AENSI Journals
Advances in Environmental Biology
ISSN-1995-0756 EISSN-1998-1066
Journal home page: http://www.aensiweb.com/AEB/
Corresponding Author: Fatemeh Rezaei, Dep. of Oral Medicine, School of Dentistry, Kermanshah University of Medical Sciences, Kermanshah, Iran
Tel: 989188371081; E-mail: [email protected],
The effects of Oral Health Education on the Knowledge and Attitude of Diabetic Patients
1Nafiseh Nikkerdar, 2Fatemeh Rezaei, 3Mehr Ali Rahimi, 4Mohsen Mohammadi
1dep. of Radiology, School of Dentistry, Kermanshah University of Medical Sciences, Kermanshah, Iran
2dep. of Oral Medicine, School of Dentistry, Kermanshah University of Medical Sciences, Kermanshah, Iran
3dep of Internal Medicine, School of Medicine, Kermanshah University of Medical Sciences, Kermanshah, Iran
4School of Dentistry, Kermanshah University of Medical Sciences, Kermanshah, Iran
A R T I C L E I N F O A B S T R A C T
Article history:
Received 11 June 2014
Received in revised form 21 September 2014
Accepted 25 November 2014 Available online 29 December 2014
Keywords:
Diabetes, oral diseases, training, knowledge, attitude
The improvement of patients’ awareness and attitudes about diabetes may reduce the oral and systemic complications of this disorder. This study was aimed to evaluate the effects of educational packages of oral health on the knowledge and attitude of diabetic patients. This study was conducted on a total of 90 diabetic patients selected from Diabetes Disease Center of Kermanshah city. The subjects were randomly assigned into the experimental and control groups (n=45). The experimental group was offered instructions on diabetes and oral health, and the control group received information about diseases other than diabetes or its oral complications. A self-administered questionnaire was used to assess the knowledge and attitudes regarding diabetes and its relation to oral health at baseline as well as two weeks after the educational intervention. Data were analyzed by SPSS (version 20) software using unpaired- and paired-t tests (P< 0.05). There were no significant differences between two groups in terms of demographic and clinical variables (P>0.05). With regard to the knowledge and attitudes, there were no significant differences in the scores between two groups at baseline (P>0.05), but the experimental group presented significantly higher scores than control group following educational intervention (P<0.05). Based on the findings of this study, educational packages could positively alter the knowledge and attitude of diabetic patients; suggesting education as a method with potential to improve oral health in diabetic patients.
© 2014 AENSI Publisher All rights reserved.
To Cite This Article: Nafiseh Nikkerdar, Fatemeh Rezaei, Mehr Ali Rahimi, Mohsen Mohammadi, The effects of Oral Health Education on the Knowledge and Attitude of Diabetic Patients, Adv. Environ. Biol., 8(23), 138-145, 2014
INTRODUCTION
Diabetes mellitus (DM), which includes a group of metabolic disorders with a common feature of increased levels of blood sugar (hyperglycemic), is caused as a result of reduction in the secretion of insulin hormones through Langerhans islands in the pancreas, or as a result of disorder in the performance of insulin[1]. Today, more than 135 million individuals suffer from diabetes throughout the world, and the number is on the rise[2].
According to the published reports by the World Health Organization, the percentage of the people with type II diabetes mellitus in Iran was reported to be 5.5% and 7.5% in 1995 and 2000, respectively, and it is projected to reach 8.6% by 2025[3-4].
DM affects different systems in the body either by microvascular complications (retinopathy, nephropathy and neuropathy) or macrovascular complications (heart and brain vascular diseases)[5-7]. DM, in addition to systemic effects, can also have an impact on oral and dental health. Occurrence of oral lesions and candidiasis in particular, traumatic wounds, or oral lichen planus, extends the recovery period of oral wounds in patients suffering from DM[8]. Diabetics are prone to tooth decay, and any reduction in the amount of saliva in such patients decreases their immune function in the mouth against the bacteria that cause tooth decay[9]. In addition, increased glucose levels in saliva provide a suitable environment for the growth of bacteria which consequently leads to an increase in carbohydrate fermentation and elevated levels of acidic products and intensification of dental tissue demineralization[10]. Patients with uncontrolled DM run an increased risk of periodontal diseases[11]. Neuropathy resulting from diabetes may cause paresthesia, itching, numbness, and burning or painful sensation in the mouth[12].
