A pilot study of an HbA1c chairside screening protocol for diabetes in patients with chronic periodontitis: the dental hygienist's role

Diabetes, periodontitis, and cardiovascular disease: towards equity in diabetes care

Type 2 diabetes and its associated cardiovascular risk is an escalating epidemic that represents a significant public health burden due to increased morbidity and mortality, disproportionately affecting disadvantaged communities. Poor glycaemic control exacerbates this burden by increasing retinal, renal, and cardiac damage and raising healthcare costs. This predicament underscores the urgent need for research into cost-effective approaches to preventing diabetes complications. An important but often overlooked strategy to improve metabolic control in diabetic patients is the treatment of periodontitis. Our aim is to assess whether the inclusion of periodontitis treatment in diabetes management strategies can effectively improve metabolic control, and to advocate for its inclusion from an equity perspective. We conducted a comprehensive review of the literature from 2000 to 2023. We analyzed the pathophysiological links between periodontitis, diabetes, and atherosclerotic cardiovascular disease, all of which have inflammation as a central component. We also examined the inequalities in health care spending in this context. Our findings suggest that incorporating routine screening and treatment of periodontitis into national health programs, with coordinated efforts between physicians and dentists, is a cost-effective measure to improve metabolic control, reduce complications and improve the overall quality of life of people with diabetes.

An Update on the Interdisciplinary Dental Care Approach for Geriatric Diabetic Patients

Diabetes mellitus is a prevalent health issue escalating worldwide that gives rise to numerous problems. Periodontal disorders are recognized as the sixth consequence associated with diabetes mellitus. Research shows that dental health affects overall health, and this knowledge is changing the dental field. The correct choice of glucose goal levels and the optimal selection of glucose-lowering medications are determined by a comprehensive geriatric assessment, an estimate of life expectancy, and a rationale for therapy at regular intervals in elderly diabetics. This article provides an overview of the correlation between diabetes and oral health, with a specific emphasis on xerostomia, periodontal disease, and dental caries. Thus, dentists play a significant role within the allied health profession by contributing to the provision of oral care for those diagnosed with diabetes, with a special focus on geriatric patients.

Prevalence of undiagnosed diabetes and prediabetes related to periodontitis and its risk factors in elderly individuals

OBJECTIVE

The prevalence of undiagnosed diabetes was estimated to increase with age and can reach 3.5%. The purpose of the study was to evaluate the prevalence of undiagnosed diabetes and prediabetes in the elderly patients who attended a dental clinic and to find common risk factors.

METHODS

Male patients, older than 50 years, attended their first dental visit to the School of Dentistry for a period of two years, and it was proposed to evaluate undiagnosed type 2 diabetes mellitus. Periodontal, biochemical, microbiological examinations, nutritional profile, and physical activity were performed.

RESULTS

A total of 106 patients were examined, 6 (5.6%) had diabetes, and 37 (34.9%) had prediabetes without prior diagnosis. The severity of periodontitis was greater in patients with diabetes. Most of the patients were overweight and had increased systolic blood pressure. Patients with prediabetes and periodontitis had a low adherence to the Mediterranean diet. Tannerella forsythia was present in more patients with periodontitis, and the prevalence of Aggregatibacter actinomycetemcomitans is practically absent in groups with periodontitis, except for the group with diabetes.

CONCLUSIONS

In the population studied, the prevalence of patients without a diagnosis of diabetes and prediabetes was very high and underestimated. The increased severity of periodontitis in patients with diabetes and in conjunction with the high level of cortisol seen in patients with periodontitis, especially those with diabetes, emphasize the dysregulation of the immunoinflammatory system.

CLINICAL SIGNIFICANCE

It is essential to add all this data to our dental practice to cover patient health with a broader landscape.

Referral Compliance Following a Diabetes Screening in a Dental Setting: A Scoping Review

With type 2 diabetes prevalence increasing in Australia, and the condition associated with significant morbidity and mortality, screening for dysglycaemia in the dental setting has been proposed to identify asymptomatic individuals. Screening commences with a risk assessment, and individuals identified at elevated risk for having diabetes are then referred to their medical practitioner for confirmation of their glycemic status. Therefore, for screening to be effective, individuals need to adhere to their oral health professionals’ (OHP) advice and attend their medical follow-ups. This review aims to investigate the literature on referral compliance following a risk assessment in the dental setting and identify barriers and facilitators to screened individuals’ referral compliance. A scoping review of the literature was undertaken, selecting studies of diabetes screening in a dental setting that recorded compliance to referral to follow-up, and explored any barriers and facilitators to adherence. Fourteen studies were selected. The referral compliance varied from 25 % to 90%. Six studies reported barriers and facilitators to attending medical follow-ups. Barriers identified included accessibility, cost, knowledge of the condition, and OHP characteristics.

