Proteomics, Lipidomics, Metabolomics, and 16S DNA Sequencing of Dental Plaque From Patients With Diabetes and Periodontal Disease.

Oral microbiome influences human health, specifically prediabetes and type 2 diabetes (Pre-DM/DM) and periodontal diseases (PDs), through complex microbial interactions. To explore these relations, we performed 16S rDNA sequencing, metabolomics, lipidomics, and proteomics analyses on supragingival dental plaque collected from individuals with Pre-DM/DM (n = 39), Pre-DM/DM and PD (n = 37), PD alone (n = 11), or neither (n = 10). We identified on average 2790 operational taxonomic units and 2025 microbial and host proteins per sample and quantified 110 metabolites and 415 lipids. Plaque samples from Pre-DM/DM patients contained higher abundance of Fusobacterium and Tannerella than plaques from metabolically healthy patients. Phosphatidylcholines, plasmenyl phosphatidylcholines, ceramides containing non-OH fatty acids, and host proteins related to actin filament rearrangement were elevated in plaques from PD versus non-PD samples. Cross-omic correlation analysis enabled the detection of a strong association between Lautropia and monomethyl phosphatidylethanolamine (PE-NMe), which is striking because synthesis of PE-NMe is uncommon in oral bacteria. Lipidomics analysis of in vitro cultures of Lautropia mirabilis confirmed the synthesis of PE-NMe by the bacteria. This comprehensive analysis revealed a novel microbial metabolic pathway and significant associations of host-derived proteins with PD.

Modeling longitudinal oral health status and pneumonia risk: secondary data analyses of an integrated dental-medical cohort.

BACKGROUND: Mounting evidence indicates potential associations between poor oral health status (OHS) and increased pneumonia risk. Relative pneumonia risk was assessed in the context of longitudinally documented OHS. METHODS: Electronic medical/dental patient data captured from 2007 through 2019 were retrieved from the integrated health records of Marshfield Clinic Health Systems. Participant eligibility initiated with an assessment of OHS, stratified into the best, moderate, or worst OHS groups, with the additional criterion of 'no pneumonia diagnosis in the past 90 days'. Pneumonia incidence was longitudinally monitored for up to 1 year from each qualifying dental visit. Models were assessed, with and without adjustment for prior pneumonia incidence, adjusted for smoking and subjected to confounding mitigation attributable to known pneumonia risk factors by applying propensity score analysis. Time-to-event analysis and proportional hazard modeling were applied to investigate relative pneumonia risk over time among the OHS groups. RESULTS: Modeling identified associations between any incident pneumonia subtype and 'number of missing teeth' (p < 0.001) and 'clinically assessed periodontal status' (p < 0.01), which remained significant following adjustment for prior pneumonia incidence and smoking. The hazard ratio (HR) for 'any incident pneumonia' in the best OHS group for 'number of missing teeth' was 0.65, 95% confidence interval (CI) [0.54 - 0.79] (unadjusted) and 0.744, 95% CI [0.61 - 0.91] (adjusted). The HR for 'any incident pneumonia' in the best 'clinically assessed periodontal status' group was 0.72, 95% CI [0.58 - 0.90] (unadjusted) and 0.78, 95% CI [0.62 - 0.97] (adjusted). CONCLUSION/CLINICAL RELEVANCE: Poor OHS increased pneumonia risk. Proactive attention of medical providers to patient OHS and health literacy surrounding oral-systemic disease association is vital, especially in high-risk populations.

ESTABLISHING A QUALITY IMPROVEMENT CULTURE WITHIN A LARGE INTEGRATED MEDICAL-DENTAL HEALTH SYSTEM WITH A POPULATION BASED FOCUS.

OBJECTIVES: Quality improvement strategies have been an integral part of healthcare to attain improved care delivery and effective health outcomes. The dental quality initiative improvement (DQII) presented in this manuscript represents a case study of successful implementation of a quality improvement culture within a large integrated-medical-dental health system serving a largely rural population. METHODS: The key elements of DQII included steering committee establishment, definition or dental quality measures and development/implementation of a dental quality analytics dashboard (DQAD) that provides relevant data on dental quality measures. Qualitative metrics were applied to look at the improvement in performance for the various measures relative to quality benchmarks. RESULTS: DQII facilitated improved oversight of care continuity and provider performance surrounding quality measures at granular and/or institutional level. Improvement associated with care delivery performance relative to benchmarks was observed. CONCLUSIONS: DQII further advanced the quality improvement culture prevalent in our learning healthcare environment with its focus on value-based care delivery. DQII initiative and establishment of DQAD provided ability to track performance in operational care delivery for dental providers in a clinical setting in real time.

