April 2007, Vol 97, No. 4 | American Journal of Public Health Kunzel et al.

| Peer Reviewed | Research and Practice | 725

RESEARCH AND PRACTICE

Dentists Management of the Diabetic Patient:
Contrasting Generalists and Specialists
| Carol Kunzel, PhD, Evanthia Lalla, DDS, MS, and Ira Lamster, DDS, MMSc
high performer in 1 area and high perform-
ance in other areas, and (3) investigated the
extent to which attitudes and orientations sug-
gested by theories of behavioral change, espe-
cially the Theory of Planned Behavior,
12,13
pre-
dict general dentists and periodontists active
management of the diabetic patient. By includ-
ing general dentistsapproximately 80% of all
dental practitionerswe cast the broadest pos-
sible net in terms of access to oral health
care.
14
By including periodontists, we exam-
ined dental specialists whose postgraduate
training emphasized the dental and medical
management of patients with periodontal dis-
ease, including those with diabetes.
METHODS
Data were collected through a postal sur-
vey of actively practicing dentists identified as
general dentists or periodontists in the north-
eastern United States: Massachusetts, Rhode
Island, Connecticut, New York, New Jersey,
Pennsylvania, Delaware, Washington, DC, and
Maryland. Two random samples (general den-
tists =180, periodontists =180) were drawn
from lists supplied by the American Dental
Association for general dentists
15
and the
American Academy of Periodontology for the
periodontists.
16
We received 105 responses
from 132 eligible general dentists and 103
responses from 142 eligible periodontists
(general dentist response rate=80%; peri-
odontist response rate=73%). Respondents
were classified as eligible if (1) their primary
professional activity was the practice of gen-
eral dentistry or periodontics and (2) they
practiced in the designated geographic area.
The proportional state-based, random sam-
pling strategy we used and the postal survey
data collection approach we implemented,
have been previously described.
17,18
Measures
We created 3 scalesassessment (rated on
a 6-point scale), discussion (rated on a 4-point
scale), and active management (rated on a 4-
point scale)to measure dentists management
National survey data have documented that
diabetes is a major health problem in both
men and women and in all races and ethnic
groups in the United States and that its preva-
lence increases with age.
15
It is also well es-
tablished that patients with diabetes are more
likely to develop periodontal diseases (inflam-
matory disorders affecting the supporting
structures of the teeth) than are nondiabetic
individuals.
6
In 1993, Loe called periodontitis
the sixth complication of diabetes melli-
tus.
7(p329)
As both the life expectancy of the
US population and the prevalence of diabetes
continue to rise, it is expected that dental
practitioners will be seeing and treating
greater numbers of diabetic patients with
periodontal complications.
Diabetes is a risk factor for periodontal dis-
eases,
8,9
and dentists can help reduce this risk
by assessing, advising, and closely monitoring
the diabetic patient.
10,11
Through such office-
based activities, dentists assume functions
characteristic of primary and preventive
health care clinicians. We think of this ex-
panded role as having 3 phases of involve-
ment: assessment, discussion, and active man-
agement. Assessment constitutes dentists
asking the diabetic patient about the type and
severity of disease (regimen used to control
blood glucose, duration of disease, and pres-
ence of any complications). Discussion repre-
sents their communication with the patient
(about importance of tight blood glucose con-
trol, association of diabetes with oral health,
and, conversely, association of dental treat-
ment with blood glucose control). Active man-
agement reflects actions taken to ameliorate
the diabetic patients oral health care (moni-
toring blood glucose level, communicating
with the patients physician, adjusting the fre-
quency of dental visits).
In this study, we (1) measured general den-
tists and periodontists performance within
these 3 facets of managing the diabetic patient,
(2) examined the association between being a
Objectives. We measured and contrasted general dentists and periodontists
involvement in 3 areas of managing diabetic patientsassessment of health sta-
tus, discussion of pertinent issues, and active management of patientsand iden-
tified and contrasted predictors of active management of diabetic patients.
