Abstract
The association among certified diabetes educator nurses’ knowledge, attitudes, and practices related to oral management has not been well examined. The aim of this study was to examine the association between knowledge and attitude as variables for nurses’ practice of oral management as certified diabetes educators at medical facilities in Japan. The questionnaires were administered to 300 certified diabetes educator nurses from 1277 medical facilities. The items regarding knowledge, attitude, and practice of oral management were assessed using items from the guidelines, reports, and books on diabetes and periodontal disease, as well as the exhaustive findings of previous studies. More than 70% of the participants did not practice adequate oral management. Logistic regression analysis revealed that all the items were negatively associated with nurses’ confidence in oral management (Factor 1: odds ratio [OR] = 0.55; 95% confidence interval [CI] 0.37–0.83; Factor 2: OR = 0.35; 95% CI 0.18–0.70; Factor 3: OR = 0.38; 95% CI 0.24–0.61; Factor 4: OR = 0.29; 95% CI 0.18–0.49). The practice of oral management coupled with an explanation regarding periodontal disease as a diabetic complication (OR = 2.67; 95% CI 1.01–7.02), and supporting collaboration with multiple medical departments (OR = 2.65; 95% CI 1.24–5.65) were positively associated with nurses’ education. These results suggest that more strategies for nurses’ education are needed to understand the importance of oral management practices and to improve knowledge, attitudes, and confidence in patient oral management.
Keywords: Cross-sectional study, Health knowledge, Attitude, Nurses’ practice patterns, Oral management, Type 2 diabetes
Introduction
Periodontal disease is a chronic inflammatory condition triggered by bacterial infection in the gingival sulcus, and its progression causes serious tooth loss [1, 2]. This disease is recognized as one of the most common diseases worldwide [1, 2], and approximately 90% of adults have inflammatory conditions caused by it [3–5]. Japan has one of the highest rates of tooth loss caused by periodontal disease worldwide [6]. In 2014, more than three million people were diagnosed with the disease in Japan, and this number continues to increase [7, 8].
There is some evidence of a bidirectional relationship between diabetes and periodontal disease [9]. A longitudinal study has shown that patients with type 2 diabetes have a 2.6 times higher incidence rate of periodontal disease compared with people without diabetes [10]. Other studies have suggested that periodontal disease can cause chronic inflammation, which increases insulin resistance [11] and tooth loss. It also reduces chewing ability, which leads to poor nutrition [12]. Thus, patients with diabetes are more likely to develop periodontal disease with worsening glycemic control [11]. However, it has been reported that patients are often do not realize that they have periodontal disease because it is relatively asymptomatic [1, 13, 14].
With the gradual increase in the perceived importance of oral management of patients with systemic diseases, maintaining good oral condition is important for patients who receive treatment in medical settings [15]. During diabetes treatment, patients are found to have oral problems other than periodontal disease, which may go unnoticed by these patients, and such problems can be more serious. However, given that approximately 70% of general hospitals in Japan, where most patients with diabetes are treated [16], dental services are not provided. It has also been reported that more than 70% of doctors still do not cooperate with dentists in medical settings in Japan [17]. Moreover, we previously reported that 68.2% of patients with type 2 diabetes have not undergone regular dental checkups during the preceding year [18]. Consequently, there is a concern that the patient's oral problems will be left unattended if they do not have dental consultations. Hence, oral management of patients with diabetes is required not only in dentistry, but also in medical settings [20]. Oral management practiced by medical professionals must go beyond oral hygiene to include patient education, and the importance of assessing their oral condition should be emphasized [15].
Oral management is a basic nursing role, indicating that a patient’s oral health status is reflective of the quality of nursing care [21]. Nurses are generally responsible for providing oral management in medical settings [22]. Moreover, they play a key role in preventing diabetes complications and hence in the management of oral problems in patients with diabetes in medical settings [19, 20].
Most patients with diabetes are treated on an outpatient basis. This places the responsibility on patients to be aware of and perform self-management of oral care at home. However, many patients may not identify oral complications as the problems progress. Therefore, oral problems require continuous observation of the oral condition as with foot care for foot lesions. Such observations can prevent the onset and exacerbation of oral problems. Hence, continuous patient education in an outpatient medical setting is important for the prevention of the worsening of diabetes and management of oral complications. Previous studies reported that medical professionals will be able to support patients with diabetes by changing the educational approach based on the background of periodontal disease in patients [18].
Certified diabetes educators (CDEs) in Japan are medical staff with advanced and broad expertise to support the self-management of people with diabetes. This qualification is offered to nurses, registered dietitians, pharmacists, clinical technologists, and physical therapists who have a certain amount of experience and have passed the necessary examination [23]. Nurses as CDEs account for 45% (8463 of 18,774) of the total number [24] and play an important role in providing self-management education to outpatients in medical settings. Hence, they are expected to emphasize oral management to promote the oral health of outpatients with diabetes. It has been pointed out in other countries that most diabetes care providers do not practice oral management due to a lack of knowledge and attitude regarding it [14]. Furthermore, it is unclear how much care nurses as CDEs provide oral management and the extent of knowledge and attitude regarding it in Japan. We previously reported the barriers associated with the provision of periodontal care by nurses as CDEs for outpatients with diabetes mellitus in medical settings in Japan [25]. This indicates that the educational needs of nurses as CDEs must emphasize the enhancement of their knowledge, skills, and confidence in oral assessments. Although the previous study investigated four types of periodontal care, the present study focused on the specific behaviors, knowledge, and attitudes regarding oral management among nurses. It provides useful information to clarify the specific educational content that should be included in oral management, including periodontal care.
Regarding education for medical staff, enhancing the knowledge and attitudes necessary for behavior change promotes a positive attitude toward behavior and, in turn, encourages behavioral changes [26]. Although knowledge may not always be associated with behavior change, accurate knowledge about the prevention, early detection, and treatment of health problems is a prerequisite to encourage appropriate behaviors. Moreover, several theories imply that knowledge and attitudes are associated with behaviors. For instance, they are positioned as prerequisites for behavioral change in the Predisposing, Reinforcing, Enabling Constructs in Education/Environmental Diagnosis and Education-Policy, Regulatory, and Organizational Constructs in Educational and Environmental Development (PRECEDE-PROCEED) model [27]. Hence, the acquisition of knowledge and attitudes may promote oral management.
To our knowledge, the association between knowledge, attitude, and practice related to oral management among diabetes mellitus outpatients in medical settings of nurses as CDEs in Japan has not been well examined yet. The present study examined this association among nurses as CDEs at medical facilities in Japan. Our hypotheses are as follows:
H1: Nurses as CDEs have lower levels of knowledge, attitudes, and practices than other medical staff regarding oral management.
H2: Nurses as CDEs who have higher levels of knowledge about the bidirectional relationship between periodontal disease and diabetes, and higher levels of attitude, will practice oral management more frequently than those with lower levels of knowledge and attitude.
Method
Participants
A cross-sectional survey was conducted at a national level in Japan, with 1277 medical facilities where diabetologists and nurses were enrolled as CDEs. Anonymous self-administered questionnaires were mailed to these facilities. Nurses who worked in outpatient departments for diabetes were included in this study. Participants who were unwilling to participate or did not work at the facility at the time of answering the questionnaire were excluded from the study. Finally, the study had 300 participants, after excluding those who did not provide valid responses. The participants were recruited between November 2019 and January 2020.