Feasibility of establishing tele-dental approach to non-traumatic dental emergencies in medical settings.

PURPOSE: Non-traumatic dental condition visits (NTDCs) represent about 1.4% to 2% of all Emergency Department (ED) visits and are limited to palliative care only, while associated with high cost of care. Feasibility of establishing a tele-dental approach to manage NTDCs in ED and Urgent care (UC) settings was undertaken to explore the possibility of utilizing remote tele-dental consults. METHODS: Participants with NTDCs in ED/UCs were examined extra and intra-orally: (1) directly by ED provider, (2) remotely by tele-dental examiner (trained dentist) using intra-oral camera and high-definition pan-tilt-zoom (PTZ) camera, (3) directly by treating dentist post ED/UC visit (if applicable) and, (4) secondary assessment by tele-dental reviewer. Comparisons were drawn between differential diagnoses and recommended managements provided by ED/UC providers, tele-dental examiner, treating dentist, and tele-dental reviewer. RESULTS: 13 patients participated in the study. The overall inter-rater agreement between the tele-dental examiner and tele-dental reviewer was high while it was low between tele-dentists and the ED providers. The preliminary testing of tele-dental intervention in the ED/UC setting demonstrated potential feasibility in addressing the NTDC landing in ED/UC. Larger interventional studies in multi-site setting are needed to validate this approach and especially evaluate impact on cost, ED/UC workflow and patient outcomes. CLINICAL SIGNIFICANCE: Using tele-dentistry to triage non-traumatic dental visits to the emergency room may be a promising approach. Once this approach is validated through a larger study, tele-dental outreach could help in directing non-traumatic dental emergency patients to the appropriate dental setting to provide treatment for the patients.

Patient Awareness of Association of Diabetes and Periodontal Disease.

This cross-sectional study sought to assess the current awareness, knowledge, and behavior regarding diabetes mellitus (DM) and periodontal disease (PD) association among a convenience sample of patients from a large Wisconsin-based integrated medical-dental health care organization serving largely rurally based communities. An anonymous 10-question survey was distributed at regional medical and dental centers of dental and medical clinics of a single health care institution over a 4-week period, to achieve a cross-sectional sampling of patients aged 18 to 80 years. Among 946 respondents, 616 were female. Patient-reported periodicity for dental visits was highest between 6 months and 1 year (56.4%). Respondents reporting "poor-fair" knowledgeability surrounding DM-PD association correlated with highest interest in learning more about DM-PD relationship (p <.0001). While over 80% of respondents correctly answered questions about gum disease symptomology and contribution of oral health practices on diabetes prevention, only 51% knew that PD affected blood sugar control. Willingness to comply with medical screening conducted by dental providers for diseases affecting oral health was indicated by 44% of respondents (p < .0001). Study results indicated that knowledgeability levels among patients surrounding the effect of PD on DM needed improvement. Strategic educational interventions targeting improved health literacy among patients may further promote prevention of DM-PD complications. Health literacy gaps remain to be addressed in patient understanding of the importance of detecting and managing dysglycemia for maintenance of periodontal health, creating opportunities for patient education.

Updates from the Evidence Base Examining Association between Periodontal Disease and Type 2 Diabetes Mellitus: Current Status and Clinical Relevance.