Methods. We conducted a cross-sectional mail survey of random samples of
general dentists and periodontists in the northeastern United States during fall
2002, using lists from the 2001 American Dental Directory and the 2002 Ameri-
can Academy of Periodontology Directory. Responses were received from 105
of 132 eligible general dentists (response rate=80%) and from 103 of 142 eligi-
ble periodontists (response rate=73%).
Results. Confidence, involvement with colleagues and medical experts, and
professional responsibility were influential predictors of active management for
periodontists (R
2
=0.46, P<.001). Variables pertaining to patient relations were
significant predictors for general dentists (R
2
=0.55, P<.001).
Conclusions. Our findings permitted us to assess and compare general dentists
and periodontists behavior in 3 realmsassessment of diabetic patients health
status, discussion of pertinent issues, and active management of diabetic
patientsand to identify components of potentially effective targeted interven-
tions aimed at increasing specialists and generalist dentists involvement in the
active management of diabetic patients. (Am J Public Health. 2007;97:725730.
doi:10.2105/AJPH.2006.086496)
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RESEARCH AND PRACTICE

TABLE 1General Dentists and Periodontists Scoring on Assessment, Discussion, and Active
Management Scales: Northeastern United States, 2002
Assessment Scale Discussion Scale Active Management Scale
General Dentists Periodontists General Dentists Periodontists General Dentists Periodontists
(n =103) Cumulative (n =102) Cumulative (n =102) Cumulative (n =102) Cumulative (n =103) Cumulative (n =101) Cumulative
Scale Score No. (%) % No. (%) % No. (%) % No. (%) % No. (%) % No. (%) %
060 19 (18.4) 18.4 8 (7.8) 7.8 3 (2.9) 2.9 . . . . . . 48 (46.6) 46.6 14 (13.9) 13.9
6170 13 (12.6) 31.1 3 (2.9) 10.8 7 (6.9) 9.8 . . . . . . 13 (12.6) 59.2
a
16 (15.8) 29.7
7180 15 (14.6) 45.6 10 (9.8) 20.6 15 (14.7) 24.5 2 (2.0) 2.0 17 (16.5) 75.7
a
27 (26.7) 56.4
8190 15 (14.6) 60.2
a
13 (12.7) 33.3 27 (26.5) 51.0 15 (14.7) 16.7 11 (10.7) 86.4
a
12 (11.9) 68.3
a
9199 15 (14.6) 74.8
a
11 (10.8) 44.1 15 (14.7) 65.7
a
13 (12.7) 29.4 11 (10.7) 97.1
a
17 (16.8) 85.1
a
100 26 (25.2) 100
a
57 (55.9) 100
a
35 (34.3) 100
a
72 (70.6) 100
a
3 (2.9) 100
a
15 (14.9) 100
a
0.86 0.87 0.71 0.63 0.64 0.61
Group scale 84.37
b
83.63
b
87.78
c
96.10
c
69.32
d
75.84
d
mean
Grand mean 84.64 (81.9, 87.4) 92.25 (90.7, 93.8) 72.82 (70.5, 75.1)
(95% CI)
e
Note. CI =confidence interval; ANCOVA =analysis of covariance. For an explanation of scoring, see Methods section.
a
High performance level.
b
Specialist group, P=.882, calculated with analysis of covariance (ANCOVA); adjusted for age, number of years of postdoctoral training, number of dental consultations per week, and number of
medical consultations per week.
c
Specialist group, P<.001, calculated with ANCOVA; adjusted for number of dental consultations per week and number of medical consultations per week.
d
Specialist group, P=.125, calculated with ANCOVA; adjusted for number of dentists in office, number of years of postdoctoral training, percentage of patients who pay with Medicaid, percentage of
neighborhood residents on welfare, and number of medical consultations per week.
e
Evaluated with the following covariates: age, number dentists in office, number of years of postdoctoral training, percentage of patients who pay with Medicaid, percentage of neighborhood
residents on welfare, number of dental consultations per week, and number of medical consultations per week.
of the diabetic patient. For each scale, we used
Likert-type questionnaire items.
