Factors associated with oral health care behavior of people with type 2 diabetes mellitus: A hospital-based, cross-sectional study (2024)

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PMC11104682

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PLoS One. 2024; 19(5): e0303530.

Published online 2024 May 20. doi:10.1371/journal.pone.0303530

PMCID: PMC11104682

PMID: 38768159

Kamonchanok Sairat, Conceptualization, Data curation, Formal analysis, Investigation, Methodology, Project administration, Supervision, Writing – original draft, Writing – review & editing^1,² and Nitikorn Phoosuwan, Conceptualization, Formal analysis, Investigation, Methodology, Project administration, Resources, Supervision, Writing – review & editing^1,^3,^*

Gaetano Isola, Editor

Author information Article notes Copyright and License information PMC Disclaimer

Associated Data

Supplementary Materials

Data Availability Statement

Abstract

Background

Oral healthcare behavior determines oral health status and the incidence of oral diseases. People with type 2 diabetes mellitus (T2DM) are at-risk of having low oral healthcare behavior and disease-related oral health.

Objective

To investigate the oral health status and factors associated with oral healthcare behavior among people with T2DM in Thailand.

Methods

In total, 401 people with T2DM participated in the study based on their attendance at a non-communicable disease clinic at sub-district health promotion hospitals in Bueng Kan, a north-eastern province in Thailand. A structured questionnaire was used to obtain variables of interest. Linear regression analysis at the 95% confidence interval (CI) was applied.

Results

The majority of participants were female (73.8%). More than three-quarters had more than 20 permanent teeth (77.6%), a decay missing filling tooth index was 10.6 teeth/person. Many participants had four permanent occlusal pairs (69.6%), had tooth decay (74.6%), and some participants had tooth filling (32.2%). Statistically significant factors associated with oral healthcare behavior were: having complications associated with diabetes mellitus (Beta = -0.097, 95%CI = -1.653, -0.046), oral health literacy (Beta = 0.119, 95%CI = 0.009, 0.150), educational level (Beta = 0.123, 95%CI = 0.103, 0.949), oral healthcare attitude (Beta = 0.258, 95%CI = 0.143, 0.333), and oral health services (Beta = 0.430, 95%CI = 0.298, 1.408).

Conclusions

People with T2DM had good oral health status. People with T2DM with low oral health literacy, low attitude, and low level of oral health services were at a higher risk of poor oral healthcare behavior.

Introduction

Diabetes is a chronic disease caused by a disorder in which the body produces insufficient insulin hormone. The related high blood sugar levels result in complications, such as retinopathy, kidney failure, and coronary arteries, and in the easier formation of wounds that are slow-healing, numbness of the feet, and oral disease [1]. Worldwide, more than 450 million people (9%) suffer from diabetes, which is estimated to grow more than 780 million people in 2045 [2]. In Southeast Asia, the number of people with type 2 diabetes mellitus (T2DM) is expected to increase from 90 million cases in 2021 to 152 million in the next 25 years [2].

Thailand has been classified as a middle-income country. Currently, the incidence of diabetes is continuously increasing, with about 300,000 new cases per year and about 5.3 million people with T2DM. The prevalence rate of people with T2DM was about 10% in 2014 (8.9% for men and 10.8% for women), with the rate being higher among those with a low level of education [3]. Patients with poor glycemic control are associated with oral diseases, such as tooth decay, gingivitis, oral disease, and periodontitis. These diseases result in tooth loss, a poor digestive system, which directly impact nutrient intake. People with T2DM are more likely to have an oral disease than those without T2DM [4]. Biomarkers producing immune response (e.g. transforming growth factor-β1 (TGF-β1), N-terminal portion of the B-type natriuretic propeptide, and vascular endothelial growth factor (VEGF)) play a crucial role as a mediator for immune response, result in periodontitis, especially people with chronic diseases, like diabetes [5, 6].

According to the 8^th National Survey of oral health, Thai people aged 35–45 years an average of 3.6% had lost a tooth, with many of the people (62.4%) having either gingivitis problems or periodontitis, while one-quarter (25.9%) had tooth decay [7]. This oral health status can lead to tooth loss in the near future.

