الفهرس 
AIM OF THE STUDYOnly 14 pages are availabe for public view
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Abstract
Diabetes mellitus is a major public health problem. The world health organization (WHO) has declared DM as a pandemic chronic disease in 2007. According to WHO estimates, 366 million people will suffer from diabetes worldwide by the year 2030 and there will be 7 million people suffer from diabetes by the year 2030 in Egypt. This recent rise in diabetes is not a genetic shift only but also an environmental shift as a result of lifestyle habits such as a high sugar diet, physical inactivity and obesity.
Many authors have linked DM as a risk factor for some oral diseases including gingivitis, periodontitis, dental caries, xerostomia, oral candidiasis, taste impairment, burning mouth syndrome, Poor oral wound healing, geographic and fissured tongue, Neurosensory oral Disorder, tempromandibular joint dysfunction and sialosis.
People with diabetes have more knowledge about their increased risk for systemic complications associated with diabetes than they do for oral complications. The current study shows that the proper oral health knowledge and self reported practice are lacking in diabetic patients and there are a need for improving knowledge and self reported practice among diabetics regarding oral health.
Objectives of the study:
The general objective of the study was to assess the oral health condition of diabetic patients, to compare between the oral health condition of controlled and uncontrolled diabetics, to assess knowledge and practice of diabetic patients concerning oral health, to construct; implement and evaluate the impact of the educational program for diabetic patients concerning oral health.
The study was conducted in three phases:
I- Preparatory phase II- Operational phase III- Analytical phase
Two phases of studies were used:
Phase I: Cross sectional design was conducted to assess oral health condition of diabetic patients and to assess their knowledge and practice regarding oral health. This phase was considered as a pre-test for the second phase. The study was conducted on a sample of 200 diabetic patients.
Phase II: Intervention design (One group pretest post-test design) to evaluate the impact of an oral health educational program on the knowledge and practice and to assess oral health condition among a sub-sample of 100 diabetic patients.
The study was conducted on diabetic patients attending the outpatient diabetic clinic in the Alexandria Main University and El-Ramed Hospital either for treatment or follow-up.
Data were collected using the following tools:
A pre-designed structured interviewing questionnaire about the sociodemographic characteristics, family and medical history and the personnel habits:
i. Socio-demographic data as: age, gender, marital status, residence, level of education, occupation, monthly income, family size and number of rooms.
ii. Family and medical history of diabetes mellitus as: family history of DM, age of onset of DM, duration of disease, type of DM, type of treatment, complications and frequency of blood glucose monitoring. iii. Personnel habits as: Smoking and physical activity.
Clinical examination of the oral cavity:
The oral cavity was examined for the presence or absence of removable or fixed dentures, gingival condition, periodontal condition, presence or absence of plaque, presence or absence of calculus, number of decayed teeth, number of filled teeth and number of missed teeth. Besides, periodontal disease index (PDI) was calculated to assess the gingival index, periodontal index, plaque index and calculus index.
A pre-designed structured interviewing questionnaire to collect data about knowledge and self reported practice regarding oral health:
This includes knowledge about DM and its relation to oral health diseases such as gingivitis, periodontitis, teeth mobility, dental caries and dry mouth were assessed. It includes also oral health practice regarding the frequency of tooth brushing, daily dental flossing, regular use of dental cleaning methods, frequent interdental cleaning, regular dental check up, managing dry mouth, care of removable prosthetic appliances.
Laboratory test:
The level of glycosylated haemoglobin concentration (HbA1c) was assessed.
Review of the medical records:
It was done for collection of any missed data regarding sociodemographic data, medical history of diabetes like type of diabetes, its duration, blood glucose level, current medication used and presence of diabetic related systemic complications.
Intervention program:
An educational program was designed according to the results that obtained from the preliminary phase which considered as a pre-test for the intervention.
The sub sample of diabetic patients were divided into four subgroups. The content of the oral health program covered four educational sessions (total sessions were 16 sessions). At the end of the program, a small booklet on the importance of oral health in diabetics (which was developed by the researcher) was distributed to each diabetic patient. In addition demonstration using dental models and patients’ education posters were used. Three months after termination of the intervention program, the same pre-designed structured interviewing questionnaire about the knowledge and self reported practice regarding oral health was used as a post test for intervention. Add to this, clinical examination of the oral cavity was assessed again using the periodontal disease index and the DMFT index were assessed also.
The collected data was revised, coded and fed to statistical software SPSS version 20.
The study revealed the following results:
Description of the study sample:
The majority of the diabetic patients were females (89.0%), married (74.0%), illiterate and read and write (57.1%) and housewives (83.5%) from urban areas (77.0%) with insufficient income (61.0%) and a crowding index of 2 persons/room (58.5%). Majority of diabetics were non smokers (93.0%) with sedentary life (97.0%). The majority of patients had either first, second and third degree relatives with positive family history of DM (82.0%). High percentage of diabetic patients were type II DM (85.0%). About 80.0% of diabetics had co-morbidities mainly neuropathy (72.2%).
Assessment of the oral health condition of diabetic patients:
High percentage of diabetic patients had at least one natural tooth (93.5%). About two-thirds of diabetics had periodontitis (66.3%), of them 79.9% had a moderate form of periodontitis. About one-third of diabetics had gingivitis (32.1%), half of them had a severe form of gingivitis. High percentage of diabetic patients had dental plaque (97.9%) and 69.4% of them had severe form of dental plaque. Almost all diabetics had dental calculus (94.7%), half of them was moderate form of calculus (50.3%). Big majority of diabetic patients (86.1%) had decayed teeth, about one-third of diabetics (27.9%) had filled teeth and 85.6% had missed teeth. 78.0% had dry mouth.