Measures
Participants’ background information, knowledge about the bidirectional relationship between diabetes and periodontal diseases, and attitude and practice regarding oral management of outpatients with type 2 diabetes were assessed using a self-reported questionnaire developed for this study. First, the contents of the questionnaire were obtained from guidelines, reports, and books on diabetes and periodontal disease, and exhaustive research on the results of previous studies was conducted. Second, issues faced by nurses in the oral management of outpatients with type 2 diabetes were extracted, and each item related to nurses' knowledge, attitudes, and practices regarding oral management were extracted from them and drafted as a questionnaire. We created the same 40 items on attitude and practice because we thought that the same oral management items were needed to assess it. Third, the questionnaire was reviewed and revised through discussions among researchers specializing in the field of chronic nursing. Finally, we conducted a pilot test with four nurses, including two CDE nurses who were eligible for inclusion in the study.
The participants’ background information included sex, age, work experience after becoming a CDE, education in oral management of patients with diabetes, institution, and the existence of an outpatient department specialized in diabetes care at their work institution. In addition, perception of “I’m not confident about the oral management of people with diabetes.” was assessed using an ordinal scale ranging from 1 (“I do not think it at all”) to 4 (“I think it well”).
Knowledge about the bidirectional relationship between diabetes and periodontal diseases was assessed using an ordinal scale ranging from 1 (“I do not know it at all”) to 4 (“I know it well”).
Attitude was measured using 40 items on the oral management of outpatients with type 2 diabetes. The responses were provided using an ordinal scale ranging from 1 (“not important at all”) to 4 (“very important”).
Practice was measured using 40 items on the oral management of outpatients with type 2 diabetes. The responses were provided using an ordinal scale ranging from 1 (“never”) to 4 (“always”).
Statistical analysis
All statistical analyses were performed using IBM SPSS Statistics 25.0. Descriptive statistics were calculated for all measured variables. Exploratory factor analysis (EFA) of knowledge items and practice was performed to extract latent factors among the contributing items using the principal factor method with promax rotation. Additionally, the EFA of attitude was performed to extract latent factors among the contributing factor items using the weighted least squares method with promax rotation. We repeated the factor analysis until we obtained a solution in which all included items had factor loadings > 0.40, for only one factor. The latent factor score was calculated as the sum of the scores of the items included in the factor. Cronbach’s alpha was calculated for each final factor. Logistic regression analysis was performed to examine the association of knowledge and attitude with nursing practice regarding the oral management of outpatients with type 2 diabetes. Work experience after becoming a CDE, education about oral management of patients with diabetes, number of beds in the facility, existence of an outpatient department specialized in diabetes care at a work institution, and “I’m not confident about oral management of people with diabetes” were included in the model as possible confounding factors. The level of significance was set at p < 0.05, and all p values were based on two-sided tests. Missing values were omitted from the analysis.
Ethical considerations
The study protocol was approved by the Institutional Review Board at the University of Tsukuba (approval number: 1453, approval date: 10/10/2019). The requested letters include a written explanation of the survey. Submitting the answers to the questionnaire was considered as expressing consent to participate in the survey.
Results
The overall response rate was 25.8% (328/1277). Data from 28 respondents were excluded because they did not respond to more than half of the attitude and practice items. Finally, 300 valid responses were analyzed.
The participant characteristics are presented in Table 1. On average, the participants had worked as CDEs for 10 years. Less than 70% of the participants had received education in oral management of patients with diabetes and 68.8% answered, “I’m not confident in oral management of people with diabetes.”
Table 1.
Characteristics of participants
| Female | 289 (96.3%) |
|---|---|
| Age (years) | 48.1 ± 7.7 |
| Work experience as CDE (years) | 10.4 ± 5.7 |
| Experience in oral management education of patients with diabetes | 207 (69.0%) |
| Institution | |
| Clinic | 83 (27.7%) |
| Hospital | 206 (68.7%) |
| No description | 11 (3.7%) |
| Existence of an outpatient department specialized in diabetes care at a work institution | 239 (79.7%) |
Note. N = 300. n (%) or Mean ± standard deviation
Dental specialist: dentist and/or dental hygienist
The results of the EFA of the knowledge items are listed in Table 2. Two items with high correlation coefficients and similar content were excluded. Descriptive statistics of the final knowledge items are presented in Table 3. Participants’ knowledge was highest regarding “Advanced periodontal disease causes tooth loss,” “Informing the dentist about patients’ diabetes,” and “Dental consultation can prevent periodontal disease,” and lowest regarding “Regular diet can prevent periodontal disease.”
Table 2.
Exploratory factor analysis of knowledge items
| Factor 1 | Factor 2 | Factor 3 | Factor 4 | α | |
|---|---|---|---|---|---|
| Factor 1: Bidirectional relationship between diabetes and periodontal disease | 0.83 | ||||
| Periodontal disease is an infection triggered by bacterial plaque | 0.72 | ||||
| Subjective symptoms appear with the progression of periodontal disease | 0.67 | ||||
| Patients with long-term diabetes are at an increased risk of periodontal disease | 0.65 | ||||
| Advanced periodontal disease causes tooth loss | 0.65 | ||||
| Periodontal disease is asymptomatic in the early stages | 0.64 | ||||
| Periodontal disease affects the onset and progression of heart lesions and nephropathy | 0.63 | ||||
| Periodontal disease can worsen diabetes | 0.57 | ||||
| Periodontal disease is a type of diabetic complication | 0.54 | ||||
| Periodontal disease worsens with deterioration of other diabetic complications | 0.51 | ||||
| Patients with symptoms of chronic diabetic complications are at a higher risk for periodontal disease | 0.46 | ||||
| Factor 2: Patients with high priority for oral management | 0.83 | ||||
| Priority oral management is necessary for patients who do not brush their teeth daily | 0.91 | ||||
| Priority oral management is necessary for patients who have not had dental check-ups for more than a year | 0.80 | ||||
| Priority oral management is necessary for patients with tooth defect (no dentures) | 0.75 | ||||
| Priority oral management is necessary for patients with dry mouth | 0.75 | ||||
| Priority oral management is necessary for patients with untreated oral problems | 0.73 | ||||
| Oral management at the outpatient department of diabetes is necessary for preventing periodontal disease for patients with diabetes | 0.40 | ||||
| Factor 3: Eating habits for prevention of periodontal disease | 0.85 | ||||
| Regular diet can prevent periodontal disease | 0.72 | ||||
| Eating less sweets can prevent periodontal disease | 0.58 | ||||
| Chewing well can prevent periodontal disease | 0.58 | ||||
| Factor 4: Dental referral for prevention of periodontal disease | 0.89 | ||||
| Informing the dentist about patients' diabetes | 0.75 | ||||
| Diabetes cooperation notebook includes a checklist regarding patients’ oral condition as assessed by the dentist | 0.53 | ||||
| Dental consultation can prevent periodontal disease | 0.53 | ||||
| Factor correlation | Factor 1 | 0.67 | 0.61 | 0.55 | |
| Factor 2 | 0.65 | 0.53 | |||
| Factor 3 | 0.40 |
N = 300. Principal factor method, promax rotation
α: Cronbach’s alpha
Table 3.
