Tobacco use and diabetes mellitus are two such well-documented risk factors for oral disease,² both of which are associated with significant oral manifestations.^3–9 Dentists need to be involved in the prevention and management of both to improve the treatment of oral disease, as well as to improve patients’ overall health. By actively intervening to promote smoking cessation, as well as to identify and monitor patients with diabetes mellitus, dentists have an opportunity to improve patients’ oral and systemic health.

	TOBACCO USE

TOP ABSTRACT TOBACCO USE DIABETES MELLITUS SUBJECTS, MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Tobacco use is the single-most-important cause of premature and preventable death.¹⁰ It is responsible for a number of cancers, chronic obstructive pulmonary disease, coronary heart disease, stroke and peripheral vascular disease.¹¹ Khurana and colleagues¹² estimated that one-third of all smokers in this country will die prematurely as a consequence of tobacco use. A study by the National Center for Disease Prevention and Health Promotion, Centers for Disease Control and Prevention, estimated that from 1995 to 1999, smoking caused approximately 440,000 premature deaths in the United States annually.¹³ Although our tendency is to focus on premature mortality, the morbidity associated with tobacco use is important. The reduction in quality of life, which can range from relatively minimal diminished respiratory capacity to an inability to perform the tasks of daily living, is substantial and can last from a brief period to decades.

The oral ramifications of tobacco use are significant. All forms of tobacco have been established as causal for oral and pharyngeal cancer, and they are responsible for more than 75 percent of deaths resulting from these malignancies in the United States.⁷ Tobacco use also is associated with premalignant lesions, poor wound healing and tooth discoloration.^5,6 In addition, tobacco use is the major behavioral risk factor for periodontitis and is widely recognized as having a negative impact on periodontal treatment outcomes.

Smokers do not heal as well as nonsmokers after periodontal therapy, and they experience a lower reduction in periodontal pathogen levels. Numerous studies^14–16 have reported a less favorable reduction in probing depths and smaller clinical attachment gains in smokers treated both nonsurgically and surgically compared with non-smokers. It is encouraging to note that clinical studies have demonstrated that periodontal disease progression slows in patients who quit smoking, and these patients experience a response to periodontal therapy that is similar to that of nonsmokers.⁶

	DIABETES MELLITUS

TOP ABSTRACT TOBACCO USE DIABETES MELLITUS SUBJECTS, MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Eleven million people in the United States have been diagnosed as having diabetes, and another 5 million are thought to have the disease but have not been diagnosed.^17,18 Diabetes is the sixth leading underlying cause of death in the United States, and it has been estimated to cost $91.5 billion dollars annually in medical care and lost productivity.¹⁸ The long-term complications of diabetes are many and varied. It is the leading cause of blindness, end-stage renal disease and lower-extremity amputations.^17,19 Macrovascular complications include cardiac, cardiovascular and peripheral vascular diseases. These conditions have a negative effect on patients’ lifestyles, work productivity, health care costs and society as a whole, and they underscore the importance of early detection and effective treatment of the diabetic patient.^18,20

The association between diabetes and periodontitis (with regard to increased occurrence, progression and severity of periodontitis) is well-established, and periodontitis has been designated the "sixth complication of diabetes."²¹ Early diagnosis of diabetes, with strict control of blood glucose levels, is important in preventing or mitigating the numerous complications associated with the disease, including periodontitis. Harris and Eastman¹⁹ reported that, in many cases, the severity of diabetes had progressed significantly before clinical diagnosis, indicating that complications had developed during the asymptomatic, preclinical phase of the disease. Thus, with regard to the prevention or treatment of periodontal disease, it is important that practitioners identify undiagnosed patients with diabetes, as well as closely monitor patients with diagnosed disease.

Leaders at national symposia and consensus conferences have voiced concern about the lack of clinical application of advances in understanding the relationship between oral diseases and systemic conditions. They have challenged dental leaders to become more aware of how clinicians learn and to promote the translation of scientific advances into clinical practice.²² The implications of these advances suggest an increased primary and preventive care role for the dentist.²³ Two ways in which dentists can achieve this goal are by actively intervening to promote smoking cessation and actively identifying and monitoring patients with diabetes mellitus.

We conducted a study to investigate dentists’ behaviors, attitudes and beliefs with respect to the treatment of patients with either or both of these risk factors (known or unknown at the time of the dental visit). In particular, we examined the following:

– extent to which dentists identifying themselves as general practitioners (GPs) reported having performed smoking-cessation and diabetes management activities in their practices;

– nature of their attitudes and orientations toward the adoption of these primary and preventive care behaviors in the dental office;

– implications of these attitudes and orientations with regard to increasing smoking-cessation and diabetes management activities in dental offices of GPs.