There is a reciprocal relationship between DM and oral and dental health. Periodontal diseases, as an inflammatory condition, impair the metabolic control of blood sugar. Glycemic control in people with DM and periodontal disease is more difficult[13]. Inflammation increases the cells’ resistance to insulin, in most cases, resistance to factors such as bacterial and viral infections which makes it much more difficult to control blood sugar[14-15].
In diabetic patients with periodontal disease, the mortality rate due to ischemic heart disease is two to three times and the mortality rate of diabetic nephropathy is five to eight times more than the diabetic patients without periodontal disease[16-17].
Despite interactive effects between diabetes and oral health, many patients are not aware of the existence of such a relationship, and oral health is often overlooked by patients[18]. However, a substantial part of the recovery process of diabetes and its implications for oral health issues depends on the proper functioning of patients; therefore, the patients’ awareness plays an important role in the treatment process[19]. Thus, this study was carried out to analyze the effect of education on improving the awareness and attitude of patients with diabetes mellitus in relation to oral diseases.
MATERIALS AND METHODS
In this quasi-experimental study, the patients with diabetes mellitus type I or type II, who were under the coverage of the Diabetes Center of Kermanshah, were studied in 2013. A total of 90 patients were selected using cluster sampling method. The research objectives and procedures were explained to the patients, and patients were enrolled after completion of forms and submission of their informed consent forms.
The patients were randomly assigned to two groups of experiment (45 individuals) and control (45 individuals). The education schedule for the experiment group consisted of two class sessions, each session lasting for an hour, in which information about diabetes and oral and dental health were provided to the patients through lecture, videos and Power Point presentation. The control group was similarly trained, with this difference that the provided information was about other diseases, in particular oral cancer, hepatitis and AIDS.
The awareness and attitude of patients were assessed in two stages (before training, and two weeks after training) by a researcher-made questionnaire. Questionnaires were completed without mentioning the names of patients.
The questionnaire consisted of 5 sections; one section included the demographic and clinical information (age, gender, marital status, education, occupation, type of diabetes, duration of illness, and fasting blood sugar) totaling 8 questions and other sections consisted of awareness of diabetes (6 questions), awareness of oral and dental health (6 questions), attitude towards diabetes (6 questions), and finally attitude towards oral and dental health (6 questions).
The validity of the questionnaire was verified by the opinions of 5 faculty members of dental faculty and the Diabetes Center of Kermanshah. To evaluate the reliability of the content and reliability of reproducibility, Cronbach's alpha and Intraclass Correlation Coefficient (ICC) methods were utilized, respectively. Cronbach's alpha values for awareness of diabetes questions, awareness of oral and dental health questions, attitude regarding diabetes questions, and attitude towards oral and dental health questions were calculated to be 0.434, 0.471, 0.642 and 0.696, respectively; while it came to be 0.972 for ICC.
The collected data were analyzed using SPSS (Version 20) statistical software. Frequency distribution, percentage, mean and standard deviation were used to provide descriptive data. Chi-square, Mann-Whitney, Fisher's exact test and t-test were used to compare demographic and clinical variables between the two groups.
To analyze the difference between awareness and attitudes before and after training tests, the independent t-test was used. P value less than 0.05 was considered statistically significant.
Results:
From the total of 90 patients who were enrolled, one patient in the experimental group withdrew from the study; therefore, 44 patients in the experimental group and 45 patients in the control group were assessed.
Demographic and clinical data of the patients are shown in Tables 1 and 2, respectively. Demographic and clinical variables between the experimental group and the control group showed no statistically significant difference between them (p>0.05). The results of t-test showed a difference in the mean of fasting blood sugar level of the experiment group (221.7 ± 101.8) in comparison to the control group (254.8 ± 69.0), which was not statistically significant (P=0.095).