Knowledge about the bidirectional relationship between diabetes and periodontal disease
| Knowledge | |
|---|---|
| Factor 1: Bidirectional relationship between diabetes and periodontal disease | |
| Periodontal disease is an infection triggered by bacterial plaque | 3.6 ± 0.5 |
| Subjective symptoms appear with the progression of periodontal disease | 3.7 ± 0.5 |
| Patients with long-term diabetes are at an increased risk of periodontal disease | 3.6 ± 0.6 |
| Advanced periodontal disease causes tooth loss | 3.8 ± 0.5 |
| Periodontal disease is asymptomatic in the early stages | 3.6 ± 0.6 |
| Periodontal disease affects the onset and progression of heart lesions and nephropathy | 3.4 ± 0.7 |
| Periodontal disease can worsen diabetes | 3.8 ± 0.4 |
| Periodontal disease is a type of diabetic complication | 3.8 ± 0.4 |
| Periodontal disease worsens with deterioration of other diabetic complications | 3.5 ± 0.7 |
| Patients with symptoms of chronic diabetic complications are at a higher risk for periodontal disease | 3.4 ± 0.7 |
| Factor 2: Patients with high priority for oral management | |
| Priority oral management is necessary for patients who do not brush their teeth daily | 3.6 ± 0.6 |
| Priority oral management is necessary for patients who have not had dental check-ups for more than a year | 3.4 ± 0.7 |
| Priority oral management is necessary for patients with tooth defect (no dentures) | 3.4 ± 0.7 |
| Priority oral management is necessary for patients with dry mouth | 3.5 ± 0.6 |
| Priority oral management is necessary for patients with untreated oral problems | 3.6 ± 0.6 |
| Oral management at the outpatient department of diabetes is necessary for preventing periodontal disease for patients with diabetes | 3.3 ± 0.7 |
| Factor 3: Eating habits for prevention of periodontal disease | |
| Regular diet can prevent periodontal disease | 3.3 ± 0.8 |
| Eating less sweets can prevent periodontal disease | 3.3 ± 0.7 |
| Chewing well can prevent periodontal disease | 3.4 ± 0.7 |
| Factor 4: Dental referral for prevention of periodontal disease | |
| Informing the dentist about patients' diabetes | 3.8 ± 0.5 |
| Diabetes cooperation notebook includes a checklist regarding patients' oral condition as assessed by the dentist | 3.6 ± 0.8 |
| Dental consultation can prevent periodontal disease | 3.8 ± 0.5 |
Note. N = 300. Mean ± standard deviation
Knowledge is calculated by scoring each of the 22 items; 4 = “I know it well,” 3 = “I know it roughly”
2 = “I don't know it so much,” and 1 = “I don't know it at all.” The score ranges from 1 to 4
Regarding practice and attitude, the EFA was conducted for each of the 40 items assessed as practice and attitude.
The EFA of nurses’ attitudes about the oral management of outpatients with type 2 diabetes is shown in Table 4. During the two analyses, two items with low factor loadings were excluded. Descriptive statistics of the final solutions are presented in Table 5. Participants’ attitudes were highest regarding “Explain the importance of oral management for diabetes management,” “Explain the necessity of controlling blood sugar for oral management,” “Explain the importance of regular dental checkups,” “Explain the association between periodontal diseases and other diabetic complications,” and “Explain the importance of showing the diabetes cooperation notebook to the dentist during dental consultation,” and lowest regarding “Explain salivary gland massage.”
Table 4.
Exploratory factor analysis of nurses' attitudes towards oral management of outpatients with type 2 diabetes
| Factor 1 | Factor 2 | Factor 3 | Factor 4 | α | |
|---|---|---|---|---|---|
| Factor 1: Explaining self-care for maintaining good oral health | 0.82 | ||||
| Explain salivary gland massage | 0.83 | ||||
| Explain the decrease in salivary secretion due to aging | 0.82 | ||||
| Explain the importance of using mouth rinse for oral cleaning | 0.81 | ||||
| Introduction to items for self-care | 0.80 | ||||
| Explain the risk of mouth ulcers due to dentures | 0.77 | ||||
| Explain oral cleaning for self-care | 0.75 | ||||
| Explain the appropriate way to wear dentures | 0.73 | ||||
| Explain how chewing food affects the oral health | 0.71 | ||||
| Explain the association between oral management and timing of diet | 0.71 | ||||
| Explain an alternative way to clean if patients cannot brush their teeth | 0.68 | ||||
| Explain the importance of using dental floss and/or interdental brush for oral cleaning | 0.67 | ||||
| Explain the effect of oral cleaning | 0.62 | ||||
| Explain the importance of using a toothbrush for oral cleaning | 0.58 | ||||
| Factor 2: Check the patient's oral condition | 0.82 | ||||
| Check tooth mobility | 0.88 | ||||
| Check the gingival bleeding | 0.88 | ||||
| Check for dental caries | 0.82 | ||||
| Check for gingival edema | 0.81 | ||||
| Check for oral malodor | 0.76 | ||||
| Check for contamination in the mouth | 0.74 | ||||
| Check for conditions involving mastication such as biting | 0.66 | ||||
| Check the number of missing teeth | 0.53 | ||||
| Check for any sharp pain when eating hot or cool food | 0.50 | ||||
| Check for dry mouth | 0.49 | ||||
| Factor 3: Explain the knowledge necessary for oral management including that about periodontal disease being a diabetic complication | 0.87 | ||||
| Explain the association between periodontal diseases and diabetes | 0.89 | ||||
| Explain the importance of oral management for diabetes management | 0.86 | ||||
| Explain the necessity of controlling of blood sugar for oral management | 0.83 | ||||
| Explain the necessity of dental consultation if the patients have subjective oral symptoms | 0.82 | ||||
| Explain periodontal disease | 0.80 | ||||
| Explain the importance of regular dental checkups | 0.77 | ||||
| Explain the association between periodontal disease and other diabetic complications | 0.74 | ||||
| Explain the importance of showing the diabetes cooperation notebook to the dentist during dental consultation | 0.57 | ||||
| Factor 4: Education to enhance self-efficacy of patients with type 2 diabetes about the oral management | 0.86 | ||||
| Check patients’ concerns about oral condition | 0.61 | ||||
| Check patients’ subjective oral symptoms | 0.58 | ||||
| Check the patient’s oral cavity | 0.56 | ||||
| Evaluate the patient’s oral condition using an oral assessment tool | 0.54 | ||||
| Support the patient in enhancing their self-efficacy for dental consultation | 0.46 | ||||
| Consult the doctor about the oral management of patients with diabetes | 0.46 | ||||
| Set goals for oral management to enhance patients’ self-efficacy | 0.43 | ||||
| Factor correlation | Factor 1 | 0.77 | 0.61 | 0.62 | |
| Factor 2 | 0.60 | 0.65 | |||
| Factor 3 | 0.52 |
N = 300. Weighted least squares method, Promax rotation
α: Cronbach’s alpha
Table 5.
