Oral Health Knowledge, Attitude and Practice among adults living with diabetes in Makkah City

Raghad Alhajaji^*

^*Correspondence: Raghad Alhajaji, Family Medicine Specialist, Health Programs Administration, Saudi Arabia, Email:

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Introduction

Diabetes Mellitus (DM) is a critical issue confronting public health and according to the World Health Organization (WHO), Saudi Arabia ranks as the second highest in the Middle East and seventh in the world with regard to the prevalence of diabetes [1]. About 18.3% of the Saudi adult population has been diagnosed with diabetes and around 3 million are pre-diabetic [2]. Diabetes mellitus, a chronic metabolic disease [3], is characterized by high blood glucose levels that accumulates in the body and can gradually damage most organ systems, particularly the eyes, kidneys, nerves, heart, and blood vessels [4]. Additionally, it has been found to be linked to several oral complications [5] including periodontal and gingival disease [6]. Moreover, an increasing number of studies have documented a bidirectional link between diabetes and periodontitis where on one hand, uncontrolled Hyperglycemia may increase the likelihood of periodontitis [7] and negatively impact periodontal treatment outcomes [8] while on the other hand, presence of periodontal inflammation impedes glycaemic control [7] and may also contribute to the development of diabetes mellitus [9].

Thus, in view of this bilateral relationship and the fact that good oral hygiene and regular dental visits have an important role in the prevention and management of oral health problems [10], it is crucial to educate people with diabetes regarding proper oral hygiene habits and engage people in appropriate oral self-care practices that reduces their susceptibility to periodontal disease or hinder their diabetes management [11,12]. Conversely, people with lower health literacy levels tend to have a reduced understanding of the importance of prevention and maintenance, which in turn contributes to poor health outcomes [13].

Nevertheless, numerous studies conducted globally have indicated that diabetic people lack sufficient knowledge pertaining to oral health [14]. For instance, Abu-Gharbieh et al. reported that oral health knowledge among adults in UAE was sub-optimal particularly concerning the reasons for practicing healthy habits such as flossing and brushing teeth, and that they lacked knowledge regarding the implications of diabetes in relation to oral health [15]. With regard to attitude, there is evidence that people with diabetes tend to demonstrate lower priority when it comes to their oral health as indicated by lower perceived need and importance [16,17], and it has been reported that dental visits are less common among diabetic patients as compared to non-diabetics [18]. Accordingly, healthy practices relating to oral health have been shown to be inadequate, for instance, in a crosssectional study by Basu et al. among 339 diabetic patients in Delhi, India only 18.6% of the study participants reported to practice twice-daily brushing and 15.6% undertook a dental examination in the previous year [19].

Thus, the current study aims to examine the knowledge, attitude and practices related to oral health among diabetic adults living in Makkah City, Saudi Arabia.

Methodology

A cross-sectional study was carried out to assess the knowledge of oral health and determine the attitude of DM patients toward oral hygiene by using simple random technique. The sample size consisted of 222 adult diabetic patients attending the Chronic Disease Clinic and Family Medicine Clinic at governmental Primary Health Care Centres in Makkah City, Saudi Arabia. Adult diabetic patients (18 years old and above) from both genders were included in the study while excluding pregnant ladies with diabetes, and diabetic patients younger than 18 years of age. Data was collected by an intervieweradministered (face to face interview) questionnaire. The questionnaire was composed of close-ended questions that were derived from two relevant previous studies in the same area [20,21]. The study tool adopted a simplified and modified English version questionnaire to accommodate the aim of this study. The questionnaire was divided into four main parts: part one, contained questions related to the demographic data of the participants, part two included general questions to assess the medical and dental history, part three and four consisted of simple questions with dichotomous response format to assess knowledge and attitude of the participants toward oral health.

Before the data collection, an informed consent was obtained from all potential participants, The ethical approval was obtained from the institutional review board IRB of Ministry of Health (IRB number: H-02- K-076-0121-445).

