Volume 82 Number 3

Knowledge About the Association Between Periodontal Diseases and Diabetes Mellitus: Contrasting Dentists and Physicians
Areej K. Al-Khabbaz,* Khalaf F. Al-Shammari,* and Noha A. Al-Saleh
Background: There is a strong body of evidence that supports the relationship between periodontal diseases and diabetes mellitus (DM). Many patients are unaware of the effects of diabetes on oral health. Whether health care providers are applying the information about the link between DM and periodontal diseases in their practices depends on the levels of their knowledge of such valuable information. Therefore, the aims of this study are to evaluate the knowledge of dental and medical practitioners concerning the effects of diabetes on periodontal health and to nd out if the practitioners are aware of the bidirectional relationship between periodontal diseases and DM. Methods: This was a cross-sectional survey of randomly selected general practitioners practicing in Kuwait. Participants were asked about specic periodontal complications that they believed patients diagnosed with diabetes were more susceptible to, and their awareness of the bidirectional relationship between diabetes and periodontal diseases was evaluated. Results: A total of 510 general practitioners (232 physicians and 278 dentists) participated in the study. There were no signicant differences between the two groups regarding mean ages, sex distributions, and years in practice. Only 50% of all study participants believed that patients with diabetes were more susceptible to tooth loss because of periodontal diseases than were individuals without diabetes. Dentists were signicantly more aware of gingival bleeding, tooth mobility, and alveolar bone resorption than were physicians. Factors signicantly associated with having knowledge about the effects of diabetes on periodontal health in logistic regression analyses were older age, female sex, and the dental profession. Conclusion: The knowledge about the association between periodontal diseases and DM should be increased among dental and medical practitioners to effectively prevent, manage, and control diabetes and periodontal diseases. J Periodontol 2011;82:360-366. KEY WORDS Awareness; diabetes mellitus; knowledge; periodontal diseases.
* Division of Periodontics, Department of Surgical Sciences, Faculty of Dentistry, Kuwait University, Safat, Kuwait. Ministry of Health, Kuwait City, Kuwait.

ystemic reviews of the current literature support a bidirectional relationship between diabetes mellitus (DM) and periodontal diseases.1,2 DM is a risk factor for developing periodontal diseases, and patients diagnosed with diabetes are considered a high risk group with greater susceptibility to severe forms of periodontal destruction.3,4 Periodontal diseases are potentially progressive bacterial infections that may lead to tooth loss because of extensive destruction of alveolar bone. The most common form of periodontal diseases among adults is periodontitis.5 Several controlled clinical studies6-8 showed that subjects diagnosed with diabetes have a greater prevalence of periodontal diseases compared to healthy individuals, and severe periodontitis may increase the risk of poor glycemic control.9,10 The current scientic evidence supports the concept that treating periodontal infections can be inuential and contribute to glycemic control management and, possibly, the reduction of the burden of complications of DM.11-14 In turn, this evidence emphasizes the importance of clinically relevant preventive and therapeutic measures for the management of DM and periodontal diseases in adults and children. The World Health Organization stated that oral diseases, including periodontal diseases, are a serious health problem and increasing the awareness of oral health worldwide should be

