|Year : 2020 | Volume
| Issue : 5 | Page : 432-438
The association between functional oral health literacy and periodontal disease among adults with type 2 diabetes mellitus in the northeast region of Thailand
Rajda Chaichit1, Supasin Deeraksa2
1 Department of Preventive Dentistry, Faculty of Dentistry, Khon Kaen University, Khon Kaen, Thailand; Research Group on Prevention and Control of Diabetes Mellitus in the Northeast Region, Thailand, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand
2 Research Group on Prevention and Control of Diabetes Mellitus in the Northeast Region, Thailand, Faculty of Public Health, Khon Kaen University, Khon Kaen, Thailand; Department of Dental Public Health, Thakuntho Hospital, Kalasin Provincial of Public Health Office, Kalasin, Thailand
|Date of Submission||11-Dec-2019|
|Date of Decision||09-Apr-2020|
|Date of Acceptance||13-Apr-2020|
|Date of Web Publication||21-Oct-2020|
Dr. Supasin Deeraksa
Department of Dental Public Health, Thakuntho Hospital, Kalasin Provincial of Public Health Office, Kalasin.
Source of Support: None, Conflict of Interest: None
Aim: To analyze the association between functional oral health literacy (FOHL) and oral health behaviors with periodontal disease among adults with type 2 diabetes mellitus (T2DM). Materials and Methods: A cross-sectional analysis study was conducted among 1110 adults with T2DM who were selected by multistage random sampling from 10 hospitals of five provinces in the northeast region of Thailand. A structured questionnaire was developed, and face to face interview and also clinical oral examination and blood glucose investigation were carried out. Data distribution was performed by descriptive statistic and chi-square test. The multiple logistic regression was used to determine the association between variables after adjustment for confounders. Results: In this study, a total of 1110 adults with T2DM divided into two groups according to the severity of periodontal disease showed 51.89% of moderate–severe periodontal disease. The study examined the association of periodontal disease with the independent variables after adjusted odd ratios, it was found to be statistically significant with the FOHL level (adjusted odds ratio [AOR] = 1.80, 95% confidence interval [CI] = 1.30–2.40), toothbrushing frequency (AOR = 1.73, 95% CI = 1.24–2.40), smoking (AOR = 2.25, 95% CI = 1.45–3.40), and betel nut crewing (AOR = 2.13, 95% CI = 1.28–3.45). Moreover, the demographic characteristics of patients with T2DM associated with the severity of periodontal disease in variables of gender, age, education level, duration with diabetes, and health insurance were also statistically significant at P < 0.05. Conclusion: The FOHL level and oral behaviors among adults with T2DM were statistically significant with periodontal disease. However, the patients of T2DM with low FOHL and poor oral health behaviors need extra support from dental health personnel to reduce the risk of oral disease.
Keywords: Functional oral health literacy, Oral health behaviors, Periodontal disease, Type 2 diabetes mellitus
|How to cite this article:|
Chaichit R, Deeraksa S. The association between functional oral health literacy and periodontal disease among adults with type 2 diabetes mellitus in the northeast region of Thailand. J Int Oral Health 2020;12:432-8
|How to cite this URL:|
Chaichit R, Deeraksa S. The association between functional oral health literacy and periodontal disease among adults with type 2 diabetes mellitus in the northeast region of Thailand. J Int Oral Health [serial online] 2020 [cited 2022 Sep 27];12:432-8. Available from: https://www.jioh.org/text.asp?2020/12/5/432/298795
| Introduction|| |
Diabetes mellitus patients are having the risk of periodontal disease affecting tooth mobility and severe bone loss. The American Diabetes Association (ADA) defined periodontal disease as one of the six most prevalent complications in diabetes; around 10.8% of patients are affected., An individual with type 2 diabetes mellitus (T2DM) leads to higher dental plaque, calculus, gingival diseases and deep periodontal pockets., Some studies analyzed the relationship between T2DM and oral health status, which statistically proposed two-way relationship significantly., However, the effect of oral health status in patients with diabetes reflected by oral health behaviors and oral health knowledge.,,
Health literacy was developed from the health literacy concept in 1974 that was used and introduced for public health and health care. It is important to refer to a person’s capacity to understand verbal and written health information, access to health information and service, and decision in their health. Nutbeam used health literacy and separated the classification by three levels of health literacy: functional level, interactive level, and critical level. This study focuses on functional oral health literacy (FOHL) that is characteristic of the basic literate skill from writing, reading, and understanding the specific oral health information. The FOHL is defined as “the degree to which individuals can obtain, process and understand basic oral and craniofacial health information and service needed to make appropriate health decisions.”, There are many instruments to measure oral health literacy, and most used FOHL instrument is the Rapid Estimate of Adult Literacy in Dentistry-30 items (REALD-30). It consisted of 30 common dental terms and was translated into Thai language, and its reliability and validity relative to the effectiveness of basic skills in Thai adults were tested.
