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 Table of Contents  
Year : 2017  |  Volume : 9  |  Issue : 3  |  Page : 148-152

Evaluation of oral health knowledge, attitude, and practices among diabetics in a Northern Union Territory of India

1 Department of Periodontics, Dr. Harvansh Singh Judge Institute of Dental Sciences and Hospital, Panjab University, Chandigarh, India
2 Department of Oral Surgery, Dr. Harvansh Singh Judge Institute of Dental Sciences and Hospital, Panjab University, Chandigarh, India

Date of Web Publication7-Aug-2017

Correspondence Address:
Shipra Gupta
Department of Periodontics, Dr. Harvansh Singh Judge Institute of Dental Sciences and Hospital, Panjab University, Chandigarh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/IJDS.IJDS_35_17

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Background: Periodontal disease has been labeled as the “sixth” complication of diabetes. The two diseases have a bidirectional adverse relationship to each other. Diabetes can aggravate periodontitis, and periodontitis can negatively affect the glycemic control of diabetics. Oral hygiene awareness and treatment of periodontal diseases play an important part not only in prevention of many complications due to diabetes but also decrease the morbidity due to these manifestations. Aim: The goal of this cross-sectional study was to determine the actual awareness of diabetic patients about their oral health and the oral hygiene measures being practiced by them. Another aim was to evaluate their knowledge regarding the impact of oral health on glycemic control. It was also assessed whether there was any significant difference in the oral health awareness levels with their nondiabetic counterparts. Materials and Methods: One hundred diabetic and one hundred nondiabetic respondents filled up a validated questionnaire which comprised questions on personal data, oral hygiene knowledge, attitude, oral hygiene practices, and their knowledge regarding the correlation of oral health to adverse glycemic control and vice versa. Data were compiled and subjected to statistical analysis. Results: The results indicate no statistically significant differences in the variables assessed in both the groups, indicating that no further knowledge had been imparted to the diabetics after they were detected with the disease. Seventy-three percent of nondiabetics and 76% of diabetics were unaware of the relationship between oral health and diabetes. Conclusion: The study concludes that both diabetics and nondiabetics lack awareness of the relationships between diabetes and oral health. To provide better oral health care, more knowledge needs to be made available to the diabetic patients and the medical community.

Keywords: Diabetes mellitus, knowledge, oral health, oral hygiene practices, periodontitis

How to cite this article:
Gupta S, Sood S, Jain A, Garg V, Gupta J. Evaluation of oral health knowledge, attitude, and practices among diabetics in a Northern Union Territory of India. Indian J Dent Sci 2017;9:148-52

How to cite this URL:
Gupta S, Sood S, Jain A, Garg V, Gupta J. Evaluation of oral health knowledge, attitude, and practices among diabetics in a Northern Union Territory of India. Indian J Dent Sci [serial online] 2017 [cited 2023 Sep 29];9:148-52. Available from: http://www.ijds.in/text.asp?2017/9/3/148/212394

  Introduction Top

The World Health Organization declared diabetes mellitus as an epidemic.[1] Diabetes and periodontal diseases share a bidirectional relationship.[2] Diabetes accounts for 4.6 million deaths annually worldwide.[3] According to the International Diabetes Federation, around 366 million people are currently estimated to have diabetes, of which 80% live in low- and middle-income countries.[2] India itself heads the world with about 62.4 million people having diagnosed with diabetes in 2011.[3] Anjana et al. reported the weighted prevalence of diabetes in Chandigarh to be 13.6%.[4] Deepa et al. conducted a nationwide survey to assess awareness and knowledge about diabetes, wherein Chandigarh, a union territory, represented the north zone. According to their survey, 50.8% of urban and 27.6% of rural population of Chandigarh were aware about diabetes. Awareness of diabetes in literate was 38.1% and in illiterate 17.1%.[5] However, this study did not take into account the two-way relationship between periodontitis and diabetes, and no data were collected regarding the same.

