non-communicable diseases in high street dental practices and community pharmacy: a cross-sectional study. BMJ open. 2018;8(11):e024503. 8. Marcheselli F, Mandalia, D., Finn, D., Eguchi, K. Adult Oral Health Survey. In: Research NCfS, editor. UK Data Service: Office for Health Improvement and Disparities; 2023. 9. Impact E. Time to put your money where your mouth is: addressing inequalities in oral health. London: European Federation of Periodontology (EFP); 2024 Feb 13th 2024. 10. Unit EI. Time to take gum disease seriously: The societal and economic impact of periodontitis. Economist: European Federation of Periodontology; 2021. 11. Yonel Z, Cerullo E, Kröger AT, Gray LJ. Use of dental practices for the identification of adults with undiagnosed type 2 diabetes mellitus or non-diabetic hyperglycaemia: a systematic review. Diabet Med. 2020;37(9):1443-53. 12. Yonel Z, Dietrich T, Gray L, Chapple I. Early case detection of diabetes in dental practice: a missed opportunity. Br Dent J. 2023;235(9):667. 13. Lalla E, Cheng B, Kunzel C, Burkett S, Lamster IB. Dental findings and identification of undiagnosed hyperglycemia. J Dent Res. 2013;92(10):888-92. 14. Barasch A, Gilbert GH, Spurlock N, Funkhouser E, Persson LL, Safford MM, et al. Random plasma glucose values measured in community dental practices: findings from The Dental Practice-Based Research Network. Clinical oral investigations. 2013;17(5):1383-8. 15. AlGhamdi AST, Merdad K, Sonbul H, Bukhari SMN, Elias WY. Dental Clinics as Potent Sources for Screening Undiagnosed Diabetes and Prediabetes. American Journal of the Medical Sciences. 2013;345(4):331-4. 16. Tanwir F. Dental clinic as a health centre for screening of undiagnosed diabetes. Journal of the College of Physicians and Surgeons Pakistan. 2009;19(12):747-9. 17. Tsutsui P, Rich SK, Wilson SG. Diabetes screening in the dental office. Cda j. 1985;13(1):49-52. 18. Chapnick L, Jolley HM, Newman S. Diabetic screening in the dental office. Le Journal dentaire du Quebec. 1974;11(8):10-3. 19. Rothenberg MS. Improved diabetes screening technic for the dental office. Dent Surv. 1973;49(9):52. 20. Grossi SG, Zambon JJ, Ho AW, Koch G, Dunford RG, Machtei EE, et al. Assessment of risk for periodontal disease. I. Risk indicators for attachment loss. Journal of periodontology. 1994;65(3):260-7. 21. Cleary TJ, Hutton JE. An assessment of the association between functional edentulism, obesity, and NIDDM. Diabetes care. 1995;18(7):1007-9. 22. Noack B, Jachmann I, Roscher S, Sieber L, Kopprasch S, Luck C, et al. Metabolic diseases and their possible link to risk indicators of periodontitis. Journal of periodontology. 2000;71(6):898-903. 23. Genco RJ, Grossi SG, Ho A, Nishimura F, Murayama Y. A proposed model linking inflammation to obesity, diabetes, and periodontal infections. Journal of periodontology. 2005;76(11 Suppl):2075-84. 24. Sanz M, Ceriello A, Buysschaert M, Chapple I, Demmer RT, Graziani F, et al. Scientific evidence on the links between periodontal diseases and diabetes: Consensus report and guidelines of the joint workshop on periodontal diseases and diabetes by the International diabetes Federation and the European Federation of Periodontology. Diabetes research and clinical practice. 2018;137:231-41. 25. Löe H. Periodontal Disease: The sixth complication of diabetes mellitus. Diabetes care. 1993;16(1):329-34. 26. Preshaw PM, Alba AL, Herrera D, Jepsen S, Konstantinidis A, Makrilakis K, et al. Periodontitis and diabetes: a two-way relationship. Diabetologia. 2012;55(1):21-31. 27. Chapple IL, Genco R. Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. J Clin Periodontol. 2013;40 Suppl 14:S106-12. 28. Nonaka K, Kajiura Y, Bando M, Sakamoto E, Inagaki Y, Lew JH, et al. Advanced glycation end-products increase IL-6 and ICAM-1 expression via RAGE, MAPK and NF-κB pathways in human gingival fibroblasts. Journal of periodontal research. 2018;53(3):334-44. 29. Herrera D, Sanz M, Shapira L, Brotons C, Chapple I, Frese T, et al. Periodontal diseases and cardiovascular diseases, diabetes, and respiratory diseases: Summary of the consensus report by the European Federation of Periodontology and WONCA Europe. The European journal of general practice. 2024;30(1):2320120. 30. Herrera D, Sanz M, Shapira L, Brotons C, Chapple I, Frese T, et al. Association between periodontal diseases and cardiovascular diseases, diabetes and respiratory diseases: Consensus report of the Joint Workshop by the European Federation of Periodontology (EFP) and the European arm of the World Organization of Family Doctors (WONCA Europe). Journal of Clinical Periodontology. 2023;50(6):819-41. 31. NICE. Type 2 diabetes: prevention in people at high risk | Guidance and guidelines | NICE. In: Excellence NIoHaC, editor. NICE CKS - Clinical Knowledge Summary Health topics A to Z Diabetes - type 2 Management Scenario: Management - adults: NICE; Updated Jan 2026. 