Final oral management items for assessing nurses' attitudes towards outpatients with type 2 diabetes
| Attitude | ||
|---|---|---|
| Factor 1: Explaining self-care for maintaining good oral health | ||
| Explain salivary gland massage | 3.3 ± 0.8 | |
| Explain the decrease in salivary secretion due to aging | 3.5 ± 0.7 | |
| Explain the importance of using mouth rinse for oral cleaning | 3.4 ± 0.7 | |
| Introduction to items for self-care | 3.4 ± 0.7 | |
| Explain the risk of mouth ulcers due to dentures | 3.4 ± 0.7 | |
| Explain oral cleaning for self-care | 3.6 ± 0.6 | |
| Explain the appropriate way to wear dentures | 3.4 ± 0.7 | |
| Explain how chewing food affects the oral health | 3.5 ± 0.7 | |
| Explain the association between oral management and timing of diet | 3.5 ± 0.7 | |
| Explain an alternative way to clean if patients can't brush their teeth | 3.5 ± 0.7 | |
| Explain the importance of using dental floss and/or interdental brush for oral cleaning | 3.6 ± 0.6 | |
| Explain the effect of oral cleaning | 3.6 ± 0.6 | |
| Explain the importance of using a toothbrush for oral cleaning | 3.6 ± 0.6 | |
| Factor 2: Check the patient’s oral condition | ||
| Check tooth mobility | 3.5 ± 0.7 | |
| Check the gingival bleeding | 3.5 ± 0.7 | |
| Check for dental caries | 3.6 ± 0.6 | |
| Check for gingival edema | 3.6 ± 0.6 | |
| Check for oral malodor | 3.5 ± 0.7 | |
| Check for contamination in the mouth | 3.6 ± 0.6 | |
| Check for conditions involving mastication such as biting | 3.5 ± 0.7 | |
| Check the number of missing teeth | 3.4 ± 0.7 | |
| Check for any sharp pain when eating hot or cool food | 3.4 ± 0.7 | |
| Check for dry mouth | 3.5 ± 0.6 | |
| Factor 3: Explain the knowledge necessary for oral management including that about periodontal disease being a diabetic complication | ||
| Explain the association between periodontal diseases and diabetes | 3.8 ± 0.4 | |
| Explain the importance of oral management for diabetes management | 3.8 ± 0.5 | |
| Explain the necessity of controlling of blood sugar for oral management | 3.8 ± 0.5 | |
| Explain the necessity of dental consultation if the patients have subjective oral symptoms | 3.8 ± 0.4 | |
| Explain periodontal disease | 3.7 ± 0.5 | |
| Explain the importance of regular dental checkups | 3.8 ± 0.5 | |
| Explain the association between periodontal disease and other diabetic complications | 3.8 ± 0.5 | |
| Explain the importance of showing the diabetes cooperation notebook to the dentist during dental consultation | 3.8 ± 0.5 | |
| Factor 4: Education to enhance self-efficacy of patients with type 2 diabetes about the oral management | ||
| Check patients’ concerns about oral condition | 3.6 ± 0.6 | |
| Check patients’ subjective oral symptoms | 3.6 ± 0.6 | |
| Check the patient’s oral cavity | 3.5 ± 0.7 | |
| Evaluate the patient’s oral condition using an oral assessment tool | 3.4 ± 0.7 | |
| Support the patient in enhancing their self-efficacy for dental consultation | 3.5 ± 0.6 | |
| Consult the doctor about the oral management of patients with diabetes | 3.6 ± 0.6 | |
| Set goals for oral management to enhance patients’ self-efficacy | 3.4 ± 0.6 | |
| Check for dentures | 3.5 ± 0.7 | |
| Consult dental specialists regarding the oral management of patients with diabetes | 3.6 ± 0.6 | |
N = 300. Mean ± standard deviation
Attitude assessed through scoring of 40 items; 4 = “Very important,” 3 = “Important,” 2 = “Less important,” 1 = “Not important at all.” The scores range from 1 to 4
The EFA of nurses’ practice of oral management of outpatients with type 2 diabetes is shown in Table 6. Two items with high correlation coefficients and similar content were excluded. During the three analyses, three items with low factor loadings were excluded. The final solutions are presented in Table 7. Participants’ practice were highest regarding “Explain the necessity of dental consultation if the patients have subjective oral symptoms” and “Explain the importance of showing diabetes cooperation notebook to the dentist during dental consultation,” and lowest regarding “Evaluate the patient's oral condition using an oral assessment tool.”
Table 6.
Exploratory factor analysis of nurse's practice regarding oral management for outpatients with type 2 diabetes
| Factor 1 | Factor 2 | Factor 3 | Factor 4 | α | |
|---|---|---|---|---|---|
| Factor 1: Check the patient’s oral condition | 0.86 | ||||
| Check tooth mobility | 0.92 | ||||
| Check for gingival edema | 0.91 | ||||
| Check for conditions involving mastication such as biting | 0.84 | ||||
| Check for oral malodour | 0.82 | ||||
| Check for dental caries | 0.80 | ||||
| Check for gingival bleeding | 0.78 | ||||
| Check for dentures | 0.76 | ||||
| Check for any sharp pain when eating hot or cool food | 0.75 | ||||
| Check the number of missing teeth | 0.74 | ||||
| Check for contamination in the mouth | 0.73 | ||||
| Check for dry mouth | 0.71 | ||||
| Check the patient's oral cavity | 0.50 | ||||
| Factor 2: Explain the knowledge necessary for oral management including that about periodontal disease being a diabetic complication | 0.88 | ||||
| Explain the importance of oral management for diabetes management | 0.90 | ||||
| Explain the necessity of controlling of blood sugar for oral management | 0.88 | ||||
| Explain the association between periodontal diseases and diabetes | 0.88 | ||||
| Explain the association between periodontal disease and other diabetic complications | 0.84 | ||||
| Explain the importance of regular dental checkups | 0.81 | ||||
| Explain periodontal disease | 0.77 | ||||
| Explain the necessity of dental consultation if the patients have subjective oral symptoms | 0.76 | ||||
| Explain the importance of showing diabetes cooperation notebook to the dentist during consultation | 0.71 | ||||
| Factor 3: Explaining self-care for maintaining good oral health | 0.86 | ||||
| Explain the importance of using mouth rinse for oral cleaning | 0.91 | ||||
| Explain oral cleaning for self-care | 0.89 | ||||
| Introduction to items for self-care | 0.84 | ||||
| Explain the importance of using dental floss and/or interdental brush for oral cleaning | 0.81 | ||||
| Explain an alternative way to clean if patients can't brush their teeth | 0.70 | ||||
| Explain the effect of oral cleaning | 0.68 | ||||
| Explain the importance of using a toothbrush for oral cleaning | 0.56 | ||||
| Explain salivary gland massage | 0.50 | ||||
| Explain the decrease in salivary secretion due to aging | 0.48 | ||||
| Factor 4: Support the collaboration with multiple medical departments for oral management of patients | 0.85 | ||||
| Consult the doctor about the oral management of patients with diabetes | 0.75 | ||||
| Check patients’ concerns about oral condition | 0.57 | ||||
| Consult dental specialists regarding the oral management of patients with diabetes | 0.57 | ||||
| Check patients’ subjective oral symptoms | 0.50 | ||||
| Set goals for oral management to enhance patients’ self-efficacy | 0.46 | ||||
| Support the patient in enhancing their self-efficacy for dental consultation | 0.44 | ||||
| Factor correlation | Factor 1 | 0.57 | 0.68 | 0.69 | |
| Factor 2 | 0.61 | 0.64 | |||
| Factor 3 | 0.63 |
N = 300. Principal factor method, promax rotation
α: Cronbach’s alpha
Table 7.