The northeast region in Thailand has the highest proportion of people with T2DM in the country, accounting for 38.84 percent and this is expected to increase in the coming years [8]. In Health Region 8, the incident rates of diabetes per 100,000 population for the period 2018, 2019, 2020, and 2021 were 511.53, 525.28, 580.10, and 538.65, respectively. In Bueng Kan province, Thailand, the rates of new diabetes cases per 100,000 population for the same period were 572.53, 528.48, 614.26, and 555.40, respectively, and the prevalence rate of people with T2DM was 5573.9 per 100,000 population. A screening protocol for oral health for people with T2DM aged 45–59 years showed that 19.43%, 17.15%, and 11.21% of the people were screened in the fiscal years 2020, 2021, and 2022, respectively. Of the above, 16.03%, 15.84%, and 12.11%, respectively, of the people received oral health examinations [9].

Oral healthcare behavior includes personal oral behavior, food consumption behavior, and medical care behavior [10]. Sociodemographic factors associated with oral healthcare behavior are age, sex, and educational level [11]. Knowledge factors regarding oral healthcare behavior are the core determinants of oral healthcare [12]. Attitudes, beliefs, knowledge, and behavior are also indicated, with the level of oral healthcare being interrelated with the level of knowledge of individuals [13, 14]. Furthermore, living and working conditions are related to oral healthcare behavior; a working population with a higher level of income determines the need for more oral services [15]. However, there has been no published investigation of the oral health status, and the factors associated with oral healthcare behavior in Thailand, which is a serious omission. Thus, people with T2DM should be educated to carry out correct oral healthcare, especially those with T2DM, to encourage good oral health. Hence, this study aimed to explore the factors associated with oral healthcare behavior among people with T2DM in Bueng Kan province, Thailand.

Methods

Aim

This hospital-based cross-sectional study was aimed at exploring oral health status and associated factors with oral healthcare behavior among people with T2DM.

Participants

This study was carried out in Bueng Kan, a north-eastern province of Thailand located 754 kilometers from Bangkok, the capital city of Thailand. The province is close to the Lao People’s Democratic Republic and the Mekong River, with a population of approximately 420,000 [9]. The province has a mixture of residential areas (rural, and semi-urban) and of cultures (Thai and Laotian). There are eight districts and 61 Sub-district Health Promotion Hospitals (SHPHs) in Bueng Kan that are responsible for approximately 4,472 people with T2DM aged 40–59 years who visit a Non-communicable Disease (NCD) clinic annually [16].

The sample size was calculated based on a formula [17], where α = 95%, acceptable margin of error (precision) = 0.0692, standard deviation (SD) = 0.63 [18], resulting in a minimum sample number of 351. To allow for some missing data, this study collected data from 401 people with T2DM. The participants were selected using a multi-stage random sampling method (stage one: cluster sampling by selecting the Bueng Khong Long district; stage two: stratified random sampling by a proportion of people with T2DM among males and females in each of the four SHPHs in the Bueng Khong Long district; and stage three: systematic random sampling using a population list in each SHPH sorted by name from which the samples were randomly selected from equal intervals to obtain the final samples). Bueng Khong Long district was randomly selected for data collection because people with T2DM in that district had similar characteristics (occupation, income, and education level) compared to the seven other districts. The inclusion criteria were people with T2DM who: (1) were diagnosed with T2DM by a physician for at least one year; (2) aged 40–59 years in the year of data collection; (3) received at least one of oral services (i.e. oral examination, tooth scaling, tooth extraction, tooth filling, fluoride vanishing, oral cancer screening) within one year at a SHPH in Bueng Khong Long district; (4) could communicate in Thai; and (5) had ability to provide informed consent to participate in the study. The participants were excluded if they: (1) reported having mental health problems from medical records (e.g. substance-induced psychosis); and (2) had serious complications (end stage of kidney disease).

Instrument

A questionnaire containing seven parts was used for data collection, where the respective parts covered: (I) sociodemographic and oral healthcare of participants, (II) oral health literacy, (III) attitude to oral healthcare, (IV) oral cleaning equipment used, (V) oral health services, (VI) multi-dimensional scale of perceived social support (r-T-MSPSS), and (VII) oral healthcare behavior. The questionnaire was tested for validity by four Thai experts with PhD qualifications and experience in healthcare services (Structure Content Validity Index: = 0.97). A reliability test was carried out using 30 people with T2DM who did not participate in the study, with the overall Cronbach’s alpha coefficient = 0.708.

