lications 24 (2010) 409–414WWW.JDCJOURNAL.COM

Journal of Diabetes and Its Comp

Knowledge and awareness about diabetes and periodontal healthamong Jordanians

Rola Al Habashneha,⁎, Yousef Khaderb, Mohammed M. Hammada, Mohammed Almuradia

aDepartment of Preventive Dentistry, Jordan University of Science and Technology, Irbid 22110, JordanbDepartment of Community Medicine, Faculty of Medicine, Jordan University of Science and Technology, Irbid 22110, Jordan

Received 15 April 2009; accepted 19 June 2009

Abstract

The aim of this study is to evaluate the awareness, perception, sources of information, and knowledge of diabetes mellitus and periodontalhealth among Jordanians, to examine the factors related to their knowledge, and organize effective education programs. A random sample of500 diabetic patients was recruited from three hospitals and three comprehensive health centers that represent both urban and ruralpopulations in Jordan between September 25, 2006, and February 20, 2007. Completed questionnaires with the answers were returned by 405participants (response rate was 81%). Only 28% indicated that they followed up gum diseases with the dentist; 48% were aware that diabeticpatients are more prone to gum diseases and oral health complications. About a third (38%) recognized that their periodontal health mightaffect their glycaemic level. Television and Internet were the main source of knowledge for dentists with the rate of 50%. Knowledge aboutdiabetes and periodontal health among diabetic patients is low, and majority of patients were unaware of the oral health complications of theirdisease and the need for proper preventive care. Issues on education need to be addressed. Therefore, appropriate educational programsshould be planned according to community needs, and the target of these programs should be patients with irregular visits to the dentist andphysicians. The clinical implication of our findings is that dentists, physicians, and other health providers should inspect diabetic patients forgum diseases each time they come for care and recommend that diabetic patient see a dentist regularly.© 2010 Elsevier Inc. All rights reserved.

Keywords: Awareness; Knowledge; Periodontal health; Diabetic patients

1. Introduction

Diabetes mellitus is a very common metabolic disorderand constitutes a global public health burden (Ajlouni,Khader, Batieha, Ajlouni, & El-Khateeb, 2008 Diamond,2003; King, Aubert, & Herman, 1998; Valdez, Yoon, Liu, &Khoury, 2007). A growing body of research has shown anassociation between periodontal diseases and diabetes.Periodontal disease is one of the major oral health problemsencountered in patients with diabetes (Graves, Liu, & Oates,2007; Grossi and Genco, 1998; Mealey & Oates, 2006;

⁎ Corresponding author. Departments of Preventive Dentistry, Facultyof Dentistry, Jordan University of Science and Technology, P.O. Box (3030),Irbid 22110, Jordan.

E-mail address: rolaperio@yahoo.com (R. Al Habashneh).

1056-8727/$ – see front matter © 2010 Elsevier Inc. All rights reserved.doi:10.1016/j.jdiacomp.2009.06.001

Southerland, Taylor, Moss, Beck, & Offenbacher, 2006;Stewart, Wager, Friedlander, & Zadeh, 2001). Thoroughmeta-analyses revealed that periodontitis is more severe indiabetic adults compared to nondiabetics (Khader, Dauod,El-Qaderib, Alkafajeia, & Batayha, 2006). In fact, a two-way relationship between diabetes and periodontitis hasbeen discussed (Grossi & Genco, 1998; Iacopino, 2001).Studies have shown that periodontitis may impair themetabolic control and adequate treatment of diabeticpatients. However, the good news is that treatment ofperiodontitis may have promise to improve glycaemiccontrol (Faria-Almeida, Navarro, & Bascones, 2006; Grossiet al., 1997; Janket, Wightman, Baird, Van Dyke, & Jones,2005; Jones et al., 2007).

Therefore, prevention and control of periodontaldisease must be considered an integral part of diabetes

410 R. Al Habashneh et al. / Journal of Diabetes and Its Complications 24 (2010) 409–414

control. However, little is known about patients' percep-tions of their disease and the link with periodontal health.Also, while the importance of control of periodontaldiseases in achieving good glycaemic control is accepted,little is known about diabetic patients' attitudes towardthis issue.

