Dental Visits Among Dentate Adults with Diabetes --- United States, 1999 and 2004

One of the major complications of diabetes is periodontal disease (1), a chronic infection of tissues supporting the teeth and a major cause of tooth loss. Adults with diabetes have both a higher prevalence of periodontal disease and more severe forms of the disease (2), contributing to impaired quality of life and substantial oral functional disability (3). In addition, periodontal disease has been associated with development of glucose intolerance and poor glycemic control among adults with diabetes (4,5). Regular dental visits provide opportunities for prevention, early detection, and treatment of periodontal disease among dentate adults (i.e., those having one or more teeth); moreover, regular dental cleaning improves glycemic control in patients with poorly controlled diabetic conditions (6,7). One of the national health objectives for 2010 is to increase the proportion of persons with diabetes who have an annual dental examination to 71% (revised objective 5-15) (8). To estimate the percentage of dentate U.S. adults aged >18 years with diabetes who visited a dentist within the preceding 12 months, CDC analyzed data from the Behavioral Risk Factor Surveillance System (BRFSS) surveys for 1999 and 2004. This report describes the results of that analysis, which indicated that, in 2004, age-adjusted estimates in only seven states exceeded 71% and estimated percentages for four states and District of Columbia (DC) increased significantly from their levels in 1999. The findings underscore the need to increase awareness and support for oral health care among adults with diabetes, including support for national and state diabetes care management programs.

BRFSS uses state-based telephone surveys to collect data about major health-risk behaviors, use of preventive health practices, and access to health care among a representative sample of noninstitutionalized adults aged >18 years in the 50 states, DC, Guam, Puerto Rico, and the U.S. Virgin Islands. In 1999, three oral health questions were included for the first time in the BRFSS rotating core questionnaire and asked of all survey participants, and two of these questions were used in this analysis: 1) "How long has it been since you last visited a dentist or a dental clinic for any reason?" and 2) "How many of your permanent teeth have been removed because of tooth decay or gum disease?" These questions were last included in the 2004 BRFSS survey. Persons with diabetes were defined as respondents who answered "yes" to the core question, "Has a doctor ever told you that you have diabetes?" Because BRFSS data are state-specific, median annual prevalences are reported instead of national averages. The median response rate in 2004 across 49 states and DC was 52.7% (range: 32.2% [New Jersey]--66.6% [Nebraska]); 25,736 respondents for whom age data were available reported having been told by a doctor they had diabetes (excluding women told so only during pregnancy). Of these, 82% were dentate. Approximately 0.01% of the survey participants provided no information on the dental visit question. All estimates were age-adjusted to the 2000 U.S. adult population. Differences in estimates were considered statistically significant if their 95% confidence intervals (CIs) did not overlap.

In 2004, among states/areas, the median estimated age-adjusted percentage of dentate adults with diabetes who had a dental visit during the preceding 12 months was 67% (range: 49.1%--83.3%). The estimated percentage, including the lower confidence limit, was >71% in seven states: Kansas, Minnesota, Nebraska, Pennsylvania, Rhode Island, Utah, and Wisconsin (Table 1). The lowest percentages were in Arkansas, Florida, Georgia, Louisiana, Mississippi, New York, South Carolina, Texas, West Virginia, and Wyoming. The estimated percentage increased significantly from 1999 to 2004 in Arizona, Kansas, Minnesota, Ohio, and DC, but decreased significantly in North Carolina. The lowest estimated percentage in any one state/area increased from 37% in 1999 (DC) to 49.1% in 2004 (Mississippi).

The age-adjusted estimated prevalence was significantly associated with race/ethnicity, education level, income level, smoking status, health insurance status, and having taken a course in diabetes management (Table 2). Estimated percentages were lower among non-Hispanic blacks, persons with lower education and income, those who lacked health insurance, and those who had never taken a course or class in how to manage their diabetes.

Reported by: PI Eke, PhD, GO Thornton-Evans, DDS, Div of Oral Health; GL Beckles, MD, Div of Diabetes Translation, National Center for Chronic Disease Prevention and Health Promotion, CDC.

Editorial Note:

One of the revised national health objectives for 2010 is to increase the proportion of adults with diabetes who have an annual dental examination to at least 71% (objective 5-15). The results of this study indicate that only seven states had reached this objective as of 2004. Further research is needed to identify real or perceived barriers that might underlie the lower estimated percentage among dentate adults with diabetes in the other states.

