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Table of Contents
Year : 2020  |  Volume : 3  |  Issue : 4  |  Page : 292-298

Assessment of dental health status, knowledge, and practice among Saudi diabetic patients attending general practice Clinic

1 Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
2 Department of Dental Services, King Abdulaziz Medical City, Riyadh, Saudi Arabia
3 Department of Periodontics and Community Dentistry, College of Dentistry, Prince Sattam Bin Abdulaziz University, Riyadh, Saudi Arabia
4 Department of Dentistry, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia; Harvard School of Dental Medicine, Boston, MA, USA
5 Department of Family and Community Medicine, College of Medicine, King Saud University; Alfarabi College of Medicine, Alfarabi Colleges, Riyadh, Saudi Arabia
6 Department of Dental Health Care, Ministry of Health, Riyadh, Saudi Arabia

Date of Submission09-Jun-2020
Date of Decision21-Jun-2020
Date of Acceptance27-Jun-2020
Date of Web Publication02-Oct-2020

Correspondence Address:
Aljohara Saud Almeneessier
Department of Family and Community Medicine, College of Medicine, King Saud University, Riyadh
Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JNSM.JNSM_64_20

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Objective: Diabetic quality indicators are missing a major part of diabetes care management. We aimed to explore the diabetic patients' knowledge of oral health care and identify the periodontal health status among them. Materials and Methods: This study was a cross-sectional study on diabetic patients at a diabetic care clinic in the primary care setting. Data collection instrument was structured to measure knowledge and dental hygiene practice. Clinical examination was done to assess dental health using the Simplified Oral Hygiene Index (OHI-S) and Periodontal Screening and Recording. Data were analyzed using Statistical Package for the Social Sciences (SPSS 22). Results: One hundred and ninety-five individuals were included in the study, with a mean age of 54.32 ± 11.58. Knowledge assessment showed that 47.2% of the respondents answered ≥50% of the questions. Dental hygiene behavior showed that 58.6% brushed teeth one to two times per day, 66.8% never used flossing, and 14% never visited a dental care clinic. Forty-seven individuals had dental examination. The mean OHI was 1.71 ± 1.06. The relationship between OHI and glycated hemoglobin, fasting blood sugar, diabetes duration, brushing, flossing, and vegetable and fruit consumption could not be detected with P= 0.61, 0.78, 0.93, 0.97, 0.86, 0.98, and 0.7, respectively. Patients' perception of dental health status is positively correlated with the clinical dental examination and statistically significant with P= 0.004. Conclusions: Oral health literacy should be improved with implementation of educational intervention. A positive correlation between patient perception and dental examination will help the health-care provider in diabetic care adoption of oral health care within diabetic management at the primary care setting, which will improve the quality of diabetic care.

Keywords: Dental care, dental health, diabetes, diabetic care, diabetic patients, periodontal disease, primary care setting

How to cite this article:
Almeneessier AS, Almunaiseer NS, Alnufaiy BM, Bahammam SO, Alyousefi NA, Batais MA, Alodhayani AA, Almigbal TH, Alkhalaf RK. Assessment of dental health status, knowledge, and practice among Saudi diabetic patients attending general practice Clinic. J Nat Sci Med 2020;3:292-8

How to cite this URL:
Almeneessier AS, Almunaiseer NS, Alnufaiy BM, Bahammam SO, Alyousefi NA, Batais MA, Alodhayani AA, Almigbal TH, Alkhalaf RK. Assessment of dental health status, knowledge, and practice among Saudi diabetic patients attending general practice Clinic. J Nat Sci Med [serial online] 2020 [cited 2023 Feb 5];3:292-8. Available from: https://www.jnsmonline.org/text.asp?2020/3/4/292/297119

  Introduction Top

Diabetes is one of the prevalent noncommunicable diseases in the world. The International Diabetes Federation projected an increase in number of adults with diabetes to 55% by the year 2035.[1] Among Saudis, population prevalence will increase from 16.8% in the year 2010 to 18.9% in the year 2030.[2]

Periodontitis has been linked to diabetes, and it affects the oral health of diabetic patients and ends in many problems including tooth loss. It is the most prevalent under-recognized dental disease with moderate forms of periodontitis affecting 40%–60% of adults.[3] Severe periodontitis is estimated to affect 743 million worldwide,[4] with a peak in the late 30 of age.[5] Its prevalence increased five folds among patients with diabetic retinopathy.[6] Smoking, diabetes, compromised immunity, nutritional defects, osteoporosis, medication such as calcium channel blockers and phenytoin, genetics, and local dental factors are known as risk factors predisposing to periodontitis.[3]

