Evaluation of knowledge and practice regarding oral health care among diabetic patients in PHCCs in Al Ahsa, 2006

Periodontal disease is one of the common complications of Diabetes Mellitus. Adults with diabetes have both a higher prevalence of periodontal disease and more severe forms of the disease. This study was conducted to study knowledge and practices of diabetic patients regarding oral health and their perception of the management by dentists. A cross-sectional study was conducted among diabetic patients attending general clinics of nine randomly selected Primary Health Care Centers (PHCCs) in Al-Ahsa area of Eastern region, Saudi Arabia. A pair of one male and one female health worker was trained at each health center to interview patients using a structured questionnaire, and extracting relevant data from their records.

Among 530 diabetic patients, mean age was 53.6 years (SD±13), 50.4% were female, and over half were uneducated (57.9%). Among the diabetic patients interviewed, 20.5% were smokers (current smokers 7.5% and ex-smokers 13.0%); while 57.9% had other concurrent chronic diseases. Mean duration of diabetes was 9.6 years (SD ±7). Most of the patients (73.8%) brushed their teeth and 25.1% used miswak. Only 18.9% pointed out oral and gum problems as complications of diabetes. Among the total, 109 (20.6%) had routine checkup for some oral problem and overall 30.7% were referred to dentists. Over half had some oral problem (47.5%), including spontaneous toothache (35.1%), bleeding gums (10.8%) and bad breath (10.2%). 65.3% claimed to have received health education about oral health; sources included television (28.9%), dentists (24.2%) and doctors (20.8%).

Regular follow up of diabetic patients in dental clinic was thought to be important by 419 patients (79.1 %). Four hundred thirty patients (81.1 %) had had oral surgery, 427 (80.6%) undergone tooth extraction. Only 43 (8.1%) used dentures.

One hundred fifty patients (28.3%) reported that they had fear of going to the dentist. Among all the diabetic patients, 156 (29.4%) were not satisfied with the dental care in the health facility.

Oral health problems were more common among females (P<0.001), uneducated (P=0.012), unemployed (P<0.001), patients with longer duration of diabetes (P=0.10), with other coexisting chronic diseases (P=0.004).

It was concluded that a large proportion of diabetic patients had oral health problems, while the majority had reasonably satisfactory oral hygienic practices. Referral of diabetic patients for routine check-up was not satisfactory; and when patients are referred for dental care, at times their diabetic status was not fully taken into consideration. Fixed features like lower educational status, unemployment, chronic diseases, and longer duration of diabetes show a positive relationship with existence of oral problems; while changeable behavioral factors like smoking, brushing teeth, using miswak, visiting dental clinics, acquiring and possessing health knowledge showed an inverse relationship with existence of oral problems.

Editorial note:

One of the major complications of diabetes is periodontal disease,[1] which has been associated with development of glucose intolerance and poor glycemic control among adults with diabetes.[2,3]

The treatment of diabetes has always centered on the control of blood sugar through medication and appropriate nutritional intake. Preventing oral infection, as an adjunct in controlling blood sugar, has been given little attention.

Regular dental visits provide opportunities for prevention, early detection, and treatment of periodontal disease among dentate adults; moreover, regular dental cleaning improves glycemic control in patients with poorly controlled diabetic conditions.[4,5]

Physicians and dentists should cooperate to improve the current diabetes dental care by taking the appropriate steps to improve the delivery of dental services to diabetic patients. These steps should include formulation of guidelines, update current curriculums of dental schools on diabetes, and improve participation of dentists and nurses in oral health education.

In this study, almost half of the diabetic patients had some oral health problem, and among them quite a few had toothache, dental extractions and bleeding gums. However, it appears that diabetic patient do not clearly appreciate that their dental problems are related to their diabetes, since only one fifth mentioned it as complication of diabetes. Oral self-care plays a role in maintaining and promoting periodontal health and the prevalence of periodontal disease varies according to individual health behavior.[6] The study showed some good habits that can help in reducing oral problems, over two thirds brushed their teeth and actually 41.2% brushed their teeth twice daily. Almost a quarter also used Miswak and a few used dental floss. These healthy oral health practices are expected to prevent oral diseases, as observed in a study conducted in USA for assessment of periodontal disease in type I diabetes, which showed an association between periodontal disease and tooth brushing less than once per day.[6]

It is recommended that referral for routine dental examination should be emphasized to physicians managing diabetes in PHCCs. Dental surgeons should ensure control of diabetes in their diabetic patients before surgery in accordance with the standard guidelines, while keeping the visits of the patients to minimal to improve patient satisfaction. Patients should be provided with health education regarding the role of diabetes in oral health, requesting physicians for routine dental check-up, improving their diabetes control, and the importance of testing and control of diabetes prior to dental surgery.

References

1. Loe H. Periodontal disease -the sixth complication of diabetes mellitus. Diabetes Care 1993;16(Suppl 1):329-34.
2. Saito T, Shimazaki Y, Kiyohara Y, et al. The severity of periodontal disease is associated with the development of glucose intolerance in non-diabetics: the Hisayama Study. J Dent Res 2004; 83:485-90.
3. Taylor G. Periodontal treatment and its effects on glycemic control. Oral Surg Oral Med Oral Pathol 1999; 87:311-6.
4. Committee on Research, Science, and Therapy, American Academy of Periodontology. Diabetes and periodontal disease. J Periodontal 2000; 71:664-78.
5. Grossi SG, Skrepcinski FB, DeCaro T, et al. Treatment of periodontal disease in diabetics reduces glycated hemoglobin. J Periodontol 1999; 68:713-9.
6. Almas K, Al-Lazzam S, Al-Quadairi A. The Effect of Oral Hygiene Instructions On Diabetic Type 2 Male Patients With Periodontal Diseases. J Contemp Dent Pract 2003;(4)3: 040051.