| Abstract|| |
Aim: The aim of this study was to compare audio-visual and verbal education on oral health related quality of life, dental anxiety and dental neglect, on diabetes mellitus patients attending Teerthanker Mahaveer Hospital, Moradabad. Materials and Method: The current longitudinal interventional study was conducted to check the efficiency of audio-visual and verbal education on OHRQoL, Dental anxiety and dental neglect, on diabetes mellitus patients attending Teerthanker Mahaveer Hospital, Moradabad, U.P., India. A 14-item questionnaire, OHIP-14, with emphasis on seven proportions of impact was used to collect information on OHRQoL. Corah Dental Anxiety Scale (DAS) will be used to collect data on Dental Anxiety. A prevalidated revised proforma of Dental Neglect Scale (DNS) was used to gather information on Dental Neglect. The questionnaire was a six-question instrument related to dental problems. After collecting the initial baseline data, the sample was divided into two groups: verbal education group (n = 1030) and audio-visual education group (n = 1030). Then oral health education (OHE) was provided verbally to Group I patients and OHE with audio-visual aids was given to Group II patients visiting Teerthanker Mahaveer Hospital. OHE was repeated every 2 months. At every 6, 12 and 18 months, questionnaire was repeated to evaluate the effectiveness of OHE. Inspection will be conducted under natural daylight in hospital premises. To avoid the disruption while conducting the examination, adequate supply of instruments was taken. Instruments were sterilized by autoclaving in the college. Results: A total of 1926 patients attended all the follow-up and review examinations. Subject dropout for Group I was 2% with 1009 at 6th month; 3% with 978 at 12th month and 1% with 967 at 18th month. Subject dropout rate for Group II was 3% with 999 at 6th month; 0% with 999 at 12th month and 4% with 959 at 18th month. The difference of subject dropout among the groups was not statistically significant (P = 0.23). Group mean total OHIP-14 score after 18 months was recorded as 15.36 ± 8.61, whereas in Audio-visual education group mean total OHIP-14 score after 18 months was recorded as 14.42 ± 7.59. At the end of study mean DAS score for DAS ≥15 (severe anxiety) was found to be 1.95 ± 2.18 in verbal education group, whereas in audio-visual education group mean DAS score for DAS ≥15 (severe anxiety) was found to be 2.24 ± 1.98. At the end of the study mean DN score for DNS ≥15 (severe Dental Neglect) was found to be 3.54 ± 2.63 in verbal education group, whereas audiovisual education group mean DN score for DNS ≥15 (severe Dental Neglect) was found to be 2.59 ± 2.75. Conclusion: The quality of life is a factor that can be considerably affected by oral health, which in turn reflects the general health of an individual. The main part of oral disease prevention is done by use of personal oral hygiene measures and maintaining oral hygiene. It is the duty of dental professionals to motivate, show and instruct patients to maintain appropriate oral health and oral hygiene. The study concludes that the program of this kind may be beneficial in improving many dimensions of dental health of an individual that includes physical health, emotional well-being, OHRQoL, inter-personal relationship and the fear related to dental treatment.
Keywords: Audio-visual health education, dental anxiety, dental neglect, oral health impact profile (OHIP), verbal health education
|How to cite this article:|
Jain A, Tangade P, Singh V, Yadav P, Yadav J. Comparative evaluation of audio-visual and verbal education method on OHRQoL, dental anxiety, dental neglect of diabetes mellitus patients attending a teaching hospital in India. Indian J Dent Res 2021;32:354-61
|How to cite this URL:|
Jain A, Tangade P, Singh V, Yadav P, Yadav J. Comparative evaluation of audio-visual and verbal education method on OHRQoL, dental anxiety, dental neglect of diabetes mellitus patients attending a teaching hospital in India. Indian J Dent Res [serial online] 2021 [cited 2022 May 26];32:354-61. Available from: https://www.ijdr.in/text.asp?2021/32/3/354/338133
| Introduction|| |
As there is a new concept of health that not only concerns physical and mental well-being but also considers emotional and social well-being on the same multi-dimensional concept OHRQoL works. OHRQoL takes into account various aspects of health viz. physical, social, psychological, mental, and emotional and hence will lead to overall wellbeing of an individual. Overall wellbeing should be visualized aside from just mental and physical health when rendering health services to the community. As the OHRQoL becomes significant for consideration so thus the need for the scale to measure it and hence many questionnaires have been prepared to calculate OHRQoL. These questionnaires are being used in many research studies to measure OHRQoL.,
The quality of life has been a recent focus on health-related research. Restrictions in diet, use of medication, concomitant disease and symptoms of diabetes may cause deterioration in the HRQoL.