	SUBJECTS, MATERIALS AND METHODS

TOP ABSTRACT TOBACCO USE DIABETES MELLITUS SUBJECTS, MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
We used a four-page structured questionnaire to ask subjects to describe the extent to which they assessed patients for smoking behavior and diabetes (diagnosed and undiagnosed by a physician) and the manner in which they evaluated and treated patients with a history of smoking and those with a history of diabetes. In addition, we asked subjects to describe perceived barriers in treating these patients, perceived expectations of patients and colleagues, and self-assessed knowledge and competence in these areas.

We collected data via a mailed survey of actively practicing GPs and periodontists in the northeastern United States: Massachusetts, Rhode Island, Connecticut, New York, New Jersey, Pennsylvania, Delaware, Washington and Maryland. Two random samples (n = 180 for GPs and n = 180 for periodontists) were drawn from lists supplied by the American Dental Association (for GPs)²⁴ and the American Academy of Periodontology (for periodontists).²⁵ The ADA sampling frame included both members and nonmembers.

For each group of dentists, we used a proportional, state-based random sampling strategy, in which the number randomly selected from each state was proportional to the percentage of GPs or periodontists in that state relative to the total number for each group in the region. Potential respondents who were ill, retired, dead or practicing outside the geographic limits of the study, as well as those who did not identify themselves as GPs or periodontists, were classified as ineligible, leaving a net sample of 132 for GPs and 142 for periodontists (GP response rate = 80 percent [105 of 132]; periodontist response rate = 73 percent [103 of 142]).

We sent out three mailings during a four-week period in September and October 2002. The first mailing included a cover letter, a stamped return envelope, the questionnaire and a $5 cash honorarium. Ten days later, we sent out a second, personalized reminder letter. Approximately three weeks after the second mailing, we sent out the final mailing via express mail; it contained a replacement questionnaire and a stamped return envelope. The analysis described below is restricted to GPs. We classified respondents as eligible if they identified their primary professional activity as the practice of general dentistry and if they practiced in the designated geographic area.

	RESULTS

TOP ABSTRACT TOBACCO USE DIABETES MELLITUS SUBJECTS, MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Assessing and treating the patient who smokes. To help assess dentists’ reported smoking-cessation activities, we used the "5 A’s" presented in the U.S. Public Health Service’s Clinical Practice Guideline, "Treating Tobacco Use and Dependence"²⁶:

– ask about tobacco use;

– advise patients to stop;

– assess willingness to quit;

– assist in treatment;

– arrange for follow-up.

The questionnaire asked respondents about the extent to which they asked patients about tobacco use and the extent to which they recorded the information in a chart. Seventy-eight (75 percent) of 104 GPs indicated that they obtained information regarding smoking behavior from new patients orally or via a questionnaire. (The number of responses does not always total 105 because some respondents did not answer all of the questions.) Forty-six GPs (45 percent) reported that they almost always or always recorded information regarding tobacco use in patients’ records. Twenty-one GPs (21 percent) indicated that they almost always or always asked new patients who smoked if they were interested in quitting. Forty-four respondents (42 percent) indicated that they almost always or always advised patients who used tobacco to quit (Table 1).

As shown in Table 3, we asked respondents about factors with the potential to influence whether they performed smoking-cessation activities in their offices. We also asked them to assess their knowledge level with respect to tobacco-cessation activities. With respect to what to include in a smoking-cessation program and how best to deliver a smoking-cessation message, only four GPs (4 percent) and two GPs (2 percent), respectively, described their knowledge as excellent.

Table 3 also shows the results of our questions regarding the extent to which respondents believed that their colleagues expected them to perform smoking-cessation counseling and, similarly, the extent to which they believed that their patients expected them to perform such counseling. Only two respondents (2 percent) and one respondent (1 percent), respectively, strongly agreed with the statement that their colleagues or patients expected them to perform smoking-cessation counseling.

Finally, we asked GPs about barriers to performing smoking-cessation activities. Sixty-six (68 percent) of 98 respondents stated that concerns about patient resistance or complaints were very likely or somewhat likely to be a barrier, while 63 (63 percent) of 99 respondents stated that concerns about patient compliance were very likely or somewhat likely to be a barrier. Fifty GPs (51 percent) stated that they viewed smoking-cessation activities as peripheral to dentistry, and this view was very likely or somewhat likely to be a barrier to performing smoking-cessation activities.

Assessing and managing the patient with diabetes. Virtually all GPs (104 [99 percent]) reported obtaining information—either orally or via a questionnaire—from new patients about whether they had diabetes. Eighty-five respondents (83 percent) reported that they asked the patient if he or she had a family history of diabetes. GPs also reported which questions they routinely asked of new patients who had diabetes (Table 4).