PURPOSE OF THE REVIEW: Epidemiological surveillance documents an escalating epidemic prevalence of both type 2 diabetes (T2DM) and periodontal disease (PD). The principal goals of this review are to: 1) re-examine the clinical significance of associations between PD and T2DM, based on strength of collective evidence as determined by systematic review and meta-analysis, and 2) review findings of the systematic reviews and meta-analyses in light of the current understanding of PD-associated pathophysiology and intersection with T2DM pathophysiology. RECENT FINDINGS: Tooth loss predicts risk for chronic disease and mortality. PD is significantly associated with complications of diabetes, including retinopathy. Based on systematic reviews and meta-analyses, the adjunctive use of certain antibiotics enhances non-surgical periodontal treatment (NSPT) in patients with T2DM. Systematic reviews and meta-analyses support NSPT efficacy in achieving metabolic control. Systematic reviews and meta-analyses support the association between PD and T2DM, albeit the effect size may be modest. PD-T2DM interactions have important clinical implications.

Knowledgeability, Attitude and Behavior of Primary Care Providers Towards Oral Cancer: a Pilot Study.

The objective of this study was to assess current knowledgeability, attitudes, and practice behaviors of primary care providers (PCPs) towards oral cancer screening. Applying a cross-sectional design, a 14-question survey was emailed to 307 PCPs practicing at a large, multi-specialty, rurally based healthcare system. Survey data were collected and managed using REDCap and analyzed applying descriptive statistics. A 20 % response rate (n = 61/307) was achieved for survey completion. Approximately 70 % of respondents were physicians, 16 % were nurse practitioners, and 13 % were physician assistants. Nearly 60 % of respondents were family medicine practitioners. Limited training surrounding oral cancer screening during medical training was reported by 64 %. Although 78 % of respondents reported never performing oral cancer screening on patients in their practice, >90 % answered knowledge-based questions correctly. Frequency rate for specialist referral for suspicious lesions by PCPs was 56 % "frequently". Optimal periodicity for oral cancer screening on all patients selected by respondents was 61 % "annually", 3 % "every 6 months", 3 % "every visit", 2 % "not at all", and 31 % "unsure". This study established a baseline surrounding current knowledgeability, practice patterns, and opinions of PCPs towards oral cancer screening at a single, large, regional healthcare system. In the absence of evidence-based support for population-based cancer screening, this study result suggests a need for better integration of oral cancer surveillance into the medical setting, supplemented by education and training with emphasis on assessment of high-risk patients to achieve early detection. Prospectively, larger studies are needed to validate these findings.

Integrating Medical-Dental Care for Diabetic Patients: Qualitative Assessment of Provider Perspectives.

Globally, periodontal disease and diabetes have achieved epidemic proportions and have become a top health care priority. Mutual bidirectional exacerbation of these conditions is promoting creation of cross-disciplinary integrated care delivery (ICD) models that bridge the traditionally siloed health care domains of dentistry and medicine. By engaging focus groups inclusive of both medical and dental providers and one-on-one interviews, this qualitative study investigated provider knowledgeability, receptiveness, and readiness to engage ICD and sought input from the medical-dental primary care practitioner participants on perceived opportunities, benefits, and challenges to achieving ICD models for patients with diabetes/prediabetes. Statewide regional representation and inclusivity of diverse practice settings were emphasized in soliciting participants. Thematic analysis of focus group and interview transcripts was undertaken to establish current state of the art, gauge receptivity to alternative ICD models, and seek insights from practitioners surrounding opportunities and barriers to ICD achievement. Forty providers participated, and thematic analyses achieved saturation. Providers were well informed regarding disease interaction; were receptive to ICD, including implementation of better screening and referral processes; and favored improving interdisciplinary communication inclusive of access to integrated electronic health records. Perceived barriers and opportunities communicated by participants for advancing ICD were documented.

Patient awareness/knowledge towards oral cancer: a cross-sectional survey.