However, no information exists on the association between adults with T2DM in FOHL and periodontal status. Most of FOHL studied in adults, maternal, and caregivers, suggested that an individual with low oral health literacy skills often has poor oral health knowledge, unhygienic oral behaviors, and ultimately poor oral health status and outcomes than an individual who have higher oral health literacy levels.,,,,, In addition, the reason to hypothesize that T2DM’s FOHL would be related to oral health related variables and associated periodontal condition. Therefore, this study aimed to investigate the association between FOHL and oral health behaviors with periodontal disease among adults with T2DM in the northeast region of Thailand.
| Materials and Methods|| |
The cross-sectional analysis study was conducted among Thai adults with T2DM in the northeast region of Thailand. The sample size was calculated based on a formula by Hsieh et al. for multiple logistic regression. The approximate sample size was 385.5, which was future adjusted to control the over-fitting, using rho (ρ) of 0.50 and variance inflation factor equal to 2.00. Thus, the total number of sample size was 899, which was adjusted at 10% base on the expert recommendation. Therefore, the total sample size included was 1110 in this study.
The inclusion criteria of the study were literate patients with age between 20 and 59 years and patients were having natural teeth. The exclusion criteria were participants who had communication problems including hearing loss, psychological disorder, and any kind of physical disability. The multistage random sampling was used to select the sample size in the northeast region of Thailand. First, 10 hospitals were randomly selected from five provinces. Then 2 of 10 hospitals were randomly selected from each province. Finally, systematic random sampling was applied on 10 hospitals to select 1110 samples participating in the study. Structured questionnaire was used to interview the participants after obtaining their signed consent. The data collection was conducted from May 2018 to July 2018.
In presented study, the structured questionnaires were designed. In that, the demographic variables were gender, age, education level, marital status, fasting blood glucose (FBG) level ≥ 126 mg/dL on follow up with diabetic condition and health insurance. The main variables on oral health behaviors such as toothbrushing, auxiliary of dental hygiene device, smoking, betel nut chewing, and dental visit, were also obtained in the structured questioning. Moreover, for the FOHL, we used the Thai version of the Rapid Estimate of Adult Literacy in Dentistry-30 items (ThREALD-30), which was tested for validity and reliability.
The outcome of this study was the influence of periodontitis on patients with diabetes. Periodontal disease was diagnosed from the Centers for Disease Control and Prevention (CDC) and the American Academy of Periodontology (AAP) among specific definition from the interproximal site, clinical attachment loss (CAL), and probing pocket depth (PPD). Severe periodontitis (SEV) is defined as ≥2 interproximal sites with CAL ≥6 mm (not on the same tooth) and ≥1 interproximal sites with PPD ≥5 mm. Moderate periodontitis (MOD) is defined as ≥2 interproximal sites with CAL ≥ 4 mm (not on the same tooth) and ≥2 interproximal sites with PPD ≥ 3 mm (not on the same tooth). No or mild periodontitis did not show the characteristics of MOD or SEV in patients with diabetes. Thus, this study sample was divided into two groups: no/mild group and MOD/SEV group, to examine the association between FOHL and their variables with periodontal disease. The clinical oral examination was performed by a dentist with a participant sitting in a dental operating chair, assessed with a dental mirror, an explorer, and a periodontal probe.
