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J Am Dent Assoc, Vol 131, No 9, 1333-1341.
© 2000 American Dental Association
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DENTISTRY AND MEDICINE

DIABETES AND ORAL HEALTH PROMOTION: A SURVEY OF DISEASE PREVENTION BEHAVIORS



PAUL A. MOORE, D.M.D., PH.D., M.P.H., TREVOR ORCHARD, M.B.B.CH., M.MED.SCI., JAMES GUGGENHEIMER, D.D.S. and ROBERT J. WEYANT, D.M.D., DR.PH.


   ABSTRACT
TOP
 ABSTRACT
SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Background. Diabetes is a chronic metabolic disease known to affect oral disease progression. The authors surveyed health behaviors essential for preventing dental and periodontal diseases and maintaining oral health in a population of adult patients with type 1 (insulin-dependent) diabetes. The goals of this study were to assess these patients’ oral health behaviors, access to dental care and need for improved health education.

Methods. As part of a dental and periodontal examination, 406 subjects with type 1 diabetes completed a questionnaire regarding their oral health attitudes, behaviors and knowledge. The authors also evaluated 203 age-matched nondiabetic control subjects.

Results. The authors found that diabetic subjects’ tobacco use and oral hygiene behaviors were similar to those of the nondiabetic control subjects. Diabetic subjects, however, more frequently reported the cost of dental care as a reason for avoiding routine visits. Most of these subjects were unaware of the oral health complications of their disease and the need for proper preventive care.

Conclusions. Patients with diabetes appear to lack important knowledge about the oral health complications of their disease. The results of this survey did not indicate improved prevention behaviors among the subjects with diabetes compared with nondiabetic control subjects.

Clinical Implications. Dentists have an opportunity and the responsibility to promote good oral health behaviors such as regular dental examinations, proper oral hygiene and smoking cessation that may significantly affect the oral health of their diabetic patients.

Diabetes mellitus is a chronic metabolic disorder that affects more than 100 million people worldwide.1 Eleven million people in the United States have been diagnosed with diabetes, and another 5 million are thought to have the disease but have not been diagnosed. Diabetes is the sixth leading underlying cause of death in the United States and has been estimated to cost $91.5 billion dollars annually in medical care and lost productivity.

Medical complications commonly associated with diabetes include renal disease, retinopathy, neuropathy, peripheral vascular disease and coronary heart disease.1–3 The oral health complications reportedly associated with diabetes include tooth loss, gingivitis, periodontitis and oral soft-tissue pathologies.4–17 Because patients with diabetes are at an increased risk of developing oral diseases, reliable and up-to-date information regarding oral health behaviors and perceptions in diabetic populations is needed to develop effective prevention strategies that are useful for dental practitioners.

The prevalence and severity of medical and oral health complications may depend on the specific type of diabetes assessed. Approximately 10 to 20 percent of all patients with diabetes mellitus have type 1 diabetes. These patients usually are diagnosed before they are 21 years of age, have rapid onset of symptoms and are virtually unable to produce insulin. Type 2 diabetes mellitus—the most common category of diabetes—often is associated with obesity and is characterized by slow onset of symptoms, usually in patients older than 40 years of age.2

An association between diabetes and early tooth loss and edentulism has been reported in the scientific literature.2,6–10 Although some early reports suggested either an increase or decrease in caries rates, larger and more recent surveys of diabetic populations indicate that coronal caries rates are not significantly altered.7,11,18 Gingivitis has been reported in younger populations with poorly controlled diabetes, and periodontitis with attachment loss has been reported in adults.9,10,16 Overall, periodontal disease severity is associated with age, duration of the disease and smoking.12,18–21

The periodontal health of patients with type 2 diabetes has been evaluated extensively in the Arizona Pima Indian population, in which diabetes status has been significantly associated with attachment and bone loss.6 Periodontitis in patients with type 1 diabetes has not been reported consistently, possibly because the patients are younger, and glycemic control measures have improved in recent years.13,20,21 Soft-tissue pathologies, particularly lesions associated with delayed healing and candidal infections, have been observed more frequently in diabetic populations.14,15,22,23 Reported oral health differences between patients with type 1 and type 2 diabetes may relate to differences in glycemic control strategies, age, tobacco use, disease duration, percentage of minorities in the population or periodontal disease susceptibility.