Results

A total of 222 adult diabetic patients took part in the study and included almost an equal number of males (50.5%, n=112) and females (49.5%, n=110). A majority of them were 60 years old and above 133 (59.9%). Regarding their education level, 30.2% (n=67) had a bachelor’s degree while 28.4% (n=63) had less than a high school education. More than a quarter of the participants (77.9%, n=173) were married and more than half of the participants (57.7%, n=128) had a monthly income of less than 5000 Saudi riyals. With regard to clinical characteristics, majority of the study participants (79.3%, n=176) had Type 2 Diabetes Mellitus (Table 1).

Table 1: Demographic and clinical characteristics for the participants

An assessment regarding the knowledge of oral health among the participants revealed that 84.2% (n=187) of them were aware of the necessity of regular oral health examination while more than a quarter of the participants (79.7%, n=177) were aware of the effect of diabetes on general health. However, only less than half of the participants (43.2%, n=96) knew about the effect of diabetes on oral health (Table 2). Regarding the assessment of the participants’ attitude towards oral hygiene, 14.9% (n=33) reported to undergo regular check-up (Table 3). With regard to practice, 88.7% (n=197) reported to brush their teeth out of which 58.4% (n=115) brushed twice a day. With regard to flossing, only 33.3% (n=74) reported practicing it (Table 4).

Table 2: Assessment the knowledge of oral health among adults’ diabetic patients

Table 3: Assessment of participants’ attitude to oral hygiene

Table 4: Assessment of participants’ practice of oral hygiene

Regarding the mean of knowledge score in relation to demographic characteristics, education level was significantly related to knowledge score with higher scores among those with a post-graduate degree and least scores among the illiterate participants (p<0.001). Monthly income is also significantly associated with knowledge scores, with higher score among the participants with the highest monthly income and lower score among those with the lowest monthly income category (p<0.001). In relation to clinical characteristics, duration of diabetes was related to the knowledge score with the least score seen among those diagnosed less than 5 years ago (p=0.008). Recent HbA1C levels were also significantly associated with mean knowledge score, with the highest score seen the participants having an HbA1C level than 7 (p<0.001). Presence of complications was also significantly related to knowledge score (p=0.031) (Table 5.1 and Table 5.2).

Table 5.1: Mean of knowledge score by demographic and clinical characteristics for the participants

Table 5.2: Mean of knowledge score by demographic and clinical characteristics for the participants

Table 6demonstrates the univariate logistic regression for the factors associated with low level of knowledge regarding oral health among diabetic patients. It is clear that age 60 years and above is a significant factor associated with low knowledge OR (95%CI) of 3.15(1.26 – 7.83). Level of education including illiterate or primary school, elementary school, high school and bachelors are significant associated factors for low knowledge with OR(95%CI) of 31.80(3.73-271.37), 24.43(2.60-229.55), 13.95(1.64-118.70) and 8.74(1.05-72.73) respectively. A monthly income of less than 5000 SR is a significant associated factor for low knowledge with OR (95%CI) of 2.28(1.19–4.38). Duration of diabetes less than 5 years, and 5-10 years are significant associated factors for low knowledge with OR(95%CI) of 3.11(1.50-6.47), 3.55(1.55-8.12) respectively. Patients who did not know their most recent A1C level is a significant associated factors for low knowledge with OR (95%CI) of 4.95(2.02-12.14). Diabetes management plan of medication or lifestyle modification are significant associated factors for low knowledge with OR(95%CI) of 2.95(1.38-6.32), 2.63(1.38-5.01) respectively, Patients with the complication retinopathy are significantly associated with low knowledge OR(95%CI) of 3.59(1.24-10.37).

Table 6: Univariate logistic regression for the associated factors with low level of Knowledge about Oral health among Diabetes Mellitus patients

Table 7demonstrates the multivariate logistic regression for the associated factors with low knowledge levels about oral health among the diabetic patients. Age of 60 years and above was found to be a significantly associated factor for low knowledge with OR(95%CI) of 3.88(1.23-12.28). Level of education including illiterate or primary school, elementary school, high school and bachelors are significantly associated factors for low knowledge with OR(95%CI) of 22.65(2.32-221.07), 25.36(2.39-268.91), 20.75(2.16-199.56) and 18.10(1.93-170.08) respectively. Monthly income of less than 5000 SR is a significantly associated factor for low knowledge OR(95%CI) of 2.96(1.31-6.69). Not knowing recent A1C level is significantly associated with low knowledge OR(95%CI) of 43.43(1.21-9.71). Medication or lifestyle modification are significant associated factors for low knowledge OR (95%CI) of 2.59(1.08-6.24), 3.37(1.51-7.52) respectively.