It has been reported that professional feedback andreinforcement seem to be the most successful approaches inpreventing periodontal relapse and disease progression withpatients who regularly visit the dental office. Glavind andNyvad (1987) highlighted the importance of oral self care inprevention and treatment of periodontal diseases. Abehavioral relationship has been identified between oralhealth and Type 1 diabetes. Syrjälä, Kneckt, and Knuuttila(1999) found that patients with diabetes who had better toothbrushing self-efficacy, higher frequency of tooth brushing,and lower level of plaque had better glycosylated hemoglo-bin A1c (HbA1c) levels. Diabetes self-efficacy correlatedwith dental self-efficacy and with related health behaviors(Kneckt, Syrjälä, Laukkanen, & Knuuttila, 1999). Severalstudies thoroughly evaluated the medical and oral healthstatuses of a large population of patients with diabetes(Emrich, Shlossman, & Genco, 1991, Page & Beck, 1997).Few reports compared oral health attitudes, knowledge, andbehaviors between diabetic and non diabetic patients (Allen,Ziada, O'halloran, Clerehugh, & Allen, 2007; Jansson,Lindholm, Lindh, Groop, & Bratthall, 2006; Karikoski,Ilanne-Parikka, & Murtomaa, 2002; Moore, Orchard,Guggenheimer, & Weyant, 2000). Previously mentionedstudies have shown poor periodontal health among diabeticpatients, and this might be due to a lack of awareness ofperiodontal disease among diabetic patients and insufficientaccessibility of periodontal treatment. This all reinforces theneed to establish a comprehensive oral health promotionprograms for diabetic patients. More cooperation is neededbetween those involved in general health and dental care ofdiabetics, with emphasis on increasing the understanding ofthe relationship between diabetes and oral health, particu-larly periodontal disease.

The purposes of this study were to describe oral healthhabits and dental attendance among diabetic patients andassess patients' knowledge of the connection betweendiabetes and periodontal health.

2. Methods

2.1. Data collection

In this cross-sectional survey, participants were selectedusing two-stage sampling. First, Stage 3 hospitals and threecomprehensive health centers that covered the variousgeographical areas in Jordan were chosen; in the secondstage, a sample of respondents within those areas wasselected. A total of 500 subjects with confirmed diagnosis ofdiabetes mellitus attending the out patient diabetic clinics in

a 6 month period (September 2006–February 2007) wereinvited to participate. The study protocol was approved bythe institutional review board in Jordan University ofScience and Technology. Informed verbal consent from alldiabetic patients and directors of the health centers wasobtained prior to participation. All diabetic patients enteredthe study voluntarily, following an explanation of itspurpose and objectives. All subjects were requested tocomplete a comprehensive questionnaire. The questionnaireincluded 33 multiple questions designed to evaluate theknowledge, attitudes, and behavior of diabetic patientsregarding their periodontal health and diabetes management.It is divided into three parts. The first part assessedparticipants' behaviors including items on tooth brushing,using auxiliary aids and regular visits to the dentist. Thesecond part sought information on visits to the physiciansand controlling diabetes, and the third part addressedawareness that diabetic patient are more prone to gumdiseases and the effects of gum disease treatment on glucoselevel. It took the majority of the participants 5–10 min tocomplete the questionnaire.

2.2. Data processing and statistical analysis

Data were analyzed using SPSS version 15. Frequencydistributions were developed for the main dependentvariables “awareness that diabetic patients are prone togum diseases and oral health complication more than anormal person” and “awareness that treatment of diseasedgum among diabetics may help in improving glycemiccontrol” with each of the healthy behaviors (dental visits,oral hygiene habits, diabetes variables, etc.).

