More than 200 million people

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1 J Periodontol August 2008 Management of Patients With Diabetes by General Dentists in New Zealand Keshia Forbes,* W. Murray Thomson,* Carol Kunzel, Evanthia Lalla, and Ira B. Lamster Background: The prevalence of diabetes in New Zealand is reaching epidemic proportions, with serious implications for oral health. We investigated the attitudes, beliefs, and practices of New Zealand (NZ) general dental practitioners (GDPs) with respect to the management of patients with diabetes and contrasted the NZ findings with those from a similar survey of GDPs in the Northeast United States (NE US) conducted in Methods: A nationwide postal survey was conducted of NZ dentists. A random sample was selected from the 2005 New Zealand Dental Register. Responses were received from 437 dentists (response rate: 64.5%). Results: The sample was representative. Most GDPs participated in the assessment and discussion phases of managing patients with diabetes, but the prevalence of more hands-on activities (such as testing) was considerably lower. Threequarters of dentists asked new patients about their type of diabetes. Just over two in five respondents believed that their evaluation and/or management of the patient with diabetes were hindered by the lack of continuing education opportunities. Almost one-third of dentists were unwilling to screen for diabetes using a finger-stick test, and only 2.6% overall had ever done so. There were only minor differences between NZ and NE US dentists. Conclusion: Given the increasing numbers of patients with diabetes (known and unknown), there is a need for NZ and US dentists to be more involved in their active management. J Periodontol 2008;79: KEY WORDS Dentists; diabetes mellitus; periodontitis; survey. * Department of Oral Sciences, Sir John Walsh Research Institute, School of Dentistry, The University of Otago, Dunedin, New Zealand. Division of Community Health, College of Dental Medicine, Columbia University, New York, NY. Division of Periodontics, College of Dental Medicine, Columbia University. More than 200 million people worldwide have diabetes mellitus, and this number is estimated to double or triple in the next 10 years. 1 In New Zealand (NZ) alone, 157,000 people have been diagnosed with diabetes, and $170 million is spent each year in the public health system on diabetes and related complications. 2 The oral complications of uncontrolled diabetes mellitus can include periodontitis, xerostomia, poor healing, greater incidence and severity of caries, candidiasis, periapical abscesses, and burning mouth syndrome. 3 The association between diabetes and periodontal disease is well established, and periodontitis has been designated the sixth complication of diabetes. 4 Therefore, when treating the patient with diabetes in the dental office, the goals are to develop and implement preventive and therapeutic strategies that are compatible with the patient s physical and emotional ability to undergo and respond to dental care. 5 Despite widespread agreement among physicians and dentists about guidelines for the care of diabetes, the treatment of diabetes in actual practice is often suboptimal. 6 Textbooks and journals extensively discuss the proper management of the patient with diabetes in the dental office, with emphasis being placed on recognizing the signs and symptoms associated with the disease, modifying the treatment plan according to the patient s diabetic condition, and assuming an active role in managing glycemic control. 1,3,5,7 In a 2002 study, 8-10 we found doi: /jop

2 Management of Patients With Diabetes by Dentists Volume 79 Number 8 that general dental practitioners (GDPs) located in the Northeast United States (NE US) frequently perform activities involving assessing and advising the patient with diabetes but that relatively few dentists perform activities that require more proactive management of such patients. We also found large differences between periodontists and GDPs in levels of clinical performance with respect to the patient with diabetes. Overall, higher percentages of periodontists than GDPs perform such activities frequently. There was a decrease in the level of involvement for both clinician groups when moving from activities more involved in assessment and assisting to the arrange activities requiring some degree of follow-up. To our knowledge, this was the first study to document the extent of assessment and management of the patient with diabetes (and unidentified diabetes) among GDPs and periodontists. 