BODY MASS INDEX AS A PROXY INDICATOR FOR POOR ORAL HYGIENE HABITS IN ADULT DIABETIC PATIENTS Martin RANFL1*, Blaž VURZER1, Lijana ZALETEL-KRAGELJ2 1National Institute of Public Health, Regional unit Murska Sobota, Ulica arhitekta Novaka 2b, 9000 Murska Sobota, Slovenia 2University of Ljubljana, Faculty of Medicine, Chair of Public Health, Zaloška cesta 4, 1000 Ljubljana, Slovenia Received: Mar 16, 2022 Accepted: Sep 6, 2022 Original scientific article *Corresponding author: Tel. + 386 2 5302 139; E-mail: martin.ranfl@nijz.si 10.2478/sjph-2022-0028 Zdr Varst. 2022;61(4):209-215 209 INDEKS TELESNE MASE KOT NADOMESTNI KAZALNIK SLABIH NAVAD USTNE HIGIENE MED ODRASLIMI DIABETKI © National Institute of Public Health, Slovenia. Ranfl M, Vurzer B, Zaletel-Kragelj L. Body mass index as a proxy indicator for poor oral hygiene habits in adult diabetic patients. Zdr Varst. 2022;61(4):209-215. doi: 10.2478/sjph-2022-0028. ABSTRACT Keywords: oral hygiene, diabetics, health promotion, public health, health expenditures, primary health care IZVLEČEK Ključne besede: ustna higiena, sladkorni bolniki, promocija zdravja, javno zdravje, izdatki v zdravstvu Aim: To analyse if body mass index (BMI) could be used as a fast proxy indicator of poor oral hygiene habits (POHH) among the adult population with diabetes mellitus. Methods: Adults, aged 25-74, from the Slovenian 2016 nationwide cross-sectional survey based on the Countrywide Integrated Non-Communicable Disease Intervention (CINDI) Health Monitor methodology, who reported being diabetic, were included in the study (n=560). We assessed the relationship between POHH and BMI, adjusted to confounders, using multiple binary logistic regression. Results: In the total sample, the POHH prevalence was 50.9%. Taking into account BMI, POHH prevalence in participants with normal BMI values was only 37.8%, in the overweight group it was 1.22-times higher (46.0%), while in the obese group it was 1.63-times higher (61.6%) (p<0.001). Also, the odds for POHH were 2.64-times higher in the obese group in comparison to the normal BMI group (95% CI: 1.55-4.51; p<0.001). After adjustment for confounders, this OR decreased only moderately (OR=2.45; 95% CI: 1.35-4.44; p=0.003). Conclusions: BMI could be used as a readily assessable, fast, simple, and cheap tool indicating higher odds for having POHH among the diabetic population. By defining the high-risk group it could be easier for physicians and dentists to take further referrals and actions for promoting oral health in this group. The suggested tool can save time and could have an important positive impact on the quality of life of diabetics, as well as on health expenditures. Namen: Oceniti uporabnost indeksa telesne mase (ITM) kot nadomestnega kazalnika za oceno slabih navad ustne higiene med odraslimi sladkornimi bolniki. Metode: V raziskavo smo vključili odrasle osebe, stare 25–74 let, iz nacionalne presečne raziskave, izvedene leta 2016 v Sloveniji po metodologiji CINDI Health Monitor, ki so poročale o tem, da so sladkorni bolniki (n = 560). Moč povezanosti med slabimi navadami ustne higiene in ITM smo ob upoštevanju motečih dejavnikov ocenili s pomočjo binarne logistične regresije. Rezultati: Prevalenca slabih navad ustne higiene je v celotni skupini sladkornih bolnikov znašala 50,9 %. Ob upoštevanju ITM je ta med posamezniki z normalnim ITM znašala 37,8 %, pri osebah s prekomerno težo je bila 1,22-krat višja (46,0 %), med debelimi pa 1,63-krat višja (61,6 %) (p < 0,001). Tudi obeti za slabe navade ustne higiene so bili pri debelih 2,64-krat višji kot pri normalno prehranjenih (95 % IZ 1,55–4,51; p < 0,001). Ob upoštevanju motečih dejavnikov se je to razmerje obetov le zmerno znižalo (RO = 2,45; 95-odstotni IZ 1,35-4,44; p = 0,003). Zaključki: ITM lahko uporabimo kot lahko dostopno, hitro in enostavno oceno za ugotavljanje povečanega tveganja za slabe navade ustne higiene med sladkornimi bolniki. Z opredelitvijo sladkornih bolnikov s povečanim tveganjem bi lahko izbrani osebni zdravniki in zobozdravniki enostavneje pristopili k nadaljnjim napotitvam in aktivnostim promocije ustnega zdravja. Predlagani kazalnik je časovno ugoden, njegova uporaba pa ima lahko pozitivne učinke tako na kakovost življenja sladkornih bolnikov kot tudi izdatke v zdravstvu. 