Part I

This part had 18 items and was constructed by the researchers. It consisted of questions about gender, age, marital status, occupation, education, income per month, personal expenses per month, duration of diabetes, smoking, alcohol drinking, treatment, complications, and the oral health care of the participants.

Part II

This part had 14 items and was created by the researchers using the health literacy questionnaire created by the Health Education Division, Ministry of Public Health, Thailand [19]. It had seven dimensions related to oral health care: (1) receptivity of oral health care, (2) understanding of oral health care, (3) social support, (4) economic barriers, (5) access to oral health services, (6) communication skills, and (7) utilization of dentistry services. Each dimension had two questions and each question had five options (0 = never done, 1 = can do, 2 = sometimes possible, 3 = frequently done, and 4 = do it regularly). Therefore, the total score of this part was in the range 0–56. This part had a Cronbach’s alpha coefficient of 0.706.

Part III

This part consisted of eight items and was constructed by the researchers, where each question had five options (5 = strongly agree, 4 = agree, 3 = undecided, 2 = disagree,1 = strongly disagree). Therefore, each question had a score in the range 1–5 and the total possible score for this part was in the range 1–40. The reliability test was approved with a Cronbach’s alpha coefficient of 0.712.

Part IV

This part comprised eight items and was constructed by the researchers. Each item asked about a piece of equipment that the partner did or did not use. A response of having the equipment was scored as one and of not having the equipment was scored as zero. The score for this part was in the range 0–8. The Cronbach’s alpha coefficient for this part was 0.710.

Part V

This part comprised six items and was constructed by the researchers, where each question had three options (2 = always, 1 = sometimes, 0 = never). The score for each item was in the range 0–2 and the total possible score for this part was in the range 0–12. The reliability test for this part was satisfied (Cronbach’s alpha coefficient = 0.722).

Part VI

This part comprised 12 items and was constructed based on the r-T-MSPSS [19], where each question had seven options (7 = very strongly agree, 6 = strongly agree, 5 = mildly agree, 4 = neutral, 3 = mildly disagree, 2 = strongly disagree, and 1 = very strongly disagree). The score for each item was in the range 1–7 and the total possible score for this part was in the range 1–84. The reliability test for this part was satisfied (Cronbach’s alpha coefficient = 0.764).

Part VII

This part comprised 15 items that assessed the frequency of oral healthcare behavior [10]. The oral healthcare behavior covered: brush toothing behavior (eight questions), food consumption behavior (four questions), and medication behavior (three question), where each question had four options (3 = always, 2 = often, 1 = sometimes, 0 = never). The score for each item was in the range 0–3 and the total possible score for this part was in the range 0–45. The reliability test for this part was satisfied (Cronbach’s alpha coefficient = 0.718).

Ethical approval

The study was approved by the Ethics Committee, Kasetsart University, Chalermphrakiat Sakhon Nakhon province campus (ID: KU.CSC-COA65/009). In addition, permission was sought for data collection from the Bueng Khong Long District Public Health Office. All participants received written and oral information before signing a written consent form. The information emphasized the freedom to partake in the study or not and that participants were fully entitled to withdraw at any time. None of the authors was involved in the care of any of the participants.

Data collection

The directors of the selected SHPHs approved the data collection plan. Thereafter, the researchers received a list of people with T2DM from a nurse-midwife in the SHPHs from which the samples were randomly selected and invited to participate in the study voluntarily and informed about the study before signing a consent form. Each participant answered the questionnaire for about 15–20 minutes in a room at the SHPH where they received oral health services. The researchers obtained oral health information about the participants from the medical records of the SHPH, such as oral health status (number of permanent teeth, number of occlusal pairs, tooth decay, teeth missing, teeth filling). Data were collected from the 1^st of May to 30^th of September 2022.

Statistical analyses

Data were analyzed using a statistical software program. Descriptive statistics (such as frequency and mean) were calculated. Inferential statistics were conducted using regression analysis, while the dependent variable was the score for oral healthcare behavior.