9 Thefindingssuggestthat dentaleducation overall should emphasize the advantages of active management and the effects it can have for patients systemic health, oral health, and dental treatment, and dentists (general dentists and specialists) should be encouraged to discuss these issues with the patient clearly and effectively. The aim of this study was to investigate NZ GDPs behaviors, attitudes, and beliefs with respect to the management of patients with diabetes and to compare those with US dentists. MATERIALS AND METHODS A postal survey was conducted of 700 NZ GDPs randomly selected from the 2005 New Zealand Dental Register. Specialty dentists were excluded from the sampling frame prior to drawing the sample. The University of Otago Ethics Committee approved the study. Incentives for participation were offered in the form of two prize drawings, generously sponsored by two dental supply companies. Prize winners were randomly selected from those who completed and returned the survey. The survey questionnaire was posted with a cover letter explaining the study s purpose, and a reply-paid envelope was included for returning completed forms. One month later, the questionnaires were resent to the 354 dentists who had not responded. These were accompanied by an amended cover letter. The questionnaire sought data on respondents sociodemographic and practice characteristics, together with information on respondents appraisal of the extent to which they assessed patients for diabetes and the way in which they evaluated and treated patients with diabetes. They were also asked to describe perceived barriers in treating these patients, perceived expectations of patients and colleagues, and their own self-assessed knowledge and competence in the areas. Items used to measure dentists assessment and management of the patient with diabetes (known and unknown), as well as their attitudes and beliefs regarding such practice behaviors, were comparable to the items used in the 2002 mail survey of dentists in the NE US. Further details on the research design and methods used in the 2002 study were published previously For reporting purposes, respondents were grouped by gender, year of graduation (pre-1970, 1970 to 1979, 1980 to 1989, 1990 to 1999, and 2000+), and site of practice (major city, provincial city, and other). Locations classified as major cities included Auckland, Hamilton, Christchurch, Dunedin, Porirua, Upper Hutt, Lower Hutt, Wellington, North Shore, Waitakere, Manukau, and Papakura. Locations classified as provincial cities included Whangarei, Tauranga, Rotorua, Gisborne, Hastings, Napier, New Plymouth, Wanganui, Palmerston North, Masterton, Nelson- Marlborough, Kaikoura, Timaru, and Invercargill. The remaining locations were classified as other. The survey responses were entered into an electronic database and then analyzed using statistical software. Associations between categorical variables were tested for statistical significance using the x 2 test, with the a level set at RESULTS The initial random sample consisted of 700 GDPs; however, 23 were outside the sampling frame because they were retired or deceased or because address details were incorrect. From the remaining 677 dentists, 437 questionnaires were returned (males, n = 329; females, n = 108), yielding a response rate of 64.5%. Comparison of the characteristics of the responders with those of the dental profession as a whole showed that there were no significant differences, with the Register data falling within the 95% confidence interval (CI) for all of the survey estimates (Table 1). Data on the extent of dentists management and/or evaluation of patients with diabetes are presented in Table 2 by dentist characteristics. Nearly all discussed the oral implications of diabetes and the extent of the patient s diabetic control. More than three-quarters discussed how periodontal treatment affects diabetic control; this was highest among female and overseastrained dentists. Just over one-fifth of dentists made referrals for monitoring of blood glucose levels, and this was higher among females and overseas-trained dentists. Only 25.8% of respondents had referred a patient for evaluation of suspected diabetes in the previous year. Among those who had, the mean number was (range 1 to 74). With regard to the discussion Statistical Package for the Social Sciences, SPSS, Chicago, IL. 1402