1 INTRODUCTION Oral health is an integral part of general health, and oral diseases have a significant impact on the quality of life and lead to higher healthcare costs (1). Oral health and general health are associated (2), as well as oral health-related and health-related quality of life (3). Many diseases show signs or symptoms in the oral cavity. Health problems in the oral cavity can either be the first, only or even the most severe manifestation of a systemic disease, additionally oral health problems can be a leading cause in a deterioration in quality of life (4). Different untreated oral diseases can lead to tooth loss, which affects self-rated general health (2) not to mention the ability to eat, speak and interact with people. Although oral health problems usually do not represent health emergencies, they prolong the state of pain and suffering, and cause-functional, aesthetic, nutritional and psychological problems (5). Periodontitis, which is one of the most prevalent oral diseases, could be a potential contributing risk factor for a wide array of clinically important systemic diseases, such as cardiovascular diseases, autoimmune disorders, pregnancy complications as well as diabetes mellitus (DM) (6). The main factor for developing periodontitis is formation of bacterial plaque on tooth surfaces. However, some studies also suggest that poor glycaemic control is associated with higher risk for developing periodontitis (7). On the other hand, conventional periodontal treatment (scaling and root planning) results in a statistically significant reduction in glycated haemoglobin levels (8). The evidence supports a two-way relationship between oral health and DM, namely that DM has adverse effects on periodontal health, while periodontal infections have an adverse effect on glycaemic control (9, 10). The research shows that DM with a persistent hyperglycaemia leads to an exaggerated inflammatory response to the periodontal bacteria in dental plaque. The high vascularity of the inflamed periodontium, on the other hand, serves as an endocrine-like source for TNF-α and other inflammatory mediators, which affect the glucose and lipid metabolism and can act as an insulin antagonist (9). There is also an association between obesity and periodontitis, as the data indicates that an increased BMI is associated with a higher risk of developing periodontitis and that the underlying biological mechanisms of this association involve adipose tissue-derived cytokines (11). Furthermore, there is some evidence of a triangular association among DM, obesity and periodontitis (12). Diabetics with poorer anthropometric indices (e.g., high BMI values) have poorer values of periodontal indices. But on the other hand, the reduction in BMI seems to be associated with improvements in periodontal status in patients with type 2 DM (13). Good oral health which is achieved with adequate oral self-care (e.g., hygiene, 10.2478/sjph-2022-0028 Zdr Varst. 2022;61(4):209-215 210 dental check-ups and a healthy lifestyle) is thus important in obese, diabetic patients. Unfortunately, focusing on oral health in diabetics is sometimes considered of lower importance compared to other diabetic complications. General practitioners thus rarely inform their patients with DM about the association of their main disease and periodontal disease (14). An important part of oral self-care is oral hygiene (e.g., regular tooth brushing), which is imperative for maintaining a proper level of oral health and for its improvement. A recent systematic review with meta-analysis showed that the risk of periodontitis is increased approximately two to five times by poor oral hygiene compared to good oral hygiene (15). According to the International Diabetes Federation, the prevalence of DM (the age-adjusted comparative prevalence in adults from 20-79 years as a percentage) in Slovenia is about 5.8% (e.g., in Europe it is 7.0%) (16), while according to the Institute for Health Metrics and Evaluation Global Burden of Disease Study the prevalence is even higher, being 8.9% (17). Additionally, as a single disease it is in 7th place in terms of disabilities (18). On the other hand, in the Slovenia poor oral hygiene habits, with tooth brushing only once a day or less, are present in 35.7% of the population, and are more prevalent in men and those with lower education (19). The reported prevalence of inadequate oral hygiene habits is higher compared to some other European countries (20). The relatively high prevalence of DM and a high prevalence of poor tooth-brushing habits means that dentists and general practitioners in Slovenia will meet such patients quite often. In order to be able to develop evidence-based guidelines for public health activities in terms of promoting oral hygiene in the diabetic population and provide a readily accessible indicator for poor oral hygiene for general practitioners, the aim of our study was to assess if body mass index (BMI) could be used as a fast proxy indicator of poor oral hygiene habits (POHH) among the adult population with diabetes mellitus. Within this framework, the objective of the study was to assess the strength of association between BMI and POHH in Slovenian adults. 