doi: 10.1902/jop.2010.100372

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considered an important component of general health and quality of life.15 Although there is a strong body of evidence that supports the relationship between periodontal diseases and DM, several studies16-20 indicated that there is a lack in general oral health information among patients with diabetes. Most of these studies16,17,19 showed that a very low number of patients diagnosed with diabetes visit the dentists on a regular basis for periodontal checkups, and many patients were unaware of the effect of diabetes on oral health. A study by Allen et al.18 reported that the awareness of patients with diabetes about periodontal diseases is very low compared to their reported awareness of their increased risk for heart disease, eye disease, kidney disease, and circulatory problems. Whether health care providers are applying the information about the link between DM and periodontal diseases in their practice depends on the level of their awareness of such valuable information. Few studies21-23 evaluated the attitude and behavior of dentists toward the management of patients diagnosed with diabetes. Most of these studies22,23 showed that a very low number of dentists communicate with the physicians of patients, monitor glucose levels, and adjust the frequency of dental visits according to the diabetic status of patients. The prevalence of diabetes in Kuwait is reaching epidemic proportions,24,25 with serious implications for oral health. As the prevalence of diabetes continues to rise, it is expected that health care providers will see and treat greater numbers of patients with diabetes and periodontal problems. For that reason, evaluating the clinician knowledge regarding this issue will assist in providing the appropriate level of continuing-education programs and assessment for efcacy. Therefore, the aims of the study are to evaluate the knowledge of dental and medical practitioners concerning the effects of diabetes on periodontal health and to nd out if the practitioners are aware of the bidirectional relationship between periodontal diseases and DM. MATERIALS AND METHODS This is a cross-sectional survey study of randomly selected dentists and physicians practicing in the Public Health Service in Kuwait in three types of clinical settings: primary health centers, including medical and dental clinics; dental centers; and districts hospitals, including general medical practitioners working together with specialized medical practitioners in different clinics. Data were collected during 2008 over 3 months. The study protocol was approved by the Ethical Review Committee of the Faculty of Dentistry, Kuwait University, before commencement of the project. A randomized scheme was used to pro-

vide a sample size of general dentists and physicians from all six districts in Kuwait corresponding to 20% of all general dentists practicing in the country. A total of 300 dentists (aged 24 to 58 years) and 300 physicians (aged 24 to 62 years) were invited to participate in the study. Participants were requested to complete an anonymous, self-administered, structured questionnaire. Informed verbal consent from all participants was obtained prior to contribution. Participants were approached in their clinics during their clinical duties. To provide the participants with privacy while lling out the questionnaire, the participants were asked to return the questionnaire at the end of the working hours or the next day. The majority of clinicians showed interest in participating in the study. They were especially interested since the prevalence of diabetes in Kuwait is very high, and they tended to see patients with diabetes at a high frequency. One week after the rst contact, the questionnaire was distributed to the clinicians who had not responded. The rst part of the questionnaire recorded the demographic characteristics of participants including age, sex, and years in practice. Participants were then asked to which of the following periodontal complications they believed patients diagnosed with diabetes were more susceptible: gingival inammation, gingival bleeding, alveolar bone resorption, tooth loss, tooth mobility, and periodontal abscess. The knowledge about specic periodontal complications associated with diabetes was measured by marking correct or incorrect on the questionnaire. The second part of the questionnaire recorded the attitudes of participants toward the following specic oral health recommendations for patients with diabetes including: 1) regular dental checkups are important; 2) patients with poorly controlled diabetes should have more frequent dental checkups; and 3) may need more frequent dental scaling than individuals without diabetes. Finally, all participants were asked to report whether they believed that diabetes affects periodontal health, whether a periodontal condition might affect the metabolic control of diabetes, and whether a bidirectional association exists between periodontal health and diabetes. For all of these questions, participants were given the choice of yes, no, or I dont know. Statistical Analyses Data were entered and analyzed using software. Frequency distributions and descriptive statistics were generated for all study variables. A x2 test was performed to detect signicant associations among categoric variables, and the Student t test was used for continuous variables. A binary logistic regression analysis was performed to examine which
SPSS v. 17, IBM, Chicago, IL.