The results also indicate that attendance at classes to manage diabetes was associated with having had a dental visit during the preceding 12 months among dentate adults with diabetes. Lack of health insurance was significantly associated with not having had a dental visit. The National Diabetes Education Program (NDEP) recommends that persons with diabetes receive oral health management education, including instructions in oral self-care and oral self-examination. NDEP emphasizes that adults, even those without teeth, should receive at least one dental examination per year (9). In the general population, lack of health insurance, particularly dental insurance, is associated with less use of dental services and poorer oral health (10). Because dental insurance coverage typically is provided as an employee benefit, persons who are unemployed are less likely to have dental insurance. In addition, this report indicates that current smokers were less likely to have had a dental visit during the preceding 12 months than nonsmokers. Smoking is known to be strongly associated with periodontal disease (3). Measures that public health organizations can implement to increase the frequency of dental visits among persons with diabetes include 1) increasing public and professional awareness of diabetes as a risk factor for several oral conditions, 2) monitoring the oral health of persons with diabetes, 3) increasing access to dental care by providing dental coverage for adults with diabetes, 4) expanding partnerships between organizations focused on oral health and diabetes care (e.g., the American Dental Association and the American Diabetes Association), and 5) supporting tobacco-use cessation programs targeting persons with diabetes.

The findings in this report are subject to at least four limitations. First, because the BRFSS sample was drawn from a noninstitutionalized population, it excludes adults not residing in households (e.g., those in nursing homes or long-term--care facilities). Second, because the survey was conducted by telephone, it excludes persons without residential telephone service (e.g., those with lower incomes and those residing in households that use cellular telephones only). Third, the accuracy of survey participants' self-report of their dental visit was not validated against dental records, and their responses might be subject to recall bias or the tendency to give socially desirable responses during interviews. Finally, the sample size for some states/areas (e.g., DC) was small (i.e., <50) in 1999; thus, these estimates should be interpreted with caution.

Overall, in most states/areas, estimates for dental visits during the preceding 12 months among adult with diabetes 1) have not reached the targets set by the national health objectives for 2010 or 2) have not increased from estimates in 1999. These trends underscore the need to increase awareness of the importance of oral health in diabetes care management at the state and national levels. Diabetes education programs in states should emphasize personal and professional preventive dental care for all persons with diabetes, with emphasis on non-Hispanic blacks, persons with lower education and income, and those who lack health insurance.

References

1. Loe H. Periodontal disease---the sixth complication of diabetes mellitus. Diabetes Care 1993;16(Suppl 1):329--34.
2. Tomar SL, Lester A. Dental and other health care visits among U.S. adults with diabetes. Diabetes Care 2000;23:1505--10.
3. US Department of Health and Human Services. Oral health in America: a report of the Surgeon General. Rockville, MD: US National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.
4. Saito T, Shimazaki Y, Kiyohara Y, et al. The severity of periodontal disease is associated with the development of glucose intolerance in non-diabetics: the Hisayama Study. J Dent Res 2004;83:485--90.
5. Taylor G. Periodontal treatment and its effects on glycemic control, 1999. Oral Surg Oral Med Oral Pathol 1999;87:311--6.
6. Committee on Research, Science, and Therapy, American Academy of Periodontology. Diabetes and periodontal disease. J Periodontol 2000;71:664--78.
7. Grossi SG, Skrepcinski FB, DeCaro T, et al. Treatment of periodontal disease in diabetics reduces glycated hemoglobin. J Periodontol 1999;68:713--9.
8. US Department of Health and Human Services. Healthy people 2010---midcourse review. Washington, DC: US Department of Health and Human Services; 2005. Available at www.healthypeople.gov/data/midcourse.
9. National Diabetes Education Program. Working together to manage diabetes: a guide for pharmacists, podiatrists, optometrists, and dental professionals. Bethesda, MD: US Department of Health and Human Services, National Institutes of Health; 2004. Available at http://www.ndep.nih.gov/diabetes/pubs/catalog.htm.
10. Damiano PC, Shugars DA, Johnson JD. Expanding health insurance coverage and the implications for dentistry. J Public Health Dent 1992;52:52--8.

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Date last reviewed: 11/22/2005