It is proposed that diabetes causes periodontitis through alteration of oral microbiota, increased production of pro-inflammatory cytokines, increased tissue degradation, and altered neutrophil function while periodontitis is linked to insulin resistance.[7] Periodontal diseases affect glycemic control in diabetic and nondiabetic patients with an increase of 0.13% glycated hemoglobin (HbA1c) for each millimeter periodontal probing depth, and those with periodontal disease are three times higher risk for developing diabetes compared to those with better periodontal health. Jimenez et al. after 20 years of follow-up of more than 35,000 male participants of the Health Professionals Follow-up Study found a significant association between diabetes and periodontitis, with a greater risk of self-reported periodontitis.[8] The treatment of periodontitis is not merely improving diabetes status but positively affecting other systemic diseases linked with periodontal health.[7] A meta-analysis of 15 randomized controlled trials shows that nonsurgical treatment of periodontal diseases improves the status of diabetes control by reducing HbA1c about 0.38% and fasting blood sugar 9.1 mg/dl at 3-month follow-up.[9] Another meta-analysis of studies including more than 900 diabetic patients with a follow-up for a minimum of 3 months found to have improvement after the treatment of periodontal disease.[10]

Several studies revealed inconsistent data regarding diabetic patients' awareness about oral health care or relationship between diabetes and periodontitis. Patients who received diabetic education are more aware about the disease and its complication including oral health.[11],[12],[13]

Currently, there are no clear or specific guidelines for dental health care among diabetic patients. The World Health Organization (WHO) in its 2007 assembly recommends measures for oral health[14] through primary health-care setting,[15] but there was no reference to diabetic patients. The American Diabetes Association includes annual enquires about dental health and referral to a dental specialist if required.[16]

A population-based cohort study conducted on approximately one million diabetic patients managed at a primary health care found that the quality of diabetic care is lower with high-volume practices and reaches a higher level with more expertise in diabetic care.[17] Quality indicators in the management of diabetic patients include blood pressure measurement, body mass index, HbA1c, eye examination, foot examination, urine albumin, serum creatinine, and healthy lifestyle education. Vascular and neurological examinations are part of the quality indicators of diabetic care.[18] The quality of diabetic care is not optimal, and the dental checkup or examination is not considered as a part of quality indicators of diabetic care. In addition to eye and foot examination, quick gum examination looking for pale pink and firm gum is all what is needed to enhance diabetic care at the primary care setting. Gum redness, swelling, or recession [Figure 1] urges a referral to a dental care specialist. Health quality indicators and guidelines should allow the clinician to provide a customized health care to diabetic patients based on individual risk assessment.[19]
Figure 1: Different stages of periodontitis

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At a national level, we located one questionnaire-based study of patients' knowledge with no clinical examination.[20] The current study will help in exploring the diabetic patients' knowledge of oral health care. Clinical examination will link the patients' perception of their actual oral health status. Hence, the enlightening of diabetic patients about their real state of oral health will lead to better health care for both diabetes and periodontal diseases. Moreover, this study will add to the volume of evidence to expand the health quality indicators and guidelines on diabetic care to include dental checkup and periodontal screening. This will assist the clinician to customize the diabetic care plan for individual diabetic patients.

  Materials and Methods Top

This study was a cross-sectional study carried out over 6 months (June–December 2017) at a diabetic care clinic (DCC) in general practice setting. The study was approved by the College of Medicine Institution of Research Board (Ref. No. 17/0053/IRB).


The DCC is one clinic per week looking after patients who are referred from general/family practice clinics. It is run by a team of consultants (with diabetes care qualification/experience), senior registrar, clinical pharmacist, and diabetic educator.

Population and sampling

The study sample includes all Saudi diabetic patients who attended the general practice clinics and referred to the DCC, both sexes, older than 18 years of age with type 2 diabetes and consented to participate in the study. The selected participants for dental examination should meet the inclusion criteria; Saudis, older than 18 years of age, both sexes, have most of the natural teeth, provide consent for oral examination, and access to their medical files to obtain their laboratory test within 3–6 months. Exclusion criteria applied to patients who have major diseases such as cancer or heart disease; patients who receive anticoagulant medication (heparin, warfarin, dabigatran, apixaban, and rivaroxaban), calcium channel blockers, nonsteroidal anti-inflammatory drugs, or antiepileptic medication; patients with prosthetic teeth or edentulous; and patients with laboratory test results more than 6 months.