BACKGROUND: Oral cancer (OC) is associated with multiple risk factors and high mortality rates and substantially contributes to the global cancer burden despite being highly preventable. This cross-sectional study sought to assess current knowledge, awareness, and behaviors of patients in rural communities surrounding OC risk. METHODS: An anonymous 21-question survey was distributed to patients in waiting rooms of a large integrated medical-dental health system serving north-central Wisconsin. Survey results were summarized via descriptive statistics. Odds ratios surrounding health literacy on OC risk factors were obtained using unconditional univariate logistic regression analysis. RESULTS: Of 504 dental and 306 medical patients completing the survey, 62.2% were female, Caucasian/White (92%) with 41% having a ≤ high school diploma/equivalent. Current smoker/smokeless tobacco use was reported by 34%, while 39% reported former tobacco exposure. Alcohol use was reported by 54% of respondents at the following frequencies: < once/week, (35%); 1-2 times/week, (16%); 3-4 times/week, (6%); 5-6 times/week, (2%); and daily, (23%). Knowledge about tobacco and alcohol use and increased OC risk was reported by 94 and 40%, respectively. About 50% reported knowledgeability regarding cancer-associated symptomology. Tobacco cessation was reported by 20% of responders. Receipt of education on OC from healthcare providers and human papilloma virus links to OC causation was reported by 38 and 21%, respectively. CONCLUSION: Patients who smoked > 20+ cigarettes per day were more knowledgeable about tobacco and OC risk compared to non-smokers and those who smoked ≤ 19 cigarettes/day (p = 0.0647). Patients who were alcohol consumers exhibited higher knowledgeability surrounding increased OC risk with alcohol and tobacco exposures compared to alcohol abstainers (p = 0.06). We concluded that patients recognized links between tobacco and OC risk but demonstrated lower knowledge of other causal factors. Strategic patient education by providers could increase awareness of OC risk.

Status Update on Translation of Integrated Primary Dental-Medical Care Delivery for Management of Diabetic Patients.

Escalating prevalence of both diabetes and periodontal disease, two diseases associated with bi-directional exacerbation, has been reported. Periodontal disease represents a modifiable risk factor that may reduce diabetes onset or progression, and integrated models of cross-disciplinary care are needed to establish and manage glycemic control in affected patients. An ad-hoc environmental scan of current literature and media sought to characterize factors impacting status of integrated care models based on review of the existing evidence base in literature and media surrounding: (1) current cross-disciplinary practice patterns, (2) epidemiological updates, (3) status on risk assessment and screening for dysglycemia in the dental setting, (4) status on implementation of quality metrics for oral health, (5) care model pilots, and (6) public health perspectives. The survey revealed: escalating prevalence of diabetes and periodontitis globally; greater emphasis on oral health assessment for diabetic patients in recent medical clinical practice guidelines; high knowledgeability surrounding oral-systemic impacts on diabetes and growing receptivity to medical-dental integration among medical and dental providers; increasing numbers of programs/studies reporting on positive impact of emerging integrated dental-medical care models on diabetic patient healthcare access and health outcomes; a growing evidence base for clinically significant rates of undiagnosed dysglycemia among dental patients reported by point-of-care pilot studies; no current recommendation for population-based screening for dysglycemia in dental settings pending a stronger evidence base; improved definition of true periodontitis prevalence in (pre)/diabetics; emerging recognition of the need for oral health quality indicators and tracking; evidence of persistence in dental access disparity; updated status on barriers to integration. The potential benefit of creating clinically-applicable integrated care models to support holistic management of an escalating diabetic population by targeting modifiable risk factors including periodontitis is being recognized by the health industry. Cross-disciplinary efforts supported by high quality research are needed to mitigate previously- and newly-defined barriers of care integration and expedite development and implementation of integrated care models in various practice settings. Implementation of quality monitoring in the dental setting will support definition of the impact and efficacy of interventional clinical care models on patient outcomes.

Statistical Application and Cost Saving in a Dental Survey.

OBJECTIVE: To effectively achieve a robust survey response rate in a timely manner, an alternative approach to survey distribution, informed by statistical modeling, was applied to efficiently and cost-effectively achieve the targeted rate of return. DESIGN: A prospective environmental scan surveying adoption of health information technology utilization within their practices was undertaken in a national pool of dental professionals (N=8000) using an alternative method of sampling. The piloted approach to rate of cohort sampling targeted a response rate of 400 completed surveys from among randomly targeted eligible providers who were contacted using replicated subsampling leveraging mailed surveys. METHODS: Two replicated subsample mailings (n=1000 surveys/mailings) were undertaken to project the true response rate and estimate the total number of surveys required to achieve the final target. Cost effectiveness and non-response bias analyses were performed. RESULTS: The final mailing required approximately 24% fewer mailings compared to targeting of the entire cohort, with a final survey capture exceeding the expected target. An estimated $5000 in cost savings was projected by applying the alternative approach. Non-response analyses found no evidence of bias relative to demographics, practice demographics, or topically-related survey questions. CONCLUSION: The outcome of this pilot study suggests that this approach to survey studies will accomplish targeted enrollment in a cost effective manner. Future studies are needed to validate this approach in the context of other survey studies.

