Journal of Oral Rehabilitation 2008 35; 218–223
Attitudes, awareness and oral health-related quality of life
in patients with diabetes
E . M . A L L E N * , H . M . Z I A D A * , D . O ’ H A L L O R A N †, V . C L E R E H U G H ‡ & P . F . A L L E N *
*University Dental School & Hospital, Cork, †Cork University Hospital, Cork, Ireland and ‡Leeds Dental Institute, Leeds, UK
SUMMARY The purpose of this study was to assess the
knowledge diabetic patients have of their risk for
periodontal disease, their attitude towards oral
health and their oral health-related quality of life
(OHRQL). One hundred and one consecutive pa-
tients (age range 31–79 years) recruited from a
diabetic outpatient clinic participated in the study.
Twenty-seven per cent of participants had type 1
diabetes, 66% type 2 and 7% did not know what
type of diabetes they had. The length of time since
participants were diagnosed as diabetic ranged from
1 to 48 years. Metabolic control of diabetes as
determined by HbA1c levels ranged from 6Æ2% to
12Æ0% compared with the normal range of 4Æ5–6Æ0%.
Thirty-three per cent of participants were aware of
their increased risk for periodontal disease, 84% of
their increased risk for heart disease, 98% for eye
Introduction
Diabetes mellitus encompasses a group of metabolic
disorders characterized by hyperglycaemia secondary to
defects in insulin secretion, insulin action or both. Type
1 diabetes is characterized by decreased secretion of
insulin due to autoimmune or idiopathic destruction of
the B-cells in the pancreas while Type 2 diabetes, the
more common form, is characterized by insulin resist-
ance in peripheral tissues usually in combination with
decreased insulin secretion (1). Type 1 and Type 2
diabetes both have a genetic predisposition (2). The
aetiology of type 2 diabetes also appears to be related to
the consumption of a high-fat, high-sugar diet, physical
inactivity and obesity.
Diabetes has reached epidemic proportions in devel-
oped countries. It now affects 5% of the world’s
ª 2007 The Author. Journal compilation ª 2007 Blackwell Publishing Ltd
disease, 99% for circulatory problems and 94% for
kidney disease. Half of the participants who were
aware of their increased risk for periodontal disease
had received this information from a dentist. Dental
attendance was sporadic, with 43% reporting
attendance within the last year. OHRQL was not
significantly affected by the presence of diabetes in
the group surveyed, in comparison with a previous
survey of non-diabetic patients. A significant associ-
ation was found between metabolic control and
dentate status. Awareness of the potential associa-
tions between diabetes, oral health and general
health needs to be increased in diabetic patients.
KEYWORDS: diabetes, oral health, awareness, attitude,
quality of life
Accepted for publication 1 April 2007
population and its prevalence is doubling every gen-
eration (3). Diabetes is associated with an increased risk
for macro-vascular complications including cardiovas-
cular disease and for micro-vascular complications
including diabetic nephropathy, peripheral vascular
disease, neuropathy and retinopathy (4).
Diabetic patients display a higher prevalence of oral
disorders including xerostomia, taste impairment, sia-
losis, oral candidosis and oral lichen planus (5). Studies
indicate that diabetic patients are two to three times
more likely to develop periodontal disease (6–11) and
display a greater severity of periodontal disease (12),
the severity of which is related to the long-term
metabolic control of diabetes, not the duration of
diabetes (13, 14).
In addition, the co-morbid existence of periodontal
disease in diabetic patients may compromise their
doi: 10.1111/j.1365-2842.2007.01760.x
 ATTITUDES AND OHRQL IN DIABETIC PATIENTS
diabetic control as measured by their level of glycated
haemoglobin (HbA1c), which is an indicator of
glycaemic control over the previous 3 months (12,
15). The treatment of periodontal disease has been
shown to improve the metabolic control of diabetes
(16–18).
Given these potentially important interactions
between periodontal disease and diabetes mellitus, it
is important to ensure optimal oral health care for
diabetic patients. At the present time, little is known
about the knowledge diabetic patients have of their
increased risk for periodontal disease. One study found
that 83% of diabetic patients were unaware of this link
(19).
Furthermore, in consideration of the accumulating