Final oral management items regarding nurses' practice for outpatients with type 2 diabetes
| Practice | |
|---|---|
| Factor 1: Check the patient's oral condition | |
| Check tooth mobility | 1.5 ± 0.8 |
| Check for gingival edema | 1.5 ± 0.8 |
| Check for conditions involving mastication such as biting | 1.5 ± 0.8 |
| Check for oral malodor | 1.6 ± 0.8 |
| Check for dental caries | 1.7 ± 0.9 |
| Check for gingival bleeding | 1.5 ± 0.8 |
| Check for dentures | 1.9 ± 1.0 |
| Check for any sharp pain when eating hot or cool food | 1.4 ± 0.7 |
| Check the number of missing teeth | 1.5 ± 0.7 |
| Check for contamination in the mouth | 1.5 ± 0.7 |
| Check for dry mouth | 1.6 ± 0.8 |
| Check the patient's oral cavity | 1.5 ± 0.7 |
| Factor 2: Explain the knowledge necessary for oral management including that about periodontal disease being a diabetic complication | |
| Explain the importance of oral management for diabetes management | 2.5 ± 1.0 |
| Explain the necessity of controlling of blood sugar for oral management | 2.5 ± 1.0 |
| Explain the association between periodontal diseases and diabetes | 2.6 ± 1.0 |
| Explain the association between periodontal disease and other diabetic complications | 2.5 ± 1.0 |
| Explain the importance of regular dental checkups | 2.6 ± 1.0 |
| Explain periodontal disease | 2.3 ± 1.0 |
| Explain the necessity of dental consultation if the patients have subjective oral symptoms | 2.8 ± 1.1 |
| Explain the importance of showing diabetes cooperation notebook to the dentist during consultation | 2.8 ± 1.1 |
| Factor 3: Explaining self-care for maintaining good oral health | |
| Explain the importance of using mouth rinse for oral cleaning | 1.6 ± 0.8 |
| Explain oral cleaning for self-care | 1.7 ± 0.9 |
| Introduction to items for self-care | 1.5 ± 0.7 |
| Explain the importance of using dental floss and/or interdental brush for oral cleaning | 1.7 ± 0.9 |
| Explain an alternative way to clean if patients can't brush their teeth | 1.5 ± 0.8 |
| Explain the effect of oral cleaning | 1.8 ± 0.9 |
| Explain the importance of using a toothbrush for oral cleaning | 1.9 ± 1.0 |
| Explain salivary gland massage | 1.3 ± 0.6 |
| Explain the decrease in salivary secretion due to aging | 1.7 ± 0.8 |
| Factor 4: Support the collaboration with multiple medical departments for oral management of patients | |
| Consult the doctor about the oral management of patients with diabetes | 1.9 ± 0.9 |
| Check patients’ concerns about oral condition | 1.9 ± 0.8 |
| Consult dental specialists regarding the oral management of patients with diabetes | 1.6 ± 0.8 |
| Check patients’ subjective oral symptoms | 2.0 ± 0.9 |
| Set goals for oral management to enhance patients’ self-efficacy | 1.4 ± 0.7 |
| Support the patient in enhancing their self-efficacy for dental consultation | 1.7 ± 0.8 |
| Explain the risk of mouth ulcer due to dentures | 1.4 ± 0.7 |
| Explain salivary gland massage | 1.3 ± 0.6 |
| Explain the association between oral management and timing of diet | 1.8 ± 0.9 |
| Explain the effect of chewing food on oral condition | 1.8 ± 0.9 |
| Evaluate the patient’s oral condition using an oral assessment tool | 1.2 ± 0.5 |
N = 300. Mean ± standard deviation
Practice is calculated by scoring 40 items; 4 = “Always,” 3 = “Sometimes” 2 = “Rarely,” 1 = “Never.” The scores range from 1 to 4
The results of the logistic regression models of nurses’ practice of oral management of outpatients with type 2 diabetes are shown in Table 8. The participants who strongly felt “I’m not confident about the oral management of people with diabetes” were less likely to practice oral management (Factor 1: odds ratio [OR] = 0.55; 95% confidence interval [CI] 0.37–0.83; Factor 2: OR = 0.35; 95% CI 0.18–0.70; Factor 3: OR = 0.38; 95% CI 0.24–0.61; Factor 4: OR = 0.29; 95% CI 0.18–0.49). Participants who had more experience in oral management education in patients with diabetes were better at explaining the knowledge necessary for oral management, including periodontal disease as a diabetic complication (Factor 2: OR = 2.67; 95% CI 1.01–7.02). These nurses were also better at supporting collaboration with multiple specialists for the oral management of patients (Factor 4: OR = 2.65; 95% CI 1.24–5.65).
Table 8.