3. Results

A total of 405 (213 males and 192 females) patientscompleted the questionnaire with a response rate of 81%.About half of the respondents were ≥50 years old.Regarding education level, almost half of the respondentsreported lower than secondary school. Sociodemographiccharacteristics of participants are shown in Table 1. About26% of participants were smokers with an average of onepack per day. Of patients with diabetes, 30.4% had Type 1diabetes, 49.6% had Type 2 diabetes, and the rest did notknow the type of diabetes. The length of time sinceparticipants had been diagnosed with diabetic ranged from1 to 40 years with a mean of 14 years.

3.1. Dental health care behavior

About 77% of the participants reported that they brushtheir teeth (21.2% not regular brushing, 27.7% once a day,and 28.1% twice or more a day), 45% use “Tooth picks”for cleaning the space between their teeth, and 7% usedental floss.

Table 1Sociodemographic and relevant characteristic of the participants

Demographic categories n Percentage

Gender Male 213 52.6%Female 192 47.4%

Age b20 years 11 2.7%20–29 years 30 7.4%30–39 years 59 14.6%40–49 years 106 26.2%≥50 years 199 49.1%

Education Lower than secondary school 218 53.8%Secondary school 88 21.7%University or college degree 79 19.5%Higher than university or college degree 20 4.9%

Income ≤100 JD 89 22%101–300 JD 225 55.6%301–500 JD 75 18.5%N500 JD 16 4%

411R. Al Habashneh et al. / Journal of Diabetes and Its Complications 24 (2010) 409–414

A total of 246 patients reported they noticed bleedingwhile brushing their teeth. When they were asked about theirresponses when they noticed bleeding during brushing teeth,33.6% reported that they stopped cleaning the area that wasbleeding, 19.5% reported they cleaned the bleeding areavery carefully, 33.2% reported that they visited theirdentists, and 8% reported rinsing the mouth with saltedwater. The rest (13.7%) reported that they did not payattention to bleeding gums. About 60% rated their overalloral health as poor (having discomfort and/or bleedinggums). Almost 80% visited their dentist when there was aneed. Only 10% reported visiting the dentist every 6–12 months, and 28% reported scheduling visits to check ontheir periodontal health.

3.2. Diabetes care behavior

In our study, about 75% reported checking blood glucoselevel in the clinic. About two thirds (61.5%) checked theirblood glucose level regularly. Interestingly, 11.9% neverchecked their blood glucose level. Control of diabetes as

Table 2Awareness and healthy behaviors

Healthy behavior

Aware that diabetic pto gum diseases andcomplication more th

Yes

n (%)

Regular visit to the physician for diabetes 160 (82.9)Self monitoring of blood sugar 70 (36.3)Regular visit to dentist 29 (15.0)Follow up gum diseases with the dentist 90 (46.6)Teeth brushingNo/occasional 63 (32.6)One time daily 52 (26.9)N1 time daily 78 (40.4)Use of auxiliary aids to clean teeth 171 (88.6)

reported by the subjects was included in this survey to assessthe level of knowledge patients had about diabetes control(HbA1c less than 6.5). Thirty-seven percent of participantsreported good control of diabetes.

3.3. Patients' knowledge of the possible association betweendiabetes and periodontal health

About 47.7% were aware that a diabetic patient is prone togum diseases and oral health complications more than anormal person. The same percentage of participants reportedthat they ever had been told by a health care professional thatthey needed to follow proper preventive care because ofdiabetes. About one third (38%) were aware that treatment ofdiseased gums may help in controlling diabetes. The mainsources of learning about the link between diabetes and oralhealth were the diabetes nurse (43%), physician (38%),dentist (30%), internet (50%), and television (52%).

3.4. Patients' knowledge of the possible association betweendiabetes and periodontal health and diabetes and oralhealth care

The relationship between awareness of the associationbetween diabetes care and oral health care is shown inTable 2. Those who were aware of the effect of diabetes onoral health and the effect of periodontal therapy onglycemic control were more likely to report regular visitsto the physician for diabetes, self-monitoring of bloodsugar, regular visit to dentist, following up gum diseaseswith the dentist, brushing teeth more than once a day, anduse of auxiliary aids to clean teeth.