evidence which highlights the effect of oral disease on
systemic ill-health including diabetes (20, 21) and heart
disease (22), the attitude of diabetic patients to their
oral health is important. Previous studies indicate that
oral health may not be a priority for diabetic patients –
it has been reported that they are less likely to have
visited a dentist than non-diabetic patients, and that
they are also less likely to have visited a dentist than
any other health-care professional in the previous year
(23). Self-reported twice-daily tooth brushing is less
common in diabetic patients than in non-diabetic
patients (24).
The impact of disease status on overall life experience
is an important consideration in the management of
patients with chronic diseases including diabetes.
Health-related quality of life (HRQL) is affected in
diabetic patients who have macro-vascular complica-
tions, such as cardiovascular disease (25). The impact of
oral health on health-related quality of life (OHRQL) in
diabetic patients is not clear. In one survey, similar
numbers of participants in both diabetic and non-
diabetic groups have expressed satisfaction with their
teeth and mouth (83% versus 85%), (19). A further
cross-sectional study demonstrated that while HRQL
was broadly similar between diabetic and non-diabetic
groups as determined using the SF-36 questionnaire,
regression analysis did indicate that dissatisfaction with
teeth and mouth explained some variance in health
domains between the two groups but the overall
contribution of oral health to health-related quality of
life was unclear (26). A limitation of this study is the
lack of sensitivity to oral health status in the SF-36
questionnaire, which is a general health status meas-
ure.
ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd
219
The aims of this preliminary study were to determine
the knowledge of risk for periodontal disease and the
attitude to oral health in diabetic patients, and to
determine the impact of oral health on quality of life
within this group.
Materials and methods
The study protocol was reviewed and approved by the
Ethics Committee of Cork University Teaching Hospitals
in Cork city, Ireland.
Participants for the study were recruited from those
patients attending a weekly adult diabetic outpatient
clinic in Cork University Hospital. Piloting of the
questionnaires was performed at the outset. All patients
had a confirmed diagnosis of diabetes mellitus for
which they were receiving treatment and being mon-
itored. Patients who agreed to participate in the study
provided informed and written consent and completed
a self-report questionnaire as they awaited their
appointment at the outpatient clinic. Oral and written
instructions were provided to the study participants on
questionnaire completion together with assurances of
confidentiality. Completed questionnaires were collec-
ted from the participants as they departed the clinic.
Patients with intellectual impairment or reading diffi-
culties were excluded. Data was collected over a period
of 6 weeks.
General participant details were recorded, these inclu-
ded age, sex, length of time diagnosed with diabetes and
type of diabetes. Questions related to the participant’s
knowledge of complications associated with diabetes
were included as were questions related to their pattern
of attendance at a dental practice as an indicator of their
attitude towards oral health. The attitude of the partic-
ipants to their oral health was further determined by
questions exploring their willingness or otherwise to
save a back or front tooth which was causing pain.
The OHRQL instrument used in this survey was the
shortened version of the Oral Health Impact Profile
(27). This subset is a 20-item questionnaire containing
validated measures to assess oral health-related out-
comes in seven conceptual domains; functional limita-
tion, pain, psychological discomfort, physical disability,
psychological disability, social disability and handicap
(Table 2). A Likert response format to questions
phrased ‘Have you had... because of problems with
your teeth, mouth or dentures’ is used, with response
possibilities ranging from ‘never’, to ‘always’. Summary
220 E . M . A L L E N et al.
scores were calculated for each participant by counting
the number of ‘always ⁄ most of the time’ and ‘occa-
sionally ⁄ some of the time’ responses to each question.
Glycated haemoglobin levels (HbA1c) were obtained