The independent variables were based on socio-demographics and oral health care of participants, oral health literacy score, score of attitudes to oral health care, oral cleaning equipment score, score for oral health services, and a score for the r-T-MSPSS. The independent and dependent variables were verified for the assumptions of the linear regression analysis based on a test of normality for the dependent variable (Z_skewness = -0.435, Z_Kurtosis = 0.372), a test for multicollinearity problems, and the variance inflation factor.

All independent variables were included in univariable analysis for the first step. Only significant independent variables (p<0.05) from the first step were retained in the multivariable analysis based on the enter method. The degree of association was assessed using the 95% confidence interval (CI), the 0.05 significance level was used, and the coefficient of determination (R²) was used to describe the relationship between predictors and the oral healthcare behavior of people with T2DM.

Results

In total, data from 401 out of 445 people with T2DM were analyzed (response rate 90.1%). Overall, majority of the study participants were females (73.8%), 50–59 years old (72/1%), married (79.3%), agriculturists (59.4%), graduated in primary education level (83.8%), non-smokers (92.0%), non-alcohol drinkers (84.3%). See Table 1.

Table 1

Characteristics of the participants in the study (n = 401).

Characteristic	Frequency	Percentage
Gender
Female	296	73.8
Male	105	26.2
Age group (years)
40–49	112	27.9
50–59	289	72.1
Mean (SD) = 52.39 (4.94) Min = 40 Max = 59
Marital Status
Married	318	79.3
Single	38	9.5
Divorced	36	9.0
Separated	7	1.7
Widowed	2	0.5
Employment
Agriculture	238	59.4
Unemployed	82	20.4
General employment	34	8.5
Personal business	21	5.2
Trade	10	2.5
Others (e.g. government service)	16	4.0
Educational level
Primary	336	83.8
Lower Secondary	26	6.5
Upper Secondary	28	7.0
Diploma	6	1.5
Bachelor’s degree	5	1.2
Income per month (USD)
0–175	246	61.3
176–350	95	23.7
More than 350	60	15.0
Mean (SD) = 218.61 (218.26) Min = 14.6 Max = 1456.8
Personal expenses per month (USD)
0–175	288	71.8
176–350	83	20.7
More than 350	30	7.5
Mean (SD) = 157.23 (161.37) Min = 5.83 Max = 1165.5
Smoking
No	369	92.0
Yes	25	6.2
Ex-	7	1.8
Alcohol drinker
No	338	84.3
Yes	55	13.7
Ex-	8	2.0

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Note: USD 1 = THB 34.32; SD = standard deviation.

Majority of the study participants were people with T2DM diagnosed for 1–5 years (44.4%), used oral drug treatment (89.3%), had permanent teeth more than 20 (77.6%), had occlusal pairs more than 4 (69.6%), and the Decay Missing Filled Tooth (DMFT) index was 10.6 teeth/person. See Table 2.

Table 2

General health and oral health status of the participants in the study (n = 401).

General health	Frequency	Percentage
Duration of diabetes
1–5 years	178	44.4
6–10 years	142	35.4
More than 10	81	20.2
Mean (SD) = 7.84 (5.47) Min = 1.0 Max = 30.0
Treatment (multiple answers allowed)
Oral drugs	358	89.3
Diet	191	47.6
Insulin	16	4.0
Combinations of oral drugs and insulin	16	4.0
Complications (multiple answers allowed)
No	355	88.5
Yes	46	11.5
Eyes	29	7.2
Feet	22	5.5
Kidneys	8	2.0
Hearts	5	1.3
Oral health status	Frequency	Percentage
Number of permanent teeth
≥ 20	311	77.6
< 20Mean (SD) = 24.00 (6.97) Min = 0.0 Max = 32.0	90	22.4
Number of occlusal pairs
≥ 4	279	69.6
< 4	122	30.4
Tooth Decay
Yes	299	74.6
No	102	25.4
Mean (SD) = 1.97 (1.48) Min = 0.0 Max = 10.0
Tooth Missing
Yes	348	86.8
No	53	13.2
Mean (SD) = 7.87 (6.86) Min = 0.0 Max = 32.0
Tooth Filling
No	272	67.8
Yes	129	32.2
Mean (SD) = 1.76 (1.35) Min = 0.0 Max = 6.0
Decay Missing Filling Tooth index
Mean (SD) = 10.60 (7.03) Min = 0.0 Max = 32.0