Table 7: Multivariate logistic regression for the associated factors with low level of Knowledge about Oral health among Diabetes Mellitus patients

Discussion

This cross-sectional study assessed the knowledge, attitude and practices related to oral health among adults living with diabetes in Makkah city. With regard to knowledge, we report an overall lack of adequate knowledge pertaining to oral health, particularly less than half (43.2%) of the study participants were aware of the effect of diabetes on oral health. This is consistent with several previous studies that have concluded insufficient awareness regarding the association of diabetes and oral health [22-25].

In the current study it was revealed that more than a quarter (78.4%) of the participants had received no oral health education and for those who had, dentists were the most common source for oral health education (38.8%) while general practitioners and educators (18.4%, 8.2% respectively) were among the least common. While some earlier studies have suggested that oral health education was not usually received through general physicians or diabetes care providers [22,26,27], other studies have cited media [26] and physicians [28] to be the most common sources of oral health awareness. Thus, this study underlines the need for a greater role of physicians, educators and media in educating patients regarding the impact of diabetes on oral health and vice versa. Moreover, since the current study has reported that the majority of the participants (82.2%) visit the dentist only when they feel pain, the role of knowledge sources of oral health and hygiene besides the dentist becomes all the more important especially in relation to diabetes prevention and management education.

In the present study, significantly higher knowledge scores were found among the participants with higher education while lower scores were found among the participants who were illiterate or had a lower education level. This finding is similar to a previous study [24], and underscores the need to implement tailored oral health education among patient groups with lower education levels.

Majority of the participants (85.1%) did not undertake regular oral checkup indicating a poor attitude. Previous studies have cited numerous reasons for irregular dental checkups including costs, lack of need for oral health care, absence of dental related problems, unpleasant experience and effort required to schedule an appointment [14]. Although the Saudi Arabian government offers free dental treatment, and only a small portion of the population takes advantage of these services [29], it is worth exploring the factors responsible for low levels of regular checkups among the local population.

The level of healthy oral practices was found to be suboptimal with only 58.4 participants brushing their teeth twice a day and 33.3% flossing their teeth. A systematic review revealed that the less than half of the diabetic study participants (mean 49.3%, 95% CI 35.70–62.90) brushed twice a day while regular flossing (≥ 1/day) was undertaken by a mere quarter of the participants (mean 25.1%, 95% CI 10.36–39.88) [14].

Our findings highlight the gaps related to knowledge, attitude and provides crucial information related to the factors associated with low knowledge levels practice among diabetic adults in Makkah city which will be useful for program managers and policy makers in implementing interventional programs to increase the awareness among adults with or without diabetes and motivate them to practice healthy behaviours related to oral health.

We recognize limitations in our study related to short duration and strong regional focus of the study. We recommend future studies to explore national studies to assess oral health in this type of population.

In conclusion, there is inadequate knowledge related to oral health among adults living with diabetes and poor oral health practices. It is crucial to improve them especially in view of the high diabetes prevalence in Saudi Arabia.

List of Abbreviations

• WHO: World Health Organization

• DM: Diabetes Mellitus

• PHC: Primary Health Care

Ethics Approval and Consent to Participate

All necessary official permissions was secured by the higher authorities and IRB was taken from ministry of health, reference number ( H-02-K-076-0121-445).

Before the data collection, an informed consent was obtained from all potential participants, and then all participants have the right to not participate in the study.

Confidentiality and privacy were guarantee for all participants.

Consent for Publication

Not applicable.

Availability of Data and Material

The datasets generated during and/or analysed during the current study are available from the corresponding author on reasonable request.

Competing Interests

The authors declare that they have no competing interests.

Funding

This research is Self-funded. It did not receive any specific grant from funding agencies in the public, commercial, or not-for- profit sectors.

Authors Contributions

R.A. and A.A. conceived of the presented idea. R.A and A.A. and S.A. developed the theory, performed the computations, and verified the analytical methods. R.A encouraged and A.A. and S.A. to collect data. A.T. supervised the project. All authors participate in data analysis, discussed the results and contributed to the final manuscript.

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