The consequences of periodontal disease and subsequent tooth loss not only are important considerations for the quality of life of patients with diabetes, but they may affect significantly overall health by compromising patients’ ability to maintain healthy diets and proper glycemic control.

The associations and linkages between oral infections and serious systemic diseases such as diabetes have been evaluated thoroughly in the recent surgeon general’s report,24 which concludes that oral health and general health are inseparable. A collaborative epidemiology study at the University of Pittsburgh has thoroughly evaluated the medical and oral health statuses of a large population of patients with type 1 diabetes.3,12,13 This article describes their oral health attitudes, knowledge and behaviors.


   SUBJECTS AND METHODS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Population and research design. The subjects with type 1 diabetes enrolled in this oral health study were participants in the ongoing University of Pittsburgh Epidemiology of Diabetes Complication, or EDC, study. The study began in 1986; the patients were involved in it over a three-year period from 1986 through 1988. This cohort was derived from the Children’s Hospital of Pittsburgh’s registry of early-onset diabetes (in patients younger than 17 years of age), which has been shown to be representative of the residents in Allegheny County, Pa., who had been diagnosed with type 1 diabetes.25 Patients diagnosed with type 1 diabetes between Jan. 1, 1950, and May 31, 1980, and who lived within 100 miles of Pittsburgh were eligible to participate in the EDC study. Once they agreed to participate, the EDC provided the subjects with medical examinations at two-year intervals to evaluate the incidence of retinopathy, nephropathy, neuropathy and cardiovascular disease within this cohort.

The consequences of periodontal disease and subsequent tooth loss not only are important considerations for the quality of life of patients with diabetes, but they may affect significantly overall health.

All subjects scheduled for one of their regular two-year examinations for the EDC study were contacted by investigators at the University of Pittsburgh Oral Health Science Institute, informed of the purpose of the oral health evaluation and asked to participate in the current study, which was conducted between 1992 and 1994. We recruited and enrolled an age-matched control group from among the subjects’ spouses and friends and the community. We mailed the subjects questionnaires requesting medical and dental histories, oral health behaviors and psychosocial information before their biennial EDC examination. On arrival, subjects signed an institutional review board–approved consent form, and a research coordinator checked their questionnaires for accuracy and completeness.

The oral health evaluation took place in a separate room than the medical examination; the room was equipped with a portable dental chair and a side-mount dental examination light. One of two trained dental examiners performed a full-mouth coronal and root caries examination, a split-mouth periodontal examination, a soft-tissue examination and salivary function tests. Specific methods and results of these oral examinations have been published previously.12–14

After the oral health examination, the subjects underwent EDC study assessments for possible medical complications of diabetes. These assessments included a physical examination, an electrocardiogram, blood and urine analyses, and an evaluation of renal, neurological, retinal and cardiovascular functions. Methods used to conduct these evaluations have been published previously.3

Assessment of oral health behaviors. During the initial subject interview that took place immediately before the oral examination, we reviewed demographic data and medical and dental histories, with the subjects. Demographic data included age, sex, weight, height, race and marital status. Subjects also were asked to report their household incomes (within $10,000 increments) and highest levels of education on the questionnaire. From subjects’ medical histories, we obtained information regarding recent medical care, medications, hospitalizations and significant medical complications (hepatitis, epilepsy and so forth). Specific oral health questions addressed most recent visit to the dentist; treatment at most recent visit; reasons for avoiding care, if applicable; oral hygiene habits (frequency of brushing and flossing); perceived oral health treatment needs; and dental insurance status. We asked all subjects about their use of chewing tobacco, as well as their current and lifetime histories of cigarette use. We determined total weekly alcohol consumption from subjects’ weekly consumption estimates for tea and coffee, soft drinks, beer, wine, and mixed drinks and liquor; we summed data for weekly wine, beer and liquor consumption to provide an estimate of alcohol consumption in ounces per week. Published and validated questions regarding dental anxiety, determined using the Corah Dental Anxiety Scale, also were included in the patient interview.26