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Note: SD = standard deviation

The majority of the people with T2DM had the highest means of support (S1) and were able to have an accompanying family member or friend to an oral appointment (mean = 3.51, SD = 0.73), followed by receptivity (R1) and being able to pay attention to oral or oral health needs (mean = 3.31, SD = 0.73), with the T2DM group having the lowest mean of understanding (U2) and able to read oral or oral health information brochures left in oral clinics and waiting rooms. See Table 3.

Table 3

Oral health literacy of study participants (n = 401).

Oral health literacy domains	Oral health literacy items	Mean Score (SD)
Receptivity (R)	(R1) Are you able to pay attention to your oral or oral health needs? (R2) Are you able to make time for things that are good for your oral or oral health?	3.31 (0.73) 3.32 (0.72)
Understanding (U)	(U1) Are you able to fill out oral forms such as the enrollment form? (U2) Are you able to read oral or oral health information brochures left in oral clinics and waiting rooms?	3.10 (1.01) 2.99 (1.07)
Support (S)	(S1) Are you able to take a family member or friend with you to an oral appointment? (S2) Are you able to ask a family member or friend for help to understand oral or oral health information?	3.51 (0.73) 3.36 (0.75)
Economic barriers (E)	(E1) Are you able to pay to see a dentist? (E2) Are you able to afford transportation to the oral clinic?	3.18 (0.77) 3.36 (0.75)
Access (A)	(A1) Do you know where a dentist can be contacted? (A2) Do you know what to do to get a dentist’s appointment?	3.20 (0.75) 3.20 (0.75)
Communication (C)	(C1) Are you able to look for a second opinion about your oral health from a oral health professional? (C2) Are you able to use information from a dentist to make decisions about your oral health?	3.09 (0.78) 3.19(0.81)
Utilization (X)	(X1) Are you able to carry out instructions that a dentist gives you? (X2) Are you able to use advice from a dentist to make decisions about your oral health?	3.37 (0.70) 3.30 (0.68)

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Note: SD = standard deviation

The findings revealed that having the complications of diabetes mellitus (Beta = -0.097, 95%CI = -1.653, -0.046), oral health literacy (Beta = 0.119, 95%CI = 0.009, 0.150), educational level (Beta = 0.123, 95%CI = 0.103, 0.949), oral health care attitude (Beta = 0.258, 95%CI = 0.143, 0.333), and oral health services (Beta = 0.430, 95%CI = 0.298, 1.408) were statistically significant factors associated with the oral healthcare behavior of people with T2DM. The variables were able to predict 33.0% of the oral healthcare behavior of people with T2DM (R² = 0.330). See Table 4.

Table 4

Factors associated with oral healthcare behavior of people with T2DM based on multivariable linear regression analysis (n = 401).

Variables	Unstandardized coefficients		Standardized coefficients	t	p-value	95% Confidence for Interval for B
Variables	b	Std. Error	Beta	t	p-value	Lower Bound	Upper Bound
Complications of diabetes mellitus	-0.1424	0.625	-0.097	-2.276	0.023*	-1.653	-0.046
Oral health literacy	0.079	0.036	0.119	2.205	0.028*	0.009	0.150
Educational level	0.753	0.268	0.123	2.815	0.005*	0.103	0.949
Oral health care attitude	0.238	0.048	0.258	4.913	<0.001*	0.143	0.333
Oral health services	1.403	0.155	0.430	9.036	<0.001*	0.298	1.408
(Constant)	4.254	2.238	-	1.901	0.058	-0.147	8.653
R = .57 R ² = .330 F = 19.194

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*Correlation significant at p-value < 0.05.