Diabetes has been unequivocally confirmed as a major risk factor for periodontitis.[6] There is a threefold increase in the prevalence and severity of periodontitis in patients with diabetes, especially those with poor metabolic control, leading to the designation of periodontal disease as the “sixth” complication of diabetes.[6],[7],[8] Xerostomia, opportunistic infections, delayed wound healing, candidiasis, altered taste, greater accumulation of plaque, and oral paresthesia are some of the other oral consequences in uncontrolled diabetics.[5],[6],[8],[9]

The diabetic patients who do not carefully control their blood glucose levels are at high risk of systemic and oral complications. The most common chronic manifestations are macrovascular diseases which include coronary artery, peripheral vascular, and cerebrovascular diseases whereas the microvascular complications include retinopathy, neuropathy, and nephropathy.[6],[9],[10] Thorstensson et al. found periodontitis to be associated with the classic complications of diabetes wherein the diabetic adults with severe periodontitis at baseline had a significantly greater incidence of the kidney, and macrovascular complications over the subsequent 1–11 years than did diabetic adults with both gingivitis or mild periodontitis. Furthermore, around 82% of patients showed one or more cardiovascular complications as compared to patients without severe periodontitis.[11]

There is evidence to show that improvements in metabolic control can be anticipated following effective treatment of periodontitis.[6],[12],[13] The mechanisms by which this occurs are not yet clear but probably relate to reduced systemic inflammation following periodontal therapy.

Very few studies have been conducted in northern India which primarily focus on the knowledge, awareness, and perception of diabetic individuals toward maintaining their oral health. Such data are important to plan the public health programs. This study was planned to evaluate oral health status through self-administered questionnaire both in diabetics (test) and nondiabetics (control) and also to evaluate the level of awareness regarding oral health in diabetic patients and the impact of oral health on systemic health.

  Materials and Methods Top

The present study was designed as a randomized cross-sectional questionnaire survey. The study was conducted by Department of Periodontics at Dr. Harvansh Singh Judge Institute of Dental Sciences and Research, Panjab University, Chandigarh. One hundred diabetic patients (Group A/test group) and 100 nondiabetic respondents (Group B/control group) were randomly selected among diabetic patients and their family members visiting the Endocrinology Department of Government Hospital Sector-16, Chandigarh. Permission was obtained from the Medical Superintendents of the Government Hospital before conducting the study. The ethical clearance for the study was received from the Ethical Committee, Panjab University, Chandigarh. This study was conducted during outpatient department timings of the hospital.

A computer-generated randomization was utilized for selecting the patients. People not willing to participate in the study, pregnant and lactating females, people consuming tobacco in any form, people having <20 teeth in their oral cavity, of <20 years, or >70 years of age were excluded from the study. A total of 1625 patients were screened of which 200 patients were selected based on the inclusion and exclusion criteria. The controls were matched with cases for age, sex, and level of education.

The structured questionnaire was designed by the author in easy to understand English. The questionnaire was verbally explained in the local language to illiterate participants and those facing any problem. Questionnaire was checked for validity and reliability. Written consent was taken from all the participants. The questionnaire included questions regarding demographic profile of an individual including age, gender, education and occupation, body mass index (BMI) and 18 questions pertaining to knowledge regarding oral health behaviors, oral hygiene practices, and perceptions. Diabetic participants responded to ten specific questions to assess the participant's knowledge regarding risk/causative factors as well as complications of diabetes.

Statistical analysis

Discrete categorical data were presented as n (%). For categorical data, comparisons were made by Pearson's Chi-square test. All statistical tests were two-sided and performed at a significance level of α = 0.05. Analyses were conducted using SPSS for Windows (version 15.0; SPSS Inc., Chicago, IL, USA).

  Results Top

A total of 200 adults were interviewed, of which 100 were diabetic (test) and 100 were nondiabetic (control). Of 100 diabetic adults, 56 were male (M:F 1.2:1). Most of the diabetics were in the age group of 40–49 years. About 49% of diabetics and nondiabetics had no formal education. About 71% of the diabetic population was sedentary in occupation as compared to nondiabetics. Most of the diabetics (64%) of the surveyed population were obese which could be due to sedentary lifestyle and physical inactivity [Table 1].
Table 1: Demographic profile of the population

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There was no significant difference in both the test and control groups regarding their attitude toward oral health checkup or factors influencing their visit to a dentist (P ≥ 0.05) [Table 2].
Table 2: Respondents oral health behaviors

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Both the test and control groups were following similar oral hygiene practices and had almost similar opinion when asked about the best method of brushing and frequency of brushing [Table 3].
Table 3: Oral hygiene practices and perceptions of respondents

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Regarding the patients' knowledge and awareness of systemic and oral complications associated with diabetes, in this study, about 90% of patients were detected with diabetes more than a year back, 76% of cases reported positive for family history of having diabetes, and 89% of diabetics controlled their blood glucose level through medications. When enquired about their knowledge regarding the relationship between oral health and diabetes, 76% of them denied of being aware, 60% of them noticed changes in oral cavity after being diagnosed as diabetic, and about 58% visited dentist for bleeding gums, but they were never referred to the dentist by their physician nor were they made aware of the fact that the changes in their oral cavity were due to increased blood glucose levels. Only 33% of diabetics brought some changes in their lifestyle [Table 4].
Table 4: Diabetic participants (test group) response to questions on their diabetic status and on relationship of oral health with diabetes