Research proved that diabetes has detrimental effects on OHRQoL and Oral Health. Morbidity is contributed due to periodontal disease because of decrease in oral function and increase in tooth loss risk and impacts OHQRoL. After the continuous repetition of oral health education and with the help of WHO proforma, OHIP-14 Questionnaire, DAS, DNS changes in the oral health and attitude towards dental problem was determined. It has been determined that due to lack of knowledge regarding dental health and fear and anxiety related to dental treatment and due to metabolic changes related to diabetes mellitus they are suffering from various dental ailments.
When the OHRQoL was determined with other clinical indices to check the overall well-being of the patient then only the comprehensive assessment of the patient can be done.,,
The knowledge related to OHRQoL and oral disorders in patients with diabetes is needed to show the importance of the same. Many studies have shown that oral disorders affect the quality of life but their impact on patients suffering from diabetes is not measured. There is less evidence showing that subjects are aware of the increased risk of oral disorders in patients suffering from diabetes.,
Dental anxiety in population is also related to their negligence towards dental care. An investigation leads to the conclusion “a vicious cycle of dental fear,” according to which people neglect dental treatment because of fear related to dental treatment (Armfeld et al.) and when people become aware of their worsened condition, they become more anxious towards dental treatment and this anxiety again leads to avoidance towards dental care.
No former studies have been conducted to check the association between Oral Health Education and Dental Neglect so we tried to check the association between them.
Oral health education as defined by Kay is any learning activity aimed at improving the individual's knowledge, attitude and skills in relation to oral health. It provides information required for modifying attitude and changing the individual's behaviour. The purpose of this study is to impart awareness among the people and to educate the communities as a whole. The effect of interventions, such as oral health education in populations, has been reported to be beneficial, leading to improvement in oral health awareness. This, among other reasons, makes oral health education an important aspect of the activities conducted by primary oral healthcare centres.,,,,,,,
Hence, this study will be conducted to compare Audio-visual and verbal education method on OHRQoL, Dental Anxiety, Dental Neglect, Oral Health status and Treatment Needs of Diabetes Mellitus Patients attending Teerthanker Mahaveer Hospital, Moradabad.
| Methodology|| |
The current longitudinal interventional study was piloted to check the efficiency of Audio-visual and verbal education on OHRQoL, Dental Anxiety, Dental Neglect on Diabetes Mellitus Patients attending Teerthanker Mahaveer Hospital, Moradabad, U.P., India. A 14-item questionnaire, OHIP-14, emphasizes on seven proportions of impact was used to collect information on OHRQoL. Corah Dental Anxiety Scale (DAS) will be used to collect data on Dental Anxiety. A pre-validated revised proforma of Dental Neglect Scale (DNS) was used to gather information on Dental Neglect. The questionnaire was a 6-question instrument related to dental problems.
Proportion in first group P1 =0.6857 (68.57%)–OHRQoL in first method
Proportion in second group P2 = 0.7569 (75.69%)–OHRQoL in second method
Risk difference (P1–P2) = –7.1120 = d
Power of the test (%) = 95
Alpha error α (%) = 5
Side = 2
Sample size was determined on the base of pilot study. The formula that was used for sample size derivation was as follows:
P = proportion or prevalence of between two groups, q = 100–p
d or e = Clinically acceptable error between the two groups
where Za = a-level Z-value = 1.96
Zb = b-level Z-value = 1.682.
Sample size n = 1030 should be taken in each method (1030 + 1030 = 2060).
The study subjects will be allocated into two groups:
Verbal Group (n = 1030): Health Education will be given verbally to the patients.
Audio-visual Group (n = 1030): Health Education with audio-visual Aids will be imparted to patients.
The study was conducted in the hospital after taking prior permission from the Medical Superintendent of Teerthanker Mahaveer Hospital, Moradabad.
The ethical clearance was taken by the institutional ethical clearance committee of Teerthanker Mahaveer University, Moradabad previous to beginning of the study.
To avoid any future problems in study and to confirm their participation, the participants were informed about the entire procedure before the commencement of study and after the written informed consent was obtained from the concerned patient.