from the participant’s medical records. Normal HbA1c
levels range from 4Æ5% to 6Æ0%. For adults with Type 1
diabetes, the target HbA1c is <7Æ5% unless there is a
risk of arterial disease in which case the target may be
agreed to be <6Æ5%. For type 2 diabetes, the target is
6Æ5–7Æ5% (28). Values that exceed these targets repre-
sent poorer metabolic control of diabetes.
Data were entered on an Excel spreadsheet and
statistical analysis was undertaken using SPSS version
13*. In addition to presentation of descriptive data, cate-
gorical data were compared using the chi-squared test.
Pearson’s correlation coefficients were used to measure
strength of association between continuous variables.
Statistical significance was determined as P < 0Æ05.
Results
One hundred and four patients were approached to
participate in this survey, three patients declined to
participate with 101 patients participating of whom
60% were male and 40% were female. The age range of
the participants was 31–79 years, with a mean age of
56 years. Regarding dental status, 25% of the sample
was edentulous, with the remainder being dentate.
Twenty-seven per cent of participants had type 1
diabetes, 66% had type 2, 7% did not know which
form of diabetes they had. The length of time since
participants had been diagnosed as diabetic ranged from
1 to 48 years with a mean of 14 years.
The percentage of participants with knowledge of
their increased risk for heart disease was 84%, eye
disease 98%, circulatory problems 99%, kidney prob-
lems 94% and periodontal disease 33%. Type 1 diabetic
patients had a slightly higher awareness of their risk for
periodontal disease (one in 2Æ5 patients) than type 2
diabetics (one in three patients). Of the 33% of
participants who were aware of their increased risk
for periodontal disease, 51% (16% of the total group)
had received this information from their dentist, 32%
from the diabetic team, 7% from a dental hygienist and
10% from other sources.
Metabolic control of participants, as determined by
HbA1c (glycated haemoglobin), ranged from 6Æ2% to
*SPSS Inc., Chicago, IL, USA.
ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd
12Æ0%, with a mean value of 8Æ2%.There was a
significant difference by dentate status, with a higher
proportion of patients in the dentate group having
lower HbA1c scores. The proportion of participants who
had attended a dentist within the last year was 43%,
with 34% not having attended for more than 5 years.
Thirty-seven per cent of participants attended for dental
treatment once a year, with 63% attending only when
they have to.
In participants with HbA1c levels >9%, which rep-
resents poor metabolic control and the highest risk for
periodontal disease, 62% were unaware of their risk for
periodontal disease. Seventy-seven per cent of partic-
ipants with moderate metabolic control (HbA1c 7Æ5–
9Æ0%) were unaware of their increased risk for perio-
dontal disease. Further analysis of the subgroup with
moderate-to-poor metabolic control reveals that 26% of
this subgroup had attended within the last year with
9% having knowledge of the link between periodontal
disease and diabetes, and 44% had attended in the last
5 years with 15% reporting an awareness of this risk
(Table 1).
In response to the question ‘In what circumstances
would you agree to have a back (front) tooth taken
out?’ 46% of participants would ‘take out’ a loose back
tooth and 42% a loose front tooth. The ‘decision being
made by the dentist’ was favoured by 44% of respond-
ents in considering whether to take out a front tooth
and 46% in whether to take out a back tooth. Time and
cost factors were less likely to favour the taking out of a
front or back tooth.
The percentage of participants responding ‘always’ or
‘most of the time’ for the 20 items of the OHIP-20 score
ranged from 1% (for the item ‘do you avoid going out
because of problems with your teeth ⁄ dentures?’) to
66% for the item ‘ do you find food catching in your
teeth ⁄ dentures?’(Table 2).
Higher item scores in the OHIP-20 were recorded for
responses in the ‘some of the time ⁄ occasionally’
categories. Forty-three per cent of participants felt their
diet was unsatisfactory ‘some of the time or occasion-
ally’ because of problems with their teeth or dentures
(Table 2).
Discussion
This study used a self-report questionnaire that aimed
to determine the knowledge of risk for periodontal
disease in diabetic patients. The study further aimed to
 ATTITUDES AND OHRQL IN DIABETIC PATIENTS 221