4. Discussion

The surgeon general's report (US Department of Healthand Human services, 2000) raises the need to increase theawareness of every one about oral health and disease topics.

atients are proneoral healthan normal persons

Aware that treatment of diseased gumamong diabetics may help in improvingglycemic control

No Yes No

n (%) n (%) n (%)

142 (67.0) 133 (86.4) 169 (67.3)38 (17.9) 66 (42.9) 42 (16.7)9 (4.2) 27 (17.5) 11 (4.4)25 (11.8) 80 (51.9) 35 (13.9)

116 (54.7) 40 (26.0) 139 (55.4)60 (28.3) 40 (26.0) 72 (28.7)36 (17.0) 74 (48.1) 40 (15.9)152 (71.7) 137 (89.0) 186 (74.1)

412 R. Al Habashneh et al. / Journal of Diabetes and Its Complications 24 (2010) 409–414

A number of studies have examined the extent to whichpatients were aware of oral health issues (Allen et al., 2007;Genco, 1996; Jansson et al., 2006; Pohjamo, Tervonen,Knuuttila, & Nurkkala, 1995; Thorstensson, Kuylenstierna,& Hugoson, 1996; Wilson, 1999). Moreover, long-termmanagement strategies for preventing and delaying theprogression of periodontal disease and tooth loss in high-riskpatients such as those with poorly controlled diabetes havebeen considered. To the best of our knowledge, this is thefirst study that documents the extent of diabetic patients'behaviors and amount of knowledge with respect to the linkbetween diabetes and periodontal diseases. It is assumed thata patient who is aware of this link will be more likely tocheck on their teeth more regularly and will aggressivelytreat acute infections and manage medical emergencies(Genco, 1996; Wilson, 1999).

In the present study, the gender distribution is differentthan western countries where females represent a higherproportion of respondents and health seeking participants.This might be due to difficulties women might face foraccessing dental care in the developing countries. In thepresent study, the majority of the respondents rated their oralhealth as poor which are similar to the result reported byMoore et al. (2000) where diabetic subjects rated theiroverall oral health somewhat lower than did control subjects.

The present study revealed that more than half (53%) ofthe participants were unaware that they were prone toperiodontal diseases more than a normal person. Moreover,only about one third (38%) thought that treatment ofperiodontal diseases might help in controlling diabetesmellitus. This indicated that participants did not recognizethat the presence of diabetes increases the risk of periodontaldiseases. Our results agree with data from Allen et al. (2007)who found that less than half of their participants, who hadattended a dentist within the last year and less than a third ofwho had attended within the last 5 years, were aware of theirrisk for periodontal disease. Sandberg, Sundberg, &Wikblad(2001) found that 48% of diabetic patients believed that theirdentist/dental hygienist was unaware that their patients haddiabetes or were not informing known diabetic patients oftheir risk for periodontal disease. However, the attitudetowards oral health of the diabetic patients in this survey ispoor in comparison with the findings from Jansson et al.,2006, study which reported that (66%) of the diabeticpatients in the periodontally diseased group recognized thattheir diabetes might affect their oral health.

The fact that almost half of the number of the respondentsbrushed their teeth (56%) at least once a day reflects thattooth brushing is not a universal practice in this society.However, other oral hygiene practices, including interpro-ximal cleaning aids, were widely used. But only (35%) of therespondents used dental floss (7%) or an interdental brush(28%). This finding indicates a lapse in the knowledgeregarding the correct way of interproximal cleaning orinadequate efforts to maintain oral hygiene. Therefore,encouragement of the use of proper interproximal cleaning

aids together with education concerning their use should beundertaken in order to enhance periodontal health andprevent gingival diseases in this high-risk population.

Only 10% of participants in this survey attend dentalappointments regularly compared with previous studiesamong Jordanians which showed that about 20% ofJordanian adults received dental examinations and treat-ments on regular basis (Taani, 2002).