Schedule of survey
Hospital authorities were informed prior about the scheduled date of conduction of the survey. A reminder was also given a day prior to the scheduled date. The data was collected during the months of October 2017 to April 2019.
Calibration and training of the examiner
To overcome any discrepancy in the examination procedure and to check the validity and to calibrate the examiner, the examiner was trained under the able guidance of Professor and Head of Department of Public Health Dentistry, Teerthanker Mahaveer Dental College and Research Centre (TMDC&RC). To measure the intra-examiner reliability, a group of 30 participants were examined in the department at two different time periods and under similar conditions. Approximately 85%–95% value of kappa statistics was found in all the assessments, which suggest high conformity between the observations.
Training of the recording clerk
The examiner was assisted by a recording clerk who was trained and instructed about recording the data on the assessment form in the Department of Public Health Dentistry, TMDC&RC.
- Subjects who will be 18 years or older.
- Subjects diagnosed with Type I and Type II diabetes mellitus.
- Subjects who were willing to participate and gave written informed consent.
- Subjects with poorly controlled diabetes.
- Subjects with any complications that arise due to diabetes mellitus that may lead to hospitalization.
- Subjects with a risk for bacterial endocarditis.
- Subjects suffering from hypertension and who were on certain calcium channel blockers that could enhance gingival hyperplasia.
- Subjects who need several tooth extractions.
- Subjects who underwent periodontal treatment before 6 months of commencement of study.
- Subjects who are undergoing any kind of orthodontic treatment.
The patients who are clinically diagnosed with Type I (insulin-dependent) and Type II (non-insulin dependent) Diabetes Mellitus were divided into two groups. Group I was patients with Type I (Insulin Dependent) diabetes mellitus and Group II was patients with Type II (Non-Insulin dependent) Diabetes Mellitus. These two groups were further divided into Group A1 and A2 in which oral health education was given with the help of Audio-visual aids and in Group B1 and B2 in which Oral Health Education was given verbally. After giving the baseline Oral Health education with the appropriate method, the education was repeated at after each 2 months for 18 months and the clinical examination was done at an interval of 6th, 12th, and 18th month.
Descriptive and inferential statistics were done in the present study. The tests which were applied were Chi-square, Z-test, Spearman's Correlation and logistic regression analysis on categorical data. The level of significance was assessed at 5%. Microsoft Word and Excel was used to prepare graphs and tables. Software that was used for analysis was SPSS 26.0.
| Result|| |
Oral health impact profile -14 questionnaire
Verbal education group
Mean total OHIP-14 score after 18 months was recorded as 15.36 ± 8.61. Mean OHIP-14 score for individual domain was recorded and was found to be 2.10 ± 2.06 for functional limitation, 1.92 ± 1.90 for Physical Pain, 2.49 ± 2.18 for psychological discomfort, 1.86 ± 2.37 for Physical Disability, 1.83 ± 1.87 for Psychological Disability, 2.58 ± 2.29 for Social Handicap and 1.95 ± 2.28 for Handicap [Table 1] and [Table 2].
|Table 1: Mean OHIP-14 Score in Verbal education group and Audio-visual education group at Baseline, at 6th month, at 12th month and at 18th month|
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|Table 2: Mean Difference among Verbal Education Group and Audio-visual Education Group in OHIP-14 Domain Score at Baseline, at 6th month, 12th month and at 18th month|
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Audio-visual education group
Mean Total OHIP-14 score after 18 months was recorded as 14.42 ± 7.59. Mean OHIP-14 score for individual domain was recorded and was found to be 2.48 ± 2.31 for functional limitation, 2.50 ± 1.73 for physical pain, 1.97 ± 1.84 for psychological discomfort, 2.75 ± 2.41 for physical disability, 2.61 ± 1.64 for psychological disability rather than psychological discomfort, 1.87 ± 1.75 for social handicap and 2.84 ± 2.32 for Handicap.
Corah's dental anxiety scale
Verbal education group
Mean DAS score for DAS ≥15 (severe anxiety) was found to be 1.95 ± 2.18. Mean DAS score for DAS <15 (less-than-severe anxiety) was found to be 2.17 ± 1.89.