The assessment scale comprised the follow-
ing items: for a new diabetic patient, do you
routinely ask about (1) the patients type of dia-
betes, (2) when first diagnosed, (3) any diabetic
complications, and (4) regimen used to control
blood glucose? The discussion scale comprised
the following items: to what extent is each of
the following a part of your evaluation or man-
agement of a diabetic patient: (1) discuss how
well controlled the patient is, (2) discuss postop-
erative medications or infection control, (3) dis-
cuss the oral implications of diabetes, and
(4) discuss how periodontal therapy can effect
diabetic control. The active management scale
comprised the following items: to what extent
is each of the following a part of your evalua-
tion or management of a diabetic patient:
(1) refer for or monitor blood glucose levels,
(2) communicate with patients doctor, and
(3) change or adjust frequency of dental visits.
Responses in the assessment scale (4 items)
ranged from 1 (never) to 6 (always), whereas
responses in the discussion scale (4 items) and
the active management scale (3 items) ranged
from 1 (never) to 4 (often). For each partici-
pant, values for the responses to the individual
items making up each scale were summed.
Each individuals score was then divided by
the total possible score for that realm of be-
havior, resulting in a percentage value repre-
senting level of activity in each area. The per-
centage was multiplied by 100, for a possible
performance score of 0 to 100 in each area.
Categories based on score ranges of less
than 60 and decile score ranges of 60 or more
were established. We created dichotomous
low-performer versus high-performer cate-
gories based on the decile score ranges for
each scale. The decile cutpoint closest to a cu-
mulative 50% for each clinician group for
each scale, as presented in Table 1, was used
to divide clinician performance into high-
performance and low-performance categories
within each behavioral realm.
Analyses
Reliability analyses were conducted for
each of the 3 scales. Analysis of covariance
(ANCOVA) was used to assess the potential
confounding effect of significantly correlated
demographic, practice structure, and provider
characteristic variables (Table 2) on differ-
ences between group mean scale scores
within each of the 3 behavioral realms. Multi-
ple analysis of covariance (MANCOVA) was
used to assess differences among the overall
means (grand means) for the 3 behavioral
areas, adjusted for all significantly correlated
demographic, practice structure, and
provider variables presented in Table 2.
We used the Pearson product moment cor-
relation to examine associations among the 3
behavior scales and selected demographic
and practice structure characteristics. Cross-
tabular analyses were conducted to examine
the association between level of discussion
and level of active management for each clini-
cian group. Logistic regression was used to as-
sess the potential confounding effect of signif-
icantly correlated demographic, practice
structure, and provider characteristic vari-
ables on the respective associations between
high and low performance levels.
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RESEARCH AND PRACTICE

TABLE 2Correlations Between Dentists Scores Evaluating Management of Diabetic Patients
and Selected Personal and Practice Characteristics: Northeastern United States, 2002
General Dentists Periodontists
Active Active
Assessment Discussion Management Assessment Discussion Management
Scale Scale Scale Scale Scale Scale
Respondents age in years 0.23* 0.14 0.08 0.08 0.04 0.11
No. hours in typical week respondent spends in direct patient care 0.17 0.07 0.02 0.02 0.07 0.12
No. patients respondent sees in typical week 0.19 0.09 0.05 0.01 0.09 0.09
No. full-time and part-time dentists in office 0.14 0.15 0.19 0.11 0.19 0.30**
No. staff in office with respondent 0.02 0.10 0.11 0.09 0.01 0.19
No. years of postdoctoral training 0.27** 0.17 0.25* 0.14 0.03 0.05
Respondents patients who pay with Medicaid, % 0.09 0.04 0.29** 0.06 0.06 0.07
Estimated % of practice neighborhood on welfare 0.13 0.03 0.24* 0.19 0.04 0.01
No. times in average week respondent consults with dental specialist 0.23* 0.23* 0.12 0.01 <.01 0.15
No. times in average week respondent consults with medical specialist 0.21* 0.23* 0.32** 0.16 <.01 0.28**
Note. Units are Pearson product moment correlation coefficients.
*P.05; ** P.01.
In the regression model, we included the in-
dependent variables discussion activity, prac-
tice structure and provider characteristics, and
several attitudes and orientations suggested by
the Theory of Planned Behavior to identify
the contribution of each variable to level of
active management of the diabetic patient, the
dependent variable. Only those demographic,
practice structure, and personal variables that
had an initial P value of .20 or less were re-
tained for use in the final model. For all statis-
tical analyses, we used the program SPSS ver-
sion 11.0 (SPSS Inc, Chicago, Ill).