The comparison of mean scores before and after training for both groups of experiment and control are shown in Table 5. According to table 6, the results before training show no significant difference between the two groups. However, the results after training show higher mean scores for experimental group compared to the control group, revealing a significant difference between them (P<0.05).
The results in Tables 3 and 4 show the percentages of correct answers provided to the questions of awareness of diabetes and awareness of oral and dental health.
Table 1: Distribution of patients in the experimental and control groups in terms of demographic variables.
Variable Number (%)
P value
Experiment Control
Gender Male Female
16 (36.4 %) 28 (63.6 %)
13 (28.9 %) 32 (71.1 %)
0.452*
Age Group 17-24 25-34 35-54
>= 55
4 (09.1 %) 5 (11.4 %) 14 (31.8 %) 21 (47.7 %)
7 (15.6 %) 5 (11.1 %) 20 (44.4 %) 13 (28.9 %)
0.101**
Marital Status Single Married
6 (13.6 %) 38 (86.4 %)
10 (22.2 %) 35 (77.8 %)
0.292**
Education Uneducated Reading & Writing Skills
Junior High High school Diploma
Associate Degree Graduate and higher
1 (02.3 %) 17 (38.6 %) 9 (20.5 %) 12 (27.3 %) 3 (06.8 %) 2 (04.5 %)
0 9 (20.0 %) 8 (17.8 %) 16 (35.6 %) 6 (13.3 %) 6 (13.3 %)
0.204***
Occupation Freelance Employee Housewife Unemployed
other
6 (38.6 %) 4 (09.1 %) 20 (45.5 %) 3 (06.8 %) 11 (25.0 %)
4 (08.9 %) 8 (17.8 %) 21 (46.7 %) 2 (04.4 %) 10 (22.2 %)
0.204***
* Chi 2 Test ** Mann-Whitney Test
*** Fisher’s Exact Test
Table 2: Distribution of patients in the experimental and control groups in terms of clinical variables.
Variable Number (%)
P value
Experiment Control
Diabetes Type Type I Type II Pregnancy type
Don’t know
10 (23.3 %) 22 (51.2 %) 2 (04.7 %) 9 (20.9 %)
7 (15.6 %) 16 (36.6 %) 4 (08.9 %) 18 (40.0%)
0.164***
Duration (Years)
< 2 2-5 6-10
> 10
12 (27.9 %) 6 (14.0 %) 12 (27.9 %) 13 (30.2 %)
10 (22.2 %) 10 (22.2 %) 14 (31.1 %) 13 (24.4 %)
0.863**
** Mann-Whitney Test
*** Fisher’s Exact Test
Table 3: The Absolute and Relative Frequency of Correct Answers to Questions of Diabetes Awareness; Pre and Post Training in both Experiment and Control Groups.
Question Group Numbers (%)
Pre Training Post Training 1. In patients with diabetes, what will change in blood sugar
levels?
Experiment 34 (77.3 %) 38 (86.4 %)
Control 36 (80.0 %) 38 (84.4 %)
2. Which of the following could be the symptoms of diabetes?
Experiment 27 (61.4 %) 35 (79.5 %)
Control 26 (57.8 %) 27 (60.0 %)
3. Which of the following is the most accurate way to measure blood sugar?
Experiment 17 (38.6 %) 31 (70.5 %)
Control 19 (42.2 %) 20 (44.4 %)
4. Which of the following side effects is possible as a result of high blood pressure in diabetic patients?
Experiment 14 (31.8 %) 27 (61.4 %)
Control 15 (33.3 %) 18 (40.0 %)
5. Which of the following oral complications is caused by diabetes?
Experiment 07 (15.9 %) 27 (61.4 %)
Control 09 (20.0 %) 11 (24.4 %)