2 METHODS 2.1 Study design and time frame We used data from the last series of the nationwide cross-sectional health-related lifestyle studies based on the World Health Organization Countrywide Integrated Non-Communicable Disease Intervention (CINDI) (21) methodology, which was conducted in Slovenia in 2016 by the National Institute of Public Health. 10.2478/sjph-2022-0028 Zdr Varst. 2022;61(4):209-215 211 had seven categories (employed, self-employed, student, housekeeper, pensioner, unemployed and other). For the purpose of analysis, the data were combined into four categories (employed, self-employed, retired/housekeeper and unemployed). Those who chose the category “other” were excluded. The category “employed” consisted of those who were employed and those who were students, and the category “retired/housekeeper” consisted of those who were housekeepers and pensioners. In order to get the clearest possible estimate of the strength of the relationship between BMI and POHH, all listed factors were considered as confounding factors in the analysis. 2.5 Methods of analysis The association among POHH, BMI and other confounding factors, was assessed univariately using the chi-square test. Additionally, the odds ratio for POHH between groups with different BMI values was calculated. The reference group consisted of participants with normal BMI. The association among POHH, BMI as the main factor and the confounding factors was assessed also multivariately by using binary multiple logistic regression. For this purpose, a direct method was used. Dummy variables were created for BMI and all confounding variables with the simple method. In all statistical tests, p≤0.05 was considered significant. The IBM SPSS for Windows Version 21.0 (SPSS Inc., Chicago, IL., USA) software was used. 3 RESULTS 3.1 Sample description A total of 8,590 invitees responded to the invitation to participate in the survey (response rate: 54.9%). Among them, there were 560 participants with self-reported DM (6.6%). After the exclusion of all edentulous participants, we got the final sample, which included 466 dentate diabetic subjects, 255 (54.7%) men and 211 (45.3%) women. The majority of them were 55 years or older (67.6%). None of the participants had a BMI value <18.5, while 40.5% of them had a BMI value ≥30. 3.2 Results of the univariate analysis The POHH prevalence in the total sample was 50.9%. When taking into account the BMI of the participants, POHH prevalence was the lowest in the group with a BMI value ˂25.0 (37.8%). In the overweight group POHH prevalence was 1.22 times higher, while in the obese group it was 1.63 times higher compared to the group with normal BMI values (Table 1). The odds for POHH were also much higher in the obese group than in the group of participants with a BMI value ˂25.0 (OR=2.64). Additional results showed that POHH prevalence was also much higher in males, and in those with the lowest education. Detailed results are presented in Table 1. 2.2 Sampling procedure, data collection process and inclusion criteria The Statistical Office of Slovenia prepared a representative sample of N=15,639 residents, aged 25-74, using a simple random sampling method. An invitation letter with a printed questionnaire was sent to the participants, who could choose to respond through a postal or online version of the questionnaire. Every participant in the sample could answer only once, which was achieved with unique codes assigned to the participants. To increase the response rate, three reminder letters were sent. For the purpose of our study, we selected participants with DM based on the question whether or not they had previously been diagnosed with DM by their general practitioner or diabetologist. Those diabetics who had all their teeth missing, based on self-reports, were excluded from the study. 2.3 Observed outcome Oral hygiene habits were assessed with the question “How often do you brush your teeth?”, which was also the only oral hygiene related question. The participants could choose between five available answers (multiple times daily, twice daily, once daily, less than once daily, never). For the purpose of the analysis, we combined the answers into two categories: brushing teeth twice daily or more and brushing teeth once daily or less. Poor oral hygiene habits (POHH) were chosen as the observed outcome and were defined as brushing teeth once daily or less (0-no, 1-yes). 