Audio-visual education group
Mean DAS score for DAS ≥15 (severe anxiety) was found to be 2.24 ± 1.98. Mean DAS score for DAS <15 (less-than-severe anxiety) was found to be 1.96 ± 2.05 [Table 3] and [Table 4].
|Table 3: Mean Dental Anxiety Score in Verbal Education Group and Audio-Visual Education at Baseline, at 6th month, at 12th month and at 18th month|
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|Table 4: Mean Difference among DAS in Verbal Education Group and Audio-Visual Education Group at Baseline, at 6th month, 12th month and at 18th month|
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Dental neglect among type I and type II diabetes mellitus patients
Verbal education group
Mean DN score for DNS ≥15 (severe Dental Neglect) was found to be 3.54 ± 2.63. Mean DNS <15 (Appropriate Dental Care) was found to be 2.75 ± 2.72 [Table 5] and [Table 6].
|Table 5: Mean Dental Neglect Score in Verbal Education Group and Audio-Visual Education Group at Baseline, at 6th month, at 12th month and at 18th month|
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|Table 6: Mean Difference among DN Score in Verbal Education Group and Audio-Visual Group at Baseline, at 6th month, 12th month and at 18th month|
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Audio-visual education group
Mean DN score for DNS ≥15 (severe Dental Neglect) was found to be 2.59 ± 2.75. Mean DNS <15 (Appropriate Dental Care) was found to be 3.61 ± 2.41.
| Discussion|| |
Every aspect of diabetic patients can be checked using various forms like surveying patients by themselves. Advancement of suitable questionnaire made the task much easier for adults suitable for their age. The public opinion poll offers an estimated target of the patient's physical, mental, emotional and social well-being. In this study, OHIP-14 questionnaire was used to collect information.
Sum of OHIP-14 score was listed as 36.87 ± 16.12 at baseline, 28.29 ± 13.70 at 6th month, 21.04 ± 10.17 at 12th month, 15.36 ± 8.61 at 18th month. Oral symptoms, functional limitations, emotional well-being and social well-being were used as each domain in mean score.
After 18 months, patient health education program mean domain were brought down to half.
This study determines the outcome of diabetic patients enhancing their perception of oral health care, family life, physical and emotional well-being. In addition, patients deal with their self-concept. The result of our study was in accordance with study conducted by Carvalho JC and Khalifa N, et al., according to them OHE improves OHRQoL.
In the study done by us tooth score was lowered at 6th, 12th and 18th month, whereas patients who had undergone dental treatment had increased score of filled tooth. Thus, due to imparting of proper OHE, the OHRQoL was improved and hence the number of decayed teeth was reduced and the number of filled teeth was increased and it can be predicted that group health education approach can improve the health of patients with DM.
Anxiety related to dental treatments is one of the most important concerns in today's world. It is food for thought for dental professional as well as to society as a whole. The patients are too anxious for the treatment that they do not cooperate with the dentists thus leading to difficulties for the dentist and also leading to unsatisfactory treatment.
In verbal Education Group DAS ≥15 (severe anxiety) was recorded as 7.84 ± 5.04 at baseline, 5.41 ± 4.45 at 6th month, 3.79 ± 3.47 at 12th month, 1.95 ± 2.18 at 18th month. DAS <15 (less-than-severe anxiety) was recorded as 8.46 ± 4.78 at baseline, 6.38 ± 3.69 at 6th month, 4.29 ± 2.42 at 12th month, 2.17 ± 1.89 at 18th month. In audio-visual Education Group DAS <15 (less-than-severe anxiety) was recorded as 7.79 ± 5.07 at baseline, 5.81 ± 4.31 at 6th month, 3.74 ± 3.16 at 12th month, 1.96 ± 2.05 at 18th month. DAS ≥15 (severe anxiety) was recorded as 8.71 ± 4.76 at baseline, 6.63 ± 3.67 at 6th month, 4.82 ± 2.51 at 12th month, 2.24 ± 1.98 at 18th month.
The results in both the groups were statistically significant and thus it can be said that as any sort of health education helps in combating dental fear among the patients and this is better tool to improve the prevalence of dental diseases.
One of biggest concerns is the delay in seeking dental treatment. DN is one of the most alarming situations in today's world is postponement and delay of dental treatment. Delay in treatment also results in making the treatment more complex and difficult. In India, most dental hospitals are not well equipped for emergency treatment. To impart emergency treatment, well equipped dental clinics are needed with specialized facilities and very few such clinics are available today. Hence OHE programmes should be encouraged to combat the dental neglect among the DM patients.