6. How many times a year, typically the diabetic patients should visit the dentist for oral and dental examination?
Experiment 04 (09.1 %) 26 (59.1 %)
Control 14 (31.1 %) 15 (33.3 %)
Discussion:
Diabetes has been shown to have a negative impact on oral and dental health as well as an association with increased prevalence of oral mucosal lesions, periodontal disease and tooth loss [22-23]. However, most people, even those with diabetes, have a limited awareness of the relationship between diabetes and oral and dental illnesses[23]. Among the numerous ways of preventing oral diseases, health education, from the economic point of view, is the most effective method to promote the awareness of patients. Previous studies have shown the effectiveness of education and training in the control and treatment of diabetes, and education by itself is considered as the most effective means for recovery from the complications of diabetes[24]. In the current
study, the effect of education on improving the awareness and attitude of people with diabetes about diabetes and its relation to oral diseases were studied in Kermanshah.
Table 4: The Absolute and Relative Frequency of Correct Answers to Questions of Oral and Dental Health; Pre and Post Training in both Experiment and Control Groups.
Question Group Numbers (%)
Pre Training Post Training 1. What causes tooth decay when there is an increase in blood
sugar?
Experiment 14 (31.8 %) 32 (72.7 %)
Control 22 (48.9 %) 22 (48.9 %)
2. What is plaque? Experiment 05 (11.4 %) 21 (47.7 %)
Control 13 (28.9 %) 15 (33.3 %)
3. Which statement is true in the case of dental floss Experiment 08 (18.2 %) 25 (56.8 %)
Control 14 (31.1 %) 15 (33.3 %)
4. If craving to eat food containing sugar, which test is the most appropriate consuming time?
Experiment 11 (25.0 %) 24 (54.5 %)
Control 18 (40.0 %) 23 (51.1 %)
5. Which of the following is the most suitable day care program for Oral and Dental Health?
Experiment 21 (47.7 %) 30 (68.2 %)
Control 33 (73.3 %) 35 (77.8 %)
6. In testing the effect of diabetes on periodontal health which statement is correct?
Experiment 14 (31.8 %) 26 (59.1 %)
Control 18 (40.0 %) 20 (44.4 %)
Table 5: Comparison between Pre and Post Training Mean Scores in the Experiment Group and the Control Group.
Variable Group Point (mean ± SD)
*P value Pre Training Post Training
Diabetes Awareness Experiment 39.0 ± 23.0 69.7 ± 18.1 < 0.001
Control 44.1 ± 22.5 47.8 ± 22.1 0.003
Oral Health Awareness Experiment 28.3 ± 21.7 61.2 ± 25.1 < 0.001
Control 43.7 ± 24.2 48.2 ± 24.9 0.002
Attitude regarding Diabetes Experiment 61.2 ± 17.9 78.1 ± 12.7 < 0.001
Control 62.3 ± 15.6 65.4 ± 15.1 0.001
Attitude regarding Oral Health
Experiment 59.1 ± 16.8 76.3 ± 14.5 < 0.001
Control 62.6 ± 15.6 63.7 ± 15.1 0.071
*The paired T-test
Table 6: Comparison between Experiment Group and the Control Group Mean Scores in the Pre and Post Training.
Variable Group Point (mean ± SD)
*P value
Control Experiment
Diabetes Awareness
Pre Training 44.1 ± 22.5 39.0 ± 23.0 0.297
Post
Training 47.8 ± 22.1 69.7 ± 18.1 < 0.001
Oral Health Awareness
Pre Training 43.7 ± 24.2 28.3 ± 21.7 0.002
Post
Training 48.2 ± 24.9 61.2 ± 25.1 < 0.016
Attitude regarding Diabetes
Pre Training 62.3 ± 15.6 61.2 ± 17.9 0.740
Post
Training 65.4 ± 15.1 78.1 ± 12.7 < 0.001
Attitude regarding Oral Health
Pre Training 62.6 ± 15.6 59.1 ± 16.8 0.310
Post
Training 63.7 ± 15.1 76.3 ± 14.5 < 0.001
*Independent T Test
In this study, the patients were instructed by a dentist. Generally, different health-related groups, including doctors, nutritionists, psychologists, pharmacists, and nurses involved in diabetes education participated, and it seems that the presented education by any of them does not have any superiority over other groups[25].