After data collection, the summary measures for all variables were calculated with the statistical application package STATA, version 10 (StataCorp, College Station, Texas). All variables were performed by descriptive statistics using frequency and percentage between no/mild group and MOD/SEV group. Chi-square test was used to compare the study variable with the outcome variable, and the level of significance was set at 0.05. The multiple logistic regression analysis was used for examining the association between independent variables with periodontal disease with adjusted odds ratio (AOR), 95% confidence interval (95% CI), and P < 0.05.
| Results|| |
In this study, a total of 1110 adults with T2DM were divided into two groups according to the severity of periodontal disease, which showed 51.89% of moderate–severe periodontal disease (female = 49.58%, male = 58.78%). The demographic characteristics of the patients are shown in [Table 1], which was analyzed by the chi-square test. A statistically significant association was observed between the severity of periodontitis with variables of gender (P = 0.008), age (P < 0.001), an education level (P < 0.001), duration with diabetes (P < 0.001), and health insurance (P < 0.001). However, no statistically significant association was observed between the severity of periodontitis and marital status and FBG levels in the follow-up appointment at diabetes clinic.
|Table 1: Demographic characteristics of adults with type 2 diabetes mellitus (n = 1110)|
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In [Table 2], the FOHL and oral health behavior were analyzed with the severity of periodontal disease by performing the chi-square test. A statistically significant association was observed between the variables of FOHL (P < 0.001), toothbrushing frequency (P < 0.001), the auxiliary device of dental hygiene (P < 0.001), smoking (P = 0.005), and betel nut chewing (P < 0.001). However, no statistically significant association was observed between a regular dental visit with the severity of periodontitis.
|Table 2: Functional oral health literacy and oral behaviors among adults with type 2 diabetes mellitus (n = 1110)|
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Multiple logistic regression was used to check the association between the severity of periodontal disease and the variables after adjusting for potential covariate factors. A statistically significant association was found between the severity of periodontitis with the variables of male gender (AOR = 2.52, 95% CI = 1.82–3.47), aged between 50 and 59 years (AOR = 1.54, 95% CI = 1.12–2.12; reference, less than 50 years), education level of primary school (AOR = 1.53, 95% CI = 1.10–2.15) uneducated (AOR = 2.52, 95% CI = 1.82–3.47; reference, high school and above), duration with diabetic more than 5 years (AOR = 1.99, 95% CI = 1.48–2.66), and health insurance on 30 Baht UCS (Universal Coverage Scheme) (AOR = 1.84, 95% CI = 1.27–2.66; reference, CSMBS [Civil Servant Medical Benefit Scheme]/SSS [Social Security Scheme]) [Table 3].
|Table 3: Multivariate logistic regression result of demographic characteristics on periodontal disease (n = 1110)|
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The main independent variables using multiple logistic regression were found to be statistically significantly associated between the severity of periodontitis with inadequate FOHL level (AOR = 1.80, 95% CI = 1.30–2.40), which used the ThREALD-30 instrument to assess the FOHL level among Thai adults with T2DM. And the oral health behaviors were statistically significantly associated with periodontal disease after adjusting the potential covariate factors. It was found in the variable of toothbrushing frequency less than two times/day (AOR = 1.73, 95% CI = 1.24–2.40), smoking (AOR = 2.25, 95% CI = 1.45–3.50), and betel nut chewing (AOR = 2.13, 95% CI = 1.28–3.54) [Table 4].