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eases is frequent among patients with diabetes. Dentists were signicantly more aware than physicians of gingival bleeding, tooth mobility and alveolar bone resorption, with high recorded signicant differences among six districts (P <0.001). In contrast, physicians were more aware of the fact that patients with diabetes are more susceptible to periodontal abscess than healthy individuals. The attitudes of study participants regarding specic oral health recommendations for patients diagnosed with diabetes are presented in Table 3. The majority of the study participants (90%) agreed that regular dental checkups for patients with diabetes are important. Dentists were signicantly more aware of the importance of frequent dental maintenance and scaling for patients with poorly controlled diabetes than were physicians RESULTS (P <0.001). Awareness of the current scientic evidence reA total of 510 general practitioners (232 physicians garding the connection between DM and periodontal and 278 dentists) completed the questionnaire. The health is presented in Table 4. The majority of study response rate was 92.6% for dentists and 77.3% for participants (86.9%) agreed that diabetes affects physicians (with no signicant difference in response periodontal health. On the other hand, only 51.2% rebetween districts). The mean and SD ages of dental ported that they were aware of the bidirectional aspractitioners were 32.72 and 9.086 years, respecsociation between DM and periodontal health, with tively. The mean and SD ages of physicians were dentists signicantly more aware than physicians of 33.65 and 9.345 years, respectively. No signicant the association (P <0.001). difference was detected regarding the mean ages beTable 5 represents the binary logistic-regression tween the two groups (P = 0.257). Table 1 presents analysis with the knowledge score as the dependent the sociodemographic characteristics of the particivariable. Age, sex, and type of profession were the pants. No statistical differences were found between only signicant variables associated with knowledge participating dentists and physicians regarding any levels. Females (odds ratio [OR] = 1.635; 95% concharacteristic. dence interval [CI]: 1.064 to 2.511; P = 0.0025), Table 2 presents the reported knowledge of speolder-aged participants (OR = 1.055; 95% CI: 1.020 cic periodontal complications associated with DM. to 1.092; P = 0.002), and dental practitioner (OR = Around 60% to 64% of the study participants were 2.254; 95% CI: 1.469 to 3.458; P <0.001) were signifaware of specic periodontal complications coupled icantly more likely to have an adequate knowledge with diabetes. Only 50% of all study participants about the effect diabetes on periodontal health. reported that tooth loss because of periodontal disOlder-aged participants may have more experience and exposure to patients with diabetes; therefore, they are more likely to Table 1. have knowledge about the effect of diabeSociodemographic Characteristics tes on periodontal health. Although years since graduation was not a signicant Physicians Dentists All participants predictor of knowledge levels, the odds Characteristic (n [%]) (n [%]) P* (n [%]) of having knowledge decreased by a factor of 0.153 for former graduates (>5 Age (years) years). 30 112 (48.3) 150 (54.0) 0.214 262 (51.4) factors were signicant in a multivariate analysis after adjusting for confounding among effects. The regression model used the dependant variable knowledge score calculated in the following manner: a score of 1 was given if the participant correctly responded to all effects of diabetes on periodontal health (gingival inammation, gingival bleeding, tooth mobility, periodontal abscess, alveolar bone resorption, and tooth loss), and participants reported that they were aware that diabetes affects periodontal health; a score of 0 was given if any of these variables were not correctly answered. Independent variables entered in the model were age, sex, years since graduation, and profession (dentist or physician). Statistical signicance was set at P <0.05.
>30 Sex Male Female Years since graduation 5 >5
* x (P <0.05).
2

120 (51.7) 124 (53.4) 108 (46.6) 116 (50.0) 116 (50.0)

128 (46.0) 169 (60.8) 109 (39.2) 134 (48.2) 144 (51.8) 0.106

248 (48.6) 293 (57.5) 217 (42.5) 250 (49.0) 260 (51.0)

0.722

DISCUSSION There is growing evidence that identies a strong association between diabetes and periodontal diseases. The FDI World Dental Federation with the International Diabetes Federation urged the need to improve knowledge about the reciprocal link between diabetes and oral health