Concordance of three point of care testing devices with clinical chemistry laboratory standard assays and patient-reported outcomes of blood sampling methods

Background

Point of care testing (POCT) devices have been developed to facilitate immediate results with the potential to aid screening for new disease and enable patients to self-monitor their disease. Non-communicable diseases (NCDs) are the major cause of mortality globally and are increasing in prevalence as the population ages. Allied health care professionals (AHPs) are skilled in undertaking risk assessment and delivering preventative advice, providing opportunities to access large proportions of the population who may not visit their doctor, within non-traditional community settings. There is evidence of high levels of support from public, patients and health professionals for engaging AHPs in risk-targeted early case detection of certain NCDs. Thus, POCT devices offer a potential alternative to traditional venous blood collection, as novel care pathways for increasing early case detection and access to preventative care. The objectives of this study were to: (i) determine the concordance of the specific POCT devices with laboratory-based standard assays employed within clinical biochemistry laboratories. (ii) compare the sampling experience of both methods via patient-reported experiences.

Methods

A prospective, two-centre study was undertaken involving 158 participants who provided informed consent. Venous blood was collected for traditional assays of HbA1c, creatinine/ estimated Glomerular-Filtration-Rate (eGFR) and vitamin-D. Capillary blood was collected by finger prick test and also assayed for the same biochemical indices (Nova StatSensor (creatinine/eGFR); Siemens DCA-Vantage (HbA1C); CityAssays (vitamin-D)). All users were provided with device training. Participants reported any discomfort experienced by each simultaneously applied method (randomised in order) via a 100 mm Visual-Analogue-Scale.

Results

Results for each POCT device and the laboratory standard were analysed by Bland-Altman plots to determine assay concordance. POCT devices demonstrated good concordance with laboratory testing, with at least 95% of all samples being within two standard deviations, for each of the devices tested. The majority of participants reported less discomfort with POCT than venepuncture, with the average reported discomfort being 17/100 mm less for POCT compared to venous blood sample collection on the visual analogue scale.

Conclusions

The POCT devices demonstrated acceptable concordance with laboratory-based assays, and patients reported lower levels of discomfort compared to traditional means of blood collection. This study demonstrates the potential of using these devices as acceptable methods for opportunistic testing of “at-risk” individuals within non-traditional community care settings.

Chairside Screening for Undiagnosed Diabetes and Prediabetes in Patients with Periodontitis

Introduction

Globally, it is estimated that half of all people with diabetes are undiagnosed. Because of the well-documented bidirectional link between diabetes and periodontitis, dentists and dental hygienists may have the possibility to screen a targeted population for diabetes during routine dental visits. The aim of the present study is to investigate the effectiveness of one device for diagnosis of diabetes/prediabetes used in one private dental practice and investigate the correlation between the levels of HbA1c and periodontal parameters.

Methods

Periodontal patients that were never diagnosed with diabetes were asked to fill a risk assessment questionnaire for type 2 diabetes mellitus. PD, CAL, FMBS%, FMPS%, and HbA1c through a prick-finger test were measured before and after periodontal therapy or only once in patients following supportive periodontal therapy.

Results

A total of 98 subjects were screened, and among them, one had diabetes and 30 had prediabetes. The mean value of HbA1c was 5.62% for patients with untreated periodontitis and 5.42% for periodontally treated patients. The diagnosis of diabetes resulted to be correlated to FMBS% and FMPS%, while HbA1c levels were correlated to FMBS%, FMPS%, and periodontitis grade.

Conclusion

The present chairside diabetes-screening protocol allowed a consistent proportion of patients to become aware of their pathological or prepathological condition and to seek proper and timely medical care. Thus, dentists and dental hygienists could provide health promotion services and preventive measures.