|Table 4: Multivariate logistic regression result of functional oral health literacy and oral health behaviors on periodontal disease (n = 1110)|
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| Discussion|| |
This study showed 51.89% of moderate–severe periodontal disease among Thai adults with T2DM (female = 49.58%, male = 58.78%), which was higher than the Thai national survey among working-age at 25.2% in 2018. This study is in agreement with the earlier studies that showed the risk and development of periodontal disease in patients with diabetes to be more than that in adults who were non-diabetic and who had type 1 diabetes mellitus (T1DM), which were conducted by Novak et al., Preshaw et al., Susanto et al., Pranckeviciene et al., and Liu et al. A longitudinal study by Jimenez et al. showed an association between diabetes and incidence of periodontal disease with increase in the event of tooth loss. Whereas a prospective cohort study by Joshipura et al. showed there was no association between periodontal disease and the risk of diabetes. However Taylor et al., and Preshaw et al. suggested to promote oral health status to support diabetes management as an integral component as many literatures were explained the two-way relationship of periodontitis and diabetes.
In this study, there was an association between demographic characteristics and moderate–severe periodontal disease in variable of gender male (P < 0.001), age >50 years (P = 0.008), education less than high school (P = 0.004), duration with diabetes more than 5 years (P < 0.001), and health insurance in 30 Baht UCS (P = 0.001). These findings were supported by the studies conducted by Wolff et al., Han and Park, Weinspach et al., Pranckeviciene et al., and Liu et al., and a previous study from Thailand by Srisaphum and Taneepanichskul also found the association significant on periodontitis among patients with diabetes, but it was studied only in one district in Roi-Et province. The longitudinal study was demonstrated the incidence of periodontal disease among diabetes patients in the variable of male gender by Jimenez et al., and in the age variable by Joshipura et al. amongst diabetes patients for the incidence of periodontal disease. They suggested that T2DM was exhibited as a stronger relationship with the risk of periodontal disease and tooth loss amongst male with increasing of age.,,,[24-32]
The oral health behavior factors were associated with the severity of periodontitis among patients with T2DM and the frequency of toothbrushing (P = 0.001), smoking (P = 0.001), and chewing betel nut (P = 0.003). The results of earlier studies by Wolff et al., Han et al., Weinspach et al., Ramandeep et al., and Dhir et al. were consistent with those of our study, with regard to the relationship of the same factors with periodontal disease in patients with T2DM. In the Thailand study conducted by Srisaphum and Taneepanichskul, a significant association was found between periodontal disease among patients with T2DM with the frequency of brushing, but smoking and chewing betel nut showed no association. The longitudinal study of periodontitis and tooth loss in T2DM by Jimenez et al. was demonstrated the strong association between smoking and periodontal disease (P < 0.05). Moreover, a randomized control trial by Lee et al. and Nishihara et al. revealed the frequency of toothbrushing and attending the dental clinic were statistically significant in reducing periodontitis in patients with T2DM. Previous studies and this study also confirmed that the frequency of toothbrushing, attending a dental clinic, and smoking was statistically significantly associated with periodontal disease among patients with T2DM. T2DM patients with better oral health behavior tend to illustrate better control on FBS level and oral health status.
The low oral literacy score (the sum of ThREALD-30) was 33.42% among adults with T2DM, which was lower score than adults without diabetes by Wehmeyer et al. and Blizniuk et al., In multiple logistic regression analyses, the low score of FOHL had associated with the severity of periodontal disease in adults with T2DM (P<0.001). Van et al. and Bridge et al. investigated the relationship of caregiver’s oral health status and suggested statistically significant low FOHL of caregiver associated with the children poor oral health status. The similarity of the study by Wehmeyer et al. was revealed that effect oral health literacy on periodontal health status has statistically significant result after controlling the potential variables of smoking and dental health insurance. Geltman et al. and Ramandeep et al. proposed that lower oral health literacy with insufficient oral health care cost. It is believed that promoting oral health literacy presents as a significant method to improve oral health literacy in particular community setting. This cross-sectional study used the word recognition of dental terms in the Thai version of REALD 30 items and that it was intended only as a screening tool for FOHL. Moreover, it had some disadvantage by personal pronunciation because this tool concept was required reading skills as each question was in the Thai language.