Table 1. Dental attendance and knowledge of risk for periodontal disease (brackets contain percentages)

Last visit to dentist Last visit to dentist Knowledge of the risk

within 1 year within 5 years for periodontal disease

Whole sample (n = 101) 43 (43) 23 (23) 34 (34)

Participants with moderate-to-poor 26 (26) 44 (44) 24 (24)
diabetic control (HbA1c > 7Æ5%)

determine the attitude of diabetic patients to their oral
health and to determine whether oral health affected
the quality of life within this group. The key finding of
this survey is that the knowledge of increased risk for
periodontal disease within the diabetic group sampled is
low, especially in comparison with their knowledge of
other complications associated with diabetes.
This survey had some limitations; no objective
clinical data was collected to support the results
obtained from the self-report questionnaire. Some bias
may have been present due to the recruitment of
the diabetic patients from a diabetic outpatient clinic –
the results may therefore not be representative of the
whole diabetic population. In addition, relatively low

Table 2. Responses to questions in the OHIP-20 instrument (brackets contain percentages)

‘some of the time ⁄ ‘always ⁄

No In the last month occasionally’ most of the time’

1 Have you had difficulty chewing any foods because of problems with your teeth, 17 (17) 26 (26)
mouth or dentures?
2 Have you had food catching in your teeth or dentures? 14 (14) 66 (66)
3 Have you felt that your dentures have not been fitting properly? 22 (22) 13 (13)
4 Have you had painful aching in your mouth? 8 (8) 2 (2)
5 Have you found it uncomfortable to eat any foods because of problems with your 22 (22) 8 (8)
teeth, mouth or dentures?
6 Have you had sore spots in your mouth? 36 (36) 2 (2)
7 Have you had uncomfortable dentures? 14 (14) 6 (6)
8 Have you been worried by dental problems? 17 (17) 6 (6)
9 Have you been self conscious because of problems with your teeth, mouth or 20 (20) 7 (7)
dentures?
10 Have you had to avoid eating some foods because of problems with your teeth, 19 (19) 8 (8)
mouth or dentures?
11 Has your diet been unsatisfactory because of problems with your teeth, mouth or 43 (43) 4 (4)
dentures?
12 Have you been unable to eat with your dentures because of problems with them? 11 (11) 6 (6)
13 Have you had to interrupt meals because of problems with your teeth, 7 (7) 2 (2)
(5%)mouth or dentures?
14 Have(2%) you been upset because of problems with your teeth, mouth or 11 (11) 5 (5)
dentures?
15 Have you been a bit embarrassed because of problems with your teeth, mouth or 23 (23) 2 (2)
dentures?
16 Have you avoided going out because of problems with your teeth, mouth or 3 (3) 1 (1)
dentures?
17 Have you been less tolerant of your spouse or family because of problems with 4 (4) 1 (1)
your teeth, mouth or dentures?
18 Have you been a bit irritable with other people because of problems with your 7 (7) 1 (1)
teeth, mouth or dentures?
19 Have you been unable to enjoy other people’s company as much because of 8 (8) 1 (1)
problems with your teeth, mouth or dentures?
20 Have you felt that life in general was less satisfying because of problems with your 12 (12) 3 (3)
teeth, mouth or dentures?

ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd

222 E . M . A L L E N et al.
numbers of patients were recruited in this study so the
result of this survey which shows a moderate impact of
diabetes on OHRQL, specifically dietary dissatisfaction,
is a preliminary finding which requires further inves-
tigation. Finally, answers may be subject to recall bias
due to the possibility of participants giving socially
acceptable responses to questions pertaining to oral
health behaviour.
However, this study provides additional evidence
that diabetic patients have limited awareness of the
potential impact of poor oral health on their general
health. Less than half of the participants who had
attended a dentist within the last year and less than a
third of the participants who had attended within the
last 5 years, were aware of their risk for periodontal
disease. Dentists are not identifying this risk group
(a previous study, Sandberg, G.E. et al. 2001, found that
48% of diabetic patients believed that their dentist
⁄ dental hygienist was unaware of their having diabetes)
or not informing known diabetic patients of their risk
for periodontal disease.
The attitude towards oral health of the diabetic
patients in this survey is poor in comparison with the
findings from surveys of the general population
including the UK Adult Dental Health Survey (29).
Thirty-seven per cent of participants in this survey
attend regularly compared with 59% in the UK
survey. Thirty-two per cent of participants in this
survey would choose to save a painful back tooth,
whereas 79% of participants in the UK Adult Dental
Health Survey would choose to save an aching back
tooth by filling it.
Diabetic patients need to be better informed of their
risk for periodontal disease and to have an increased
awareness of the importance of oral health in their
overall general health and wellbeing. Dental practi-
tioners should play a role in this education both in
clinical practice and at a organizational level with closer
integration between the dental and diabetes professions
desirable in an effort to raise awareness of oral health
issues within the diabetic population.
The impact of oral health on quality of life was low in
the group surveyed. The mean OHIP summary score for
this group was 20 (10) with a range of 10–55.
A previous survey of patients (non-diabetics, n = 49)
attending the Dental School and Hospital, using the
same OHIP-20 instrument, found an OHIP summary
score of 32 (14) (30). It may be that given the
potentially severe complications of diabetes, oral
ª 2007 The Authors. Journal compilation ª 2007 Blackwell Publishing Ltd
problems are not a major priority for this particular
group of patients. Results from this study do indicate
that oral health may be having some effect on dietary
choices in diabetic patients.
The dentate status of patients within the group
examined had a significant association with HbA1c
levels. Further research work is required to establish the
impact of oral health on diet and thus metabolic control
within this group.
In conclusion, diabetic patients are much less well
informed of their risk for periodontal disease in
comparison with their knowledge of their increased
risk for other conditions. The dental profession needs
to raise awareness of the importance of maintaining
good oral health in diabetic patients and to integrate
better in the management of diabetic patients. Overall
self-reported OHRQL does not appear to be adversely
affected by the presence of diabetes. OHRQL is
moderately affected in the diabetic group surveyed in
the domains of food choice and satisfaction with diet.
Metabolic control was significantly associated with
dentate status.
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Correspondence: E.M. Allen, University Dental School & Hospital,
Cork, Ireland.
E-mail: e.allen@ucc.ie