Using Cochran formula, n0= Z2pq/e2 at a confidence level of 99% and precision of 0.1, the sample size was calculated as (2.58)2 × 0.5 − (1−0.5)/(0.1)2 = 6.66 × 0.25/0.01 = 167.

Assuming a response rate of 80%, the adjusted sample size is 167/0.8 = 209.

Instrument development

The instrument consisted of three parts. The first part was to collect personal data and oral health knowledge and practice through a self-administered questionnaire, the second part was designed for the dental examination that was carried out by one of the dental team, and the third part of the survey instruments was to collect data by accessing patients' medical e-records.

Questionnaire (construction, validation and reliability)

This was a pencil-and-paper questionnaire filled as self-administered or by assistance of a trained data collector (dental/medical team member) to those who are illiterate or semi-illiterate patients. The questionnaire was constructed based on a review of literature[3],[5],[11],[12],[20] and interviews with experts in the field (diabetologist and dentist). Instrument was reviewed by two family physicians: diabetologist and dentist. A pilot of the questionnaire was carried out on 15 patients for easy readability, comprehension, and timing. Changes upon recommendations and comments were applied. The Cronbach's alpha was tested as 0.74.

Dental examination instrument

Two tools are currently used in community epidemiological studies, namely Simplified Oral Hygiene Index (OHI-S) and Periodontal Screening and Recording (PSR). OHI-S is an easy visual assessment method used in research and epidemiological surveys to screen populations,[21],[22] and the OHI-S score was interpreted as excellent (OHI-S: 0), good (OHI-S: 0.1–1.2), fair (OHI-S: 1.3–3), and poor oral hygiene when OHI-S between 3.1 and 6.0.[23] For periodontal probing depth, the WHO approved instrument “No. 8 Standard Probe/CPITN Ball Tip Perio Probe 3.5/5.5/8.5/11.5.” was used to examine dental six sextants; maxillary (right, center, left) and mandibular (right, center, left).[24],[25],[26]

Study protocol

A convenience sample of 210 patients at the DCC waiting area was approached by members of the study team. The study objectives, purpose, and consent statement were explained to patients. Patients consented to participate by completing the questionnaire.

Dental examination protocol

Patients were screened by members of the dental team for eligibility for dental examination. Those who meet the inclusion criteria for dental examination were assigned to the senior dentist for examination. Patients self-assessment of dental health status was recorded on the same dental examination sheet and coded as (excellent = 0, good = 1, fair = 2, and bad = 3) similar codes were given to the OHI-S scores as (excellent = 0, good = 1, fair = 2, and bad = 3).[23] Patients were examined by the dentist using OHI-S and the WHO-approved “No. 8 Standard Probe.”

Statistical analysis

Data were analyzed using Statistical Package for the Social Sciences (SPSS 22; IBM Corp., New York, NY, USA). Continuous variables were expressed as mean ± standard deviation, and categorical variables were expressed as percentages. t-test was used for continuous variables with normal distribution, and Mann–Whitney test was used for continuous variables without normal distribution. Pearson and Spearman's rho correlation coefficients were used to assess the relation between OHI and other variables. Shapiro–Wilk test was used to assess the normality of the data. P < 0.05 was considered statistically significant.

  Results Top

A total of 195 individuals completed questionnaires, with a response rate of (92.86%). Eighteen participants declined access to their medical records. Female respondents constitute a 50.8% of the studied sample and 72.3% of the sample who had a dental examination. The sample's mean age was 54.32 ± 11.58 while the mean age of patients in the dental examination group was 52.87 ± 10.95. [Table 1] shows the different demographic and clinical data of the participants.
Table 1: Demographic characteristics of the studied sample (n=195)

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There were 14 questions to test the knowledge with good internal consistency (Cronbach's alpha = 0.796). It was agreed by the investigators to consider 50% (7 questions out of 14) of correctly answering the questions as a good knowledge. The mode was 6, and 47.2% of the respondents answered ≥50% of the questions with only six patients who answered ≥12 questions (>85% of the questions) correctly. The mean of questions answered correctly by the dental examination patient group was 6.64 ± 2.66 compared to 6.41 ± 2.73 answered correctly by the studied sample. [Table 2] details the responses to knowledge questions.
Table 2: Questions about diabetes and dental health (n=195)

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The main source of knowledge was personal reading 56.9%, primary care physicians 51.3%, TV and radio 51.3%, social media 49.2%, dentist 38.5%, and the health campaign 37.4%.