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Seventy-three percent of control group and 76% of test group had never been educated by physician regarding impact of oral health on systemic health. Very few participants of the control group and the test group had knowledge regarding the impact of oral health on systemic health and considered the same important. About 88% of diabetics and 94% of nondiabetics were of the view that they would be more careful in maintaining oral health once they are educated about its role in overall health.

  Discussion Top

The data presented in this study reveal an important finding that both the diabetics and nondiabetics were matched for age, gender, and level of education and had limited knowledge regarding the impact of diabetes on the oral cavity. About 71% of the respondents positive for diabetics had sedentary lifestyle and were overweight (BMI: 25–30) as compared to the nondiabetics. Similar results have been seen in the survey conducted by Lau et al. where the rural population was found to be less overweight and with a lower prevalence of diabetes as compared to urban areas.[14] The high prevalence of obesity is a major health problem in India.[15],[16],[17]

Our results revealed that both the diabetics and the nondiabetics did not visit their dentist on regular basis, and about 25% of them had not visited dental clinic within last year, and only 10%–12% of participants visited dental clinic on regular basis. Most of the participants thought that there was no need while 13%–18% lacked time. On the contrary, surveys conducted in the UK showed that about 37%–47% of participants visited dentist on a regular basis.[18],[19]

In terms of their oral hygiene practices, majority of the diabetics and nondiabetics brushed their once a day though both the groups used toothpaste dentifrice to clean their teeth. About 55%–62% of the participants were of the opinion that brushing should be done once a day, and majority of them changed their toothbrushes when the bristles lost their alignment. Only 56% of the diabetics rinsed after meals. Our finding was in contrast to the study conducted by Sandberg et al. who in their study have reported a daily toothbrushing frequency of 91.3% in type 2 diabetic patients.[20]

When interrogated regarding their diabetic status, more than 90% of the participants were diagnosed with diabetes more than a year back, and about 76% of the family members of the participants were suffering with it. Eighty-nine percent of the diabetics used oral hypoglycemic medications to control their blood glucose levels. About 38% of diabetics suffered from increased frequency and burning sensation on urination, 30% had effect on vision, 28% suffered loss of sensation in the feet, and 4% had diabetic ulcers; the participants were well aware of these complications. Despite the fact that 58% of diabetics suffered from bleeding gums, they had never been referred to the dentist by their physician in the past. Only 24% of them reported to the dentist where they were made aware of oral complications of diabetes. These findings are in accordance to the study conducted by Kaur et al. where about 48.4% of the diabetic respondents were not aware of self-care in diabetes.[21]

Seventy-three percent of nondiabetics and 76% of diabetics had no idea regarding the interrelationship between the systemic and oral health. About 69% of diabetics did not know about the importance of maintaining oral health. About 88% of diabetics and 94% of nondiabetics were of the view that they would be more careful in maintaining oral health once they are educated about its role in overall health. This is in accordance with the finding in the study conducted by Bowyer et al. on 229 diabetic patients, where it was concluded that 69% of the diabetics had never received any oral health education related to their medical condition.[22]