RESULTS
The education and sociodemographic char-
acteristics of the 2 samples have been de-
scribed previously.
18
Although clinician group
was significantly associated with years of post-
doctoral training, as expected, it was not signif-
icantly associated with any of the other socio-
demographic variables considered. Level of
postdoctoral training was 2 years for 53% of
periodontists, 3 years for 47% of periodon-
tists, and 1 year or more for 34% of general
dentists. Forty-one percent of periodontists
and 26% of general dentists were aged 45
years or younger. Seventy-nine percent of pe-
riodontists versus 88% of general dentists
were men. Fifty percent of periodontists and
49% general dentists reported 5 or more
continuing education courses in dentistry in
the past year for which a fee was paid.
Table 1 presents levels, frequency distri-
butions, clinician group means, grand means,
and significance testing for the 3 scales. On the
assessment scale, 45.6% of general dentists,
scoring 80 or less, and 44.1% of periodontists,
scoring 99 or less, were categorized as low
performers (Table 1). 25.2% of general den-
tists and 55.9% of periodontists scored 100,
the highest possible score on the discussion
scale. When adjusted for the demographic and
practice structure variables significantly corre-
lated with the assessment scale for both practi-
tioner groups, estimated mean scale scores are
84.4 for general dentists and 83.6 for peri-
odontists (Table 1). The effect of clinician
group membership is not significant when ad-
justed for potential confounders. The grand
mean for assessment, when adjusted for co-
variates, was 84.6.
On the discussion scale, 51.0% of general
dentists, scoring 90 or less, and 29.4% of peri-
odontists, scoring 99 or less, were categorized
as low performers (Table 1). 34.3% of general
dentists and 70.6% of periodontists scored 100,
the highest possible score on the discussion
scale. When adjusted for the demographic and
practice structure variables significantly corre-
lated with the discussion scale for both practi-
tioner groups, estimated mean scale scores
were 87.8 for general dentists and 96.1 for
periodontists (Table 1). The effect of clinician
group membership was statistically significant
when adjusted for number of times during an
average week the practitioner consulted with a
dental specialist and number of times during an
average week the practitioner consulted with a
medical specialist. The grand mean for discus-
sion, when adjusted for covariates, was 92.3.
On the active management scale, 46.6% of
general dentists, scoring 60 or less, and 56.4%
of periodontists, scoring 80 or less, were cate-
gorized as low performers (Table 1). 2.9% of
general dentists and 14.9% of periodontists
scored 100, the highest possible score on the
discussion scale. When adjusted for the demo-
graphic and practice structure variables signifi-
cantly correlated with the active management
scale for both practitioner groups, estimated
mean scale scores were 69.3 for general den-
tists and 75.8 for periodontists (Table 1). The
effect of clinician group membership was not
significant when adjusted for potential con-
founders. The grand mean for active manage-
ment, when adjusted for covariates, was 72.8.
Differences among the 3 grand means for
the 3 behavioral measures, when adjusted for
all covariates, were statistically significant
(Table 1). The highest mean level of activity
occurred for discussion, whereas the lowest
was for active management.
Table 2 compares the 2 practitioner groups
Pearson product moment correlations between
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RESEARCH AND PRACTICE

TABLE 4Results of Multivariate Regression Models Predicting Active Management of
Diabetic Patients by General Dentists and Periodontists: Northeastern United States, 2002
General Dentists Periodontists
Standard Standard
Coefficient P Coefficient P
Score on discussion scale 0.419 <.001 0.086 .407
Confidence in ability to manage patient with diabetes in office
a
0.076 .397 0.263 .009
How strongly agree: My colleagues expect me to take more active role 0.041 .742 0.284 .020
in diabetes control
b
How strongly agree: My patients expect me to take more active role in 0.270 .031 0.220 .090
diabetes control
b
Likelihood that viewing active management as responsibility of others -0.013 .887 0.325 .003
will hinder my active management
c
No. consultations with medical specialist in average week 0.215 .014 0.244 .007
% of patients who pay through Medicaid 0.258 .002 0.133 .150
Years of postdoctoral study 0.143 .111 0.007 .934
R
2
0.548 0.456
df 8, 73 8, 74
F (P) 11.081 (<.001) 7.763 (<.001)
a
Values range from not at all (1) to very (4).
b
Values range from disagree strongly (1) to agree strongly (4).
c
Values range from very likely (1) to not at all likely (4).