In this study, there was no significant difference between the patients in experimental and control groups regarding gender, age, marital status, education, occupation, type of diabetes, duration of diabetes, and fasting blood sugar levels [Tables 1, 2]. Bruce et al. reported the significant impact of demographic factors on the education of people with diabetes[26]. Aggarwal et al. showed the impact of gender, age, and control of diabetes on oral and dental health in the diabetic patients, in a way that the frequency of brushing was higher in women than in men, in the 35-44 age group compared to other age groups, and in the patients with controlled diabetes than the patients with no control over their diabetes[27].It has also been shown that the income level can have an impact on the patients’ education[28]. The clinical situation of individuals is also considered as another effective factor influencing the awareness and effectiveness of education[29-30] . Given that in the present study, the two groups were similar in terms of demographic and clinical characteristics, the difference in awareness and attitude between the experimental and control groups after intervention was related to the difference in the content of the training provided to patients.
The results of the study showed that 31.8% and 48.9% of the patients were aware that increased blood sugar causes tooth decay before intervention in the experiment and control groups, respectively. However, after intervention, the awareness in experiment group reached 72.7%, but no change was observed in the control
group which still remained at 48.9% [Table 4]. According to Ismaeili et al. more than half of the studied people (52.3%) were not aware of higher risks of oral problems in the people with diabetes[18].Also, Eldarrat et al., demonstrated that diabetic patients had lower awareness of the higher risks of oral illnesses[31].Regarding the correct use of dental floss prior to educational intervention, 18.2% and 31.1% of patients in the experiment group and control correct correctly responded the questions. With regard to the most appropriate daily oral health programs, the awareness levels were 56.8% and 33.3% among the experimental group and the control group, respectively[table 4].Aggarwal et al. reported a lower rate for awareness of correct brushing among the diabetic patients, and showed that oral health was unfavorable among diabetic patients as a result of lack of awareness of the association between diabetes and oral complications; therefore, education in this area was necessary[27]. According to the findings of Bowyer et al., only 15% of diabetic patients used dental floss on a daily basis[32]. Also, Wambugu et al., in a study conducted o diabetic patients, confirmed low levels of awareness of oral health among these patients[33].
In relation to the impact of diabetes on the periodontal health, the percentage of patients responding correctly to the questions prior to educational intervention was set 31.8% in the experimental group and 40% in the control group [Table 4]. Similarly, Habashneh et al. showed that 48% of diabetic patients were aware of the link between diabetes and periodontal health, but awareness of periodontal complications of diabetes was set much lower[34].
The results of the study showed that 77% of the studied patients believed that diabetes is associated with the incidence of other systemic diseases, but only 57% believed that diabetes is associated with oral diseases. In similar findings, Eldarrat et al. found that a greater number of people with diabetes were aware of the association between diabetes and systemic diseases, while a few of them were aware of the relationship between diabetes and oral diseases[31].
The results of this study also indicated that the education offered to patients about diabetes significantly increased their awareness level in the experiment group from 39.0% to 69.7% from the pre training to post training; whereas, the control group showed only a slight improvement from 44.1% to 47.8% [Table 5] , Similar to these findings, Dizaji et al. (2014) reported that educational programs can significantly affect the awareness and self-care behaviors of diabetic patients[19]. According to Kegels Ku, training the diabetic patients increased their awareness, which resulted in improving their ability to control their blood sugar and to improve their dietary compliance, sporting activities, and proper drug consumption[25].
The findings of the present study showed the awareness of patients in realizing the link between diabetes and oral diseases significantly increased after the intervention program [Table 5]. The study conducted by Almas et al. showed that the oral health education can improve periodontal health and have a favorable effect on reducing plaque and calculus among these patients[35]. According to the findings of Blinkhorn et al., oral health education can reduce tooth decay in children and also improve the quality of life in their families[36]. Oral health education through providing information, can, lead to an improved lifestyle, positive attitude and good oral hygiene practices by improving the awareness. Raising awareness through education, in addition to the impact it can have on the proper performance of oral hygiene behavior, can also improve clinical parameters such as oral hygiene, tooth decay and gum health[37].