Data management and analyses. Data were entered twice to verify accuracy and were transferred to a mainframe computer via the System 1032 Database Management System (Software House).12 Final analysis was carried out using statistical software (JMP Software, Version 3.1, SAS Institute Inc.).

We initially summarized and compared differences in control and diabetic subjects’ responses to survey questions using the Fisher exact test and {chi}2 tests for categorical variables and analysis of variance for continuous variables. Because patients wearing complete dentures may perceive a reduced need for regular dental care, we excluded 16 edentulous diabetic patients and one edentulous control patient from the analyses.

To improve the clarity of this study, we divided some variables into two groups based on median values or clinically relevant cut points. These redefined variables were household income (less than $20,000 compared with $20,000 or more), education level (completion of 12th or a lower grade compared with education beyond high school), alcohol consumption (7 ounces per week or less compared with more than 7 ounces per week), use of dental floss (at least once a week compared with less than once a week) and dental anxiety (Corah Dental Anxiety Scale score of 8 or lower compared with score of 9 or higher).


   RESULTS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
We contacted the 412 diabetic subjects scheduled for the EDC medical examination by telephone and asked them to participate in the oral health ancillary study. Six subjects declined enrollment, and 16 were edentulous. We recruited 203 age-matched nondiabetic control subjects. Only one control subject was edentulous.

The 390 dentate diabetic and 202 dentate control subjects completed the oral health questionnaire. As shown in Table 1Go, ages, household incomes, dental insurance status and education levels were similar between populations, while the control group had a higher ratio of women to men than did the diabetic group.


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  		TABLE 1 DEMOGRAPHICS FOR DIABETIC AND CONTROL SUBJECTS.

 
The diabetic subjects were diagnosed at a mean of 8.4 years of age (± 0.2 years, standard error, or SE) and had an average duration of disease of 24.6 years (± 0.4 years SE). At the time of the oral examination, 60 percent of the diabetic subjects had developed at least one diabetic medical complication. Prevalence rates for the medical complications were 44.5 percent with retinopathy, 27.1 percent with neuropathy, 23.4 percent with nephropathy and 10.8 percent with peripheral vascular disease.

Table 2Go provides results of the oral health behavior questionnaire. The percentages of diabetic and control subjects reporting currently smoking cigarettes, having ever smoked cigarettes or having ever tried smokeless tobacco were similar, as were percentages regarding alcohol consumption and oral hygiene behaviors. The diabetic subjects were somewhat less likely to visit their dentists for routine examinations and were somewhat more likely to visit for dental care (cleanings, restorations and oral surgery).


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  		TABLE 2 ORAL HEALTH BEHAVIORS OF DIABETIC AND CONTROL SUBJECTS.

 
Subjects’ oral health perceptions and health attitudes are shown in Table 3Go. Diabetic subjects rated their overall oral health somewhat lower than did control subjects, and they rated the need to visit a physician as a higher priority than did control subjects. Cost of dental care was reported by diabetic subjects as a reason for not visiting a dentist more often than it was by control subjects. The percentages of both diabetic and control subjects who cited fear or anxiety as a reason were similar.


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  		TABLE 3 ORAL HEALTH PERCEPTIONS AND ATTITUDES OF DIABETIC AND CONTROL SUBJECTS.

 
The responses to three oral health knowledge questions relevant only to diabetic subjects are shown in Table 4Go. Although these subjects believed that their dentists were aware of their having diabetes, few recognized that their oral health might be affected by the disease or that they should follow proper oral hygiene procedures and obtain routine dental care.


