Materials and Methods Case Study 2022

Table of Contents
Introduction......................................................................................................................................2
PICO................................................................................................................................................2
PICO Question.................................................................................................................................4
Hypotheses.......................................................................................................................................4
Aim..................................................................................................................................................4
Objectives........................................................................................................................................4
Materials and Methods....................................................................................................................5
Selection criteria..............................................................................................................................6
Collection of the data.......................................................................................................................6
Assess the studies............................................................................................................................7
Provide a critique of the methodology used................................................................................8
Assess for risk of bias..............................................................................................................10
Interpretation of results and conclusions.......................................................................................10
Conclusion.....................................................................................................................................12

Introduction/ Rationale
Type 1 Diabetes is a metabolic disorder that can cause acute and chronic complication
due to insulin resistance developed by a relative lack of insulin. The chronic inflammatory
disease can destroy dental health (Verhulst et al 2019). People suffering from T1D are more
susceptible to develop gum problems due to poor blood sugar control. People with diabetes are
more susceptible to the development of fungal infection called oral thrush , this is due to the fact,
that high amount of sugar can be found in the saliva (Verhulst et al 2019).
This study will provide a literature review to evaluate the effectiveness of verbal and the
non-verbal education to promote oral hygiene in type 1 diabetic patient.
PICO
Summary of your research
idea?
(100 words maximum)
Older Diabetic patients are often at risk of developing oral
health challenges. The most common of these problems
include dry mouth, dental caries, tooth loss and periodontal
diseases, among others (Nazir et al., 2018). The objective of
this proposed study is to assess the impact of verbal and non-
verbal oral health training on older Type 1diabetic patients,
over a period of two years.
What population group do
you intend to study (P)?*
Type 1 Diabetic Patients. (above 60 years
What intervention do you
intend to examine (I)?*
Dental health training should be provided to the older
patisnts with type 1 diabetes by the nurses. The education

will consists of both verbal and non-verbal education,
including the use of videos, presentation.
What comparator do you
intend to use (C)?*
Standard verbal as well as non –verbal oral hygiene
instructions should be given to the older patients by the
nurses.
What is/are your outcome
measure/s (O)?*/**
Oral Health Condition, measured by the incidence of dental
problems such as dental caries and periodontal diseases
( measured by Bleeding on probing, CPITN index and plaque
scores) every 6 months.
PICO Question
What is the impact of verbal and nonverbal oral health training on improving the Type 1 diabetic
older patient’s oral health, as opposed to standard verbal oral health instructions?
Hypotheses
The proposed study will aim to test the following hypotheses:
Alternative hypothesis : Verbal and Non verbal Oral hygiene instructions among Type1
diabetic patients reduces the risk of the patients developing Oral health problems such as dental
caries and periodontal diseases and offers a better control on blood sugar levels.

Null hypothesis: Standard Verbal oral hygiene instructions alone among Type1 diabetic patients
does not effectively reduce the chances of the patients developing Oral health problems such as
dental caries and periodontal diseases, which also indirectly leads to poor blood sugar levels.

Aim
Aim of this Study is to Analyze the effectiveness of verbal and non verbal Oral Health
Clinical Education in improving Oral Health in Type 1 older Male and Female Diabetic Patients
over a period of 2 years
Objectives
The objective of this study is :-
 To undertake a systematic review to Investigate the effectiveness of Verbal and
Nonverbal Oral Health education in Improving Oral health as compared to standard
verbal Oral health education in Type 1 Diabetic patients.
 To investigate the record the effectiveness of Verbal and Nonverbal Oral health
education in control of Blood sugar levels as opposed to standard verbal Oral health
education in Type 1 Diabetic patients.

Literature review
Background information
Diabetes is condition that can affect the whole body including the mouth. It has been
found that people with diabetes have a higher risk of dental conditions like dry mouth, gingivitis,
periodontitis, candidiasis and oral burning,. It has been stated that uncontrolled diabetes can
decrease the saliva resulting in dry mouth. In gingivitis, Atherosclerosis, which slows down the
flow of the nutrients from the body. People with diabetes who consumes antibiotics for fighting
against various diseases are prone to develop fungal infections. Elderly people taking
medications might disrupt the natural flora of microorganisms and facilitates the growth of
Candida albicans. The fungus thrives on the high levels of glucose found in salivary secretions.
Overall, it has been found that people with diabetes have very limited knowledge of the direct
and indirect relationship between oral condition and glucose levels and hence it is necessary to
educate patients about their increased risk of the oral health problems (Poudel et al.,2018). This
provides the rationale behind the fact, why is it necessary to educate patients about diabetes.
Kaur et al. (2015) have stated that clinicians should be empowered for explaining the need for
oral hygiene and background to their enquiries related to the gum disease.
A literature review was conducted in order to answer the PICO question as what is the
impact of both verbal and non-verbal oral health training on improving the Type 1 diabetic
patient’s general and oral health.