Based on the findings of current research, the awareness of patients with diabetes type I and II was greatly influenced by the training in both groups. Smith et al. found out that although the awareness level of patients with diabetes type I increased, the increased level was not significant; however, the awareness level in patients with diabetes type II was reported as much higher and more significant[29].
The present study revealed that education caused an improvement in the attitude of patients with diabetes about the relationship between diabetes and oral disease[table 5]. in line with this, Rezai et al. reported that diabetes education would increase awareness, attitude, performance, as well as metabolic control in this group of patients[38]. Yuen et al. found out that training by a dentist could significantly increase the awareness, attitudes, and performance of diabetic patients about oral hygiene[39]. Also, Bakhshandeh et al. observed that oral health education can reduce the amount of plaque and reduce the need for periodontal treatment among adults with diabetes[40]. Taneepanichskul & Saengtipbovorn (2014) showed that providing oral health education to people with diabetes improved periodontal health indicators, so that the plaque index, gingival index, probing depth, clinical attachment level and bleeding due to probing in patients receiving training were considerably lower compared to people without training[41]. In the present study, it was shown that training of diabetic patients led to a significant improvement in their attitudes about the importance of participating in oral health programs, so that the number of patients in the experiment group who completely agreed with the necessity of providing educational instructions by a dentist increased from 15.9% to 56.8% in the pre and post training programs, respectively. In line with this, Akyuz et al. observed that patients tended to obtain more information about diabetes and its relation to oral health through education[42]. Also, in a research conducted by Karikoski et al.92% of patients believed the diabetes nurse must be able to provide them with the necessary consultation about dental care[43] . Moreover, in a study by Bower et al. more than half of the patients requested that additional training about oral health be provided by the dentists and medical personnel[32].
In the current study, the awareness and attitude of patients, regardless of demographic variables such as age, gender, education, occupation, type of diabetes, showed a significant increase under the influence of training. In other words, the increased awareness of the subjects of this study showed no correlation with these factors.
However, previous studies have shown that demographic and clinical variables are factors affecting the awareness of patients[26,28,30].The results of this study indicated that the change in attitude of patients about diabetes and oral health in the two age groups of under 55 and over 55 years have significantly influenced by training. These findings show that training can significantly improve the attitude of people at any age group. In agreement with this, Karikoski et al. argued that age had no effect on the attitudes associated with dental visits among diabetic patients[43].
So far, no accurate information about regular and continuous training of diabetic patients, in particular with this disease and related oral illness, is published in Iran. In the United States, diabetic patients undergo training, but because of different reasons including lack of presence of specialist dentist in the training program, these trainings are less focused on the oral health issues. In Britain, although oral health education is one of the main topics related to diabetes in the National Service Framework for Diabetes, training the diabetic patients about the t oral health is not taken into consideration for this group of patients in most centers. In some Western countries, including Ireland and Canada oral health education brochures are distributed among people with diabetes, however, their reported practical usefulness or verification of their effectiveness in improving oral health have shown conflicting results[44].
A significant point in the present study was the assessment of diabetic patients as a high risk group who are prone to dental problems compared to the normal population. According to the findings of the present study about on the significant impact of training in this group of patients on increasing the awareness level, training can be an affordable method to prevent the incidence of oral lesions in patients with diabetes.
Conclusion:
The findings of this study showed that the knowledge and attitude of diabetic patients about diabetes and the relationship between diabetes and oral health was deficient.the level of the knowledge and attitude of diabetic patients about diabetes and relationship between diabetes and oral health considerably improved after training. According to the findings of this study, educational programs can be effective in improving oral health by increasing the awareness and attitude of diabetic patients.
ACKNOWLEDGMENTS
The authors wish to thank the patients, their families, and the physicians, nurses, and staff at the Diabetes Disease Center of Kermanshah city, without whom this project would not have been accomplished.
This article is based on a thesis submitted to the graduate studies office in partial fulfillment of requirenments for the degree of dentistry in Kermanshah University of Medical Sciences , Faculty of Dentisty.
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