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  		TABLE 4 DIABETIC SUBJECTS’ RESPONSES TO THREE ORAL HEALTH KNOWLEDGE QUESTIONS.

 

   DISCUSSION
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
The proper management of diabetic patients in dental practice is extensively discussed in textbooks and dental journals.27,28 Emphasis is placed on recognizing symptoms in undiagnosed patients, making treatment modifications related to their medical complications, scheduling dental appointments, timing meals and insulin doses in relation to dental treatment, aggressively treating acute infections and managing medical emergencies (that is, hypoglycemic reactions). Oral pathologies that are more frequently seen in diabetic patients also have been described. However, long-term management strategies for preventing and delaying the progression of periodontal disease and tooth loss in high-risk patients such as those with poorly controlled diabetes have only recently been considered.29,30

In the United States, diabetic patients visit physicians’ offices and emergency rooms and are hospitalized more frequently than their nondiabetic counterparts. The per capita medical expenses for patients with diabetes are two to 10 times higher than those of nondiabetic patients.1,31 Additionally, as a function of medical complications and disabilities, diabetic patients often are underemployed. Daily diabetic management is inconvenient and requires a significant time commitment for glucose monitoring, drug administration, regular exercise and frequent visits to the physician. These financial and time burdens have been reported previously for patients with type 1 diabetes and may be, in part, the reason that these patients previously have been reported as avoiding routine dental visits.32,33 An equally important consequence is that the additional financial burden of dental treatment may adversely affect a diabetic patient’s dental treatment decisions, such as electing to have dental extractions rather than more expensive restorative care. The results of our study regarding health priorities support the conclusion that competing financial and time commitments, rather than dental fear and anxiety, may explain the inadequacy of routine care in this diabetic patient population (Table 3Go).

Cigarette smoking is an established risk factor for developing periodontal disease in both healthy and diabetic patients.19,34 The risk of developing periodontal disease is significant for patients with type 1 diabetes who smoke. One study19 found smoking to increase the likelihood of developing periodontal disease sixfold in diabetic patients 19 to 40 years of age (odds ratio, or OR, 6.2; 95 percent confidence interval, or CI, 1.5–29.4), while another study13 found that smoking increased the likelihood of developing periodontal disease 10-fold in diabetic subjects 14 to 53 years of age (OR 10.2; 95 percent CI 4.7–23.2). Cigarette smoking is the most important risk factor for periodontal disease that can be prevented through oral health promotion programs.35

It has been reported that tobacco cessation counseling has been underused by dentists, with only 24.1 percent of patients who smoke receiving cessation advice from their dentists.36 Considering the impact of smoking on the progression of periodontal disease in healthy and diabetic patients, dentistry’s role in tobacco counseling should be re-emphasized. Additional prevention strategies such as periodontal maintenance programs have been shown to be effective in preventing progression of periodontal disease.37 Patients having known risk factors for periodontal disease, such as smoking and diabetes, also may require more frequent maintenance visits at shorter intervals.27,29,38

The American Dental Association endorses tobacco health education and the use of cessation interventions by the profession.39 Health promotion methods for reducing patient tobacco use have been found to be successful in dental practice.40 Pharmacological and behavioral strategies for use in a private practitioner’s office have been developed.41,42 The lack of sufficient undergraduate dental education and practitioner continuing education may be barriers to incorporating these programs as part of routine dental care.43 Although many efforts have been made to improve educational opportunities, increased attention to this important aspect of clinical practice is needed.44–47

Commitments, rather than dental fear and anxiety, may explain the inadequacy of routine care in the diabetic patient population.