Discussion

This study focused on providing a synthesis of current evidence on the oral health services, oral health care attitudes, and oral health literacy of people with T2DM and the association of these factors with oral healthcare behavior. A large proportion of respondents rated their oral health status as tooth decay (74.6%) with an average of 7.87% having lost a tooth, which was higher than the Thai national survey of oral health in Thailand (tooth decay = 49.7% and 3.2% having lost a tooth) [20]. Having complications of diabetes mellitus, low oral health literacy, low education, low oral health care attitude, low access of oral health services were factors associated with the low oral healthcare behavior of people with T2DM.

In the northeastern region, 17.4% of working-age groups and 19.4% of elderly people reportedly visited oral checkup services without symptoms, which were lower proportions than overall of those seeking services for treatment [21]. People with T2DM lack access to oral services; hence, the introduction of the tele-oral system plays a role in screening. Assessment of the risk of oral diseases and early detection of diseases, such as screening for oral caries and gingivitis and examination of oral lesions by sending information to a specialist dentist for diagnosis and receiving advice, leads to the organization of disease promotion and prevention programs according to the patient’s risk [22]. The provision of proactive oral services to promote oral health is required to prevent the occurrence or progression of oral diseases [23]. Periodontal disease is more severe in people with T2DM than in normal people and it causes bad breath and loose teeth, resulting in tooth loss and a decreased ability to chew [24]. Furthermore, receiving oral health care by scaling reduces blood sugar levels (HbA1c) by approximately 0.27–1.03% [25]. Uncontrolled blood sugar levels lead to oral disease. Risky behaviors, e.g. high sugar intake, smoking, alcohol drinking, and low physical activities, may cause oxidative stress reactions; these result in periodontal inflammation and severity of T2DM, and affect to quality of life of the people with T2DM. [5, 6]. Therefore, people with T2DM should receive oral services at least once a year to effectively reduce the risk of periodontitis [26].

Oral health literacy could contribute to increased positive oral health behavior among the participants in this study. According to the World Health Organization [27], “health literacy is a person’s cognitive and social skills that cause motivation and competence to reach understand and use health information and services to promote and maintain good health”; promoting oral health literacy is an economical way for developing countries to achieve better oral health outcomes [28]. Oral health care information access skills include mobile phone and computer applications to access information more easily, such as Facebook [29]. Channels for accessing oral health information and knowledge about oral hygiene care are necessary as a supplement to preventing oral caries and periodontal disease for the public [20], with the level of basic health literacy stemming from access to reliable and correct information. This includes understanding dentistry and having correct oral health care knowledge [30]. Therefore, oral health literacy (skills in accessing oral health information, understanding oral health care, and exchanging knowledge) might create the awareness and interest of people [31], who subsequently may make a decision to improve their oral health behavior in a sustainability manner.

Strengths and limitations

In this study, multivariable linear regression analysis was used to adjust for confounders and to demonstrate the strengths of the association. Although this study was restricted to studying people in a government setting, most people with T2DM in Thailand still use services from government sources. Thus, the findings can be referred to other people with T2DM in similar contexts and cultures, such as agricultural areas in the Lao People’s Democratic Republic. On the other hand, the research design of this study used a cross-sectional study, which might limit the causal relationship between the findings. A case-control study might be conducted in the future to reduce biases.

Conclusions

The value of the present study is its provision of new information regarding oral healthcare behavior, oral health status, and oral diseases. The majority of participants (people with type 2 diabetes mellitus) were female (73.8%), and 77.6% of the participants had more than 20 permanent teeth and 69.6% had four permanent occlusal pairs. The decay missing filled tooth (DMFT) index was 10.6 teeth/person. However, about 75% of the participants had tooth decay (74.6%) and more than 30% of the participants had tooth filling. Complications from diabetes mellitus, educational level, oral health care attitude, and oral health services were statistically significant factors associated with oral healthcare behavior. People with T2DM who have low oral health literacy, low attitude, and a low level of oral health services were at a higher risk of poor oral healthcare behavior and are in need of an intervention program, such as programs focusing on food consumption behavior medication behavior.

Supporting information

S1 Checklist

STROBE statement—checklist of items that should be included in reports of observational studies.

(DOCX)

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S1 Dataset

(XLS)

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S1 File

Ethical approval.