3 J Periodontol August 2008 Forbes, Thomson, Kunzel, Lalla, Lamster Table 1. Comparison of Respondents Sociodemographic and Degree Characteristics (%) to Those of the Actively Practicing NZ Dental Profession as a Whole Respondents (95% CI) NZ Dental Profession 16 Male 75.3 (71.1 to 79.3) 72.8 Female 24.7 (20.7 to 28.9) 27.2 Age group (years) (6.9 to 12.5) to (16.9 to 24.5) to (27.4 to 36.2) to (19.0 to 27.0) (11.4 to 18.0) 14.8 New Zealand 81.9 (78.3 to 85.5) 79.0 Overseas 18.1 (14.5 to 21.7) 21.0 of postoperative medications with the patient with diabetes, 390 (89.2%) dentists performed this task, with nearly all female dentists (98.1%) doing so. More than three-quarters of dentists would adjust the frequency of dental visits of patients with diabetes; this was considerably higher among females at almost 9 of 10. Data on dentists management of the new patient with diabetes are presented in Table 3 by dentist characteristics. Approximately three-quarters of dentists asked patients about their diabetes type; this was lower among overseas-trained dentists, of whom only twothirds asked. One-third of respondents asked about the time of first diagnosis, whereas just over 6 of 10 inquired about the presence of diabetic complications, and three-quarters asked patients with diabetes about the regimen they used for blood glucose control. Data on dentists perceptions of the barriers to taking a more active role are presented in Table 4. A lack of patient education materials was reported by almost half. Just over two in five dentists believed that their evaluation and/or management of the patient with diabetes were hindered by a lack of continuing education opportunities. This perception was most common among recent graduates and least Table 2. Dentists Evaluation/Management of Patients With Diabetes by and Practice Characteristics (N [%]) Evaluation/Management of a Patient With Diabetes Sometimes/Often Includes: Discussing Oral Implications Discussing How Periodontal Therapy Affects Metabolic Control Referral for or Monitoring Blood Glucose Levels Discussing How Well Controlled the Patient Is Discussing Postoperative Medications, Cross-Infection Control Adjusting Frequency of Dental Visits Male 304 (92.4) 245 (74.5)* 59 (17.9)* 281 (85.4) 284 (86.3)* 246 (74.8)* Female 104 (96.3) 94 (87.0) 35 (32.4) 98 (90.7) 106 (98.1) 94 (87.0) Graduating cohort Pre (87.3) 42 (66.7) 12 (19.0) 51 (81.0) 51 (81.0) 41 (65.1) 1970 to (96.9) 76 (78.4) 17 (17.5) 81 (83.5) 89 (91.8) 76 (78.4) 1980 to (95.0) 111 (78.7) 37 (26.2) 129 (91.5) 127 (90.1) 112 (79.4) 1990 to (91.9) 81 (81.8) 18 (18.2) 85 (85.9) 90 (90.9) 81 (81.8) (91.9) 29 (78.4) 10 (27.0) 33 (89.2) 33 (89.2) 30 (81.1) Practice setting Major city 257 (93.5) 217 (78.9) 55 (20.0) 235 (85.5) 243 (88.4) 213 (77.5) Provincial city 82 (92.1) 68 (76.4) 19 (21.3) 78 (87.6) 80 (89.9) 72 (80.9) Other 69 (94.5) 54 (74.0) 20 (27.4) 66 (90.4) 67 (91.8) 55 (75.3) Overseas 74 (93.7) 68 (86.1)* 26 (32.9)* 67 (84.8) 75 (94.9) 63 (79.7) New Zealand 334 (93.3) 271 (75.7) 68 (19.0) 312 (87.2) 315 (88.0) 277 (77.4) Total 408 (93.4) 339 (77.6) 94 (21.5) 379 (86.7) 390 (89.2) 340 (77.8) 1403

4 Management of Patients With Diabetes by Dentists Volume 79 Number 8 Table 3. Dentists Routine Querying of a New Patient With Diabetes by and Practice Characteristics (N [%]) Management of the New Patient With Diabetes Almost Always/Always Involves Asking About: Type of Diabetes? When First Diagnosed? Any Diabetic Complications? Regimen Used to Control Blood Glucose? Male 243 (73.9) 106 (32.2) 199 (60.5) 244 (74.2) Female 88 (81.5) 43 (39.8) 69 (63.9) 90 (83.3) Graduating cohort Pre (68.3) 27 (42.9) 42 (66.7) 43 (68.3) 1970 to (71.1) 37 (38.1) 59 (60.8) 73 (75.3) 1980 to (76.6) 48 (34.0) 90 (63.8) 113 (80.1) 1990 to (77.8) 30 (30.3) 62 (62.6) 78 (78.8) (91.9) 7 (18.9) 15 (40.5) 27 (73.0) Practice setting Major city 207 (75.3) 99 (36.0) 165 (60.0) 213 (77.5) Provincial city 69 (77.5) 27 (30.3) 58 (65.2) 67 (75.3) Other 55 (75.3) 23 (31.5) 45 (61.6) 54 (74.0) Overseas 53 (67.1)* 23 (29.1) 42 (53.2) 62 (78.5) New Zealand 278 (77.7) 126 (35.2) 226 (63.1) 272 (76.0) Total 331 (75.7) 149 (34.1) 268 (61.3) 334 (76.4) common among those who had been practicing the longest. Almost half of the respondents believed that the active management of patients with diabetes was the responsibility of others. Although almost all respondents were willing to manage patients with