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tal practitioners had knowledge about the Awareness of Periodontal Complications Associated effect of diabetes on periodontal health were 2.254 times the odds for medical pracWith DM titioners (Table 5). The low awareness of periodontal complications by physicians Periodontal Physicians Dentists All Participants could be explained by the medical curricuComplication (n [%]) (n [%]) P* (n [%]) lum and practice focus, which is mainly concerned with systemic conditions, while Gingival inammation 181 (70.0) 239 (86.0) 0.020 420 (82.4) dental education and practice focal points Gingival bleeding 109 (47.0) 215 (77.3) <0.001 324 (63.5) are on oral health. Dentists may not frequently communicate with primary Tooth mobility 104 (44.8) 222 (79.9) <0.001 326 (63.9) health care physicians regarding the oral Periodontal abscess 173 (74.6) 133 (47.8) 0.049 306 (60.0) and systemic health of patients. A previous study22 reported that only 15 of 105 general Alveolar bone resorption 91 (39.2) 235 (84.5) <0.001 326 (63.9) dentists (14%) in the Northeastern United Tooth loss 114 (49.1) 158 (56.8) 0.091 272 (53.3) States often communicate with the physi2 * x (P <0.05). cian, and general dental practitioners are less likely to take active role in manageamong health professionals.26 Increasing the knowment of patients with diabetes. Therefore, physicians ledge of health care providers will positively improve are not receiving adequate information about oral their attitudes and behaviors toward the management health problems related to diabetes from the dental of patients with diabetes. To the best of our knowlteam, and their involvement with oral health implicaedge, this is the rst study that documents and contions for patients with diabetes has not been a topic of trasts the knowledge of dentists and physicians of professional focus. Also, many physicians may feel specic periodontal complications associated with that their role is to focus on systemic-health condiDM. tions only, and they do not have the authority to In this study, although the majority of respondents manage oral health care. Our results support the in both clinician groups believe that diabetes may afimportance of collaboration between medical and fect periodontal health by causing gingival inammadental professionals. Therefore, enhancing comtion and that regular dental checkups are important, munication between medical and dental health care <64% of study respondents are aware of specic periproviders is essential to facilitate an exchange of odontal complications associated with DM. Fifty perknowledge between the two professions to provide cent of study respondents were unaware of the fact an effective management of serious chronic diseases that tooth loss is a common dental complication such as DM. among patients diagnosed with diabetes. Many studAlthough dentists were more aware than physiies27-30 documented that periodontal diseases are cians about most of the periodontal complications considered to be one of the main reasons for tooth loss associated with diabetes, their awareness level is in individuals with diabetes. The consequences of periconsidered low compared to the impact of diabeodontal diseases and subsequent tooth loss are not tes on periodontal health. Only 58.6% of the dentists only important considerations for the quality of life, believed that there is a bidirectional effect between but may also signicantly affect the overall health of inDM and periodontal diseases. Our results agree with dividuals by compromising their ability to maintain a data from the study of Kunzel et al.,22 which reported healthy diet and proper glycemic control. Our results that only 60% of general dentists discussed with show that there is an underestimation of the extent, patients with diabetes how periodontal therapy may severity, and outcomes of periodontal diseases in paaffect metabolic control. Another study by Kunzel tients diagnosed with diabetes by both dentists and et al.21 contrasted general dentists with periodonphysicians. tists and reported that 51.0% of general dentists and Our data show that physicians were signicantly 29.4% of periodontists in the Northeastern United less aware than dentists of specic periodontal comStates were categorized as low performers in terms plications associated with diabetes such as gingival of discussions with patients about the associations bleeding, alveolar bone resorption, and tooth mobilbetween diabetes and oral health, the importance of ity, and the binary regression analysis revealed that blood glucose control, and the associations between the dental profession is a signicant predictor for havdental treatment and blood glucose control. The level ing adequate knowledge about the effect of diabetes of discussion and active management was signion periodontal health. After adjustment for the other cantly associated with the number of consultations predictors in the model, the estimated odds that denwith dental and medical specialists. In our study, Table 2.
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Table 3.

Dental Care Recommendations for Patients With DM

Recommendation Regular dental checkups are important Patients with poorly controlled diabetes should have more frequent dental checkups Patients with poorly controlled diabetes should have more frequent scaling
* x (P <0.05).
2

Physicians (n [%]) 199 (85.8)

Dentists (n [%]) 260 (93.5)

P* 0.005

All Participants (n [%]) 459 (90.0)

197 (84.9)

264 (95.0)

<0.001

461 (90.4)

138 (59.5)

227 (81.7)

<0.001

365 (71.6)

Table 4.