Logistic regression models of nurses' practice regarding oral management of outpatients with type 2 diabetes
| Factor 1 (N = 240) |
Factor 2 (N = 241) |
Factor 3 (N = 241) |
Factor 4 (N = 241) |
||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| OR | 95%CI | OR | 95%CI | OR | 95%CI | OR | 95%CI | ||||||
| Knowledge | |||||||||||||
| Factor 1: Bidirectional relationship between diabetes and periodontal disease | 10–40 | 0.99 | [0.88, | 1.11] | 1.07 | [0.90, | 1.26] | 0.95 | [0.84, | 1.07] | 0.97 | [0.85, | 1.09] |
| Factor 2: Patients with high priority for oral management | 6–24 | 0.96 | [0.83, | 1.12] | 0.85 | [0.67, | 1.07] | 1.01 | [0.86, | 1.18] | 1.09 | [0.92, | 1.28] |
| Factor 3: Eating habits for prevention of periodontal disease | 3–12 | 0.87 | [0.69, | 1.10] | 1.09 | [0.77, | 1.53] | 1.01 | [0.79, | 1.29] | 1.07 | [0.83, | 1.38] |
| Factor 4: Dental referral for prevention of periodontal disease | 3–12 | 1.28 | [0.95, | 1.74] | 1.30 | [0.85, | 2.01] | 1.42 | [1.03, | 1.97] | 1.16 | [0.84, | 1.60] |
| Attitude | |||||||||||||
| Factor 1: Explaining self-care for maintaining good oral health | 13–52 | 0.97 | [0.88, | 1.08] | 0.99 | [0.85, | 1.15] | 1.07 | [0.96, | 1.19] | 1.00 | [0.90, | 1.11] |
| Factor 2: Check the patient's oral condition | 10–40 | 1.13 | [1.00, | 1.28] | 1.17 | [0.96, | 1.43] | 0.99 | [0.87, | 1.14] | 1.15 | [1.00, | 1.32] |
| Factor 3: Explain the knowledge necessary for oral management including that about periodontal disease being a diabetic complication | 8–32 | 1.00 | [0.87, | 1.15] | 1.09 | [0.89, | 1.33] | 1.05 | [0.91, | 1.22] | 1.06 | [0.92, | 1.23] |
| Factor 4: Education to enhance self-efficacy of patients with type 2 diabetes about the oral management | 7–28 | 0.96 | [0.81, | 1.15] | 0.87 | [0.65, | 1.18] | 0.90 | [0.74, | 1.09] | 0.78 | [0.62, | 0.99] |
| Check for dentures | 1–4 | 1.35 | [0.60, | 3.01] | 1.03 | [0.31, | 3.49] | 1.31 | [0.55, | 3.12] | 0.90 | [0.37, | 2.21] |
| Consult dental specialists regarding the oral management of patients with diabetes | 1–4 | 0.62 | [0.26, | 1.52] | 0.50 | [0.12, | 2.04] | 0.81 | [0.32, | 2.06] | 1.90 | [0.74, | 4.91] |
| “I’m not confident about the oral management of people with diabetes” | Yes/no | 0.55 | [0.37, | 0.83] | 0.35 | [0.18, | 0.70] | 0.38 | [0.24, | 0.61] | 0.29 | [0.18, | 0.49] |
| Work experience as CDE, years | 0.97 | [0.92, | 1.03] | 0.96 | [0.88, | 1.06] | 0.96 | [0.90, | 1.02] | 0.93 | [0.87, | 0.99] | |
| Experience in oral management education of patients with diabetes | Yes/no | 1.51 | [0.77, | 2.94] | 2.67 | [1.01, | 7.02] | 2.01 | [0.99, | 4.08] | 2.65 | [1.24, | 5.65] |
| Institution | Hospital/clinic | 0.60 | [0.30, | 1.20] | 0.10 | [0.02, | 0.54] | 0.43 | [0.20, | 0.90] | 0.47 | [0.21, | 1.07] |
| Existence of an outpatient department specialized in diabetes care at a work institutiona | Yes/no | 1.67 | [0.80, | 3.48] | 0.69 | [0.23, | 2.06] | 1.88 | [0.85, | 4.14] | 1.14 | [0.50, | 2.62] |
| Nagelkerke’s R2 | 0.19 | 0.34 | 0.32 | 0.36 | |||||||||
| Hosmer and lemeshow's test | χ2(8) = 10.87, p = 0.21 | χ2(8) = 6.08, p = 0.64 | χ2(8) = 5.47, p = 0.71 | χ2(8) = 4.39, p = 0.82 | |||||||||
Factor 1: Check the patient's oral condition. Factor 2: Explain the knowledge necessary for oral management including that about periodontal disease being a diabetic complication. Factor 3: Explaining self-care for maintaining good oral health. Factor 4: Support the collaboration with multiple medical departments for oral management of patients
Dependent variables were transformed from continuous to binomial as “0” was considered as the minimum score of factors and “1” for the others
OR Odds ratio, CI Confidence interval
*Existence of an outpatient department specialized in diabetes care at a work institution was included in the model as possible confounding factors
Discussion
To the best of our knowledge, this study is the first to examine nurses’ knowledge, attitudes, and practices regarding the oral management of patients with type 2 diabetes, and the association between knowledge, attitude, and cognitive factors influencing nurses’ practice in Japan.
In total, 69.0% of the participants had received education on the oral management of patients with diabetes. Meanwhile, 68.8% of the participants felt that they were not confident about the oral management of people with diabetes. A previous study pointed out that the education provided to CDEs regarding oral management comprises only general information on teeth and gums [28]. This might have affected nurses’ confidence in the practice of oral management. This finding suggests that education regarding oral management for nurses needs improvement so that they can practice oral management with confidence in the diabetes outpatient department.
Although participants’ scores for knowledge and attitude toward oral management were higher, those for practice tended to be lower. The importance of educational plans for medical staff to enhance knowledge and attitudes has been suggested [29], which can help develop strategies to promote positive attitudes toward behavior [30]. Hence, providing educational support for nurses to acquire the knowledge and desirable attitudes necessary to practice oral management should be effective. The knowledge-attitude-behavior (KAB) model shows that the acquisition of knowledge leads to changes in attitudes and subsequent changes in behavior [30]. This model posits that attitude changes begin when knowledge of behaviors that need to be changed accumulates, which, over time, leads to behavioral change [30]. This might explain why, in this study’s results, the practice score tended to be lower despite nurses’ scoring higher for knowledge and attitude.
The results revealed nurses’ low scores for practice of “Evaluate the patient’s oral condition using an oral assessment tool”. The effectiveness of using oral assessment tools by nurses has been reported [31, 32]. Thus, it is essential to promote the evaluation of patients’ oral conditions using an oral assessment tool among nurses.
Moreover, this study found that oral management practice for outpatients with type 2 diabetes was negatively associated with “I’m not confident about oral management of people with diabetes.” These findings suggest that education for nurses regarding oral management needs a strategy that can enhance their confidence, which could subsequently promote not only good assessment and optimal care [33, 34], but also positive attitudes and practices toward oral management of patients with type 2 diabetes.
Meanwhile, participants who had received education about the oral management of patients with diabetes were better at explaining the knowledge necessary for oral management, including that about periodontal disease as a diabetic complication (Factor 2), and supporting the collaboration with multiple medical departments for oral management of patients (Factor 4), the association of education with checking the patient's oral condition (Factor 1) and explaining self-care for maintaining good oral health (Factor 3) were not statistically significant in the model. These findings suggest that, although previous educational content on oral management of patients with diabetes for nurses can help promote oral management regarding Factors 2 and 4, it cannot promote Factors 1 and 3. Hence, further educational plans for Factors 1 and 3 are needed. To check the patient's oral condition and assess it are important aspects of the provision of support [35]. Nurses’ successful oral assessment of patients is key to improving oral care provision for patients [25]. Nurses can accurately assess oral condition by training [36]. In particular, the assessment of patients’ oral cavities for identifying patients in need of dental care is important. Therefore, nurse education to equip them with the ability to judge patients’ oral conditions and problems is imperative. Moreover, regarding the practice of explaining self-care for maintaining good oral health, many nurses believe that medical staff do not have to provide oral health care for patients who are capable of self-care [37]. Meanwhile, the recipients of oral management by nurses include patients who can perform self-care [21]. Hence, education for nurses to perceive oral management as a basic aspect of nursing care and to develop the ability to assist patients in performing self-care is important.
In the present study, the attitude regarding education to enhance self-efficacy of patients with type 2 diabetes about oral management (Factor 4) was negatively associated with the practice of supporting collaboration with multiple medical departments for oral management of patients (Factor 4). This result suggests that nurses who do not feel the necessity of education to enhance self-efficacy of patients with type 2 diabetes about oral management tend to more readily leave the patient's oral management to dentistry.
