Factors associated with the practice of periodontal management by diabetes educator nurses for outpatients with diabetes: A nationwide survey in Japan


      • Medical/dental care should manage periodontal disease of people with diabetes.
      • Many diabetes educator nurses did not provide periodontal care in Japan.
      • Assessment of oral conditions is key factor for periodontal management.
      • Psychological ability and motivation for oral health assessment should be improved.



      This study aimed to identify and prioritize factors contributing to the provision of periodontal care by certified diabetes nurse educators to outpatients with diabetes in medical settings in Japan.


      Questionnaires were administered to 321 certified diabetes educator nurses from 1277 institutions. The practice of periodontal care was assessed, with factors contributing to periodontal care through items developed based on the capability, opportunity, and motivation-behavior model. Fisher’s exact tests and logistic regression were performed.


      >70% of certified diabetes educator nurses did not provide periodontal care for diabetes patients. The respondents who assessed people’s oral conditions were more likely to engage in individual or group education and consult for oral management professionals than those who did not. Significant factors for such assessment were low psychological capability and reflective motivation, irregular and weak intention to engage in oral management, and working at an institution without an outpatient department specializing in diabetes.


      The education for certified diabetes educator nurses who do not work at an institution with an outpatient department specialized in diabetes care should be prioritized. Particularly, education to improve knowledge, skills, and confidence in oral assessments and to make periodontal management regular is needed.