Dental care practice and status

Sampled diabetic patients' dental care practice was that 58.55% brushed teeth once to two times daily, followed by those who never brushed teeth (13.47%). In response to the question about using flossing, 66.85% admitted that they never used dental flossing, followed by 13.59% as using dental flossing once to two times per day. Visiting a dental clinic only during emergencies was seen in 68.4% of the respondents, while 14% claimed that they never visited a dental care clinic. Responses to dietary habits showed that participants are good weekly consumers of vegetables and fruits (92% and 87%, respectively).

Questions concerned with periodontal health status include teeth movement, gum abscess, gum recession, and gum bleeding showed that 29.7%, 29.1%, 24.6%, and 20.5% answered yes to these problems, respectively. Only 15.45% claimed that they received gum treatment at some point in their lifetime.

Dental examination

Fifty-one patients were eligible, consented, and agreed for the dental examination, and later, four male patients declined their consent and were not examined (reasons: late for work and opposite sex dentist). Finally, we ended with 47 eligible patients who consented and agreed for the dental examination: 34 female (72.3%) and 13 male patients (27.7%). The mean OHI was 1.71 ± 1.06. OHI for the male patients was 1.46 ± 0.81 and for the female patients was 1.81 ± 1.14, with no statistical difference between male and female OHI (P = 0.323). Patients' perception of their own dental health status is positively correlated with the clinical dental examination (r = 0.415) and statistically significant with P = 0.004. [Table 3] shows patients' distribution according to periodontal status based on OHI scoring and patients' perception of own oral health. Ten patients had missing teeth or less than two teeth per se xtant (edentulous sextant).
Table 3: Patients perception of their gum health status compared to the clinical examination (Simplified Oral Hygiene Index) score (Darby and Walsh 2019 categorization)

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The relationship between OHI and HbA1c, fasting blood sugar, diabetes duration, brushing, flossing, and vegetable and fruit consumption could not be detected with P = 0.61, 0.78, 0.93, 0.97, 0.86, 0.98, and 0.7 respectively. Probing depth < 3.5 mm with bleeding on probing (code 1) was recorded in 31% of mandibular left, 32.6% of maxillary center and 34% in maxillary left sextants. Code 2 a pd < 3.5 with subgingival calculus was recorded in 28% of mandibular center sextant; pd of 3.5-5.5 mm (code 3) was recorded for 34% of maxillary right, and 34% of mandibular right sextants. A probing depth of >5.5mm (code 4) was recorded in 7.8% of all examined sextants (total 282). There were no statistical differences between male and female patients in the PSR sextants with P = 0.77, 0.98, 0.71, 0.99, 0.50, and 0.87, respectively [Table 4].
Table 4: Dental examination, mean, and standard deviation by gender

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  Discussion Top

Our study was conducted at a small scale at DCC in primary care setting targeting middle-class patients who were referred from family medicine and general practice to control their diabetes status. As expected in a specialized diabetes care clinic to have uncontrolled diabetics; almost half of our studied sample suffered diabetes for 10 years or more accompanied by high readings of fasting blood sugar (8.90 ± 3.61) and HbA1c (8.13 ± 1.93), hence diabetes is a risk factor for periodontal diseases and periodontal diseases adversely affect diabetes control status.[3] It was reported that periodontal disease progression is accelerated among diabetic patients with HbA1c ≥7% compared to those with HbA1c <7%.[27] The treatment of periodontal diseases (scaling and root planing) resulted in reduction in HbA1c level of 0.40% and reduction in fasting blood sugar level of about −8.95 mg/dl at 3 months posttreatment.[28]

We studied our sample for their knowledge and practice in oral health care in addition to comparing their perception of own periodontal health with the professional examination.