Our result is lower than that reported by Sandberg et al.2001 andAllen et al. (2007) (39%and 43%, respectively). Thedifference between our study and the previously mentionedstudies could be due to the different populations investigated.

This study provided many useful and practical insightsconcerning the factors influencing knowledge about theassociation between diabetes and periodontal health amongdiabetic patients. Healthier lifestyle behaviors were asso-ciated with greater likelihood of having had knowledgeregarding the association between diabetes and oral health.Diabetic patients who reported using interproximal aids weremore likely to know the information compared to those whodid not. Participants who followed periodontal conditionswith a dentist, checked blood glucose level more frequentlyand rated their diabetic control as good were each morelikely to be aware of the link between diabetes and oralhealth. This could be explained due to increased exposure ofdiabetic patients to health care providers. However, thesefactors have not been reported in any previous studies toallow comparison with the present study. In the presentstudy, smoking was not significantly related to reportingpositive association between diabetes and oral health. In thepresent study, the majority of the respondents did not reportsmoking (74%), which reduced the power to assess theassociation between this behavior and knowledge about theassociation between diabetes and oral health.

About 48% of the participants indicated that a diabeticpatient is prone to periodontal diseases more than a normalperson and the same percent had been told by a health careprofessional that they need to follow proper preventive carebecause they had diabetes. Jansson et al. (2006) found that(66%) of the diabetic patients in the periodontally diseasedgroup recognized that their diabetes might affect their oralhealth. This indicated that participants in the present studywere less aware regarding possible connection betweenperiodontal diseases and diabetes and did not recognize thatthe presence of diabetes increased the risk of periodontaldiseases. This is an area where education could be valuablein changing perceptions regarding the harmful effects ofperiodontal diseases on the outcomes of their diabetesmellitus. It is important for the diabetic patients to know thatthe dentist should be included in their health care team.

In the present study, the majority about (50%) indicatedthat each of the following television and internet were usefulin learning about diabetes and oral health. Among thosesited, others, about half, received information about connec-tions between periodontal diseases and diabetes fromfriends. Thus, some of the knowledge acquired by the

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diabetic patients came from informal sources, which couldlack a scientific basis. This suggests that oral healtheducational material for diabetic patients needs to beavailable in educational programs for diabetic patients. Thefact that (62%) of the sample did not receive advice from aphysician to check their dental condition indicated conside-rable shortage among physicians of the importance of dentalcare for diabetic patients. Dentists, physicians, and healthcare providers should provide accurate and easy to under-stand material for diabetic patients about the associationbetween diabetes and oral health and should encourage alldiabetic patients to seek oral health examinations. Thediabetic patients should be informed that, through preventiveoral health practice, most dental diseases associated withpregnancy can be minimized or avoided and outcomes ofdiabetic control could be improved.

Three potential limitations of this investigation could berelated to the validity of the data collected and methods. Firstis the reliance on data self-reported by the study participantsto the survey without validation of their medical or dentalcharts or any other sources. Second, the results of the studydemonstrate a population with low dental attendance (mainlyfor symptomatic care) and relatively low levels of self-carefor diabetes. Third, none of the participant's responses havebeen validated by an intra oral examination. Therefore, ourresults can hardly be generalized to a broader populationwith more diverse education, higher levels of oral healthknowledge/practice, or more intensive management of thediabetic condition.

Public and private health care providers and insurancecompanies need to develop mechanisms to eliminatefinancial barriers to oral heath care for diabetic patients.Diabetic patients should be encouraged to establish dentaltreatment in early stages of the diabetes. Insurance companiesshould be encouraged to include dental insurance for diabeticpatients as a part of standard health insurance. Reducingperiodontal diseases would save considerable health caremoney. Prevention of these oral health problems includingtooth loss, periodontal disease and soft-tissue disease—depends on education and health promotion strategies such asearly diagnosis, proper oral hygiene and diet, rigorousglycemic control measures, and smoking cessation counse-ling. To date, increasing the proportion of diabetic patientswho have at least an annual dental examination is one of themain objectives of the National Institutes of Health's HealthyPeople 2010 (www.health.gov/healthypeople/Document/HTML/Volume1/05Diabetes.htm).