Awareness of the Association Between DM and Periodontal Health

DM and Periodontal Health Diabetes affects periodontal health Periodontal health affects metabolic control Bidirectional association between diabetes and periodontal health Knowledge score 1 0 Physicians (n [%]) 175 (75.4) 102 (44.0) 98 (42.2) Dentists (n [%]) 268 (96.4) 167 (60.1) 163 (58.6) P* <0.001 <0.001 <0.001 All Participants (n [%]) 443 (86.9) 269 (52.7) 261 (51.2)

45 (19.4) 187 (80.6)

90 (32.4) 188 (67.6)

0.001

135 (26.5) 375 (73.5)

Results represent the number of participants who believed that the above-mentioned statements are correct. * x2 (P <0.05). A score of 1 was given if the participant correctly identied gingival inammation, gingival bleeding, tooth mobility, periodontal abscess, alveolar bone resorption, and tooth loss as inuenced by diabetes, and the participant reported that he or she was aware that diabetes affects periodontal health; a score of 0 was given if any of the variables were not correctly answered.

female dentists are signicantly more likely to have adequate knowledge about the effect of diabetes on periodontal health, and this result agrees with data from a study by Forbes et al.23 that reported that female dentists were signicantly more likely to refer patients with diabetes for monitoring blood glucose, adjusting the frequency of dental visits, and discussing how periodontal therapy affects metabolic control than were male dentists. We speculate that there is a lack of interaction among general dentists, dental specialists, and medical practitioners. Advances in understanding the relationship between oral disease and systemic conditions need to be translated into integrated clinical practice and collaboration among different health care specialties is crucial. General dental practitioners may underestimate the
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need for referral to dental specialists. In a 2003 study, Bader et al.31 investigated the ability of general dental practitioners to assess risk factors of periodontal diseases, and their results suggested a need for improvement among general dentists, particularly in their ability to recognize diabetes as an indicator of a high risk for periodontal diseases. Another survey32 of 160 members of Michigan Dental Association showed that a negative attitude toward periodontal referrals among general dentists and the more positively dentists evaluated their dental education in periodontics, the more conservative they were when considering the percentage of bone loss as a basis for referral and the more frequently they used systemic antibiotics in their treatment of periodontal diseases. Because general dentists are considered the primary

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Table 5.

Logistic Regression Analysis of Factors Associated With Knowledge Level of Effects of Diabetes on Periodontal Health
Factor Older aged participant Sex (female) Years since graduation (>5 years) Dental practitioner
B = coefcient.

B (SE) 0.054 (0.017) 0.492 (0.219) -0.153 (0.333) 0.813 (0.218)

Adjusted OR (95% CI) 1.055 (1.020 to 1.092) 1.635 (1.064 to 2.511) 0.858 (0.447 to 1.647) 2.254 (1.469 to 3.458)

P 0.002 0.0025 0.645

faculties (medicine, dentistry, and health professions) in Dalhousie University in Canada already implemented an interprofessional educational program model to develop the interprofessional patient-centered collaborative skills of students,36 and their experiences demonstrated that collaborative, social learning and reective practice are very useful to the work of interprofessional education.

referral source of patients with advanced periodontal conditions, periodontists should play a major role in educating general practitioners about the risk of developing periodontal diseases in patients diagnosed with diabetes. These results demonstrate the importance of an interdisciplinary, medical orientation for the management of patients with diabetes in order to facilitate exchanging medical and dental information among health care providers. Many people are not aware that they have diabetes and many do not receive a diagnosis until after the development of complications, which include periodontal diseases. Individuals with a self-reported family history of diabetes, hypertension, high cholesterol levels, and clinical evidence of periodontal diseases bear a probability of 27% to 53% of having undiagnosed diabetes.33 Therefore, dental and medical ofces can be health care locations actively involved in screening for unidentied diabetes. Increasing the knowledge and enhancing the collaboration between dental and medical practitioners are important elements for the prevention, management, and control of diabetes and periodontal diseases. Also, formal training is a signicant factor that affects the attitudes of health care providers toward the management of patients with diabetes and the provision of advice to patients with diabetes about periodontal risk associated with diabetes.34 A questionnaire-based study by Ward et al. 35 examined the knowledge and attitudes of 137 primary care nurse practitioners regarding the periodontal diseasesystemic link, and their results showed that nurse practitioners were signicantly more likely to screen patients when they felt good about their training and continuing education, when they believed it was within their scope of practice to screen for periodontal diseases, and when they had control over the establishment of ofce protocols. These results support the importance of interprofessional and collaborative education among the medical, nursing, and dental professions. Three