2.4 Risk factors for POHH BMI, as a main factor, was calculated from self-reported data about body weight (in kg) and body height (in m). For the purpose of the analysis the participants were categorized into four groups. Depending on the value of their BMI, they were classified into the underweight (<18.5), normal (18.5-24.9), overweight (25.0-29.9) or obese group (≥30.0). Other factors included in our analysis were socio- demographic: gender, age, educational level and type of work. Age of the participants was calculated from the reported year of birth and was aggregated into five 10-year categories (25-34, 35-44, 45-54, 55-64, 65-74). Regarding the educational level, participants could choose one of seven categories (incomplete primary, primary, vocational, secondary, college, university and postgraduate level of education). For the purpose of analysis, the data were aggregated in four categories (primary or less, vocational, secondary, college and higher). The category primary or less combined the incomplete primary and primary levels of education, and the category college and higher combined the college, university and postgraduate levels of education. The question about employment status 212 10.2478/sjph-2022-0028 Zdr Varst. 2022;61(4):209-215 Table 1. Table 2. Estimates of the prevalence of poor oral hygiene habits (POHH) considering selected risk factors in a diabetic population and the results of the univariate analysis (chi-square) of the association between POHH and the risk factors: using data from a cross-sectional study, conducted in Slovenia in 2016. The results of the multivariate analysis of the association between poor oral hygiene habits and selected risk factors: using data from a cross-sectional study, conducted in Slovenia in 2016 (N=437). Legend: Ntot=total number of respondents, NPOHH=number of participants with poor oral hygiene, Ncat=number of respondents within the category Legend: OR=odds ratio, CI=confidence interval 3.3 Results of the multivariate analysis After adjusting the relationship between POHH and BMI for confounding factors, the odds for POHH in the obese participants decreased only slightly in comparison to the group with a BMI value ˂25.0 (Table 2). Additional results showed that in the multivariate model, gender (category males) and education level (category primary BMI Gender Age (years) Education level Employment status BMI Gender Age (years) Education level Employment status <18.5 18.5-24.99 25-29.99 ≥30 Men Women 25-34 35-44 45-54 55-64 65-74 Primary or less Vocational Secondary College or higher Employed, student Self-employed Retired/housekeeper Unemployed <25 25.0-29.9 ≥30.0 Female Male 65-74 25-34 35-44 45-54 55-64 Vocational Primary or less Secondary school College or higher Employed, student Self-employed Retired/housekeeper Unemployed Ncat Upper Risk factor Risk factor Category Category NPOHH/Ncat (%) p Ntot OR 95% CI for OR limits pNPOHH Lower 0 82 189 185 253 209 18 38 92 164 150 96 118 147 98 146 15 258 26 2.389 4.445 4.365 11.197 3.282 3.801 1.887 3.677 1.954 1.905 3.290 4.111 2.611 0.0 37.8 46.0 61.6 61.7 37.8 50.0 39.5 52.2 50.6 53.3 62.5 48.3 51.0 41.8 45.2 53.3 55.4 42.3 0.367 0.003 <0.001 0.063 0.675 0.181 0.705 0.028 0.583 0.884 0.955 0.020 0.964 456 462 462 459 445 1 1.316 2.454 1 2.836 1 3.238 1.233 1.719 1.108 1 1.989 1.158 1.046 1 1.034 2.152 1.022 <0.001 <0.001 0.661 0.033 0.187 0 31 87 114 156 79 9 15 48 83 80 60 57 75 41 66 8 143 11 0.725 1.355 1.843 0.936 0.463 0.778 0.651 1.076 0.686 0.574 0.325 1.126 0.400 or less) remained statistically significant factors, while employment status (category retired/housekeeper) became a statistically significant factor only in the multivariate model (Table 2). The value of the model’s Nagelkerke’s R Square statistic was 0.149, while the value of the Hosmer- Lemeshow goodness of fit test was 15.244 (p=0.055). 10.2478/sjph-2022-0028 Zdr Varst. 