diabetes in their own office (and most were willing to refer for evaluation those patients whom they suspected of having undiagnosed diabetes), only one-third of dentists were willing to screen for diabetes using a finger-stick test (Table 5). This included half of the most recently graduated dentists, but only one in five dentists who had graduated during the 1990s. Further, only 2.6% of respondents overall had ever screened for diabetes using a finger-stick test. More than half of the dentists rated as high their knowledge of managing patients with diabetes in their own office; this was higher among females and overseas-trained dentists. More overseas-trained dentists than NZ-trained dentists rated their knowledge of diabetes and its risk factors as good or excellent. More than two-thirds of overseas-trained dentists thought they had excellent knowledge in preventing/dealing with in-office emergencies compared to just more than half of NZ-trained dentists. With regard to confidence in managing patients with diabetes, almost all dentists (94.9%) were somewhat or very confident in managing a patient with diabetes in their own office, whereas only 25.2% felt confident in screening patients for diabetes. Confidence in preventing/dealing with in-office diabetic emergencies was expressed by 79.5% of respondents. There were no significant differences by dentist characteristics. Dentists thoughts on the expectations of colleagues and patients were explored. A higher proportion of overseas-trained dentists than NZ-trained dentists believed that their colleagues expect them to take a more active role in diabetes management; more than one-third of most recent graduates believed this, whereas just over one in 10 of the longer practicing dentists did. One-quarter of dentists believed that their patients expected them to take a more active role in diabetes management. Only 26.7% of respondents believed that taking a more active role in diabetes management would be easy. Although this was higher among NZ-trained dentists than overseas-trained dentists (36.8% and 24.4%, respectively; P <0.05), there were no other significant differences. Just over half of the respondents (50.7%) believed that taking an active role in diabetes management would be useful. A comparison of the NE US and NZ estimates is presented in Table 6. The two groups were broadly 1404

5 J Periodontol August 2008 Forbes, Thomson, Kunzel, Lalla, Lamster Table 4. Barriers to Dentists Taking an Active Role in the Evaluation/Management of the Patient With Diabetes by and Practice Characteristics (N [%]) Evaluation/Management of the Patient With Diabetes Is Somewhat/Very Likely Hindered by: Lack of Patient Education Materials Lack of Continuing Education Opportunities Viewing Active Management of Patient With Diabetes as the Responsibility of Others Male 146 (44.4) 135 (41.0) 151 (45.9) Female 49 (45.4) 52 (48.1) 45 (41.7) Graduating cohort Pre (36.5) 18 (28.6)* 33 (52.4) 1970 to (45.4) 38 (39.2) 43 (44.3) 1980 to (46.1) 61 (43.3) 58 (41.1) 1990 to (42.4) 50 (50.5) 45 (45.5) (56.8) 20 (54.1) 17 (45.9) Practice setting Major city 122 (44.4) 118 (42.9) 124 (45.1) Provincial city 41 (46.1) 44 (49.4) 43 (48.3) Other 32 (43.8) 25 (34.2) 29 (39.7) Overseas 36 (45.6) 37 (46.8) 35 (44.3) New Zealand 159 (44.4) 150 (41.9) 161 (45.0) Total 195 (44.6) 187 (42.8) 196 (44.9) similar over most of the domains, although there were statistically significant differences in five of the 22 items considered. A higher proportion of NE US GDPs than NZ GDPs discussed how periodontal treatment affects metabolic control with their patients (nine of 10 and three-quarters, respectively). Similarly, a higher proportion of NE US GDPs than NZ GDPs included referral for blood glucose monitoring (approximately one-third and one-fifth, respectively). With new patients, a lower proportion of NZ GDPs than NE US GDPs inquired about when they had first been diagnosed as diabetic (one-third and one-half, respectively). A higher proportion of NE US GDPs believed that their evaluation of patients with diabetes was hindered by their management being viewed as the responsibility of others (approximately two-thirds and one-half, respectively), and a higher proportion of NE US GDPs agreed that their colleagues expected them to take a more active role in diabetes management (approximately one-third and one-fifth, respectively). DISCUSSION This cross-sectional study of NZ GDPs aimed to investigate their