Update on Electronic Dental Record and Clinical Computing Adoption Among Dental Practices in the United States.

This study sought to re-characterize trends and factors affecting electronic dental record (EDR) and technologies adoption by dental practices and the impact of the Health Information Technology for Economic and Clinical Health (HITECH) act on adoption rates through 2012. A 39-question survey was disseminated nationally over 3 months using a novel, statistically-modeled approach informed by early response rates to achieve a predetermined sample. EDR adoption rate for clinical support was 52%. Adoption rates were higher among: (1) younger dentists; (2) dentists ≤ 15 years in practice; (3) females; and (4) group practices. Top barriers to adoption were EDR cost/expense, cost-benefit ratio, electronic format conversion, and poor EDR usability. Awareness of the Federal HITECH incentive program was low. The rate of chairside computer implementation was 72%. Adoption of EDR in dental offices in the United States was higher in 2012 than electronic health record adoption rates in medical offices and was not driven by the HITECH program. Patient portal adoption among dental practices in the United States remained low.

Medical Providers' Oral Health Knowledgeability, Attitudes, and Practice Behaviors: An Opportunity for Interprofessional Collaboration.

OBJECTIVE: Evaluation of current knowledgeability, attitudes, and practice behaviors of medical providers from a large health care system toward oral health was undertaken as a pilot effort to better understand and integrate oral health into the overall health care delivery. METHODS: Invitations to complete a 28-question survey, designed in a web-based platform (SurveyMonkey(®)), were emailed to 1407 medical multispecialty physicians, residents, and nurses within the health system. The questionnaire included sections on provider demographics, oral health knowledgeability and attitudes, and current practice conducting oral health screenings. RESULTS: A 14% (n = 199/1407) response rate was achieved for survey completion. There were 16% who reported good coverage of oral/dental health topics in their medical training curriculum. Competency level was <30% for identifying tooth decay and oral pathology. There were 95% who reported never applying fluoride varnish in their practice, while >80% answered knowledge-based questions correctly. Frequency rates for dental referral by the medical providers were 32% 'frequently' and 68% 'infrequently.' Perceptions of optimal frequency for conducting oral health assessment in their professional practices ranged from 69% indicating 'frequently' to 25% indicating 'infrequently.' CONCLUSION: Overall, positive attitudes were observed toward incorporation of oral health examination into medical practice. The study identified lack of oral health treatment and infrequent referral by medical providers to dental providers. Results support likelihood for acceptance of care models that incorporate a medical/dental team-based approach complemented by oral health training for medical providers to enhance holistic health care delivery. Limitations of this pilot study include potential selection bias and lack of generalizability beyond our institution; further studies are planned in additional settings statewide to validate findings.

Regional epidemiologic assessment of prevalent periodontitis using an electronic health record system.

An oral health surveillance platform that queries a clinical/administrative data warehouse was applied to estimate regional prevalence of periodontitis. Cross-sectional analysis of electronic health record data collected between January 1, 2006, and December 31, 2010, was undertaken in a population sample residing in Ladysmith, Wisconsin. Eligibility criteria included: 1) residence in defined zip codes, 2) age 25-64 years, and 3) ≥1 Marshfield dental clinic comprehensive examination. Prevalence was established using 2 independent methods: 1) via an algorithm that considered clinical attachment loss and probe depth and 2) via standardized Current Dental Terminology (CDT) codes related to periodontal treatment. Prevalence estimates were age-standardized to 2000 US Census estimates. Inclusion criteria were met by 2,056 persons. On the basis of the American Academy of Periodontology/Centers for Disease Control and Prevention method, the age-standardized prevalence of moderate or severe periodontitis (combined) was 407 per 1,000 males and 308 per 1,000 females (348/1,000 males and 269/1,000 females using the CDT code method). Increased prevalence and severity of periodontitis was noted with increasing age. Local prevalence of periodontitis was consistent with national estimates. The need to address potential sample selection bias in future electronic health record-based periodontitis research was identified by this approach. Methods outlined herein may be applied to refine oral health surveillance systems, inform dental epidemiologic methods, and evaluate interventional outcomes.

