The outcomes in this study demonstrate that the proposed intervention program improved the glycaemic and oral hygiene status in T2DM older patients with chronic periodontitis. On completion of the program, the patients’ glycaemic values significantly decreased when comparing the DOC group and the control group at 3- and 6-months follow-ups. The results showed an improvement in HbA1c value in the intervention group from 8.94–8.08% in 3-month, and 8.08–7.83% in 6-month. Therefore, the program could reduce HbA1c 0.86% in 3-month, and 0.25% in 6-month. However, the reduction of HbA1c level did not meet the target of American Diabetes Association treatment goal that the HbA1c level must be reduced to less than 7.5 in healthy older people12. In other previous studies24–27, periodontal therapy in diabetic patients could significantly reduce HbA1c levels from 0.29–0.64% in 3-month and 0.2% in 6-month after completion of the therapy 28. As the combination of lifestyle changes and dental care program also decreased HbA1c (0.29%) after 3-months follow-ups, whereas the HbA1c increased 0.09% in the control group19. Simpson et al.13 found periodontal therapy could reduce the HbA1c values of 0.29% at 3-month and 0.02% at the 6-month period. However, the effect of periodontal treatment alone on uncontrolled type 2 diabetes mellitus in Thai older subjects was not significant although HbA1C values for the treatment group dropped by -0.2% three months after completion of the treatment29. Similar to full-mouth non-surgical scaling and root planing, it could improve periodontal health, but it had no significant effects on glycaemic control based on HbA1c values of -0.04%30.
The oral hygiene status of participants, including OHI-S in the intervention group, also decreased after the DOC program was finished, and it showed the improvement of the OHI-S score when compared with the control group. Previous research showed a similar result that non-surgical periodontal therapy and oral hygiene instruction of T2DM subjects with chronic periodontitis could reduce the plaque index by more than 80% after three months31. Intensive oral hygiene care for periodontitis in T2DM patients could significantly reduce the plaque index after six months32. The oral health instruction of periodontitis patients with T2DM also reduced plaque index significantly, and HbA1c was reduced by 0.2% within 6-months period, although the difference was not statistically significant33.
In this study, the component of the Health Belief Model, perceived susceptibility, perceived severity, perceived benefit of diabetic older patients increased in the DOC group. This increase can be attributed to the effect of education, presenting the image on a slide presentation, distributing leaflets, interactions of patients in the group training and individual oral hygiene consulting also could increase their understanding. The perceived barrier of these patients decreased due to the education intervention, oral care practising, available of dental treatment services, distributing a package of oral care tools. Moreover, perceived self-efficacy also increased by empowering the patient’s practical training to increase the capability of controlling and managing their oral health care behaviours continuously. Similar to the previous study found that knowledge, behaviour and attitude toward T2DM and oral health were increased after the intervention19 whereas the education package in T2DM patients did not affect knowledge scores between the two groups after one month34 due to lack of motivation periods. Moreover, a similar study based on the Health Belief Model to promote the oral and dental health of patients with type 2 diabetes mellitus, three months after the intervention, awareness of the patients and perceived susceptibility, benefits, self-efficacy, internal cue to action, and performance in oral and dental hygiene-related behaviours had increased in the intervention group35.
The strengths of this study are 100% response rate, the use of biomarkers to examine outcomes, and a double-blinded technique due to our study has gathered data in one place that dentists and interviewers did not know that patients come from interventions or control groups. Moreover, patients did not know which group they belong to, and there is less contamination between the two groups because they lived in a remote village, and we made an appointment at different times. The limitation of this study is to reduce the oral hygiene index from the DOC program, which cannot ensure that the decline came from changes in oral health behaviour or scaling and root planing treatment since our program included of both activities. We suggest that future research should have a longer follow-up period or repeat DOC program at six months per year. For immediate action, with the potential benefit to all diabetic patients, the DOC program could be used routinely in other health centres or hospitals at least every six months. For further action, we recommend that the policy should make fast-track dental services for diabetic patients to receive scaling and root planning every 6 months for preventing periodontal disease and control glycaemic status. Finally, the program needs to be repeated in other contexts such as in different provinces and cross cultures to confirm the positive effects and broad application in various settings.