behaviors, attitudes, and beliefs with respect to the management of patients with diabetes. It found that a clear majority participated in the assessment and discussion phases of management with their patients with diabetes. The more proactive behaviors, such as monitoring blood glucose levels, were less common. It is noteworthy that these findings are similar to those from the 2002 NE US survey The first consideration in any such study is the extent to which the findings are generalizable; that is, is the study s sample representative? Scrutiny of the data in Table 1 indicates that there were no statistically significant differences between the study respondents and the entire Dental Register with respect to gender, age group, or the source of the primary dental qualification. Therefore, it is possible to generalize the findings to all GDPs in NZ (albeit cautiously, because we were unable to make comparisons of any other characteristics). A limitation of the study is that it is reliant upon self-reported data rather than on direct observation of dentists behaviors. A possible limitation of such data is social desirability bias, which is the bias toward reporting or overreporting a behavior that the respondent believes is held in high regard (or expected) by others. 11,12 However, it does not seem to have affected the findings because the respondents reported low levels of active management of the patient with diabetes, 1405

6 Management of Patients With Diabetes by Dentists Volume 79 Number 8 Table 5. Dentists Active Management of Patients With Diabetes by and Practice Characteristics (N [%]) Manage Patients With Diabetes in Own Office Dentists Are Willing to: Refer Patients for Evaluation of Suspected Diabetes Screen for Diabetes Using a Finger-Stick Test Male 291 (92.1) 281 (88.1) 94 (29.8) Female 99 (92.5) 100 (93.5) 34 (31.8) Graduating cohort Pre (87.5) 53 (91.4) 18 (32.7)* 1970 to (90.4) 88 (92.6) 29 (30.5) 1980 to (92.8) 119 (85.6) 42 (30.4) 1990 to (95.9) 89 (90.8) 21 (21.4) (91.7) 32 (88.9) 18 (50.0) Practice setting Major city 247 (92.5) 236 (88.1) 84 (31.5) Provincial city 77 (90.6) 81 (93.1) 24 (28.2) Other 66 (93.0) 64 (90.1) 20 (28.6) Overseas 71 (89.9) 69 (87.3) 28 (35.9) New Zealand 319 (92.7) 312 (89.9) 100 (29.1) Total 390 (92.2) 381 (89.4) 128 (30.3) and the findings are largely consistent with those from the earlier NE US study of GDPs management of patients with diagnosed and undiagnosed diabetes. Almost all respondents to the current survey felt confident in managing patients with diabetes in their own office. A clear majority sometimes or often discussed oral implications, periodontal therapy effects, diabetic control, and postoperative medications with their patients with diabetes, and over threequarters were willing to adjust the frequency of dental visits. This is an important finding, given the status of periodontal disease as a major complication of diabetes. 4 Most GDPs rated their knowledge as good or excellent with regard to managing patients with diabetes and knowing the condition s complications. A US survey of insulin-dependent patients with diabetes found that they frequently were unaware of the oral health complications of their disease. 13 With a clear majority of NZ dentists rating their knowledge as good/excellent with regard to the management of patients with diabetes, they should be in a sound position to advise them. Where the management of the new patient with diabetes is concerned, most respondents routinely assessed the patient s condition by inquiring about the type and complications and the regimen used to control blood glucose. Gathering such details from patients with diabetes is a routine part of basic medical history taking and can give important information on how well the patient s condition is controlled. The patient with uncontrolled (or poorly controlled) diabetes can have oral complications, such as periodontal disease and poor healing, and is prone to having a hypoglycemic or hyperglycemic crisis in the dental office. Fortunately, most respondents in the current study rated their knowledge of preventing and dealing with in-office diabetic emergencies as good or excellent, and almost four-fifths of GDPs felt confident with this aspect of patient care. However, the respondents levels of active involvement with the undiagnosed patient with diabetes was considerably lower with respect to activities such as using a finger-stick test to screen patients for diabetes. Fewer than 3% had ever screened for diabetes using a finger-stick test, and seven of 10 did not believe that it was their role. These low levels of willingness may reflect medicolegal concerns, particularly in view of the 2004 introduction of defined scopes of practice for health professions in NZ, as well as a perceived lack of knowledge and skill for performing such a task. A similarly low prevalence of screening for diabetes with a finger-stick test was observed in the survey of 1406