32. England OotCDO. Commissioning standard: dental care for people with diabetes. In: England OotCDO, editor.: NHS England; 6 June, 2024. 33. Yonel Z, Batt J, Jane R, Cerullo E, Gray LJ, Dietrich T, et al. The Role of the Oral Healthcare Team in Identification of Type 2 Diabetes Mellitus: A Systematic Review. Current Oral Health Reports. 2020. 34. Greenberg BL, Glick M, Frantsve-Hawley J, Kantor ML. Dentists' attitudes toward chairside screening for medical conditions. Journal of the American Dental Association. 2010;141(1):52-62. 35. Greenberg BL, Kantor ML, Jiang SS, Glick M. Patients' attitudes toward screening for medical conditions in a dental setting. J Public Health Dent. 2012;72(1):28-35. 36. Greenberg BL, Thomas PA, Glick M, Kantor ML. Physicians' attitudes toward medical screening in a dental setting. J Public Health Dent. 2015. 37. Yonel Z, Kuningas, K., Sharma, P. et al. Concordance of three point of care testing devices with clinical chemistry laboratory standard assays and patient-reported outcomes of blood sampling methods. BMC Med Inform Decis Mak 22, 248 (2022). 2022. 38. Research NIoHaC. INtroducing DIabetes Checks in A denTal practice Environment: INDICATE NIHR: Department of Health and Social Care; Feb 2020 [Available from: https://fundingawards.nihr.ac.uk/award/NIHR300171. 39. Braun V, Clarke V. Supporting best practice in reflexive thematic analysis reporting in Palliative Medicine: A review of published research and introduction to the Reflexive Thematic Analysis Reporting Guidelines (RTARG). Palliat Med. 2024;38(6):608-16. 40. Braun V, Clarke V. Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health. 2019;11(4):589-97. 41. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006;3(2):77-101. 42. Sansare K, Raghav M, Kasbe A, Karjodkar F, Sharma N, Gupta A, et al. Indian patients' attitudes towards chairside screening in a dental setting for medical conditions. International dental journal. 2015;65(5):269-76. 43. Laniado N, Shah P, Cloidt M, Robles E, Badner V, Sydney E. Point-of-care glycemia testing in a safety-net dental care setting: A feasibility study. The Journal of the American Dental Association. 2025;156(4):292-9.e1. 44. Ide M, Mainas G, Kansagra N, Al-Zaeim I, Ang RN, Owen DR, et al. Association between HbA1c chairside values and periodontitis. Journal of dentistry. 2026;167:106563. 45. Brunton L, Soiland-Reyes C, Wilson P. A qualitative evaluation of the national rollout of a diabetes prevention programme in England. BMC health services research. 2023;23(1):1043. 46. Bower P, Soiland-Reyes C, Heller S, Wilson P, Cotterill S, French D, et al. Diabetes prevention at scale: Narrative review of findings and lessons from the DIPLOMA evaluation of the NHS Diabetes Prevention Programme in England. Diabetic Medicine. 2023;40(11):e15209. 47. Sekhon M, Cartwright M, Francis JJ. Acceptability of health care interventions: A theoretical framework and proposed research agenda. British Journal of Health Psychology. 2018;23(3):519-31. 48. NHS England PHE, Diabetes UK. NHS Diabetes Prevention Programme overview and FAQ: An overview of the NHS Diabetes Prevention Programme and some answers to some frequently asked questions. NHS England: NHS England; 2017. 49. England N. Clinical guide for dentistry. In: DHSC, editor. 2 ed. NHSE2023. 50. Rodgers LR, Hill AV, Dennis JM, Craig Z, May B, Hattersley AT, et al. Choice of HbA1c threshold for identifying individuals at high risk of type 2 diabetes and implications for diabetes prevention programmes: a cohort study. BMC medicine. 2021;19(1):184. 51. Doughty J, Large JF, Daley AJ, Yonel Z. Integrating health screening for non-communicable diseases into dental services: what do we know? Community dental health. 2024;41(4):237-43. Additional Declarations There is no duality of interest Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: revise 02 Jun, 2026 Review # 2 received at journal 07 May, 2026 Reviewer # 2 agreed at journal 18 Apr, 2026 Review # 1 received at journal 05 Apr, 2026 Reviewer # 1 agreed at journal 31 Mar, 2026 Reviewers invited by journal 26 Mar, 2026 Editor assigned by journal 24 Mar, 2026 Submission checks completed at journal 24 Mar, 2026 First submitted to journal 22 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information

Related documents

• The Effect of Oral Hygiene and Full Mouth Scaling on Metabolic Control in Patients With Type II Diabetes#154814
• Dutch Dental Hygienists and Their Daily Scope of Practice-A Survey Study.#818
• Innovative Didactic Learning Formats: Have They Improved Dental Education? A Systematic Review and Meta-Analysis.#174710
• Integrated Diabetes and Oral Health Care in Oman#918708
• Can a Low-threshold Check-up Motivate Older People to Schedule a Dental Visit?#911328