CONCLUSIONS Within the limitations of the present <0.001 study, which relies upon self-reported data, the knowledge of specic periodontal complications associated with diabetes among this sample is generally low. Because the number of dentists in this sample represent >25% of the entire general dentists working in Kuwait at the time of the study, it is possible to generalize the ndings for dental practitioners in Kuwait. Professional attention should be given to the importance of the relationship between oral health and systemic health. It is very essential for dental and medical primary health care providers to understand the relationship between DM and periodontal diseases to give the appropriate assessment, prevention, and management of the health needs of patients with diabetes. The knowledge about the association between periodontal diseases and diabetes can be increased through conducting educational programs and establishing an integrated practice structure for managing all aspects of diabetes to enhance teamwork and the exchange of knowledge between dental and medical practitioners. ACKNOWLEDGMENTS This study was supported by Kuwait University (research grant No ZD 02/07). The authors report no conicts of interest related to this study. REFERENCES
1. Taylor GW. Bidirectional interrelationships between diabetes and periodontal diseases: An epidemiologic perspective. Ann Periodontol 2001;6:99-112. 2. Mealey BL, Oates TW. Diabetes mellitus and periodontal diseases. J Periodontol 2006;77:1289-1303. 3. Johnson NW, Grifths GS, Wilton JM, et al. Detection of high-risk groups and individuals for periodontal diseases. Evidence for the existence of high-risk groups and individuals and approaches to their detection. J Clin Periodontol 1988;15:276-282. 4. Grossi SG, Zambon JJ, Ho AW, et al. Assessment of risk for periodontal disease. I. Risk indicators for attachment loss. J Periodontol 1994;65:260-267. 5. American Academy of Periodontology. Epidemiology of periodontal diseases (position paper). J Periodontol 2005;76:1406-1419. 365

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6. Hugoson A, Thorstensson H, Falk H, Kuylenstierna J. Periodontal conditions in insulin-dependent diabetics. J Clin Periodontol 1989;16:215-223. 7. Tervonen T, Karjalainen K, Knuuttila M, Huumonen S. Alveolar bone loss in type 1 diabetic subjects. J Clin Periodontol 2000;27:567-571. 8. Lalla E, Cheng B, Lal S, et al. Diabetes mellitus promotes periodontal destruction in children. J Clin Periodontol 2007;34:294-298. 9. Taylor GW, Burt BA, Becker MP, et al. Severe periodontitis and risk for poor glycemic control in patients with non-insulin-dependent diabetes mellitus. J Periodontol 1996;67(Suppl. 10):1085-1093. 10. Collin HL, Uusitupa M, Niskanen L, et al. Periodontal ndings in elderly patients with non-insulin dependent diabetes mellitus. J Periodontol 1998;69:962-966. 11. Kiran M, Arpak N, Unsal E, Erdogan MF. The effect of improved periodontal health on metabolic control in type 2 diabetes mellitus. J Clin Periodontol 2005;32:266-272. 12. Skaleric U, Schara R, Medvescek M, Hanlon A, Doherty F, Lessem J. Periodontal treatment by Arestin and its effects on glycemic control in type 1 diabetes patients. J Int Acad Periodontol 2004;6(Suppl. 4):160-165. 13. Jones JA, Miller DR, Wehler CJ, et al. Does periodontal care improve glycemic control? The Department of Veterans Affairs Dental Diabetes Study. J Clin Periodontol 2007;34:46-52. 14. Grossi SG, Skrepcinski FB, DeCaro T, et al. Treatment of periodontal disease in diabetics reduces glycated hemoglobin. J Periodontol 1997;68:713-719. 15. World Health Organization. Global policy for improvement of oral health in the 21st century-implications to oral health research of World Health Assembly 2007. Available at: http://www.who.int/oral_health/publications/en/. Accessed May 2009. 16. Al Habashneh R, Khader Y, Hammad MM, Almuradi M. Knowledge and awareness about diabetes and periodontal health among Jordanians. J Diabetes Complications 2010;24:409-414. 17. Centers for Disease Control and Prevention (CDC). Dental visits among dentate adults with diabetes United States, 1999 and 2004. MMWR Morb Mortal Wkly Rep 2005;54:1181-1183. 18. Allen EM, Ziada HM, OHalloran D, Clerehugh V, Allen PF. Attitudes, awareness and oral health-related quality of life in patients with diabetes. J Oral Rehabil 2008;35: 218-223. 19. Jansson H, Lindholm E, Lindh C, Groop L, Bratthall G. Type 2 diabetes and risk for periodontal disease: A role for dental health awareness. J Clin Periodontol 2006;33:408-414. 20. Moore PA, Orchard T, Guggenheimer J, Weyant RJ. Diabetes and oral health promotion: A survey of disease prevention behaviors. J Am Dent Assoc 2000;131: 1333-1341. 21. Kunzel C, Lalla E, Lamster I. Dentists management of the diabetic patient: Contrasting generalists and specialists. Am J Public Health 2007;97:725-730.