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        • Ministry of Health, Labour and Welfare
        National Health and Nutrition Survey in Japan, 2016.
        2017 (Available online: https://www.mhlw.go.jp/content/000681180.pdf (Accessed 12 October 2020))
        • The Japanese Society of Periodontology
        JSP Clinical Practice Guideline for the Periodontal treatment, 2015.
        2017 (Available online: http://www.perio.jp/publication/upload_file/guideline_perio_plan2015_en.pdf (Accessed 12 October 2020))
        • Inagaki K.
        • Kikuchi T.
        • Noguchi T.
        • et al.
        A large-scale observational study to investigate the current status of diabetic complications and their prevention in Japan: oral and dental findings at baseline—JDCP study 6.
        J. Jpn. Diabetes Soc. 2020; 63: 195-205https://doi.org/10.11213/tonyobyo.63.195
        • Preshaw P.M.
        • Alba A.L.
        • Herrera D.
        • et al.
        Periodontitis and diabetes: a two-way relationship.
        Diabetologia. 2012; 55: 21-31https://doi.org/10.1007/s00125-011-2342-y
        • Saremi A.
        • Nelson R.G.
        • Tulloch-Reid M.
        • et al.
        Periodontal disease and mortality in type 2 diabetes.
        Diabetes Care. 2005; 28: 27-32https://doi.org/10.2337/diacare.28.1.27
        • Shultis W.A.
        • Weil E.J.
        • Looker H.C.
        • et al.
        Effect of periodontitis on overt nephropathy and end-stage renal disease in type 2 diabetes.
        Diabetes Care. 2007; 30: 306-311https://doi.org/10.2337/dc06-1184
        • Promotion Foundation
        Chi-iki I-ryoh no Arata-naru ten-kaiI-ka Shi-ka ren-kei ji-rei Shuh [New Developments in Community Medicine ― Casebook of Medical and Dental Collaboration].
        8020 Promotion Foundation, 2009
        • Kuwamura Y.
        • Sumikawa M.
        • Tanioka T.
        • et al.
        Development of the Diabetes Oral Health Assessment Tool© for nurses.
        Health. 2015; 07: 1710-1720https://doi.org/10.4236/health.2015.712186
        • Kuwamura Y.
        • Sakamoto E.
        • Sumikawa M.
        • et al.
        Assessing the oral health of patients with diabetes using a clinical version of the Diabetes Oral Health Assessment Tool© and its association with dental examinations.
        J. Med. Invest. 2019; 66: 328-336https://doi.org/10.2152/jmi.66.328
        • Simpelaere I.S.
        • Van Nuffelen G.
        • Vanderwegen J.
        • et al.
        Oral health screening: feasibility and reliability of the oral health assessment tool used by speech pathologists.
        Int. Dent. J. 2016; 66: 178-189https://doi.org/10.1111/idj.12220
        • Kawaguchi T.
        Certified diabetes expert nurse and nurse educators in Japan.
        Diabetes Res. Clin. Pract. 2007; 77: S205-S207https://doi.org/10.1016/j.diabres.2007.01.058
        • Haneda M.
        • Noda M.
        • Origasa H.
        • et al.
        Japanese clinical practice guideline for diabetes 2016.
        J. Diabetes Investig. 2018; 9: 657-697https://doi.org/10.1111/jdi.12810
        • Certification Board for Diabetes Educators in Japan
        Toh-nyoh-byoh Ryoh-yoh Shi-Doh Guidebook <2020> Toh-nyoh-byoh Ryoh-yoh Shi-Doh Shi No Ga-Ku-shuh Mo-Ku hyoh to Ka-Dai. [Guidebook of Diabetes Education <2020> Learning Goals and Challenges for Diabetes Educators].
        Certification Board for Diabetes Educators in Japan, 2020
        • Certification Board for Diabetes Educators in Japan
        CDEJ (Nihon Toh-nyoh-byoh Ryoh-yoh Shi-doh Shi) to-wa [What is the Certified Diabetes Educator of Japan?].
        Certification Board for Diabetes Educators in Japan, 2020 (Available online: https://www.cdej.gr.jp/modules/general/index.php?content_id=1 (Accessed 12 January 2020))
        • Ueda I.
        • Tsuji A.
        • Suzuki Y.
        Effects of professional autonomy and approval from others on job satisfaction in nurses qualified as a Certified Diabetes Educator of Japan: focus on the presence or absence of responsibility for outpatient specialty diabetes care.
        J. Jpn. Acad. Diabetes Educ. Nurs. 2007; 21: 28-38
        • Ohara Y.
        • Seto N.
        • Shibayama T.
        • et al.
        Field survey on diabetes educational classes for outpatients in certified medical facilities—with special emphasis on the schedules, contents, and educators.
        J. Jpn. Acad. Diabetes Educ. Nurs. 2017; 21: 119-129
        • Kuwamura Y.
        • Sumikawa M.
        • Sakamoto E.
        • et al.
        Utilization of the diabetes oral health assessment tool for nurses by diabetes nurse specialists.
        J. Nurs. Investig. 2019; 15: 1-10
        • Poudel P.
        • Griffiths R.
        • Wong V.W.
        • et al.
        Knowledge and practices of diabetes care providers in oral health care and their potential role in oral health promotion: a scoping review.
        Diabetes Res. Clin. Pract. 2017; 130: 266-277https://doi.org/10.1016/j.diabres.2017.06.004
        • Bissett S.M.
        • Stone K.M.
        • Rapley T.
        • et al.
        An exploratory qualitative interview study about collaboration between medicine and dentistry in relation to diabetes management.
        BMJ Open. 2013; 3e002192https://doi.org/10.1136/bmjopen-2012-002192
        • Michie S.
        • van Stralen M.M.
        • West R.
        Behavior change wheel: a new method for characterizing and designing behavior change interventions.
        Implement. Sci. 2011; 6: 42https://doi.org/10.1186/1748-5908-6-42
        • Atkins L.
        • Hunkeler E.M.
        • Jensen C.D.
        • et al.
        Factors influencing variation in physician adenoma detection rates: a theory-based approach for performance improvement.
        Gastrointest. Endosc. 2016; 83: 617-626.e2https://doi.org/10.1016/j.gie.2015.08.075
        • Mills W.L.
        • Pimentel C.B.
        • Snow A.L.
        • et al.
        Nursing home staff perceptions of barriers and facilitators for implementing a quality improvement intervention.
        J. Am. Med. Dir. Assoc. 2019; 20: 810-815https://doi.org/10.1016/j.jamda.2019.01.139
        • Varisco T.J.
        • Downs C.G.
        • Rathburn K.R.
        • et al.
        Applying the capability, opportunity, motivation, and behavior model to identify opportunities to increase pharmacist comfort dispensing naloxone in Texas: a structural equation modeling approach.
        Int. J. Drug Policy. 2020; 83102827https://doi.org/10.1016/j.drugpo.2020.102827
        • Newton J.T.
        • Asimakopoulou K.
        Behavioral models for periodontal health and disease.
        Periodontology. 2000; 78: 201-211https://doi.org/10.1111/prd.12236
        • The Japan Diabetes Society
        Sen-mon-I no Ken-saku [Search for Certified Diabetologists].
        The Japan Diabetes Society, 2020 (Available online: http://www.jds.or.jp/modules/senmoni/ (Accessed 1 December 2020))
        • Certification Board for Diabetes Educators in Japan
        CDEJ no Iru Shi-setsu wo Sagasu [Find an Institution with CDEJ].
        Certification Board for Diabetes Educators in Japan, 2020 (Available online: http://www.cdej.gr.jp/modules/general/index.php?content_id=4 (Accessed 1 December 2020))
        • Velicer W.F.
        • Eaton C.A.
        • Fava J.L.
        Construct explication through factor or component analysis: a review and evaluation of alternative procedures for determining the number of factors or components.
        in: Goffin R.D. Helmes E. Problems and Solutions in Human Assessment: Honoring Douglas N. Jackson at Seventy. Kluwer Academic/Plenum Publishers, New York2020: 41-71https://doi.org/10.1007/978-1-4615-4397-8_3
        • Nam S.
        • Chesla C.
        • Stotts N.A.
        • et al.
        Barriers to diabetes management: patient and provider factors.
        Diabetes Res. Clin. Pract. 2011; 93: 1-9https://doi.org/10.1016/j.diabres.2011.02.002
        • Kudoh R.
        • Shibayama T.
        • Hidaka K.
        The role of knowledge and self-efficacy on dental consultation behavior in patients with type 2 diabetes.
        Jpn. J. Nurs. Sci. 2020; e12378https://doi.org/10.1111/jjns.12378