7 J Periodontol August 2008 Forbes, Thomson, Kunzel, Lalla, Lamster Table 6. Comparison of NZ and NE US GDPs Practice With Respect to Patients With Diabetes NE US GDPs 9 (% [95% CI]) NZ GDPs (% [95% CI]) Respondents (n) Management includes: Discussing oral implications 92.3 (87.2 to 97.4) 93.4 (91.1 to 95.7) Discussing how periodontal therapy affects 90.2 (84.5 to 95.9) 77.6 (73.7 to 81.5)* metabolic control Referral for monitoring blood glucose 36.5 (27.3 to 45.7) 21.5 (17.6 to 25.4)* Discussing how well controlled patient is 89.4 (83.5 to 95.3) 86.7 (83.5 to 89.9) Discussing postoperative complications 96.2 (92.5 to 99.9) 89.2 (86.3 to 92.1) Adjusting frequency of visits 75.0 (66.7 to 83.3) 77.8 (73.9 to 81.7) Assessment of new patients involves asking: Type of diabetes? 64.4 (55.2 to 73.6) 75.7 (71.7 to 79.7) When first diagnosed? 49.0 (39.4 to 58.6) 34.1 (29.7 to 38.5)* Any complications? 70.2 (61.5 to 78.9) 61.3 (56.7 to 65.9) Regimen used to control blood glucose? 72.8 (64.3 to 81.3) 76.4 (72.4 to 80.4) Evaluation/management of patient hindered by: Lack of patient education materials 51.9 (42.3 to 61.5) 44.6 (39.9 to 49.3) Lack of continuing education opportunities 44.7 (35.2 to 54.2) 42.8 (38.2 to 47.4) Viewing their management as others responsibility 65.0 (55.9 to 74.1) 44.9 (40.2 to 49.6)* Dentists are willing to: Manage patient with diabetes in own office 92.3 (87.2 to 97.4) 92.2 (89.7 to 94.7) Refer patients for evaluation of suspected diabetes 96.1 (92.4 to 99.8) 89.4 (86.5 to 92.3) Screen for diabetes using a finger-stick test 31.4 (22.5 to 40.3) 30.3 (26.0 to 34.6) Have ever screened for diabetes using a finger-stick test 2.9 (0.0 to 6.0) 2.6 (1.1 to 4.1) Knowledge is good/excellent: In managing patients with diabetes 63.5 (54.3 to 72.7) 57.0 (52.4 to 61.6) Of diabetes and its risk factors 76.0 (67.8 to 84.2) 64.2 (59.7 to 68.7) In preventing/managing in-office diabetic emergencies 63.5 (54.3 to 72.7) 59.8 (55.2 to 64.4) Agree with the statement: My colleagues expect me to take a more active role in diabetes management My patients expect me to take a more active role in diabetes management 36.5 (27.3 to 45.7) 22.9 (19.0 to 26.8)* 35.0 (25.9 to 44.1) 24.8 (20.8 to 28.8) NE US GDPs, thereby suggesting that the latter is probably of more relevance. Nearly half of the NZ GDPs viewed more active management of patients with diabetes as the responsibility of others. These findings are also consistent with those from our previous NE US study 10 in which this viewpoint seemed to be even more widely held among GDPs and suggests the need for ongoing development of skills in the area of active management of the patient with diabetes during undergraduate, postgraduate, and continuing dental education. More than half of the NZ GDPs believed that taking an active role in diabetes management was useful, but only about one-quarter thought that it was easy. One of the barriers for GDPs was the lack of continuing education opportunities; more than half of the most recent graduates saw this as a major barrier to active management of the patient with diabetes. The respondents perceptions of the expectations of colleagues and patients were revealing. More than one-third of the most recent graduates, but just over one in 10 of the longest practicing dentists, believed that their colleagues expected them to take a more active role in diabetes management. This difference may reflect changes in the dental curriculum over time; perhaps more recent graduates have adopted an understanding of the systemic oral health connection, whereas the longer practicing dentists are more accustomed to the traditional dental approach of focusing on the oral cavity. 1407