Comparison between oral health of controlled and uncontrolled diabetes:
Most of diabetic patients had poor glycaemic control (87.5%) followed by moderate (10.0%) and good glycaemic control (2.5%). There was no association between the diabetic control level from one side and socio-demographic characteristics, the decayed, filled and missed teeth and gingival and periodontal health on the other side although periodontitis are more common in poor diabetic control.
Severe form of plaque (71.5%) is more common among poor diabetic control. Again, moderate form of calculus (53.2%) was present among poor diabetic control patients. Both relations show statistical significance difference.
Assessment of knowledge and self reported practice of diabetic patients regarding oral health:
Dentist was the common source of oral health knowledge (46.5%) followed by Television (41.0%). About two-fifths of diabetics (41.5%) and two-thirds of diabetics (64.0%) knew teeth cleaning methods (toothbrush and toothpaste) and importance of teeth brushing to prevent the oral diseases respectively. About two-thirds of diabetic patients didn’t know the effect of fluoride in toothpaste and 83.0% didn’t know the uses of dental floss. High percentage of the diabetic patients didn’t had enough knowledge regarding the dental caries, methods of caries prevention, meaning of dental plaque and meaning of dental calculus. High percentage of the diabetic patients (94.0%) knew the effects of sweets and candies in causing dental caries. There was a fair level of knowledge among diabetes regarding the relation between diabetes and oral diseases. There was a lacked knowledge about the importance of regular dental visits (96.5% of diabetics) and improper frequency of dental visits among diabetic patients. With respect to the total knowledge score, the present study revealed that less than three-quarters (72.0%) of diabetics had fair oral health knowledge and more than one-fourth of diabetics (27.5%) had poor oral health knowledge. Regarding the level of knowledge and education, 41.7% of illiterate patients had poor oral health knowledge with statistical significance difference. Patients from rural areas had poor oral health knowledge (47.8%) and 80.3% of patients with crowding index of 2 persons/room had fair/good oral health knowledge. There was no significance difference regarding family and medical history of DM and level of oral health knowledge. High percentage of diabetic patients with poor level of diabetic control had poor oral health knowledge (90.9%) with no significant difference. The correlation between gingivitis score, periodontitis score, plaque index, calculus and level of oral health knowledge shows statistical significant difference. Linear regression analysis revealed that high level of education, being unmarried and urban residence were significantly associated with better oral health knowledge. Regarding self reported practice, about half of diabetic patients brush their teeth using toothbrush and toothpaste (48.5%) and almost half patients brush once/day (53.2%). All patients didn’t use dental floss. All patients visit the dentist only when there is an oral problem. The current study showed that three-quarters and one-fourth of diabetic patients had poor and fair self reported practice respectively.
There was a statistical significant difference between level of oral health self reported practice and level of diabetic control (90.0% of poor diabetic control had poor self reported practice). On the other hand, 89.1% of poor self reported practice had poor oral health knowledge. There was a significance correlation between oral health self reported practice and the presence of gingivitis, plaque and calculus. Linear regression of the factors affecting self reported practice showed that insufficient income is a statistically significant factor associated with poor oral health self reported practice.
Evaluation of the impact of an educational program for diabetic patients concerning oral health:
The intervention program was statistically effective in improving the oral health knowledge of diabetic patients as regards teeth and their cleaning methods, dental caries, plaque, calculus, gingival bleeding and effect of sweets, relation between diabetes and oral diseases, role of dentistry in diabetic oral health in one side and the total knowledge score on the other side at the end of the intervention oral health program. There was also a statistical significant improvement in the total oral health score of knowledge at the end of the program. The intervention program was a statistically effective in improvement of the oral health self reported practice of diabetic patients regarding teeth and their cleaning, dental visits, eating sweets, managing dry mouth and dealing with removable dentures on one side and the total self reported practice score on the other side at the end of the program. The program shows also a statistical significant improvement of the mean of the gingivitis score, dental plaque and dental calculus at the end of the oral health educational program.
It can be concluded from the study that:
The planned oral health education program was effective in improving the oral health knowledge, oral health self reported practice and oral health condition of diabetic patients.
Based on the results of the study, the following items are recommended:
Oral health should be promoted in people with diabetes as an integral component of their overall diabetes management. Training and advising both healthcare professionals and patients concerning importance of good oral health in diabetic patients are needed. Utilization of media to educate and spread knowledge of proper dental care and prevention of dental diseases and educate the public about the oral manifestations of diabetes and its complications on oral health and importance of keeping blood glucose level within normal levels. Raising the awareness among diabetic patients of their increased risk for oral diseases and the impact of oral health on their general health.
Summary
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Educating the diabetic patients on how to control dental plaque and calculus to prevent gingivitis, periodontitis and early tooth loss. Educating the diabetic patients on the importance of regular tooth brushing, the importance of use of interdental cleaning aids like dental floss, the importance of regular dental check up visits and to keep the oral cavity moist by stimulating salivary flow and frequent water drinking. Educating patients with diabetes about the importance of good oral health for their glycemic control and the management of their diabetes and to prevent harmful dental complications and expensive treatment. Controlling the blood and urinary glucose level within normal levels by regular blood glucose monitoring. Applying proper oral hygiene measures. A sequential educational program combined with daily self-monitoring of the practice to be changed are important for improving diabetics’ oral hygiene habits