Table 6 (page 1150) shows how GPs rated their perceived knowledge level with respect to managing patients with diabetes, their knowledge of diabetes and its risk factors, and preventing or dealing with an in-office emergency. Less than 15 percent of GPs rated their knowledge as excellent. Thirty-two respondents (31 percent) viewed themselves as very confident with respect to managing patients with diabetes, and 18 (17 percent) were very confident with respect to preventing or managing in-office emergencies. Ten GPs (10 percent) rated themselves as very confident with respect to screening for diabetes.

	DISCUSSION

TOP ABSTRACT TOBACCO USE DIABETES MELLITUS SUBJECTS, MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
A number of characteristics of dental practice in general are consistent with dentists’ assuming a role as primary care providers. Dentists treat large numbers of patients each year. In addition, the dental care setting provides an excellent environment in which to provide primary and preventive health care. Dentists frequently see patients on a regular basis, and these visits often are preventive in nature.

To the best of our knowledge, this is the first study to document the extent of dentists’ practice activities with respect to the management of patients with diagnosed or undiagnosed diabetes. It follows that, for the first time, we are able to compare dentists’ practices with regard to smoking-cessation activities and management of patients with diabetes. This type of comparison can increase our understanding of these two areas of dentists’ activities at the behavioral, informational and normative levels. In addition, this study includes information regarding attitudes and orientations frequently thought to influence clinicians’ willingness to adopt clinical behaviors.^27–29

Our data show that the majority of GPs do not incorporate smoking-cessation activities into their practices on a routine basis. With the exception of asking about tobacco use, less than 50 percent of GPs reported having performed any of the smoking-cessation activities at the highest frequency levels (that is, often or almost always/ always). It is interesting to note that our survey results are consistent with a number of articles published during the past 15 years.^30–37 It appears that there has been little or no increase in dentists’ smoking-cessation practices in the past 15 years despite increased national attention to the deleterious effects of smoking on general and oral health.

We anticipated that rates of adherence to smoking-cessation practices would be higher than rates of involvement in managing patients with diabetes, because the former has been the focus of extensive professional and national health policy attention.^38,39 Management of diabetic patients, on the other hand, is widely discussed in textbooks, but has not been the focus of as much national and professional attention.^40,41

However, our data show that, with respect to the assessment and management of diabetic patients, a clear majority of GPs reported that they inquired about a new patient’s diabetes (percentages ranged from nearly 50 percent to nearly 75 percent of respondents). These percentages are higher than those found for GPs with regard to smoking-cessation behaviors. For the more proactive behaviors (that is, monitoring blood glucose levels, communicating with the patient’s physician and adjusting the frequency of dental visits), the percentages drop considerably and more closely resemble those of GPs performing proactive smoking-cessation activities.

Two caveats exist, however, with respect to these findings. First, it is possible that dentists’ reports regarding patients with diabetes are more subject to social desirability than are their reports regarding in-office smoking-cessation activities. It is conceivable that practitioners find it more difficult to admit having less involvement with a medically compromised patient than they do with a patient compromised by substance abuse. Second, some might view the "sometimes" category as an appropriate reply for some of the items involving evaluation of the diabetic patient; however, we would argue that the standard of appropriate care should correspond to performance of activities at the "often" level.

Our data also reveal a pattern of declining levels of involvement as one moves through the suggested "5 A’s" for promoting smoking cessation. Although 75 percent of dentists asked about tobacco use, only 42 percent reported that they took a more active role by almost always or always advising patients to quit using tobacco products. The percentages drop even further with regard to more tailored strategies, such as often setting a quit date (2 percent) or almost always or always providing follow-up activities (7 percent). These findings suggest that GPs are more willing to perform smoking-cessation activities on an assessing/advising basis than on a more active basis (such as helping patients set a quit date). Hastreiter and colleagues³² characterized this pattern of declining percentages as taking a "superficial" approach to the delivery of smoking-cessation care.

A similar pattern emerged with regard to GPs’ assessment and management of patients with diabetes; higher percentages of GPs reported that they frequently asked patients about disease status or discussed the connection between diabetes and oral disease or other issues related to diabetes management. The proportion of GPs who reported performing activities that required a more active stance (such as communicating with the patient’s physician) was lower than the proportion who reported performing more passive activities. Again, these findings suggest that GPs are more willing to manage the care of diabetic patients on an assessing/advising basis than on a more active basis.

Views regarding knowledge and competence. GPs apparently found mastering the knowledge base with regard to smoking-cessation practices complex and challenging. Less than one-third of GPs viewed their knowledge of what to include in a smoking-cessation message as good or excellent, while less than one-fourth viewed their knowledge of how best to deliver a smoking-cessation message at the same level. By contrast, higher percentages of respondents reported that their knowledge regarding managing the care of patients with diabetes, preventing and managing in-office diabetic emergencies, and diabetes and its risk factors was good or excellent.