Less than half (47%) of our sample was able to answer 50% or more of the questions, this result is within the reported figures of other studies.[11],[12],[13],[20],[29],[30] The high degree of uncertainty (20%–44%) if added to the wrong answers will lead us to consider this as a major deficiency in the required knowledge for self-management of diabetic patients in regards to oral health self-care. The relationship that linked diabetes to oral health apparently was not grasped by the respondents. The major source of information was personal reading. Hence, a significant proportion of the educational health materials are above the skills of an average person, and almost 75% of our sample had secondary or lower education with half of the respondents with no or low level of literacy; they are expected to lack the academic skills or strategies for fruitful reading, especially when it comes to a complex subject such as diabetes and oral health. It was reported that 61% of patients attending general practice were below the learning competency level to understand educational health materials.[31] The process of gathering, understanding, and utilizing information to decide on their own health is embedded within modifiable social health determinants (age, gender, education, income, and family support).[31] Good dental hygiene behavior is to brush teeth one before bedtime and a second brushing any time in the day, daily flossing to remove plaques and microfilms between teeth, regular dental clinic visits, and healthy diet. The optimal number of brushing is three times or more per day. Less than ten percent of our sample are brushing ≥3 times/day and more than two-thirds of the sample (66.9%) never use flossing and see a dentist only during emergencies (68.4%); these findings were in agreement with what was reported; Karikoski et al. concluded that this “is a failure in dental hygiene behavior”.[32] Along with the presence of other comorbidities and uncontrolled diabetes among our sample, we can say that this group of patients is at risk of developing periodontal diseases and worsening their medical conditions.[7],[9] A 10year followup of more than 1,80,000 individuals found that brushing ≥3 times/day was negatively associated with the development of new-onset diabetes[33] in the same cohort frequent brushing (≥3 times/day) and professional dental cleaning decreased the risk of developing atrial fibrillation and heart failure.[34] Frequent interdental cleaning such as flossing between four and seven times per week is associated with better periodontal health.[35] It is worth the effort to educate diabetic patients to adopt oral health behavior for general health promotion. In a controlled trial of educational intervention on 120 diabetic patients to increase awareness, perceived susceptibility and benefits, and performance of oral hygiene, after 3-month follow-up, the performance of oral and dental hygiene in the intervention group increased from 2.16 ± 0.71 to 3.25 ± 0.49 (P = 0.001) after the education program.[36] In our study, it was noticed during the educational sessions; the diabetic educator emphasized on different educational topics except dental hygiene behavior as a factor or an element in diabetes control. She responded to a patient inquiry about the effect of diabetes on dental health “do you prefer to loss a tooth or to loss a limb or have a heart attack,” and justification for this response was the prioritization of diabetic problems and management needs during the “short consultation time in the clinic.”

In our studied sample, we could not detect a relationship between the OHI scoring and different risk factors such as HbA1c, fasting blood sugar, brushing and flossing teeth, and diet. This could be explained by factors such as the size of the sample and the nature of the participants with the cultural use of miswak. Miswak is traditionally used by Arab and found to have a strong antiplaque effect, anti-streptococcal and anti-lactobacilli.[37] The positive relationship between patient awareness of the dental health status and what was detected during clinical examination indicated the ability of a patient to assess his/her own dental health status and could be utilized during patient education programs by increasing their awareness about the link between diabetes and periodontal diseases and during patients' visit to the DCC where asking patients about the dental/oral care and health is important in diabetic care.

  Conclusion Top

This study explored the knowledge of diabetic patients and dental hygiene behavior. Knowledge level was in agreement with what was reported by other studies as below the expected to maintain a good dental health, and they fail to follow to the recommended dental hygiene practice. Clinical examination of periodontal status ranked most of our patients as good to fair state. To achieve optimal diabetic care, periodontal care should be incorporated into the management plan of diabetic patients.

Limitation and recommendation

This study was carried out in the DCC in primary care setting. Two major constraints were faced during the time of the study; as the dental examination was conducted in the general clinic, this led to some patients' discomfort. Another major mishap was the institutional policy to shift referred diabetic patients to a specialized clinic outside the primary care setting and result in a reduced number of patients approached for the study.

Based on the result of this study and the recommendation by the WHO through early detection and continuity of oral health,[38] we recommend adopting intervention on professional level and community level. At a professional level; education and training of medical and dental undergraduate students by incorporated oral health topics in an interprofessional teaching strategy (including medical practitioners, dentists, oral hygienists, and health/diabetic educators). At the community level, health promotion campaigns, programs, and educational materials should be tailored to the public literacy level. Increasing awareness of both health-care providers and health-care recipients will strengthen the bond and improve the quality of diabetic care.


The authors thank the Deanship of Scientific Research and ISU at King Saud University for their technical support. In addition, we thank Dr. Fahad Saleh Al Sweleh Consultant, Dental University Hospital, KSU, for his advice and review of the manuscript.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1]

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


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