5. Conclusion

Current research has shown that diabetes is a risk factorfor impaired oral health. It is known that diabetic patientshave higher rates of tooth loss, periodontal disease and soft-tissue diseases than do nondiabetic patients. This survey ofan adult population of diabetic subjects found that 52% of

diabetic patients were not aware of the effect of diabetes onperiodontal health. Also, 62% did not know that treatment ofperiodontal diseases might help in controlling diabetesmellitus. Regular visits to the physician for diabetes, self-monitoring of blood sugar, regular visits to the dentist,following up gum diseases with the dentist, brushing teethmore than once a day, and use of auxiliary aids to clean teethwere all explanatory factors to report awareness of theassociation between diabetes and periodontal health.

The clinical implication of our findings is that dentists,physicians, and other health providers should recommendthat a diabetic patient see a dentist regularly. Dentalpractitioners have an opportunity and the responsibility toeducate diabetic patients about the oral complications ofdiabetes and to promote proper oral health behaviors.

Acknowledgments

The authors thank the staff in the dental center for theirhelp and support.

References

Ajlouni, K., Khader, Y. S., Batieha, A., Ajlouni, H., & El-Khateeb, M.(2008). An increase in the prevalence of diabetes mellitus in Jordan over10 years. Diabetes Complications, 22(5), 317−324.

Allen, E. M., Ziada, H. M., O'halloran, D., Clerehugh, V., & Allen, P. F.(2007). Attitudes, awareness and oral health-related quality of life inpatients with diabetes. Journal of Oral Rehabilitation, 35, 218−223.

Diamond, J. (2003). The double puzzle of diabetes. Nature, 423, 599−602.Emrich, L. J., Shlossman, M., & Genco, R. J. (1991). Periodontal disease in

non-insulin dependent diabetes mellitus. Journal of Periodontology, 62,123−131.

Faria-Almeida, R., Navarro, A., & Bascones, A. (2006). Clinical andmetabolic changes after conventional treatment of Type 2 diabeticpatients with chronic periodontitis. Journal of Periodontology, 77(4),591−598.

Genco, R. J. (1996). Current view of risk factors for periodontal diseases.Journal of Periodontal, 67, 1041−1050.

Glavind, L., & Nyvad, B. (1987). The scientific basis for oral healthrecommendations for self-care. Promotion of self care in oral health: asymposium held in Oslo, Norway, September, 1986 (pp. 77−93). Oslo:Scandinavian Working Group for Preventive Dentistry.

Graves, D. T., Liu, R., & Oates, T. W. (2007). Diabetes-enhancedinflammation and apoptosis- impact on periodontal pathosis.Periodontology 2000, 45, 128−137.

Grossi, S. G., & Genco, R. J. (1998). Periodontal disease and diabetesmellitus: A two-way relationship. Annals of Periodontology, 3,51−61.

Grossi, S. G., Skrepcinski, F. B., DeCaro, T., Robertson, D. C., Ho, A. W.,Dunford, R. G., & Genco, R. H. (1997). Treatment of periodontal diseasein diabetics reduces glycated hemoglobin. Journal of Periodontology,68, 713−719.

Iacopino, A. (2001). Periodontitis and diabetes interrelationships: Role ofinflammation. Annals of Periodontology, 6, 125−137.

Janket, S. J., Wightman, A., Baird, A. E., Van Dyke, T. E., & Jones, J. A.(2005). Does periodontal treatment improve glycemic control in diabeticpatients? A meta-analysis of intervention studies. Journal of DentalResearch, 84(12), 1154−1159.

Jansson, H., Lindholm, E., Lindh, C., Groop, L., & Bratthall, G. (2006).Type 2 diabetes and risk for periodontal disease: A role for dental healthawareness. Journal of Clinical Periodontology, 33, 408−414.