8 Management of Patients With Diabetes by Dentists Volume 79 Number 8 CONCLUSIONS This study provided some insight into NZ and US dentists behaviors, attitudes, and beliefs regarding the management of the patient with diabetes. Dentists participated actively in the assessment and discussion phases of the management of the patient with diabetes. They had good knowledge of (and felt confident in) the treatment of patients with diabetes, and they felt confident in their ability to handle diabetic emergencies. However, they fell short in the more active management of the patient with diabetes. Currently among NZ adults, approximately one in 32 Europeans, one in 12 Maori, and one in 12 Pacific Islanders are known to have diabetes. By the year 2020, the condition s prevalence will have increased by 31% in Europeans and by 50% among Maori and Pacific Island adults. 2,14,15 Dentists in NZ (and in the US) are likely to be treating more patients with diabetes in the future, and they have a responsibility to improve those patients awareness of the condition s oral health implications. Generalists need to work closely with patients, dental specialists, and physicians to ensure that patients periodontal and general health conditions are appropriately managed. GDPs and periodontists need to be well prepared to conduct risk assessment activities with patients with diagnosed and undiagnosed diabetes and to engage in more active management activities, such as referring for or monitoring blood glucose activity and communicating with the patient s physician, and changing or adjusting the treatment schedule, if necessary. Although the proportion of periodontists often performing such activities was higher than GDPs in the US study, 9 the percentages of both groups of dentists often performing these activities were lower than for the discussion-oriented activities. The conduct of further studies in NZ and elsewhere to assess the practices of periodontists and GPDs with regard to the assessment and management of the (un)diagnosed patient with diabetes would be appropriate, followed by the development of appropriate and effective continuing dental education initiatives in this field. ACKNOWLEDGMENTS This study was funded by the University of Otago. SellAgence, Auckland, New Zealand, and Henry Schein Regional, Auckland, New Zealand, supplied prize packs as incentives for responders. The authors report no conflicts of interest related to this study. REFERENCES 1. Little JW, Miller C, Rhodus NL, Falace D.Diabetes. In: Dental Management of the Medically Compromised Patient. St. Louis, MO: CV Mosby; 1997: Diabetes New Zealand. Diabetes Fact Sheet Available at: DiabetesFacts2006.pdf. Accessed August 18, Vernillo AT. Diabetes mellitus: Relevance to dental treatment. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91: Loë H. Periodontal disease: The sixth complication of diabetes mellitus. Diabetes Care 1993;16: Miley D, Terezhalmy GT. The patient with diabetes mellitus, etiology, epidemiology, principles of medical management, oral disease burden and principles of dental management. Quintessence Int 2005;36: Kern DH, Mainous AG. Disease management of diabetes among family physicians and general internist opportunism or planned care? Fam Med 2001;33: Mealey B, Oates TW. Diabetes mellitus and periodontal diseases. J Periodontol 2006;77: Kunzel C, Lalla E, Albert DA, Yin H, Lamster IB. On the primary care frontlines: The role of the general practitioner in smoking-cessation activities and diabetes management. J Am Dent Assoc 2005;136: Kunzel C, Lalla E, Lamster IB. Management of the patient who smokes and the diabetic patient in the dental office. J Periodontol 2006;77: Kunzel C, Lalla E, Lamster IB. Dentists management of the diabetic patient contrasting generalists and specialists. Am J Public Health 2007;97: Fisher RJ. Social desirability bias and the validity of indirect questioning. J Consum Res 1993;20: DePoy E, Gitlin LM. Introduction to Research: Understanding and Applying Multiple Strategies. St. Louis: Mosby; 1998: Moore PA, Orchard T, Guggenheimer J, Weyant RJ. Diabetes and oral health promotion: A survey of disease prevention behaviors. J Am Dent Assoc 2000; 131: Joshy G, Simmons D. Epidemiology of diabetes in New Zealand: Revisit to a changing landscape. N Z Med J 2006;119:U Berkeley J, Lunt H. Diabetes epidemiology in New Zealand Does the whole picture differ from the sum of its parts? N Z Med J 2006;119:U Dental Council of New Zealand Workforce Analysis. Wellington, New Zealand: Dental Council of New Zealand; Correspondence: Dr. W.M. Thomson, School of Dentistry, P.O. Box 647, Dunedin 9054, New Zealand. Fax: ; murray.thomson@stonebow.otago.ac.nz. Submitted December 10, 2007; accepted for publication February 7,