  Conclusion Top

The present study suggests that both diabetics and nondiabetics lack awareness of the relationships between diabetes and oral health. This study also emphasizes the need for educating and training the medical fraternity involved in diabetes care regarding the role of oral care in diabetes control. Education about risk factors, complications, diet control, physical activity, and regular checkups should be conducted for better diabetic control and to reduce the burden of complications due to diabetes. The role of dental professionals needs to be expanded to wider general health services; it seems that dental professionals might play an important role on diabetes care.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Smyth S, Heron A. Diabetes and obesity: The twin epidemics. Nat Med 2006;12:75-80.  Back to cited text no. 1
Taylor GW. Bidirectional interrelationships between diabetes and periodontal diseases: An epidemiologic perspective. Ann Periodontol 2001;6:99-112.  Back to cited text no. 2
International Diabetes Federation. In: Unwin N, Whiting D, Guariguata L, Ghyoot G, Gan D, editors. Diabetes Atlas. 5th ed. Brussels, Belgium: International Diabetes Federation; 2011. p. 11-74.  Back to cited text no. 3
Anjana RM, Pradeepa R, Deepa M, Datta M, Sudha V, Unnikrishnan R, et al. Prevalence of diabetes and prediabetes (impaired fasting glucose and/or impaired glucose tolerance) in Urban and Rural India: Phase I results of the Indian Council of Medical Research-INdia DIABetes (ICMR-INDIAB) study. Diabetologia 2011;54:3022-7.  Back to cited text no. 4
Deepa M, Bhansali A, Anjana RM, Pradeepa R, Joshi SR, Joshi PP, et al. Knowledge and awareness of diabetes in Urban and Rural India: The Indian Council of Medical Research India Diabetes Study (Phase I): Indian Council of Medical Research India Diabetes 4. Indian J Endocrinol Metab 2014;18:379-85.  Back to cited text no. 5
Preshaw PM, Alba AL, Herrera D, Jepsen S, Konstantinidis A, Makrilakis K, et al. Periodontitis and diabetes: A two-way relationship. Diabetologia 2012;55:21-31.  Back to cited text no. 6
Mealey BL, Ocampo GL. Diabetes mellitus and periodontal disease. Periodontol 2000 2007;44:127-53.  Back to cited text no. 7
Löe H. Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care 1993;16:329-34.  Back to cited text no. 8
Skamagas M, Breen TL, LeRoith D. Update on diabetes mellitus: Prevention, treatment, and association with oral diseases. Oral Dis 2008;14:105-14.  Back to cited text no. 9
Rani PK, Raman R, Subramani S, Perumal G, Kumaramanickavel G, Sharma T. Knowledge of diabetes and diabetic retinopathy among Rural populations in India, and the influence of knowledge of diabetic retinopathy on attitude and practice. Rural Remote Health 2008;8:838.  Back to cited text no. 10
Thorstensson H, Kuylenstierna J, Hugoson A. Medical status and complications in relation to periodontal disease experience in insulin-dependent diabetics. J Clin Periodontol 1996;23(3 Pt 1):194-202.  Back to cited text no. 11
Jones JA, Miller DR, Wehler CJ, Rich SE, Krall-Kaye EA, McCoy LC, et al. Does periodontal care improve glycemic control? The Department of Veterans Affairs Dental Diabetes Study. J Clin Periodontol 2007;34:46-52.  Back to cited text no. 12
Yun F, Firkova EI, Jun-Qi L, Xun H. Effect of non-surgical periodontal therapy on patients with type 2 diabetes mellitus. Folia Med (Plovdiv) 2007;49:32-6.  Back to cited text no. 13
Lau SL, Debarm R, Thomas N, Asha HS, Vasan KS, Alex RG, et al. Healthcare planning in North-East India: A survey on diabetes awareness, risk factors and health attitudes in a rural community. J Assoc Physicians India 2009;57:305-9.  Back to cited text no. 14
Popkin BM, Adair LS, Ng SW. Global nutrition transition and the pandemic of obesity in developing countries. Nutr Rev 2012;70:3-21.  Back to cited text no. 15
Popkin BM. The nutrition transition and obesity in the developing world. J Nutr 2001;131:871S-3S.  Back to cited text no. 16
Caballero B. A nutrition paradox – Underweight and obesity in developing countries. N Engl J Med 2005;352:1514-6.  Back to cited text no. 17
Allen EM, Ziada HM, O'Halloran D, Clerehugh V, Allen PF. Attitudes, awareness and oral health-related quality of life in patients with diabetes. J Oral Rehabil 2008;35:218-23.  Back to cited text no. 18
Bakhshandeh S, Murtomaa H, Vehkalahti MM, Mofid R, Suomalainen K. Oral self-care and use of dental services among adults with diabetes mellitus. Oral Health Prev Dent 2008;6:279-86.  Back to cited text no. 19
Sandberg GE, Sundberg HE, Wikblad KF. A controlled study of oral self-care and self-perceived oral health in type 2 diabetic patients. Acta Odontol Scand 2001;59:28-33.  Back to cited text no. 20
Kaur K, Singh MM, Kumar, Walia I. Knowledge and self-care practices of diabetics in a resettlement colony of Chandigarh. Indian J Med Sci 1998;52:341-7.  Back to cited text no. 21
Bowyer V, Sutcliffe P, Ireland R, Lindenmeyer A, Gadsby R, Graveney M, et al. Oral health awareness in adult patients with diabetes: A questionnaire study. Br Dent J 2011;211:E12.  Back to cited text no. 22


  [Table 1], [Table 2], [Table 3], [Table 4]

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