2022;61(4):209-215 213 4 DISCUSSION The results of our study suggest that BMI can serve as a useful indicator in a simple and rapid assessment of diabetic patient risk for POHH, and consequently for the existence of potential oral diseases that may impair the stability of DM. The results of our study related to the prevalence of POHH in a diabetic population are consistent with the results of other, similar studies. The systematic review of oral health attitudes, knowledge and practices presented in Poudel et al. revealed that slightly more than half of the participants with DM brushed their teeth only once daily or less (49.3% brushed their teeth twice a day, 95% CI 35.70–62.90) (22). However, there exist studies reporting higher as well as lower rates of POHH among DM patients. In a Finnish study, for example, poor oral hygiene was present in 62% (23) of the sample, while a study by Commisso et al. performed on a diabetic population in central Italy revealed that the prevalence of POHH was 28.8% (7). Similarly in the study of Bowyer et. al. performed in the United Kingdom the prevalence was 32.8% (24). Thus, the prevalence of POHH among diabetics in Slovenia is not among the highest in the literature, but this does not mean that it does not pose a problem, as it is much higher than in the general population, where it is around 36% (19). This makes oral hygiene in the Slovenian diabetic population an important public health problem, which is even greater when we consider the results of past studies which suggested that the majority of diabetics had inadequate oral health knowledge and low awareness of the association between DM and the risks for oral health complications (22, 24). The high strength of association between POHH and obesity was unsurprising, due to the fact that regular tooth brushing is also one of the elements of a healthy lifestyle. The literature suggests that obese persons in general are less likely to brush their teeth at least twice daily, and are also more likely to have higher Decayed, Missing, Filled Teeth (DMFT) scores (25, 26), which are a direct consequence of plaque-related oral diseases. Additional results of our study confirmed some socio- economic risk factors for POHH i.e., gender and education. This is in line with previous research in Slovenia (19, 27), as well as in other countries. Raskiliene et al., for example showed that male gender, a lower education and living in rural environments were associated with poorer self-reported tooth brushing frequency. Additionally, poor tooth brushing frequency was associated with an unhealthy lifestyle (smoking, along with high alcohol, low vegetable and high confectionery consumption) (25). Moreover, obese diabetic patients with socio-economic risk factors are at greater risk of oral health complications which are associated with general health problems and the health-related quality of life (2, 3). Our study has some potential limitations. First, our data were collected in a self-reported survey, and thus the actual data could be different. However, even such rough information provides a sufficient foundation for interventions at the population level. We assume that due to the self-reporting nature of our study, the results are biased towards positive answers, and consequently our conclusion about the prevalence of POHH habits in the DM population could be treated as solid. Second, only one question regarding oral hygiene habits was used in the POHH assessment. We are aware of this limitation, but we used data that are routinely collected in Slovenia in the frame of a national survey. As a result, we were able to use the data that was available. Since the survey is not only intended to study oral health, data related to oral health are limited. However, we believe that the information provided by one question is sufficient for the initial analysis. Third, one might dispute that we did not define tooth-brushing habits appropriately, as some dental experts claim that brushing once daily could be enough to maintain oral health. However, it is widely accepted that proper oral health care includes tooth brushing twice daily (28). Next, our sample was reduced as we excluded edentulous subjects, because we could not use the question on tooth brushing with this group of participants. However, the sample size was still big enough to perform the planned analysis. Next, one might think that our study highlights only a few of the biological and socio-demographic factors that influence tooth-brushing habits in the diabetic population. However, we believe that these are the most important and reasonable factors to be included in the identification of diabetics with POHH habits. Next, the p-value of the Hosmer-Lemeshow goodness-of-fit test showed a marginally good fit of the model to the data. However, the value was still within the recommended limits. Finally, one might perceive that there are many studies already published on similar topics. However, this is only true to a certain extent. Studies that were available in accessible