414 R. Al Habashneh et al. / Journal of Diabetes and Its Complications 24 (2010) 409–414

Jones, J. A., Miller, D. R., Wehler, C. J., Rich, S. E., Krall-Kaye, E. A.,McCoy, L. C., Rothendler, J. A., & Garcia, R. I. (2007). Doesperiodontal care improve glycemic control? The Department of VeteransAffairs Dental Diabetes Study. Journal of Clinical Periodontology, 34,46−52.

Karikoski, A., Ilanne-Parikka, P., & Murtomaa, H. (2002). Oral self-careamong Finnish adults with diabetes mellitus—a focus on periodontaldiseases. Community Dentistry and Oral Epidemiology, 30,216−223.

Khader, Y. S., Dauod, A., El-Qaderib, S., Alkafajeia, A., & Batayha, W.(2006). Periodontal status of diabetics compared with nondiabetics: Ameta-analysis. Journal of Diabetes and Its Complications, 20,59−68.

King, H., Aubert, R. E., & Herman, W. H. (1998). Burden of diabetes, 1995-2025: Prevalence, numerical estimates, and projections. Diabetes Care,21, 414−1431.

Kneckt, M. C., Syrjälä, A. M. H., Laukkanen, P., & Knuuttila, M. L. E.(1999). Self-efficacy as a common variable in oral health behavior anddiabetes adherence. European Journal of Oral Sciences, 107, 89−96.

Mealey, B. L., & Oates, T. W. (2006). Diabetes mellitus and periodontaldiseases. Journal of Periodontal, 77, 1289−1303.

Moore, P. A., Orchard, T., Guggenheimer, J., & Weyant, R. J. (2000).Diabetes and oral health promotion: A survey of disease preventionbehaviors. Journal of American Dental Association, 131, 1333−1341.

Page, R. C., & Beck, J. D. (1997). Risk assessment for periodontal diseases.International Dental Journal, 47, 61−87.

Pohjamo, L., Tervonen, T., Knuuttila, M., & Nurkkala, H. (1995). Adultdiabetic and nondiabetic subjects as users of dental services: Alongitudinal study. Acta Odontologica Scandinavica, 53(2), 112.

Sandberg, G. E., Sundberg, H. E., & Wikblad, K. F. (2001). A controlledstudy of oral self-care and self-perceived oral health in Type 2 diabeticpatients. Acta Odontologica Scandinavica, 59, 28−33.

Southerland, J. H., Taylor, G. W., Moss, K., Beck, J. D., & Offenbacher, S.(2006). Commonality in chronic inflammatory diseases: Periodontitis,diabetes, and coronary artery disease. Periodontology 2000, 40,130−143.

Stewart, J. E., Wager, K. A., Friedlander, A. H., & Zadeh, H. H. (2001). Theeffect of periodontal treatment on glycemic control in patients with Type2 diabetes mellitus. Journal of Clinical Periodontology, 28, 306−310.

Syrjälä, A. M., Kneckt, M., & Knuuttila, M. L. E. (1999). Dental self-efficacyas a determinant to oral health behaviour, oral hygiene and HbA1c levelamong diabetic patients. Journal of Clinical Periodontology, 26,616−621.

Taani, D. Q. (2002). Periodontal awareness and knowledge and pattern ofdental attendance among adults in Jordan. International Dental Journal,52, 94−98.

Thorstensson, H., Kuylenstierna, J., & Hugoson, A. (1996). Medical statusand complications in relation to periodontal disease experience ininsulin-dependent diabetics. Journal of Clinical Periodontology, 23,194−202.

U.S. Department of Health and Human Services (2000). Oral health inAmerica: A Report of the Surgeon General. Rockville, MD.

Valdez, R., Yoon, P. W., Liu, T., & Khoury, M. J. (2007). Family history andprevalence of diabetes in the US population: Results from the NationalHealth and Nutrition Examination Survey (1999–2004). Diabetes Care,30, 2517−2522.

Wilson, T. G. (1999). Not all patients are the same: Systemic risk factors foradult periodontitis. General Dentistry, 47(6), 580−588.