Rigorous glycemic control has become the primary medical strategy for managing and preventing diabetic complications. The findings of the Diabetes Control and Complication Trial, or DCCT, published in 1993 demonstrated that intensive efforts to reduce the hyperglycemia associated with diabetes decreased incidence of retinopathy, neuropathy and nephropathy by 40 to 75 percent.48 Strict metabolic control was maintained in the DCCT through frequent daily blood glucose monitoring and three or more insulin injections each day. Recommendations for diabetic patients to normalize blood glucose values greater than 7.9 percent are being promoted by the American Diabetic Association,49 and both medical and oral health complications are likely to occur less frequently in the future. Although glycemic control has improved in recent years, particularly for patients with the most poorly controlled diabetes (those with glycated hemoglobin values greater than 12 percent), the recommendations to "normalize" glucose levels are difficult, if not impossible, to achieve by the majority of diabetic patients.50,51 This can be noted in the current study, where the mean glycated hemoglobin value of the diabetic subjects was 11.0 percent (± 1.7 percent, SE).

This trend toward improvement in metabolic control requires significant changes in diabetic patient compliance and is likely to affect oral health. With tight glycemic control, glucose levels are more likely to fall below normal levels, and patients’ risk of experiencing hypoglycemia will increase. The symptoms of acute hypoglycemia range from impaired motor coordination and cognitive dysfunction to seizures and coma.52 Since these adverse results may be more likely to occur during the stress of dental treatment, practitioners should be prepared to recognize and manage this medical emergency. The oral health complications resulting from diabetes, however, probably will be less common as glycemic control strategies and technologies are promoted. There is preliminary evidence that periodontal infections may contribute to the problems of glycemic control.53,54 Rigorous, ongoing clinical investigations designed to determine if improvement in glycemic control occurs after periodontal disease therapy will define this possible interaction more clearly.


   CONCLUSIONS
TOP
 ABSTRACT
 SUBJECTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
Current research has shown that diabetes is a risk factor for impaired oral health. It is known that diabetic patients have higher rates of tooth loss, periodontal disease and soft-tissue diseases than do nondiabetic patients. This survey of an adult population of insulin-dependent diabetic subjects found that they frequently were unaware of the oral health complications of their disease and that they avoided regular dental care because of the cost. We found that the prevalence of dental anxiety and fear was not greater among the diabetic subjects than among control subjects, and the prevalence of smoking among the diabetic and control subjects (19.0 percent vs. 21.8 percent, respectively) was similar.

Prevention of these oral health sequelae—tooth loss, periodontal disease and soft-tissue disease—depends on education and health promotion strategies such as early diagnosis, proper oral hygiene and diet, rigorous glycemic control measures, and smoking cessation counseling. Increasing the proportion of people with diabetes who have at least an annual dental examination is an objective of the National Institutes of Health’s Healthy People 2010.55 Annual dental examinations may benefit these patients by improving the likelihood that oral disease will be diagnosed early.

Dental practitioners have an opportunity and the responsibility to educate diabetic patients about the oral complications of diabetes and to promote proper oral health behaviors that limit the risks of tooth loss, periodontal disease and oral soft-tissue pathologies.


   FOOTNOTES
 

Mr. Orchard is a professor, Department of Epidemiology, Graduate School of Public Health, University of Pittsburgh.


Dr. Guggenheimer is a professor, Department of Oral Medicine and Pathology, School of Dental Medicine, University of Pittsburgh.


Dr. Weyant is an associate professor, Department of Dental Public Health, School of Dental Medicine, University of Pittsburgh.


Support for this study was provided by National Institutes of Health contract NIH-NIDR-1-91-R4 and grant R01-DK34818.


The authors would like to thank Mary Beth Mongelluzzo, Dr. Daniel Myers, Dr. Karen Rossie, Dr. Heidi Hubar and Dr. Harvey Block of the Oral Health Science Institute, and Marie Smith, Marlene Moore and Robb Wilson of the Epidemiology of Diabetes Complication study for their assistance and support of this project.


Dr. Moore is a professor of pharmacology and dental public health, Department of Dental Public Health and Community Dentistry, School of Dental Medicine, University of Pittsburgh, 380 Salk Hall, Pittsburgh, Pa. 15261, e-mail "PAM7{at}pitt.edu". Address reprint requests to Dr. Moore.


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 DISCUSSION
 CONCLUSIONS
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