A survey of oral health education provided by certified diabetes educators

Abstract

The purpose of this study was to investigate certified diabetes educators’ (CDEs) perceptions of the adequacy of their diabetes education curricula in providing oral health information. A questionnaire was mailed to all CDEs with a mailing address in South Carolina (SC), United States (US). Of the 130 respondents, between 50%–60% indicated that they adequately addressed frequent dental visits, daily brushing and flossing, and importance of good oral hygiene. Almost all (93.8%) reported that their curricula did not include an oral health module; the two predominant reasons were: not having enough time (61.0%), and not knowing enough about oral health and its relationship to diabetes (37.0%). Respondents who expressed that they did not know enough about oral health and its relationship to diabetes were less likely to provide adequate ‘oral-health-related information’ (p = 0.008), especially information about the effect of periodontal disease on diabetes (p = 0.016). This study indicates that SC CDEs do not routinely provide comprehensive oral health education to people with diabetes primarily due to lack of time and knowledge related to oral health. To better serve their patients, CDEs should integrate oral health education in the diabetes education curriculum.

Introduction

Diabetes mellitus is a chronic metabolic disease with serious oral health implications. People with diabetes, especially those with poorly controlled or uncontrolled diabetes, have an increased susceptibility to chronic infections and inflammation of oral tissues, including periodontal diseases (chronic gingivitis and periodontitis) [1], [2], [3], dental caries [4], [5], and oral candidiasis [5], [6], which contribute to substantial oral functional disability [7]. The likelihood of having periodontal disease among people with diabetes is about 3 times greater than for people without diabetes [2]. For people with poorly controlled or uncontrolled diabetes, periodontal disease progresses more rapidly and more severely than in their controlled or non-diabetic counterparts [2]. Studies [5], [8], [9], [10], [11], [12] also suggest a bidirectional relationship between periodontal disease and diabetes, with periodontal disease worsening glycemic control, and poorly controlled or uncontrolled diabetes increasing the likelihood of destructive periodontitis.

In addition, dry mouth is a common diabetic phenomenon [5]. The decrease of salivary flow may predispose people with diabetes to dental caries and oral candidiasis [13]. Frequent daily intake of refined carbohydrates may also contribute to a higher incidence of caries among people with diabetes [14]. Effective control of oral disease can be attained systemically through better glycemic control and locally through improved oral hygiene [15], [16].

Furthermore, studies [17], [18] have shown that poor perception of one's oral health status (including dissatisfaction with teeth and mouth, and feeling of dry mouth) among people with diabetes has a strong negative impact on their health-related quality of life. Therefore, people with diabetes must be educated about the importance of removing oral plaque daily through meticulous oral hygiene, managing mouth dryness and diet, ceasing tobacco use [19], [20], [21], and obtaining regular professional dental care and cleaning [16], [22]. Studies also show that improved oral health may facilitate better glycemic control in people with poorly controlled diabetes [23], [24], [25].

Although adults with diabetes are more likely to develop periodontitis than their peers without diabetes, they are less likely to visit a dentist. Several national and statewide studies [26], [27], [28], [29] found that the proportion of adults with diabetes who reported a dental visit during the preceding year was consistently below 70% (ranging from 60% to 69%). In those without diabetes, 73% of adults reported a dental visit within the preceding year [29]. The proportion of smokers with diabetes who reported a dental visit was even lower (59%) [28]. Subsequently, adults with diabetes required more emergency dental care service than adults without diabetes [30]. Karjalainen et al. also found dental health behaviors (oral hygiene and dental visit frequency) were more irregular among those individuals with poorly controlled diabetes [31]. The main reason for adults with diabetes not visiting a dentist was that they did not perceive a need [29]. Moore et al. [16] found most adults with diabetes were unaware of the oral health complications of the disease. In addition, they were less willing to spend time and money on their teeth compared to their peers without diabetes [30].

Because adults with diabetes were less likely to have seen a dentist than to have seen a health care provider for diabetes care in the preceding year (<70% versus 86.3%) [29], diabetes educators can be a potential source for diabetes-related oral health information. Patients with diabetes who identified a regular primary provider for their diabetes care were more likely to have received more recommended elements of diabetes care (though not dental checkups) and to have better glycemic control than patients without such a provider [27]. Lack of significant differences related to dental care between the two groups (regular primary health care provider versus no regular primary health care provider) may be due to the fact that the provider did not educate the patients about the importance of dental checkups.

Given the importance of good oral hygiene among people with diabetes and the relationship of poor glycemic control to the severity of periodontal disease, adequate oral hygiene instruction and healthy life style information related to oral health are essential for this population. Thus, the main purposes of this study were to (1) determine diabetes educators’ perceptions of the adequacy of their diabetes education curricula in providing diabetes-related oral health information to people with diabetes; (2) identify potential barriers related to the inclusion of oral health education in their curricula; and (3) explore the association between the inclusion of an oral health module in the diabetes education curriculum and the diabetes educator respondents’ practice characteristics, as well as adequacy in the coverage of various diabetes-related oral health topics. Results obtained from this study may provide information for diabetes educators to improve oral health education for people with diabetes, and over time, may lead to improvements in oral health as well as diabetes control in people with diabetes.