(JPG)

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Acknowledgments

The authors thank all the respondents who participated in this study, the Faculty of Public Health, Kasetsart University for providing resources and materials, and the government Sub-district health promotion hospitals in Bueng Khong Long, Buengkan Province, Thailand, Thailand for their cooperation.

Funding Statement

The author(s) received no specific funding for this work.

Data Availability

All relevant data are within the paper and its Supporting Information files.

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PLoS One. 2024; 19(5): e0303530.

Decision Letter 0

2024; 19(5): e0303530.

Published online 2024 May 20. doi:10.1371/journal.pone.0303530.r001

Gaetano Isola, Academic Editor

11 Mar 2024

PONE-D-23-32407Factors associated with oral health care behavior of people with type 2diabetes mellitus: A hospital-based, cross-sectional studyPLOS ONE

Dear Dr. Phoosuwan,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

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Reviewers' comments:

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Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1:Partly

Reviewer #2:Yes

Reviewer #3:Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1:Yes

Reviewer #2:Yes

Reviewer #3:Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

Attachment

Submitted filename: PLOS 2024 thai.pdf

Click here to view.^{(192K, pdf)}

PLoS One. 2024; 19(5): e0303530.

Author response to Decision Letter 0

2024; 19(5): e0303530.

Published online 2024 May 20. doi:10.1371/journal.pone.0303530.r002

27 Mar 2024

Response to reviewers' comments

Dear Editor,

We thank you and the reviewers for remarks which have helped us improve the manuscript. Please see our response below.

Reviewer #1: In the manuscript entitled: "Factors associated with oral health care behavior of people with type 2 diabetes mellitus: A hospital-based, cross-sectional study" the authors aimed to assess the factors associated with oral healthcare behavior among people with T2DM in Thailand. The authors found that the majority of participants were female (73.8%) and most of the participants had received primary education (83.8%). More than three-quarters (77.6%) had more than 20 permanent teeth, while many of the participants (69.6%) had four permanent occlusal pairs. A decay missing filling tooth index was 10.6 teeth/person. The authors concluded that people with T2DM had good oral health status. People with T2DM with low oral health literacy, low attitude, and low level of oral health services were at a higher risk of poor oral healthcare behavior.

Major comments: In general, the idea and innovation of this study regards the analysis of oral health in patients with diabetes is interesting and novel because the role these aspects in medicine are validated but further studies on this topic could be an innovative issue in this field could be open a creative matter of debate in literature by adding new information. Moreover, there are few reports in the literature that studied this interesting topic with this kind of study design. The study was well conducted by the authors; However, there are some concerns to revise that are described below.

The introduction section resumes the existing knowledge regarding the important factor linked with the impact mediators involved together oral health and with periodontitis. However, as the importance of the topic, the reviewer strongly recommends, before a further re-evaluation of the manuscript, to update the literature through read, discuss and must cites in the references with great attention all of those recent interesting articles, that helps the authors to better introduce and discuss the role of mediators (NT-PRO-BNP and TGF beta 1) in periodontitis and related recessions by adding as a references these article, before any further assessment of the manuscript: 1) DOI: doi: 10.1002/JPER.23-0063. PMID: 37433155; 2) DOI: 10.1177/1721727X1301100217

Response: Thank you for your suggestion and comments. We have read the articles and written texts in the Introduction section, page 3/25 and added in the reference list.

The authors should be better specified, at the end of the introduction section, the rationale of the study and the aim of the study.

Response: We have already specified the rationale and aim of the study in the introduction section, page 4/25 and in the Aim section page 5/25.

In the central section, should better clarify inclusions and exclusions criteria of the selected sample.

Response: We have already clarified the criteria in the Participants section, page 6/25.

Please better state the results obtained in the abstract.

Response: We have already rewritten and added texts for the results in the Results section, pages 9-10/25.

Response: We have already rewritten and added texts in the Discussion section, page 12/25.

The conclusion should reinforce in light of the discussions.

Response: We have already rewritten and added texts in the Conclusions section, page 13/25.

Minor Comments:

Abstract:

- Better formulate the abstract section by better describing the aim of the study

Response: We have already rewritten the aim of the study in the Abstract section, page 2/25.

Discussion

- Please add a specific sentence that clarifies the results obtained in the first part of the discussion

Response: We have already added texts in the Discussion section, page11/25.