Nonverbal Education Group DNS ≥15 (severe Dental Neglect) was recorded as 8.92 ± 5.82 at baseline, 6.76 ± 4.81 at 6th month, 4.31 ± 3.48 at 12th month, 2.59 ± 2.75 at 18th month. DNS <15 (Appropriate Dental Care) was recorded as 8.97 ± 5.86 at baseline, 6.76 ± 4.81 at 6th month, 4.26 ± 3.59 at 12th month, 2.75 ± 2.72 at 18th month. In audio-visual Education Group DNS ≥15 (severe Dental Neglect) was recorded as 8.92 ± 5.82 at baseline, 6.76 ± 4.81 at 6th month, 4.31 ± 3.48 at 12th month, 2.59 ± 2.75 at 18th month. DNS <15 (Appropriate Dental Care) was recorded as 9.26 ± 6.24 at baseline, 7.79 ± 4.72 at 6th month, 5.48 ± 3.59 at 12th month, 3.61 ± 2.41 at 18th month.
The results in both the groups were statistically significant and thus it can be said that as any sort of health education helps in combating the dental fear among the patients and this is better tool to improve awareness about dental diseases. The result of current study was in accordance with studies by Irani et al. and Allen et al. who found that T2DM did not impact OHRQoL. Nevertheless, it was found that chronic periodontitis and gingivitis were associated with poorer OHRQoL in non-diabetic patients. One possible explanation for the lack of association between diabetes and OHRQoL, was that diabetic patients may have been more concerned about other health problems related to their diabetes. Therefore, they may not have prioritized oral health as having a significant impact on their well-being. The study was in contradiction with Khalifa N, et al. who found that Diabetes Mellitus is not affected by OHRQoL.
This study has few limitations, though the questionnaire was administered by the examiner and though it showed effective cooperation, it is difficult to determine cause-effect relationship. Future studies need large sample size to be adopted by Case- control designs. Whenever studies will be organized in future, it should include certain other perspectives like social, political and cultural factors of the participants. There are many other techniques which can be used in such programmes like demonstration, drama and methods that include instructions for the patients.,,
| Conclusion|| |
As the oral health related quality of life becomes important, so does the need for the scale to measure it and hence many questionnaires have been prepared to calculate OHRQoL. These questionnaires are being used in many research studies to measure OHRQoL. The current study represents a pioneering approach to evaluating the possible welfares of oral health promotion on Oral health, OHRQoL, Dental anxiety and Dental Neglect. After the continuous repetition of oral health education and with the help of WHO proforma, OHIP-14 Questionnaire, DAS, DNS changes in the oral health and attitude towards dental problem was determined. It has been determined that due to lack of knowledge regarding dental health and fear and anxiety related to dental treatment and due to metabolic changes related to diabetes mellitus, they are suffering from various dental ailments. It was found through the study that continuous reinforcement of OHE results in an improved OHRQoL, reduced dental anxiety, reduced dental neglect and improved oral health status. The aim of such programs were to reinforce the knowledge in diabetic patients regarding the ill effects of this metabolic condition on oral cavity and how DM is interlinked to the Oral Health. To guard and preserve oral health of patients suffering from Diabetes mellitus, tremendous amount of importance should be attached to health promotion programs. The programs should consider oral health, anxiety related to dental problems, dental neglect due to fear and the OHRQoL. Thus the study concludes that programs of this kind may be beneficial in improving many dimensions of dental health of an individual that includes physical health, emotional well-being, OHRQoL, interpersonal relationships, the fear related to dental treatment, the anxiety related to dental treatment, the delay in assessing dental care due to dental neglect. The magnitude of OHRQoL is such that it can result in improving the mental health of an individual. The final measurements of the study reveal that the study population (patients with Type I and II DM) depicts a sense of autonomy. Generalizability of the findings and results of the study can be done.
Though the findings can be generalized, there is still the need for further studies in the future to assess the effectiveness of OHE on OHRQoL, dental anxiety and dental neglect. Social, cultural, political aspects of health can also be considered in some future studies to know about the overall effect of OHE. Apart from verbal and audio-visual education, certain other methods can be used like use of instruction method, drama and demonstration.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Dr. Ankita Jain
Department of Public Health Dentistry, Teerthanker Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]