TABLE 3Cross-Tabulation of General Dentists and Periodontists Discussion Scale Scores
and Active Management Scale Scores: Northeastern United States, 2002
Discussion Scale
General Dentists, No. (%)
a
Periodontists, No. (%)
b
Active Management Scale Low Score 90 High Score 91 Low Score<100 High Score =100
Low score 60 35 (67.3) 13 (26.0)
High score 61 17 (32.7) 37 (74.0)
Total 52 (100.0) 50 (100.0)
Low score 80 24 (82.8) 33 (45.8)
High score 81 5 (17.2) 39 (54.2)
Total 29 (100.0) 72 (100.0)
a
For Fisher exact test, P.001. P<.05 from multivariate logistic regression, after we controlled for number of years of
postdoctoral training, percentage of patients who pay with Medicaid, proportion of neighborhood residents on welfare,
number of consultations with medical specialists, and number of consultations with dental specialists, with low performance
level on the discussion scale as the reference group.
b
For Fisher exact test, P=.001. P<.05 from multivariate logistic regression, after we controlled for number of dentists in office
and number of consultations with medical specialists, with low performance level on the discussion scale as the reference group.
scale scores evaluating management of diabetic
patients and demographic, personal, and prac-
tice characteristics. Among general dentists,
level of assessment was positively and signifi-
cantly associated with years of postdoctoral
training, number of dental specialist consulta-
tions, and number of medical consultations and
was negatively and significantly associated with
age. Of the 10 characteristics considered, none
was significantly related to periodontists level
of assessment or to their level of discussion
with the diabetic patient. Level of discussion for
general dentists was positively and significantly
associated with number of consultations with
dental specialists and medical specialists. Level
of active management for general dentists was
positively and significantly associated with
years of postdoctoral training, percentage of
Medicaid patients, proportion of neighborhood
residents on welfare, and number of consulta-
tions with medical specialists. Among periodon-
tists, level of active management was positively
and significantly associated with number of
dentists in the office as well as number of con-
sultations with medical specialists.
As shown in Table 3, 74% of general den-
tists who scored high on the discussion scale
also scored high on the active management of
the diabetic patient scale; the comparable
figure for periodontists was 54%. The associ-
ated multivariate logistic regression models
were also statistically significant.
In Table 4, 2 regression models are pre-
sented, 1 for general dentists and 1 for
periodontists. To assess the role of each in in-
fluencing the active management scale (the
dependent variable), we included the follow-
ing independent variables in both models:
involvement in discussion activity with dia-
betic patients (the discussion scale), demo-
graphic and practice characteristics, variables
informed by the Theory of Planned Behavior
focusing on feelings of mastery or control
(assessment of confidence level), perceived
support from others (colleagues expectations,
patients expectations), and perceived rele-
vance of the activity (view activity as the re-
sponsibility of others). Except for number of
consultations with medical specialists, signifi-
cant predictors in each model varied. Both
models were statistically significant (P<.001),
with R
2
=0.55 for the general dentist model
and R
2
=0.46 for the periodontist model.
DISCUSSION
Our analysis demonstrates the importance
of deconstructing and measuring dentists
management of the diabetic patient according
to the 3 areas of activity consideredassess-
ment, discussion, and active managementfor
greater understanding of the frequency with
which each task is performed relative to the
others as well as the relative participation of
generalists versus specialists. It also highlights
the need to differentiate between the levels or
cutoff points used to designate general den-
tists and periodontists, respectively, as low
performers and high performers. In addition,
this approach provides scored measures of
participation rather than the frequently
used item-by-item assessment of dentists
behavior.