databases, and were similar to the current work, focused on topics such as: adiposity and glycaemic control in patients with periodontal disease; on the diagnosis, treatment and prevention of oral disorders in patients with diabetes; and on the prevalence of oral health problems among diabetic patients (11, 12, 29). However, none of these earlier studies had the same focus as ours, as none of them studied the association between BMI and periodontal health in diabetics in the sense of using BMI as fast proxy indicator for risk assessment in practice. Consequently, our study presents a unique way of using BMI in clinical practice and in oral public health. On the other side, despite the potential limitations of this study one advantage is that it shows that BMI can serve as a rough, simple, cheap and always available tool to estimate which patients with DM should be referred to a preventive examination of the oral cavity. An additional advantage is that the observed relationship was controlled for with regard to selected socio-economic factors related to oral hygiene, which contributed to gaining a clearer idea of observed relationship. This study has some important implications. Tooth brushing is the cornerstone of maintaining and improving oral health, and in the scope of the bidirectional relationship between oral and general health it is even more important in a diabetic population (8, 10). Appropriate information and advice should thus be given to the diabetic population about oral health and oral hygiene practices. As such, for public health professionals our study provides the basic information needed for developing educational workshops, and making adjustments for oral health promotion materials. The facts confirmed in our study could be used to tailor and prepare health promotion material for the diabetic population. Moreover, our study also has important implications for primary care physicians and diabetologists. Oral health should not be treated as less important in an obese diabetic population, since the abilities to bite and chew are important for a healthy diet. People with poorer periodontal status and those who are edentulous have poorer masticatory performance, and it is known that higher masticatory performance prevents the occurrence of diabetes (30). For primary care physicians, BMI could be used as an indicator for referring diabetic patients to their dentists. According to our results it is a readily assessable and good proxy for assessing high-risk groups of diabetic patients regarding their oral health. It could also have an influence on the financial burden of oral diseases, on general health and consequently on the quality of life. The referral of a diabetic patient to a dentist could also improve dental self-efficacy. As dental self-efficacy (related to brushing teeth and visiting dentists) and self-efficacy in diabetes management (nutritional habits, physical exercise and insulin management) are correlated, improving one could also improve the other (31). Improved self-efficacy could lead to a better oral and general health, and thus a better quality of life. Finally, our study could have implications for dental professionals, as the process also goes in the opposite direction – dentists should consider overweight/obese individuals with poor oral hygiene as at-risk-for-DM. They should therefore ask those patients about their medical history regarding DM and direct them to their general practitioner. The proper oral hygiene of DM patients and proper management of the diabetic population in dental offices is also important, keeping in mind the bidirectional association of oral health and DM. There is also some evidence of reducing glycosylated haemoglobin in diabetic patients by periodontal therapy (scaling and root planning) in the short term, but sadly no evidence of maintaining these results for a longer period (32). Nevertheless, based on the bidirectional relationship between DM and oral health, some experts suggest that an oral health evaluation and possible onward referral should be incorporated into the recommendations for routine diabetes care (33). In the future, it would be interesting to identify the high- risk-for POHH profiles, which would be targeted with focused and consequently more individualised preventive activities. A similar approach has already been suggested to deal with other public health problems (34, 35). However, this extension of the analysis was out of scope of the current study. Next, for more detailed research about the factors influencing POHH, and to explore the attitudes toward oral health in a diabetic population, further research based on a bigger sample with specific oral health questions would be appropriate. 