Our results suggest that nurses as CDEs need further education to understand the importance of their practicing oral management involving oral assessments and to improve their knowledge, attitudes, and confidence. With more awareness of the guidelines [38, 39], nurses as CDEs know about the association between diabetes and periodontal disease. Meanwhile, oral management practices in medical facilities are inadequate and non-systematized, even though guidelines exist [40]. The present results also showed that the oral management of patients with type 2 diabetes is inadequate. There is a need for educational plans to enhance knowledge to promote positive attitudes toward the practice of oral management, which should include informational content regarding basic knowledge about diabetes and periodontal disease, details of standard oral management methods that nurses can perform in outpatient departments, and how to contact dentistry [20, 41]. Moreover, to promote oral management and support patients with diabetes, new educational tools to promote oral management as routine work should be developed for medical staff, including nurses [20]. If oral management of outpatients with type 2 diabetes is practiced by more nurses in a range of medical facilities, they can practice oral management by assessing the general condition of patients from the perspective of diabetes management. Furthermore, this may be useful for preventing diabetes complications in patients.
Limitations
The present study has some limitations. First, although this study included 1,277 facilities in Japan, data from participants who provided valid responses constituted only 23.4% of all respondents. The participants in this study may have a relatively high interest in the oral management of patients with diabetes. Second, nurses’ knowledge about the bidirectional relationship between diabetes and periodontal disease was measured using a self-report questionnaire completed by participants. For this reason, there may be a difference between the participants’ reports and the actual amount of knowledge amongst nurses. Moreover, although the participants in this study were CDEs, not all nurses specialized in providing care at outpatient departments for patients with diabetes in Japan [42]. Hence, further studies should collect data in a more representative manner. Third, the cross-sectional design of this study prevented the examination of causal relationships between cognitive factors and nursing practice for supporting dental treatment. Further prospective studies are required to confirm these findings.
Conclusion
In summary, we conducted a cross-sectional survey at a national level using a self-reported questionnaire to examine the association of knowledge and attitude with CDE nurses’ oral management practices at medical facilities in Japan. In this study, we set H1 and H2 as hypotheses. As H1, we thought that nurses as CDEs had lower levels of knowledge, attitude, and practice regarding oral management. As for H2, we thought that nurses as CDEs who have higher levels of knowledge about the bidirectional relationship between periodontal disease and diabetes, and higher levels of attitude, would practice oral management more frequently than those with lower levels of knowledge and attitude. Surprisingly, the results showed that participants had higher levels of knowledge and attitude regarding oral management, while few CDE nurses engaged in oral management. In other words, despite their higher levels of knowledge and attitude, they did not frequently practice oral management.
Oral management of outpatients with type 2 diabetes was negatively associated with “I’m not confident about oral management of people with diabetes.” Experience of education was positively associated with the explanation about the knowledge necessary for oral management, including that about periodontal disease being a diabetic complication and supporting the collaboration with multiple specialists for the oral management of patients. Meanwhile, the education experience was not statistically significant for checking a patient’s oral condition and the explanation about self-care for maintaining good oral health. These findings suggest that a better education strategy for nurses as CDEs is needed to understand the importance of practicing oral management and improving their knowledge, attitudes, confidence and practice.
Acknowledgements
This work was supported by the Japan Society for the Promotion of Science under JSPS KAKENHI (Grant Number 19K10946). The authors declare no conflict of interest.
Declarations
Human rights statement and informed consent
All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (institutional and national) and with the Helsinki Declaration of 1964 and later versions. Informed consent or substitute for it was obtained from all patients for inclusion in the study.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.FDI World Dental Federation. White paper on prevention and management of periodontal diseases for oral health and general health; 2018. https://www.fdiworlddental.org/sites/default/files/media/resources/gphp-2018-white_paper-en.pdf. Accessed 04 Jan 2019.
- 2.Kassebaum NJ, Bernabe E, Dahiya M, Bhandari B, Murray CJ, Marcenes W. Global burden of severe periodontitis in 1990–2010: a systematic review and meta-regression. J Dent Res. 2014;93:1045–1053. doi: 10.1177/0022034514552491. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Dye BA. Global periodontal disease epidemiology. Periodontol. 2000;2012(58):10–25. doi: 10.1111/j.1600-0757.2011.00413.x. [DOI] [PubMed] [Google Scholar]
- 4.Petersen PE, Ogawa H. The global burden of periodontal disease: towards integration with chronic disease prevention and control. Periodontol. 2000;2012(60):15–39. doi: 10.1111/j.1600-0757.2011.00425.x. [DOI] [PubMed] [Google Scholar]
- 5.Claydon NC. Current concepts in toothbrushing and interdental cleaning. Periodontol. 2000;2008(48):10–22. doi: 10.1111/j.1600-0757.2008.00273.x. [DOI] [PubMed] [Google Scholar]
- 6.Kassebaum NJ, Bernabe E, Dahiya M, Bhandari B, Murray CJ, Marcenes W. Global burden of severe tooth loss: a systematic review and meta-analysis. J Dent Res. 2014;93:20–28. doi: 10.1177/0022034514537828. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7.Ministry of Health, Labour and Welfare. Patient research; 2014. (in Japanese) https://www.mhlw.go.jp/toukei/saikin/hw/kanja/14/. Accessed 25 Nov 2019.
- 8.Ministry of Health, Labour and Welfare. Patient research; 2017. (in Japanese) https://www.mhlw.go.jp/toukei/saikin/hw/kanja/17/dl/02.pdf. Accessed 25 Nov 2019.
- 9.D’Aiuto F, Gable D, Syed Z, Allen Y, Wanyonyi KL, White S, Gallagher JE. Evidence summary: the relationship between oral diseases and diabetes. Br Dent J. 2017;222:944–948. doi: 10.1038/sj.bdj.2017.544. [DOI] [PubMed] [Google Scholar]
- 10.Nelson RG, Shlossman M, Budding LM, Pettitt DJ, Saad MF, Genco RJ, Knowler WC. Periodontal disease and NIDDM in Pima Indians. Diabetes Care. 1990;13:836–840. doi: 10.2337//diacare.13.8.836. [DOI] [PubMed] [Google Scholar]
- 11.Mauri-Obradors E, Estrugo-Devesa A, Jane-Salas E, Vinas M, Lopez-Lopez J. Oral manifestations of diabetes mellitus. A systematic review. Med Oral Patol Oral Cir Bucal. 2017;22:586–594. doi: 10.4317/medoral.21655. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Brennan DS, Spencer AJ, Roberts-Thomson KF. Quality of life and disability weights associated with periodontal disease. J Dent Res. 2007;86:713–7. doi: 10.1177/154405910708600805. [DOI] [PubMed] [Google Scholar]
- 13.Luo H, Wu B. Self-awareness of “gum disease” among US adults. J Public Health Manag Pract. 2017;23:1–7. doi: 10.1097/PHH.0000000000000408. [DOI] [PubMed] [Google Scholar]
- 14.Poudel P, Griffiths R, Wong VW, Arora A, Flack JR, Khoo CL, George A. Oral health knowledge, attitudes and care practices of people with diabetes: a systematic review. BMC Public Health. 2018;18:1–12. doi: 10.1186/s12889-018-5485-7. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15.Kishimoto H, Oishi Y, Nagaosa S. From oral care to oral management: the importance of medical-dental collaboration. Japan Medical Journal. Tokyo: Japan Medical Journal; 2009; pp. 54–8. (in Japanese)
- 16.Ministry of Health, Labour and Welfare. Survey of medical facilities (static and dynamic). Outline of hospital report; 2019. (in Japanese) https://www.mhlw.go.jp/toukei/saikin/hw/iryosd/19/dl/02sisetu01.pdf. Accessed 3 Sep 2021.