22. Kunzel C, Lalla E, Lamster IB. Management of the patient who smokes and the diabetic patient in the dental ofce. J Periodontol 2006;77:331-340. 23. Forbes K, Thomson WM, Kunzel C, Lalla E, Lamster IB. Management of patients with diabetes by general dentists in New Zealand. J Periodontol 2008;79:1401-1408. 24. Moussa MA, Alsaeid M, Abdella N, Refai TM, AlSheikh N, Gomez JE. Prevalence of type 2 diabetes mellitus among Kuwaiti children and adolescents. Med Princ Pract 2008;17:270-275. 25. Moussa MA, Alsaeid M, Abdella N, Refai TM, Al-Sheikh N, Gomez JE. Prevalence of type 1 diabetes among 6- to 18year-old Kuwaiti children. Med Princ Pract 2005;14:87-91. 26. The International Dental Federation. Oral health and diabetes symposium. 2007. Available at: http://www. idf.org/diabetes-and-oral-health. Accessed May 11, 2009. 27. Al-Shammari KF, Al-Khabbaz AK, Al-Ansari JM, Neiva R, Wang HL. Risk indicators for tooth loss due to periodontal disease. J Periodontol 2005;76:1910-1918. 28. Kapp JM, Boren SA, Yun S, LeMaster J. Diabetes and tooth loss in a national sample of dentate adults reporting annual dental visits. Prev Chronic Dis 2007;4:A59. 29. Oliver RC, Tervonen T. Periodontitis and tooth loss: Comparing diabetics with the general population. J Am Dent Assoc 1993;124:71-76. 30. Kaur G, Holtfreter B, Rathmann WG, et al. Association between type 1 and type 2 diabetes with periodontal disease and tooth loss. J Clin Periodontol 2009;36:765-774. 31. Bader JD, Shugars DA, Kennedy JE, Hayden WJ Jr., Baker S. A pilot study of risk-based prevention in private practice. J Am Dent Assoc 2003;134:1195-1202. 32. Lee JH, Bennett DE, Richards PS, Inglehart MR. Periodontal referral patterns of general dentists: Lessons for dental education. J Dent Educ 2009;73:199-210. 33. Borrell LN, Kunzel C, Lamster I, Lalla E. Diabetes in the dental ofce: Using NHANES III to estimate the probability of undiagnosed disease. J Periodontal Res 2007;42:559-565. 34. Esmeili T, Ellison J, Walsh MM. Dentists attitudes and practices related to diabetes in the dental setting. J Public Health Dent 2010;70:108-114. 35. Ward AS, Cobb CM, Kelly PJ, Walker MP, Williams KB. Application of the theory of planned behavior to nurse practitioners understanding of the periodontal diseasesystemic link. J Periodontol 2010;81:1805-1813. 36. Mann KV, Mcfetridge-Durdle J, Martin-Misener R, et al. Interprofessional education for students of the health professions: The Seamless Care model. J Interprof Care 2009;23:224-233. Correspondence: Dr. Areej K. Al-Khabbaz, Department of Surgical Sciences, Faculty of Dentistry, Kuwait University, P.O. Box 24923, Safat, Kuwait, 13110. Fax: 965-25326049, E-mail: areejalkhabbaz@hsc.edu.kw. Submitted June 15, 2010; accepted for publication August 17, 2010.

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