Implementation and analysis of an enhanced screening and testing protocol for prediabetes in a dental school patient population

OBJECTIVES

This project aimed to enhance the identification of patients at-risk for prediabetes or diabetes within a dental school patient population by introduction of a modified screening tool and related training of dental residents and students.

METHODS

The American Diabetes Association Risk Tool (ADART) was modified by addition of three diabetes-linked oral health questions. Of the 1477 dental patients screened, 551 (37.3%) indicated an at-risk status using the modified tool. A subset of 138 patients received follow-up chairside HbA1c blood testing conducted by dental residents and students. Data was analysed to determine a) the influence of the modifications on the tool's discrimination strength and b) change in the tool's predictive value.

RESULTS

The addition of the 3 oral health questions to the 7-item ADART resulted in a 9.4% increase in identification of patients at-risk for pre-diabetes/diabetes. The predictive value of the tool remained stable. Residents and students successfully incorporated the new screening activities within their assigned clinics.

CONCLUSIONS

This project demonstrates that screening for risk for prediabetes/diabetes is both prudent and practical in the dental setting. Dental personnel, including trainees, can successfully incorporate enhanced screening methods within their traditional activities. Further, screening tools used in the dental setting might be enhanced by inclusion of certain oral health variables associated with diabetes. These findings add to emerging knowledge on the importance of screening for prediabetes/diabetes in dental settings and have particular relevance and application to institutional practice.

Periodontitis and identification of undiagnosed hyperglycemia

Abstract Introduction Individuals with pre-diabetes have altered glycemic levels, are generally asymptomatic, and are at increased risk for developing type 2 diabetes mellitus. Objective Identify the prevalence of periodontal individuals with undiagnosed hyperglycemia and associated impact factors. Material and method Fifty-six patients with periodontitis and without diabetes self-report, users of dental clinic services at Federal University of Juiz de Fora were included in this research, during one year and a half of experimental evaluation. Socioeconomic and demographic data, anthropometric patterns, fasting capillary blood glucose, and complete periodontal examination (six sites per tooth) were evaluated. Result The sample consisted of 58.9% female, mean age 53 years old, 58.9% obese/overweight and 45.3% had a low level of education. A total of 28.6% (n=16) participants had undiagnosed hyperglycemia (between 100 to 160 mm / dL), of which 81.3% were obese/overweight, 25% were smokers, 56.3% reported having a history of diabetes in the family, 93.8% had a family income up to 2 brazilian´s minimum wages. BMI values were higher in the group of patients with hyperglycemia (29.8 ± 5.7, p = 0.03) compared to the group without hyperglycemia (26.6 ± 5.6). Patients with hyperglycemia had a greater number of sites with clinical attachment loss (CAL) between 4 and 6 mm (p = 0.04) when compared with the normoglycemic group. Conclusion Undiagnosed CAL attachment loss between 4 and 6 mm due to periodontitis than normoglycemic individuals.

Prediabetes/diabetes screening strategy at the periodontal clinic

Objective

The aim of the study was to propose an efficient chairside clinical strategy for the identification of undiagnosed hyperglycaemia in periodontal clinics.

Material and methods

Α chairside system was used for assessment of glycated hemoglobin 1c (HbA1c) and active Matrix Metalloproteinase‐8 levels (aMMP‐8) were analyzed by immunotest in patients (n = 150) who fulfilled the criteria for screening of the Centers for Disease Control and Prevention. Full‐mouth periodontal parameters were assessed and various data such as Body Mass Index (BMI), smoking and education were recorded.

Results

Thirty‐one patients out of 150 tested were found with unknown hyperglycaemia (20.7%). Regarding sex, education, parent with diabetes, normal BMI, smoking, age ≥45 years and prior testing for diabetes, no differences were observed between subjects displaying HbA1c < 5.7 and ≥5.7% (Pearson's Chi‐square test, p > .05). Subgroups differed regarding BMI (kg/m²), tooth count, percentages of 4 and 5 mm pockets (Mann–Whitney and z‐test, p < .05). The diagnostic performance for HbA1c ≥5.7 was tested by Receiving Operator Characteristic curves and Areas Under the Curve (AUC) for the following: age ≥ 45 years and BMI (AUC 0.651, p = .010), the above and aMMP‐8 (AUC 0.660, p = .006), age ≥ 45 years, BMI and Stage of Periodontitis (AUC 0.711, p < .001) and age ≥ 45 years, BMI, aMMP‐8 and stage of periodontitis (AUC 0.713, p < .001).