19,20
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RESEARCH AND PRACTICE

The data also demonstrate the importance
of considering demographic, practice structure,
and postdoctoral education variables in under-
standing levels of generalist and specialist ac-
tivity in the management of diabetic patients.
When such variables were considered, differ-
ences between the 2 groups in terms of assess-
ment and active management diminished. For
these 2 activities, differences in scores were
less about clinician group and more about the
organization of the dentists practice. These
findings highlight a need for better under-
standing of the structure and dynamics of prac-
tices of these 2 groups
21
and the implications
for practitioners clinical behaviors.
2224
Interestingly, the only activity for which
there was a significant difference between the
2 clinician groups was discussion: specialists
scored higher here than did generalists, al-
though levels of activity were high for both
groups. Because periodontists are referral-
based practitioners, they may be more likely
to see patients with more advanced periodon-
tal disease and to engage in more invasive
procedures, making them more conscious of
the need to explain the basis for and conse-
quences of the procedures they will be doing,
particularly in relation to the medical condi-
tion of the patientin this case, the diabetic
patient. Also, because periodontics is a referral-
based practice, there may be more emphasis
on establishing a relation or basis of under-
standing with the patient, who is likely to be
a newcomer to the practice.
Notably, although 74% of general dentists
with high scores for discussion also had high
scores for active management, the compara-
ble figure for periodontists was 54%. Perhaps
periodontists, as referral-based specialists, be-
lieve their relationship with the patient should
be focused on the particulars of the special-
ized matter for which the patient was re-
ferred. They may therefore be more likely to
focus on the oral problem at hand than on
the active management or consideration of
the patients overall systemic condition.
Table 4 provides other factors that influence
whether or not general dentists or periodontists
are active managers of the diabetic patient. For
periodontists, variables that reflected feelings of
confidence, involvement with colleagues and
medical experts, and viewing active manage-
ment of the diabetic patient as belonging in
their sphere of professional responsibility were
influential predictors. Such variables pertain, in
general, to notions of professional responsibility
and capability, as well as to intraprofessional
relations (with dental colleagues) and interpro-
fessional relations (with medical specialists).
Missing as influences were variables pertaining
to patient relations, such as discussion with pa-
tients, patient expectations, and the Medicaid
status of their patients. Interestingly, these were
the variables that were most significant in the
general dentist predictive model. Thus, these 2
models suggest that general dentists were more
influenced by patientsthe extent to which
they, as dentists, engage their patients in dis-
cussion, their perceptions of patient expecta-
tions, and the socioeconomic level of their
patientswhereas periodontists were more in-
fluenced by their colleagues and their ability to
perform what they perceived to be their pro-
fessional role.
Among general dentists, the percentage of
patients who paid for services through Medic-
aid was also an influential predictor of active
management of diabetic patients. Diabetes
disproportionately affects socially and materi-
ally disadvantaged adults
25,26
; payment for
health care through Medicaid is an indicator
of such status. Dentists who see more Medic-
aid patients quite possibly see more diabetic
patients. These factors, which are consistent
with the influence patients have on general
dentists, highlight a need for continued inves-
tigation of the relative influence of patient
characteristics versus physician attributes in
clinical decisionmaking.
27
The predictive models further indicate that
discussion is an influential predictor of active
management among general dentists but not
among periodontists. We speculate that the act
of discussion serves different functions for the
2 clinician groups. For the general dentist, dis-
cussion inspires in the patient trust in the den-
tists knowledge and expertise and legitimizes
the dentists assumption of a more active role in
managing the patient. The periodontist, as a
specialist, may believe that the step of legitimiz-
ing expertise is unnecessary or that the general
dentist, who is usually the referral source, has
already performed this step. Instead, as indi-
cated by the model, periodontists were influ-
enced by their sense of confidence in their abil-
ity to manage the patient with diabetes.
The 1 variable that was influential for
both groupsnumber of consultations with
a medical specialist in an average week
demonstrates the importance of an interdisci-
plinary, medical orientation regarding man-
agement of the diabetic patient and of ease
on the part of the dentist in seeking and ob-
taining medical consultations.