The data will be important to investigate the relationship of the FOHL with periodontal disease in adults with T2DM. Moreover, it will be necessary to use the FOHL instrument ThREALD-30 for an intervention study for improving the oral health status and their knowledge, attitude, and practice. Also, studies should examine approaches that can help people to overcome barriers to oral health literacy.
The FOHL level and oral behaviors among Thai adults with T2DM were statistically significant with periodontal disease representing the determinant of health relationship to the risk of oral disease. However, the patients of T2DM with low FOHL and poor oral health behaviors need extra support from dental health personnel to reduce oral disease in them.
We would like to acknowledge all patients who participated in this study. We also appreciate the support from the director and dental health personnel of hospitals that helped this study achieve its goal successfully.
Financial support and sponsorship
This study was supported by the Research Group on Prevention and Control of Diabetes Mellitus in the Northeast Region, Thailand, Faculty of Public Health, Khon Kaen University (KKU), Thailand.
Conflicts of interest
There are no conflicts of interest.
Ethical policy and Institutional Review board statement
The ethical approval for this study (HE.612061) was obtained from Khon Kaen University Ethical Committee on March 21, 2018.
Patient declaration of consent
Informed written consents were taken from the participants before enrolling them into study.
Data availability statement
Data will be available on valid request by contacting the corresponding author mail.
| References|| |
Taylor GW, Manz MC, Borgnakke WS Diabetes, periodontal disease, dental caries, and tooth loss: A review of the literature. Compend Contin Educ Dent 2004;25:179-92.
Löe H Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care 1993;16:329-34.
Novak MJ, Potter RM, Blodgett J, Ebersole JL Periodontal disease in Hispanic Americans with type 2 diabetes. J Periodontol 2008;79:629-36.
Bascones-Martinez A, Matesanz-Perez P, Escribano-Bermejo M, González-Moles MÁ, Bascones-Ilundain J, Meurman JH Periodontal disease and diabetes—Review of the literature. Med Oral Patol Oral Cir Bucal 2011;16:e722-9.
Pranckeviciene A, Siudikiene J, Ostrauskas R, Machiulskiene V Severity of periodontal disease in adult patients with diabetes mellitus in relation to the type of diabetes. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2014;158:117-23.
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.
Agarwal R, Baid R Periodontitis and diabetes: A bidirectional, cycle relationship—A brief review. Acta Med Int 2017;4:46-9.
Han DH, Lim SY, Kim JB The association of smoking and diabetes with periodontitis in Korean population. J Periodontal 2012;83:1397-406.
Han K, Park JB Clinical implication of age and sex in the prevalence of periodontitis in Korean adults with diabetes. Exp Ther Med 2018;15:3865-73.
Simonds SK Health education as social policy. Health Educ Monograph 1974;2:1-25.
Nutbeam D Health promotion glossary. Health Promot Int 1998;13:349-64.
Nutbeam D Health literacy as a public health: A challenge for contemporary health education and communication strategies into the 21st century. Health Promot Int 2000;15:259-67.
Lee JY, Rozier RG, Lee SY, Bender D, Ruiz RE Development of a word recognition instrument to test health literacy in dentistry: The REALD-30–A brief communication. J Public Health Dent 2007;67:94-8.
Deeraksa S, Chaichit R, Muktabhant B, Udompanich S Reliability and validity of the Thai version of rapid estimate of adult literacy in dentistry. J Int Oral Health 2019;11:132-6.
Vann WF Jr, Lee JY, Baker D, Divaris K Oral health literacy among female caregivers: Impact on oral health outcomes in early childhood. J Dent Res 2010;89:1395-400.