Conclusions

Findings of the study suggest that the combination of stage of periodontitis, increasing age, BMI and aMMP‐8, without chairside HbA1c assessment appears to be a viable screening strategy for referring dental patients for testing for prediabetes/diabetes.

Use of dental practices for the identification of adults with undiagnosed type 2 diabetes mellitus or non-diabetic hyperglycaemia: a systematic review

AIM

Type 2 diabetes is a growing global challenge. Evidence exists demonstrating the use of primary care (non-hospital based) dental practices to identify, through risk assessments, those who may be at increased risk of type 2 diabetes or who may already unknowingly have the condition. This review aimed to synthesize evidence associated with the use of primary care dental services for the identification of undiagnosed non-diabetic hyperglycaemia or type 2 diabetes in adults, with particular focus on the pick-up rate of new cases.

METHOD

Electronic databases were searched for studies reporting the identification of non-diabetic hyperglycaemia/type 2 diabetes in primary care dental settings. Returned articles were screened and two independent reviewers completed the data-extraction process. A descriptive synthesis of the included articles was undertaken due to the heterogeneity of the literature returned.

RESULTS

Nine studies were identified, the majority of which utilized a two-stage risk-assessment process with risk score followed by a point-of-care capillary blood test. The main barriers cited were cost, lack of adequate insurance cover and people having previously been tested elsewhere. The pick-up rate of new cases of type 2 diabetes and non-diabetic hyperglycaemia varied greatly between studies, ranging from 1.7% to 24% for type 2 diabetes and from 23% to 45% for non-diabetic hyperglycaemia, where reported.

CONCLUSION

This review demonstrates that although it appears there may be benefit in using the dental workforce to identify undiagnosed cases of non-diabetic hyperglycaemia and type 2 diabetes, further high-quality research in the field is required assessing both the clinical and cost effectiveness of such practice. (Prospero Registration ID: PROSPERO 2018 CRD42018098750).

Prevalence of Undiagnosed Diabetes and Prediabetes in the Dental Setting: A Systematic Review and Meta-Analysis

Background

With the close link between diabetes mellitus (DM) and periodontal disease (PD), dentists have an unrealized opportunity to make a chance discovery of a patient's medical condition. Unlike in the medical setting, information on the point of care (PoC) and opportunistic screening for DM in the dental setting is limited. To make a reliable estimate on the prevalence of undiagnosed type 2 diabetes mellitus (T2DM) and prediabetes among dental patients in the dental setting and to assist healthcare planners in making an informed decision, information on the disease frequency and strategies employed to address this issue is of paramount importance.

Objectives

To summarize the data on the prevalence of undiagnosed T2DM and prediabetes amongst dental patients and further explore the effectiveness of the PoC screening and its implication for use in the dental setting.

Methods

A MEDLINE-PubMed, EMBASE, Web of Science, and Cochrane Library search was conducted with no time specification. Information on study characteristics and diagnostic parameters was retrieved for meta-analysis. All the studies were assessed for methodological quality using the QUADAS-2 tool. Proportions were presented in tables and forest plots. All statistical analysis was performed using the MedCalc software.

Results

Nine studies met the inclusion criteria. The proportion of dental patients identified to be at a risk of hyperglycaemia with the PoC screening using random blood glucose (RBG) and HbA1 was 32.47% and 40.10%, whilst the estimated proportion with undiagnosed T2DM and prediabetes was identified as 11.23% and 47.38%.

Conclusion

A significant proportion of dental patients can be identified as undiagnosed T2DM and prediabetes. Targeted opportunistic screening is a feasible approach and can help reduce the prevalence of undiagnosed T2DM and prediabetes.

Prevalence of undiagnosed diabetes and pre-diabetes in chronic periodontitis patients assessed by an HbA1c chairside screening protocol

OBJECTIVES

The objective of the present study was to implement a chairside diabetes screening strategy for the identification of undiagnosed hyperglycaemia in periodontal patients.