28
Limitations
We recognize the limitations inherent in self-
reported data. If social desirability bias, that is,
bias toward reporting or overreporting a behav-
ior that one feels is held in high regard or ex-
pected by others, was present in this self-
reported data, its presence does not temper the
tone of the studys results.
29,30
Periodontists
and general dentists reported rather low levels
of active management regarding diabetic pa-
tients. Although our study was restricted to re-
spondents from the northeastern United States,
we see no reason to suspect that respondents
were less likely than were dentists in other re-
gions of the country to engage in active man-
agement of diabetic patients.
In addition, although our sample sizes were
rather small, several steps were taken to en-
sure that the samples were representative. We
used a proportional, state-based, random sam-
pling strategy in which the number of ran-
domly selected periodontists and general den-
tists from each state was proportional to the
percentage of periodontists and general den-
tists in that state relative to the total number
in the region. We also followed a multistep
respondent contact protocol that resulted in a
73% response rate for periodontists and an
80% response rate for general dentists. These
steps make it unlikely that the data collected
would vary systematically within the subset of
states included and further help to ensure
that the data are representative.
Conclusions
Considering intervention approaches found
effective in other areas of care delivery,
31
the
results presented here have implications for
the development of provider-targeted interven-
tion strategiesfor general dentists and peri-
odontists, respectivelyto achieve the goal of
fostering dentists active management of the di-
abetic patient. For periodontists, our results
suggest a strategy that features (1) professional
American Journal of Public Health | April 2007, Vol 97, No. 4 730 | Research and Practice | Peer Reviewed | Kunzel et al.

RESEARCH AND PRACTICE

endorsements capable of convincing the peri-
odontist that active management of the dia-
betic patient is supported by his or her profes-
sional leadership at the national, regional, and
local levels, and (2) didactic training emphasiz-
ing that the scope of practice for a specialist
should include active management of both the
systemic and the oral health of the patients re-
ferred to them, particularly that of the diabetic
patient.
For general dentists, our results suggest a
strategy that focuses on the patient. Patients
should be educated so that they expect more
active management of both their systemic and
oral health from their dentist as a component
of appropriate dental care and inquire about
or request it if they do not receive it. Dentists
should be educated about the advantages that
such management can have for the patients
health-related outcomes, i.e., their systemic
health, oral health, and dental treatment out-
comesand trained to communicate and dis-
cuss these issues with the patient clearly and
effectively.
The findings presented here provide the
initial step toward identifying the components
of targeted interventions aimed at increasing
specialists and generalist dentists level of in-
volvement in the management of the diabetic
patient, thereby contributing to the improve-
ment of the dental patients oral and systemic
health. Approximately 5% of all patients seen
in dental offices are estimated to have dia-
betes.
32
Among patients aged 60 to 74 years,
the prevalence of diabetes may be as high as
20% to 25%.
5,32
It is predicted that both gen-
eral dentists and periodontists will be treating
greater numbers of patients, and older pa-
tients with this disease owing in part to the in-
creasing longevity of Americans and the
growing prevalence of diabetes. Dentists have
an opportunity and responsibility to aid in the
maintenance of oral health and concurrently
to improve the general health status of pa-
tients with diabetes.
About the Authors
The authors are with the College of Dental Medicine,
Columbia University, New York, NY. Carol Kunzel is also
with the Mailman School of Public Health, Columbia
University, New York.
Requests for reprints should be sent to Carol Kunzel,
PhD, Division of Community Health, College of Dental
Medicine, Columbia University, 630 W 168th St, New
York, NY 10032 (e-mail: ck60@columbia.edu).
This article was accepted August 16, 2006.
Contributors
C. Kunzel participated in the conceptualization and de-
sign of the study, oversaw data collection, cleaned and
analyzed the data, and prepared the article. E. Lalla
and I. Lamster collaborated in the conceptualization
and design of the study, interpretation of the data, and
the writing of the article.
Human Participant Protection
The institutional review board at Columbia University
Medical Center reviewed and approved the studys pro-
tocol and materials.
Acknowledgments
This work was supported by a National Institute of
Dental and Craniofacial Research grant (R01
DE14898; I. Lamster, principal investigator).
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