Geltman PL, Adams JH, Cochran J, Doros G, Rybin D, Henshaw M, et al
. The impact of functional health literacy and acculturation on the oral health status of Somali refugees living in Massachusetts. Am J Public Health 2013;103:1516-23.
Bridges SM, Parthasarathy DS, Wong HM, Yiu CK, Au TK, McGrath CP The relationship between caregiver functional oral health literacy and child oral health status. Patient Educ Couns 2014;94:411-6.
Ramandeep G, Arshdeep S, Vinod K, Parampreet P Oral health literacy among clients visiting a rural dental college in north India—A cross-sectional study. Ethiop J Health Sci 2014;24:261-8.
Wehmeyer MM, Corwin CL, Guthmiller JM, Lee JY The impact of oral health literacy on periodontal health status. J Public Health Dent 2014;74:80-7.
Blizniuk A, Ueno M, Zaitsu T, Kawaguchi Y Association of oral health literacy with oral health behaviour and oral health status in Belarus. Community Dent Health 2015;32:148-52.
Hsieh FY, Bloch DA, Larsen MD A simple method of sample size calculation for linear and logistic regression. Stat Med 1998;17:1623-34.
Eke PI, Page RC, Wei L, Thornton-Evans G, Genco RJ Update of the case definitions for population-based surveillance of periodontitis. J Periodontol 2012;83:1449-54.
Bureau of Dental Health. Report of the 8th National Oral Health Survey of Thailand 2017. Sam Charoen Commercial Company Limited, Bangkok, Thailand. 2018. (in Thai).
Preshaw PM, de Silva N, McCracken GI, Fernando DJ, Dalton CF, Steen ND, et al
. Compromised periodontal status in an urban Sri Lankan population with type 2 diabetes. J Clin Periodontol 2010;37:165-71.
Susanto H, Nesse W, Dijkstra PU, Agustina D, Vissink A, Abbas F Periodontitis prevalence and severity in Indonesians with type 2 diabetes. J Periodontol 2011;82:550-7.
Liu Y, Yu Y, Nickel JC, Iwasaki LR, Duan P, Simmer-Beck M, et al
. Gender differences in the association of periodontitis and type 2 diabetes. Int Dent J 2018;68:433-40.
Jimenez M, Hu FB, Marino M, Li Y, Joshipura KJ Type 2 diabetes mellitus and 20 year incidence of periodontitis and tooth loss. Diabetes Res Clin Pract 2012;98:494-500.
Joshipura KJ, Muñoz-Torres FJ, Dye BA, Leroux BG, Ramírez-Vick M, Pérez CM Longitudinal association between periodontitis and development of diabetes. Diabetes Res Clin Pract 2018;141:284-93.
Wolff RE, Wolff LF, Michalowicz BS A pilot study of glycosylated hemoglobin levels in periodontitis cases and healthy controls. J Periodontol 2009;80:1057-61.
Weinspach K, Staufenbiel I, Memenga-Nicksch S, Ernst S, Geurtsen W, Günay H Level of information about the relationship between diabetes mellitus and periodontitis—Results from a nationwide diabetes information program. Eur J Med Res 2013;18:6.
Srisaphum N, Taneepanichskul S Oral health status in diabetes patients at Chankhan district, Roietprovint, Thailand. J Health Res 2010;24:45-50.
Dhir S, Wangnoo S, Kumar V Impact of glycemic levels in type 2 diabetes on periodontitis. Indian J Endocrinol Metab 2018;22: 672-7.
Lee HK, Choi SH, Won KC, Merchant AT, Song KB, Jeong SH, et al
. The effect of intensive oral hygiene care on gingivitis and periodontal destruction in type 2 diabetic patients. Yonsei Med J 2009;50:529-36.
Nishihara U, Tanabe N, Nakamura T, Okada Y, Nishida T, Akihara S A periodontal disease care program for patients with type 2 diabetes: A randomized controlled trial. J Gen Fam Med 2017;18:249-57.
[Table 1], [Table 2], [Table 3], [Table 4]