TADA: The Topology-Accommodating Direction Assignment Algorithm for Liquid Crystals.

Despite the fact that topological defects are a hallmark of liquid crystalline materials, current computational techniques for identifying topological defects in particle-based simulations of these materials─which rest upon Q-tensor theory─do not leverage topological features of the system. In this work, we describe the topology-accommodating direction assignment (TADA) algorithm, a novel approach for identifying disclination cores in liquid crystalline materials, which is sensitive to topology: this method assigns to each mesogen a unique vector, thereby extending the concept of the liquid crystal director field down to the scale of mesogens. In systems containing disclination cores, TADA identifies line segments along which this assigned vector field is discontinuous, with cores located at the interior termination points of these line segments. The mere presence of defects can be identified by searching far away from them. We validate this approach by comparing its results to those obtained using the scalar order parameter for a variety of liquid crystalline assemblies sourced from molecular-dynamics simulations. We also discuss several benefits of the TADA algorithm over existing approaches for identifying topological defects in liquid crystalline materials.

DentaSeal: A school-based dental sealant efficiency assessment tool to support statewide monitoring and reporting: A field report.

BACKGROUND: The evidence base supports effectiveness of dental sealants for prevention of childhood caries in school-aged children. OBJECTIVE: This study describes planning, development, usability testing and outcomes following implementation of DentaSeal, a web-based application designed to accurately track unique student data and generate reports for all Wisconsin school-based sealant placement (SP) programs. METHODS: Application software development was informed by a steering committee of representative stakeholders who were interviewed to inform design and provide feedback for design of DentaSeal during development and evaluation. Software development proceeded based on wireframes developed to build architectural design. Usability testing followed and informed any required adjustments to the application. The DentaSeal prototype was beta tested and fully implemented subsequently in the public health sector. RESULTS: The DentaSeal application demonstrated capacity to: 1) track unique student SP data and longitudinal encounter history, 2) generate reports and 3) support administrative tracking. In 2019, DentaSeal captured SP data of 47 school-based programs in Wisconsin that sponsored > 7,000 program visits for 184,000 children from 62 counties. Delivery of > 548,000 SP services were catalogued. CONCLUSIONS: For public health initiatives targeting reduction in caries incidence, web-based applications such as DentaSeal represent useful longitudinal tracking tools for cataloguing SP in school-based program participants.

How Medical-Dental EHR Integration Can Improve Diabetes Care.

Since the mid-1990s, poor oral health has been neglected as a public health threat, despite its recognition as epidemic in scale by the US Department of Health and Human Services Office of the Surgeon General. Americans' poor oral health influences their overall health and, from a population standpoint, incurs dire economic and human costs. This article describes how health information transfer within the Marshfield Clinic Health System's integrated medical and dental practice can improve diabetes care. This article also considers ethics and equity implications of improving MDP electronic health record interoperability in this large, rural Wisconsin organization.

Variations in temporal trends in non-traumatic dental condition related emergencies.

OBJECTIVE: The objective of the study was to investigate temporal trends in non-traumatic dental condition (NTDC) related emergency visits at Emergency Department (ED), urgent care (UC), and at a Federally Qualified Health Center (FQHC) that providing dental services to a mid-sized rural community. METHODS: Temporal trends over a 9-year period (2008-2016) in NTDC rates at ED, UC, FQHC and in a region around the FQHC were determined. Statistically significant changes (α = 0.05) in the proportion of NTDC visits between FQHC and UC across each of the time points were investigated. RESULTS: Proportion of NTDC ED visits was relatively stable over the study period; whereas those at FQHC exceeded those at UC site beginning 2012 and were significantly (α = 0.05) higher than that of UC subsequently (2015-2016). CONCLUSIONS: NTDCs are preventable dental conditions and the care provided in treating NTDCs in emergency settings is palliative and does not address the underlying conditions resulting in poor outcomes. The results presented elucidate the critical role of FQHCs in significantly reducing NTDC visits. These might be precursors to a potential shift in NTDC care seeking behavior and expected to favorably impact oral health outcomes.