5 CONCLUSION Our study confirmed that BMI could be used as a fast and simple proxy indicator to identify a high-risk group of diabetic patients regarding their poor oral health habits. These results are important, due to the fact that there is a low awareness of the oral-systemic health link among diabetics and some practitioners, and they could be used for more appropriate intervention planning. Oral health has a bidirectional association with multiple conditions, including DM. Poor oral hygiene leads to worsening of oral health, and consequently to worsening of a person’s quality of life, and has also an impact on diabetes control. Professionals treating patients with DM should thus consider the association between DM and oral health, especially in obese diabetic individuals, and refer them to their dentists. On the other hand, dentists should consider the possibility of having undiscovered DM in obese patients with poor oral hygiene. Keeping in mind the association of BMI and POHH could improve the oral and general health of DM patients, which could have a positive impact on their quality of life and their diabetes management. CONFLICTS OF INTEREST All authors declare that no conflicts of interest exist. FUNDING The study was not financed by any institution. ETHICAL CONSIDERATION The legal basis for the survey and data collection rests on the National Statistics Act and on the Annual Programme of Statistical Surveys for 2016. In these documents ethical considerations are also encompassed. 10.2478/sjph-2022-0028 Zdr Varst. 2022;61(4):209-215 214 REFERENCES 1. Sheiham A. Oral health, general health and quality of life. Bull World Health Organ. 2005;83(9):644. 2. Ranfl M, Zaletel-Kragelj L. Assessment of the association between dentate status and self-rated general health. Zdr Varst. 2017;56(2):131-9. doi: 10.1515/sjph-2017-0017. 3. Sekulić S, John MT, Davey C, Rener-Sitar K. Association between oral health-related and health-related quality of life. Zdr Varst. 2020;59(2):65-74. doi: 10.2478/sjph-2020-0009. 4. Porter SR, Mercadante V, Fedele S. Oral manifestations of systemic disease. Br Dent J. 2017;223(9):683-91. doi: 10.1038/sj.bdj.2017.884. 5. Spanemberg JC, Cardoso JA, Slob EMGB, López-López J. Quality of life related to oral health and its impact in adults. J Stomatol Oral Maxillofac Surg. 2019;120(3):234-9. doi: 10.1016/j. jormas.2019.02.004. 6. Nagpal R, Yamashiro Y, Izumi Y. The two-way association of periodontal infection with systemic disorders: an overview. Mediators Inflamm. 2015;2015:793898. doi: 10.1155/2015/793898. 7. Commisso L, Monami M, Mannucci E. Periodontal disease and oral hygiene habits in a type 2 diabetic population. Int J Dent Hyg. 2011;9(1):68-73. doi: 10.1111/j.1601-5037.2009.00439.x. 8. Madianos PN, Koromantzos PA. An update of the evidence on the potential impact of periodontal therapy on diabetes outcomes. J Clin Periodontol. 2018;45(2):188-95. doi: 10.1111/jcpe.12836. 9. Taylor GW, Borgnakke WS. Periodontal disease: associations with diabetes, glycemic control and complications. Oral Dis. 2008;14(3):191-203. doi: 10.1111/j.1601-0825.2008.01442.x. 10. Mealey BL, Rethman MP. Periodontal disease and diabetes mellitus: bidirectional relationship. Dentistry Today. 2003;22(4):107-13. 11. Arboleda S, Vargas M, Losada S, Pinto A. Review of obesity and periodontitis: an epidemiological view. Br Dent J. 2019;227(3):235- 9. doi: 10.1038/s41415-019-0611-1. 12. Levine RS. Obesity, diabetes and periodontitis - a triangular relationship? Br Dent J. 2013;215(1):35-9. doi: 10.1038/ sj.bdj.2013.627. 13. Bazyar H, Adibmanesh A, Javid AZ, Maghsoumi-Norouzabad L, Gravand E, Alipour M, et al. The relationship between metabolic factors and anthropometric indices with periodontal status in type 2 diabetes mellitus patients with chronic periodontitis. Obes Med. 2019;16:100138. doi: 10.1016/j.obmed.2019.100138. 14. Ahern J, Nunn J. The integration of oral health-related best practice recommendations in the management of patients with diabetes: a cross-sectional survey of primary care physicians. J Public Health Dent. 2021;81(3):245-8. doi: 10.1111/jphd.12397. 15. Lertpimonchai A, Rattanasiri S, Vallibhakara SAO, Attia J, Thakkinstian A. The association between oral hygiene and periodontitis: a systematic review and meta-analysis. Int Dent J. 2017;67(6):332-43. doi: 10.1111/idj.12317. 16. International Diabetes Federation. IDF diabetes atlas. 