- 17.The jaw bone necrosis review committee. Pathophysiology and management of bone resorption inhibitor-related osteonecrosis of the jaw: jaw bone necrosis review committee position paper; 2016. (in Japanese) https://www.jsoms.or.jp/medical/wp-content/uploads/2015/08/position_paper2016.pdf. Accessed 3 Oct 2020.
- 18.Kudoh R, Shibayama T, Hidaka K. The role of knowledge and self-efficacy on dental consultation behavior of patients with type 2 diabetes. Jan J Nurs Sci. 2021;18:1–9. doi: 10.1111/jjns.12378. [DOI] [PubMed] [Google Scholar]
- 19.International Diabetes Federation. Guideline on oral health for people with diabetes. 2009. file:///C:/Users/ftxsm/Downloads/OralHealth_EN_RTP.pdf. Accessed 21 Nov 2018.
- 20.American Association of Diabetes Educators. AADE thought leader summit: diabetes and oral health; 2016. https://www.diabeteseducator.org/docs/default-source/default-document-library/aade-diabetes-oral-health-white-paper.pdf?sfrsn=2. Accessed 25 Mar 2020.
- 21.Henderson V. Basic principles of nursing care. Genève: International Council of Nurses; 2004. [Google Scholar]
- 22.Pai RR, Ongole R, Banerjee S. Oral care in cancer nursing: practice and barriers. Indian J Dent Res. 2019;30:226–230. doi: 10.4103/ijdr.IJDR_343_17. [DOI] [PubMed] [Google Scholar]
- 23.Kawaguchi T. Certified diabetes expert nurse and nurse educators in Japan. Diabetes Res Clin Pract. 2007;77:205–207. doi: 10.1016/j.diabres.2007.01.058. [DOI] [PubMed] [Google Scholar]
- 24.The Certification Board for Diabetes Educators in Japan What is the Certified Diabetes Educator in Japan?; 2020. (in Japanese) https://www.cdej.gr.jp/modules/general/index.php?content_id=1. Accessed 18 Jun 2021.
- 25.Shibayama T, Kudoh R, Hidaka K. Factors associated with the practice of periodontal management by diabetes educator nurses for outpatients with diabetes: a nationwide survey in Japan. Prim Care Diabetes. 2021;15:819–824. doi: 10.1016/j.pcd.2021.05.004. [DOI] [PubMed] [Google Scholar]
- 26.Chung MC, Juang WC, Li YC. Perceptions of shared decision making among health care professionals. J Eval in Clin Pract. 2019;25:1080–1087. doi: 10.1111/jep.13249. [DOI] [PubMed] [Google Scholar]
- 27.Fukuda Y, Yabata Y, Imai H. Health promotion at a glance: theory and practice guidebook. Saitama: National Institute of Public Health; 2008. (in Japanese) https://www.niph.go.jp/soshiki/ekigaku/hitomedewakaru.pdf. Accessed 24 Feb 2019.
- 28.Lopes MH, Southerland JH, Buse JB, Malone RM, Wilder RS. Diabetes educators' knowledge, opinions and behaviors regarding periodontal disease and diabetes. J Dent Hyg. 2012;86:82–90. [PubMed] [Google Scholar]
- 29.Yi Q, Hohashi N. Comparison of perceptions of domestic elder abuse among healthcare workers based on the Knowledge-Attitude-Behavior (KAB) model. PLoS ONE. 2018;13:1–14. doi: 10.1371/journal.pone.0206640. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 30.Baranowski T, Cullen KW, Nicklas T, Thompson D, Baranowski J. Are current health behavioral change models helpful in guiding prevention of weight gain efforts? Obes Res. 2003;11:23–43. doi: 10.1038/oby.2003.222. [DOI] [PubMed] [Google Scholar]
- 31.Miller M, Kearney N. Oral care for patients with cancer: a review of the literature. Cancer Nurs. 2001;24:241–254. doi: 10.1097/00002820-200108000-00001. [DOI] [PubMed] [Google Scholar]
- 32.Ohrn KE, Wahlin YB, Sjödén PO. Oral care in cancer nursing. Eur J Cancer Care. 2000;9:22–29. doi: 10.1046/j.1365-2354.2000.00185.x. [DOI] [PubMed] [Google Scholar]
- 33.Ab Malik N, Yatim SM, Lam O, Jin L, McGrath C. Oral health care guidelines, training, and resources among stroke care providers. JDR Clin Trans Res. 2017;2:312–319. doi: 10.1177/2380084417693784. [DOI] [PubMed] [Google Scholar]
- 34.Alja'afreh MA, Mosleh SM, Habashneh SS. Nurses' perception and attitudes towards oral care practices for mechanically ventilated patients. Saudi Med J. 2018;39:379–385. doi: 10.15537/smj.2018.4.21749. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Kudoh R, Shibayama T. Concept analysis of oral care in nursing practices at hospitals:Using the Rogers evolutionary method. J Dent Hlth. accepted.
- 36.Warren J, Levy S, Hand S. The accuracy of tooth loss data collected by nurses. Spec Care Dentist. 1999;19:75–78. doi: 10.1111/j.1754-4505.1999.tb01372.x. [DOI] [PubMed] [Google Scholar]
- 37.Lee YJ, Noh HJ, Han SY, Jeon HS, Chung WG, Mun SJ. Oral health care provided by nurses for hospitalized patients in Korea. Int J Dent Hyg. 2019;17:336–342. doi: 10.1111/idh.12417. [DOI] [PubMed] [Google Scholar]
- 38.Japanese Society of Periodontology. Periodontal treatment guidelines for diabetic patients 2014 revision, 2nd ed; 2015. (in Japanese). http://www.perio.jp/publication/upload_file/guideline_diabetes.pdf. Accessed 26 Nov 2019.
- 39.Japan Diabetes Society . Diabetes clinical practice guidelines 2019. Tokyo: Nankodo; 2019. [Google Scholar]
- 40.Coker E, Ploeg J, Kaasalainen S, Fisher A. A concept analysis of oral hygiene care in dependent older adults. J Adv Nurs. 2013;69:2360–2371. doi: 10.1111/jan.12107. [DOI] [PubMed] [Google Scholar]
- 41.Talbot A, Brady M, Furlanetto DL, Frenkel H, Williams BO. Oral care and stroke units. Gerodontology. 2005;22:77–83. doi: 10.1111/j.1741-2358.2005.00049.x. [DOI] [PubMed] [Google Scholar]
- 42.Kodaira K. The present situation of nursing and the future subjects about diabetic education. J Tokyo Woman’s Med Univ. 2007;2:1–9. [Google Scholar]