Of note is the fact that only 7 percent of GPs considered themselves to be very confident in their ability to convince patients to quit smoking. Recognizing that patient-based hurdles exist, GPs apparently take a cautious approach toward the likelihood of success. More than two-thirds of GPs believed that patient resistance or complaints were somewhat or very likely to impede their smoking-cessation activities. A similar perspective was evident with respect to concerns about patient compliance with the smoking-cessation program.

Views regarding expectations of colleagues and patients. The survey results show that GPs did not view either area of activity as highly compatible with the normative expectations of colleagues and patients, two prominent reference groups. Less than one-third of GPs agreed with the statement that their colleagues expected them to perform smoking-cessation counseling, while less than one-fourth agreed that their patients expected them to perform such activities. A similar perspective was evident with respect to management of the patient with diabetes.

Approximately one-half of respondents viewed smoking-cessation activities as peripheral to their role as dental professionals, and they believed that this view was somewhat or very likely to hinder their performance of smoking-cessation activities. These findings are notable when we consider the extensive efforts made by the profession during the past 30 years^38,39 to involve dentists in smoking-cessation practices. Our survey results also show a similar perspective with respect to the view that more active management of diabetic patients is others’ responsibility.

Study limitations. As with all mailed survey studies, we recognize the limitations of self-reported cross-sectional data. However, to the extent that "socially desirable" responses may have been given, their presence has not tempered the tone of the study’s results. The GPs in this study reported relatively low levels of activity with regard to smoking cessation and management of the diabetic patient, as well as generally negative views regarding the compatibility and complexity of these behaviors for the dental professional. The cross-sectional nature of our study data limits our ability to draw conclusions about relationships among the variables examined. Our comments are intended to highlight the potential for such relationships and the need for further research in this area.

We recognize that our study was restricted to respondents from the northeastern United States. Dolan and colleagues³⁰ investigated possible regional differences in tobacco-use–cessation attitudes and practice behaviors, and they found that more dentists (79 percent) in New England, Middle Atlantic states and South Atlantic states (Region 1) than in other states advised most or nearly all smokers to quit. Region 1 overlaps our study sample’s location. On the basis of this finding, as well as the fact that states in which our subjects resided represent a range of governmental policies with respect to encouraging smoking cessation, we have no reason to suspect that our sample is unrepresentatively negative toward smoking-cessation practices or less likely than dentists in other regions of the country to engage in smoking-cessation practices or active management of patients with diabetes.

Finally, we recognize that our sample size is relatively small (n = 105). However, we took several steps to ensure its representativeness. We used the master list from the ADA that includes all dentists in the United States (both ADA members and nonmembers).²⁴ In addition, we used a proportional, state-based random-sampling strategy, in which the number of randomly selected GPs from each state was proportional to the percentage of GPs in that state relative to the total number in the region. We also sent out multiple questionnaires and reminder letters, which resulted in an 80 percent response rate. These steps make it improbable that the data varied systematically within the subset of states included. They also ensure the appropriateness of the data for descriptive-level analyses.

	CONCLUSIONS

TOP ABSTRACT TOBACCO USE DIABETES MELLITUS SUBJECTS, MATERIALS AND METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
The results of this study show that efforts aimed at moving dentists toward more active adoption of in-office smoking-cessation activities have fallen short at the behavioral, informational and normative levels. In general, GPs reported that they did not believe they had mastered the knowledge or behavioral areas involved; they viewed the performance of such activities as peripheral to their role as caregivers; and they did not believe that colleagues or patients expected them to perform such activities.

In addition, the data presented above raise similar issues with regard to dentists’ active involvement in managing the care of patients with diabetes. Here too GPs reported that they did not feel they had mastery of the knowledge or behavioral areas involved; they viewed such activities as peripheral to their role as caregivers; and they did not believe that colleagues or patients expected them to perform such activities.

These data suggest that we need to move forward on both fronts. The evidence suggests, however, that new information is not enough. Basic views of the dentist’s role as a primary and preventive care provider need to be changed to facilitate the desired behavioral changes. Within the last two decades, oral health care has evolved from a narrow focus on teeth and gingivae to the recognition that the mouth is important to patients’ overall health and well-being. With this recognition comes an opportunity to expand the boundaries of traditional dental practice.

By recognizing the importance of, and engaging in, such office-based behaviors as actively intervening to promote smoking cessation and identifying patients with diabetes mellitus and monitoring their conditions, dentists assume functions characteristic of primary and preventive health care clinicians. Through these activities, they can provide better oral health care, enhance the outcome of therapeutic procedures and play an increasingly important role in promoting the general health of patients.