10th ed. IDF: Brussels, 2021. Retrieved on February 12th, 2022 at: https://www. diabetesatlas.org. 17. GBD 2019 Diseases and Injuries Collaborators. Global burden of 369 diseases and injuries in 204 countries and territories, 1990- 2019: a systematic analysis for the Global burden of disease study 2019. Lancet. 2020;396(10258):1204-22. doi: 10.1016/S0140- 6736(20)30925-9. Erratum in: Lancet. 2020;396(10262):1562. 18. Zaletel-Kragelj L, Batista K, Bertoncelj M, Brlek A, Carli T, Grasek M, et al. Health of the Slovenian population: where do we stand? South East Eur J Public Health. 2022; 9:1-20. doi: 10.11576/seejph-5476. 19. Ranfl M, Oikonomidis C. Skrb za ustno zdravje. In: Vinko M, Kofol- Bric T, Korošec A, Tomšič S, Vrdelja M, eds. Kako skrbimo za zdravje? Z zdravjem povezan vedenjski slog prebivalcev Slovenije 2016. Ljubljana: Nacionalni inštitut za javno zdravje, 2018:41-4. 20. Cuculescu M, Slusanschi O, Boscaiu VR, Luis HPS, Fernandes Ribeiro Graça SM, dos Santos Albuquerque TMBREG, et al. Self-reported oral health-related habits, attitudes and knowledge in adults from Portugal, Romania and Sweden: a comparative study. Int J Dent Hyg. 2019;17(4):359-68. doi: 10.1111/idh.12408. 21. World Health Organization. Protocol and guidelines: Countrywide Integrated Non-communicable Diseases Intervention (CINDI) Program. Copengagen: WHO Regional Office for Europe, 1995. Retrieved on January 9th, 2022 at: http://www.sld.cu/galerias/pdf/ servicios/hta/carmen_programa_completo_ingles_111_pag.pdf. 22. Poudel P, Griffiths R, Wong VW, Arora A, Flack JR, Khoo CL, et al. Oral health knowledge, attitudes and care practices of people with diabetes: a systematic review. BMC Public Health. 2018;18(1):577. doi: 10.1186/s12889-018-5485-7. 23. Karikoski A, Ilanne-Parikka P, Murtomaa H. Oral self care among adults with diabetes in Finland. Community Dent Oral Epidemiol. 2002;30:216–23. doi: 10.1034/j.1600-0528.2002.300308.x. 24. Bowyer V, Sutcliffe P, Ireland R, Lindenmeyer A, Gadsby R, Graveney M, et al. Oral health awareness in adult patients with diabetes: a questionnaire study. Br Dent J. 2011;211:E12. doi: 10.1038/ sj.bdj.2011.769. 25. Raskiliene A, Kriaucioniene V, Siudikiene J, Petkeviciene J. Self- reported oral health, oral hygiene and associated factors in Lithuanian adult population, 1994-2014. Int J Environ Res Public Health. 2020;17(15):E5331. doi: 10.3390/ijerph17155331. 26. Hamasha AA, Alsolaihim AA, Alturki HA, Alaskar LA, Alshunaiber RA, Aldebasi WT. The relationship between body mass index and oral health status among Saudi adults: a cross-sectional study. Community Dent Health. 2019;36(1):217-22. doi: 10.1922/CDH_4361Hamasha06. 27. Artnik B, Premik M, Zaletel-Kragelj L. Population groups at high risk for poor oral self care: the basis for oral health promotion. Int J Public Health. 2008;53(4):195-203. doi: 10.1007/s00038-008-7072-7. 28. Wainwright J, Sheiham A. An analysis of methods of toothbrushing recommended by dental associations, toothpaste and toothbrush companies and in dental texts. Br Dent J. 2014;217(3):E5. doi: 10.1038/sj.bdj.2014.651. 29. Ship JA. Diabetes and oral health: an overview. J Am Dent Assoc. 2003;134:4S-10S. doi: 10.14219/jada.archive.2003.0367. 30. Yamazaki T, Yamori M, Asai K, Nakano-Araki I, Yamaguchi A, Takahashi K, et al. Mastication and risk for diabetes in a Japanese population: a cross-sectional study. PLoS One. 2013;8(6):e64113. doi: 10.1371/journal.pone.0064113. 31. Kneckt MC, Syrjälä AM, Laukkanen P, Knuuttila ML. Self-efficacy as a common variable in oral health behavior and diabetes adherence. Eur J Oral Sci. 1999;107(2):89-96. doi: 10.1046/j.0909-8836.1999. eos107203.x. 32. Simpson TC, Weldon JC, Worthington HV, Needleman I, Wild SH, Moles DR, et al. Treatment of periodontal disease for glycaemic control in people with diabetes mellitus. Cochrane Database Syst Rev. 2015;2015(11):CD004714. doi: 10.1002/14651858.CD004714. pub3. 33. Ahern J, Hamnvik OP, Barrow J, Nunn J. Incorporating oral health as part of routine diabetes care in Ireland. Ir Med J. 2017;110:660–3. 34. Zaletel-Kragelj L, Pahor M, Bilban M. Identification of population groups at very high risk for frequent perception of stress in Slovenia. Croat Med J. 2005;46(1):137-45. 35. Brajović M, Bellis M, Kukec A, Terzić N, Baban A, Sethi D, et al. Identification of adverse childhood experiences strongly predicting suicidal behaviour among emerging adults in Montenegro and Romania: a new way to targeted cost-effective prevention. Ann Ist Super Sanita. 2018;54:348-57. doi: 10.4415/ANN_18_04_12. 10.2478/sjph-2022-0028 Zdr Varst. 2022;61(4):209-215 215