Reviewer #2: Manuscript Number: PONE-D-23-32407

Full Title: Factors associated with oral health care behaviour of people with T2DM

Dear Authors. Overall, I think it is a good article that needs a few changes or additions (See below). I would suggest accepting with minor revisions.

Methods

1. Authors should clearly define what they mean by 'oral healthcare behavior.' (e.g. the actions and habits individuals adopt....).

Response: We have already added texts to clarify this in the Introduction section, page 4/25.

2. Authors should mention and describe their cross-sectional design method somewhere in the Methods, preferably at the start (e.g., in a design section).

Response: We have already added texts for the design of the study in the Methods section, page 5/25.

Discussion

1. Authors should consider providing suggestions for future research based on gaps they identified, and their limitations.

Response: We have already added texts to suggest for future research in the Strengths and limitations section, page 13/25.

Conclusions

1. The authors should also expand on what they mean by 'intervention program'.

Response: We have already added texts in the Conclusions section, page 13/25.

Reviewer #3: A relevant and important study as it relates to oral health and systemic disease (DM) especially among LMIC and MMIC. will certainly add to the current scarcity of information on these issues in the Asian environment particularly. Methodology well described. Concern is on data presentation and interpretation of Results especially Table 1. subsequently needs to look into refinement of discussion. Conclusion acceptable. Actually Abstract is better written.

Response: Thank you for your comments. We have rewritten results accordingly in the Results section, pages 9-10/25 and in the Abstract section page 2/25.

Attachment

Submitted filename: responses to revewers 28032024.docx

Click here to view.^{(31K, docx)}

PLoS One. 2024; 19(5): e0303530.

Decision Letter 1

2024; 19(5): e0303530.

Published online 2024 May 20. doi:10.1371/journal.pone.0303530.r003

Gaetano Isola, Academic Editor

26 Apr 2024

Factors associated with oral health care behavior of people with type 2diabetes mellitus: A hospital-based, cross-sectional study

PONE-D-23-32407R1

Dear Dr. Phoosuwan,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

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Kind regards,

Gaetano Isola, Ph.D.

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The manuscript can be accepted for publication.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. If the authors have adequately addressed your comments raised in a previous round of review and you feel that this manuscript is now acceptable for publication, you may indicate that here to bypass the “Comments to the Author” section, enter your conflict of interest statement in the “Confidential to Editor” section, and submit your "Accept" recommendation.

Reviewer #1:All comments have been addressed

Reviewer #3:(No Response)

**********

2. Is the manuscript technically sound, and do the data support the conclusions?

Reviewer #1:Yes

Reviewer #3:Yes

**********

3. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1:Yes

Reviewer #3:Yes

**********

4. Have the authors made all data underlying the findings in their manuscript fully available?

Reviewer #1:Yes

Reviewer #3:Yes

**********

5. Is the manuscript presented in an intelligible fashion and written in standard English?

Reviewer #1:Yes

Reviewer #3:Yes

**********

6. Review Comments to the Author

Reviewer #1:In this revised version of the manuscript, the authors have well addressed to all of the concerns raised by the reviewer. The manuscript can be accepted for publication.

Reviewer #3:Keywords . Behavior; Factor standing alone is confusing. Perhaps better to join as Behavioral Factors; Oral healthcare ; etc.

Participants and Results - your original sample after randomization is actually 445 as stated in Row 24 Results Section first line. This was not mentioned earlier in Participants section. Agreed you analyzed on 401 but calculating 401 (90.1%) response is not correct. Better to say, data was analyzed on a final sample of 401 after considering inclusion-exclusion criteria at the end of Participant section or at Row 24 Results.

Index DMF used to measure caries - F not filling but FILLED

there's a few grammatical error needing attention

**********

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Reviewer #1:No

Reviewer #3:No

**********

PLoS One. 2024; 19(5): e0303530.

Acceptance letter

2024; 19(5): e0303530.

Published online 2024 May 20. doi:10.1371/journal.pone.0303530.r004

Gaetano Isola, Academic Editor

8 May 2024

PONE-D-23-32407R1

PLOS ONE

Dear Dr. Phoosuwan,

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