MATERIALS AND METHODS

Measurement of HbA1c was performed in patients (n = 139) diagnosed with periodontal disease to determine possible unknown hyperglycaemia. Patients fulfilled the criteria for screening according to the questionnaire by the Centers for Disease Control and Prevention (CDC). The Cobas® b101 in vitro diagnostic system was used for the measurement of glycosylated haemoglobin (HbA1c) in capillary blood. Body mass index (BMI) and waist circumference were also measured to determine splanchnic obesity. Periodontal parameters were assessed with an automated probe and included probing depth, clinical attachment loss, bleeding on probing and presence/absence of plaque.

RESULTS

Most patients had moderate periodontitis. Almost 25% of the subjects tested were found to have unknown hyperglycaemia while 80.5% of them had splanchnic obesity. A significant association was found between HbA1c and BMI (Mann-Whitney test; p = 0.0021) as well as between HbA1c and waist circumference (Spearman rho test; p = 0.0007). No differences were observed regarding periodontal parameters between subjects exhibiting HbA1c ≥ 5.7% and those with HbA1c < 5.7% (Mann-Whitney test; p > 0.05) although those with HbA1c ≥ 5.7% displayed higher proportions of sites with clinical attachment loss > 5 mm (z test with Bonferroni corrections; p < 0.05).

CONCLUSIONS

Periodontal patients, especially those with a bigger than normal BMI and waist circumference, are a target group worth screening for diabetes.

CLINICAL RELEVANCE

The dental practitioner can contribute significantly to the worldwide effort of health care professionals in diabetes screening and referring for early diagnosis of the disease.

Periodontal disease increases the risk for onset of systemic comorbidities in dental hospital attendees: An 18-year retrospective cohort study

BACKGROUND

Periodontal disease closely links to various systemic diseases. This l8-year retrospective cohort study investigated whether poor periodontal condition may increase the risk for onset of systemic comorbidities.

METHODS

A total of 488 individual dental folders from 17 400 dental hospital attendees registered from 1996 to 1998 were randomly selected, and these participants were free of diabetes, cardiovascular disease, chronic obstructive pulmonary disease, cancer, stroke, cognitive impairment, hypertension, and dyslipidemia in the Clinical Management System. The records of periodontal examination and orthopantomogram on the first registration were obtained, and full-mouth bone level (BL) was measured. Onsets of the eight comorbidities concerned above until 2016 were retrieved from the system.

RESULTS

The participants with worse periodontal status on their first registration had significantly higher numbers of the eight comorbidities/mortality during the 18-year follow-ups than their counterparts (P < 0.05). BL presented as bone loss/age was independently correlated to the comorbidity profiles in two multivariate models (0 to 1 versus ≥2; 0 to 2 versus ≥3) after adjusting for age and sex (odds ratio [OR] = 1.87; OR = 2.18, P < 0.05), highlighting that the individuals with more bone resorption exhibited a greater number of the comorbidities as compared with their counterparts. Moreover, those with onsets of more comorbidities showed worse periodontal conditions according to four parameters employed (community periodontal index, BL, bone loss/age and number of remaining teeth) (P < 0.05).

CONCLUSIONS

Within the limitations of this 18-year retrospective cohort study, our findings provide the first evidence that periodontal disease experience to some extent reflects the host susceptibility to onset of common systemic comorbidities. Further studies with larger sample sizes and appropriate adjustment of critical confounders are highly warranted to substantiate the current observation.

The burden of Diabetes, Its Oral Complications and Their Prevention and Management

BACKGROUND

Diabetes mellitus (DM), chronic disease, is a public health problem that affects 8.5% adult population worldwide. The number of adults with DM has risen sharply from 108 million in 1980 to 422 million in 2014. In 2012, 1.5 million individuals died because of DM and an additional 2.2 million deaths occurred because of high blood glucose level resulting in cardiovascular and other systemic diseases. DM brings huge economic loss to patients, their families, and healthcare systems. Globally, the cost of DM was US$1•31 trillion in 2015.

AIM

This review article utilised the prevalence data of diabetes mellitus from the World Health Organization and International Diabetes Federation to provide a comprehensive picture of the disease in different parts of the world.

METHODS

Electronic databases such as Google Scholar, Medline via PubMed, Scopus, and Web of Science were used to search the literature. The library resources of Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia were used to retrieve studies on the topics of the present review.