Systematic review of studies examining contribution of oral health variables to risk prediction models for undiagnosed Type 2 diabetes and prediabetes.

OBJECTIVE: To conduct systematic review applying "preferred reporting items for systematic reviews and meta-analyses statement" and "prediction model risk of assessment bias tool" to studies examining the performance of predictive models incorporating oral health-related variables as candidate predictors for projecting undiagnosed diabetes mellitus (Type 2)/prediabetes risk. MATERIALS AND METHODS: Literature searches undertaken in PubMed, Web of Science, and Gray literature identified eligible studies published between January 1, 1980 and July 31, 2018. Systematically reviewed studies met inclusion criteria if studies applied multivariable regression modeling or informatics approaches to risk prediction for undiagnosed diabetes/prediabetes, and included dental/oral health-related variables modeled either independently, or in combination with other risk variables. RESULTS: Eligibility for systematic review was determined for seven of the 71 studies screened. Nineteen dental/oral health-related variables were examined across studies. "Periodontal pocket depth" and/or "missing teeth" were oral health variables consistently retained as predictive variables in models across all systematically reviewed studies. Strong performance metrics were reported for derived models by all systematically reviewed studies. The predictive power of independently modeled oral health variables was marginally amplified when modeled with point-of-care biological glycemic measures in dental settings. Meta-analysis was precluded due to high inter-study variability in study design and population diversity. CONCLUSIONS: Predictive modeling consistently supported "periodontal measures" and "missing teeth" as candidate variables for predicting undiagnosed diabetes/prediabetes. Validation of predictive risk modeling for undiagnosed diabetes/prediabetes across diverse populations will test the feasibility of translating such models into clinical practice settings as noninvasive screening tools for identifying at-risk individuals following demonstration of model validity within the defined population.

Identifying oral disease variables associated with pneumonia emergence by application of machine learning to integrated medical and dental big data to inform eHealth approaches.

Background: The objective of this study was to build models that define variables contributing to pneumonia risk by applying supervised Machine Learning-(ML) to medical and oral disease data to define key risk variables contributing to pneumonia emergence for any pneumonia/pneumonia subtypes. Methods: Retrospective medical and dental data were retrieved from Marshfield Clinic Health System's data warehouse and integrated electronic medical-dental health records (iEHR). Retrieved data were pre-processed prior to conducting analyses and included matching of cases to controls by (a) race/ethnicity and (b) 1:1 Case: Control ratio. Variables with >30% missing data were excluded from analysis. Datasets were divided into four subsets: (1) All Pneumonia (all cases and controls); (2) community (CAP)/healthcare associated (HCAP) pneumonias; (3) ventilator-associated (VAP)/hospital-acquired (HAP) pneumonias and (4) aspiration pneumonia (AP). Performance of five algorithms were compared across the four subsets: Naïve Bayes, Logistic Regression, Support Vector Machine (SVM), Multi-Layer Perceptron (MLP) and Random Forests. Feature (input variables) selection and ten-fold cross validation was performed on all the datasets. An evaluation set (10%) was extracted from the subsets for further validation. Model performance was evaluated in terms of total accuracy, sensitivity, specificity, F-measure, Mathews-correlation-coefficient and area under receiver operating characteristic curve (AUC). Results: In total, 6,034 records (cases and controls) met eligibility for inclusion in the main dataset. After feature selection, the variables retained in the subsets were: All Pneumonia (n = 29 variables), CAP-HCAP (n = 26 variables); VAP-HAP (n = 40 variables) and AP (n = 37 variables), respectively. Variables retained (n = 22) were common across all four pneumonia subsets. Of these, the number of missing teeth, periodontal status, periodontal pocket depth more than 5 mm and number of restored teeth contributed to all the subsets and were retained in the model. MLP outperformed other predictive models for All Pneumonia, CAP-HCAP and AP subsets, while SVM outperformed other models in VAP-HAP subset. Conclusion: This study validates previously described associations between poor oral health and pneumonia. Benefits of an integrated medical-dental record and care delivery environment for modeling pneumonia risk are highlighted. Based on findings, risk score development could inform referrals and follow-up in integrated healthcare delivery environment and coordinated patient management.