RESULTS

Systemic complications of DM include heart attack, kidney disease, limb loss, blindness, and peripheral nerve damage. More than 90% of diabetic patients were found to have oral manifestations. It is known that DM severely damages oral tissues causing periodontal disease, tooth loss, xerostomia, caries, burning mouth disorder, taste and salivary gland dysfunction, delayed wound healing, lichen planus, geographic tongue, and candidiasis. The evidence is mounting about a strong bidirectional relationship between DM and periodontal disease. Unfortunately, many diabetic patients are unaware of the association between DM and oral health, and only a small percentage of them visit the dentist for routine dental check-ups. Changes in lifestyles (control of blood glucose levels and self-care practices), regular dental check-ups with emphasis on periodontal assessment, and reinforcement of oral health instructions can effectively prevent oral complications of DM. Scaling and root planning are effective in improving glycemic control among diabetic patients.

CONCLUSION

Dental professionals should be part of the multidisciplinary team that helps individuals with diabetes.

Impaired glucose metabolism is associated with tooth loss in middle-aged adults: The Northern Finland Birth Cohort Study 1966

AIM

We investigated the association of impaired glucose metabolism with tooth loss in adults in the Northern Finland Birth Cohort Study 1966 (NFBC1966).

METHODS

We examined 4394 participants from the 46-year follow-up of the NFBC1966. Self-reported number of teeth as well as insulin and glucose values, taken during a standard oral glucose tolerance test (OGTT), served as the primary study variables. A multinomial logistic regression model served to analyse (unadjusted, smoking-adjusted and fully adjusted) the association between number of teeth (0-24, 25-27, 28-32) and glucose metabolism in women and men.

RESULTS

Among women, type 2 diabetes - whether previously known or detected during screening - pointed to a higher likelihood of 0-24 teeth (fully adjusted OR = 2.99, 95%CI = 1.54-5.80) and 25-27 teeth (OR = 1.91, 95%CI = 1.18-3.08) than did normal glucose tolerance. Similarly, impaired fasting glucose and impaired glucose tolerance together indicated a higher likelihood of 0-24 teeth (OR = 1.71, 95%CI = 1.09-2.69) than did normal glucose tolerance. A similar, statistically non-significant, pattern emerged among men. Number of teeth associated with OGTT insulin and glucose curves as well as with the Matsuda index in both women and men.

CONCLUSIONS

Tooth loss strongly associated with impaired glucose metabolism in middle-aged Finnish women.

Providing Health Screenings in a Dental Setting to Enhance Overall Health Outcomes

Data suggest that providers and patients have a favorable attitude toward chairside screening in the dental setting and are willing to participate in these activities. Likewise, efficacy studies indicate this strategy can effectively identify patients who are at increased risk of disease or have the presence of disease risk factors and could benefit from medical follow-up. Studies suggest it is feasible to conduct these screenings in the dental setting. Although the American Dental Association has established screening treatment codes, challenges to widespread implementation still exist, including developing a provider reimbursement strategy and the need for adequate provider training.

American dental hygienists' attitudes towards chairside medical screening in a dental setting

OBJECTIVES

Targeted screening for medical conditions in a dental setting can be an effective strategy for early identification of individuals at increased disease risk. Dentists, patients and physicians have a favourable attitude towards this strategy. Given that dental hygienists (DHs) are involved in preventive and educational activities, this seems like a natural extension to their roles. We report on the attitudes of American DHs towards chairside medical screening.

METHODS

A 5-point Likert scale (1 = very important/willing, 5 = very unimportant/unwilling) survey was mailed to a nationwide random sample of US practicing DHs. Descriptive statistics were used for all questions, and the Friedman nonparametric analysis of variance was used for multi-element questions.

RESULTS

A total of 3133 respondents returned the completed questionnaires for an effective response rate of 49.2% and a margin of error 1.8%. The majority of respondents felt it was important to perform/conduct chairside screening for hypertension (94%), diabetes mellitus (89%), cardiovascular disease (85%), HIV (79%) and hepatitis infection (78%); were willing to refer a patient for medical consult (94%), conduct screening that yields immediate results (85%); and were willing to collect the data/samples needed (57-95%). The most important considerations were dentist/owner support (98%), training (97%), patient willingness (98%) and time (98%).

CONCLUSION

Similar to dentists, physicians and patients, the majority of the DHs had a favourable attitude towards chairside medical screening. Integrating the DH into screening activities is likely to require additional training and education regarding the diseases of interest, something that could be accomplished through continuing education courses and eventually incorporation into the educational curriculum.