Search strategy to identify relevant articles
A proper literature search can only be conducted after using proper keywords. These
keywords cover the main concept of the research question. These key words were used in
electronic databases for identification of the relevant studies.
A literature search was performed in EMBASE applying the search terms like “ Use of
education in type 1 diabetes” , “ Instructions prompting oral hygiene in type 1 diabetes” . Peer
reviewed articles and systematic review published between the year 2013 and 2019. After this, a
further search was conducted with the search terms like “verbal and non-verbal instructions for
maintaining oral hygiene in diabetic patients.
All the studies were selected by adhering to the following inclusion criteria: - The articles
chosen were in English between the years 2013 to 2020, scientific journals with human
participants.
The exclusion criteria were studies before the year 2013, studies with animal studies and
published in language other than English. Only those papers having full text pdf version is
selected for the literature review.
Collection of the data
A tab based collection of data was designed for the item included in the review. Risk analysis
was done to evaluate the quality of the systematic review and the meta-analysis. All the data
obtained has been cross checked.
A PRISMA table has been given below to show the selection of the articles.

The search conducted in EMBASE identified
about 43,824 articles in the initial search. After rigorous research, Out of which 146 articles were
Records identified through the use of
limiters (n=3500)
Studies included
(n=7)
Records after Duplicates removed
(n=453)
Records screened
(n=146)
Full-text articles on assessment
(n=20)
Records excluded on the basis of the
title only
(n=90)
Records excluded based on abstract
(n=20)
IdentificationScreening
Eligibility
Include
d
EMBASE
(n=43824)

selected based on the title of the papers. The search conducted in EMBASE identified about the
43,824 articles in the initial search. After rigorous research, Out of which 146 articles were
selected based on the title of the papers. Out of those, 7 papers has been taken for constructing
this short systematic review. Two of the studies published in the year 2013- 2014, had
emphasized on the effectiveness of the oral hygiene instructions among the diabetic patients.
Critical appraisal of the selected studies
Assessment of the risk of bias requires a degree of the methodological expertise and can
be conducted by the development of the guidelines. Once it has been completed, the risk of the
based assessment can be used for informing the synthesis of the studies, findings and integrated
in to the overall assessment of the certain body of evidence. CASP tool has been used for
evaluating the studies. CASP is the Critical Appraisal Skills Programme, that is used to develop
an evidence based approach in health and social care.
Critique of the methodology used
The paper by Nakre and Harikiran (2013) is a systematic review evaluating the
effectiveness of educational program to maintain oral hygiene and diabetes control in patients.
The paper belongs to the level 1 of the hierarchy of evidence. As, they provide the strongest data.
This study have used about 40 articles necessary that fulfilled the inclusion and the exclusion
criteria. 40 papers has been chosen for the study. The sample size used is low, reducing the
validity and the reliability of the research. . Appropriate keywords has been used for the selecting
appropriate papers for the literature review. The article have cited correct inclusion and the
exclusion criteria. All the studies have been selected on the basis of some mentioned coding
variables. The dependent variable is the blood glucose level and the independent variable is the
oral hygiene. The review has rightfully proved that oral health education to the patients is

important to reduce dental problems and also helps in glycemic control in individuals with high
blood glucose level. The education should be provided by the nurses and the physicians.
The randomized clinical study by Raman et al. (2014), have proved that both dental
health education and periodontal therapy is necessary to treat the clinical manifestations in
chronic peridonitis in patients with the high glycemic level. A randomized control is the most
rigorous way of determining a cause and effect relation. A randomized control increases the
reliability of the study as they involve random allocation of the intervention groups. A total of
40 subjects has been included in the study, which is quite low in comparison to a randomized
control study.
Dickinson et al. (2017) have conducted a systematic review to find out the use of
languages in the diabetes care and education. This paper belongs to level one of the hierarchy of
evidence due to its high impact factor. The paper had provided information about the different
types of verbal communication that are used for educating a target population, such as the use of
strength based language and person first language. The study addressed a clearly focused
question like how effective language can be used in diabetic care and education. This paper had
chosen certain relevant papers. But some of the references were not relevant to the study.
The quasi-experimental study by Saengtipbovorn and Taneepanichskul, (2014) have
proved that together with some life style changes and dental care in one program has been found
to be helpful in managing the oral complication in elderly patients having diabetes. This paper
has employed a quasi-experimental studies as it brings about realistic features from both the
experimental data and non –experimental designs. In can be used for maximizing the internal and
the external validity of the study. 66 diabetic patients has been chosen for the study, hence the

sample size of the participant is too low. This increases the generalizability of the study. The
variables used for the study were sex, age, education levels, presence of health insurance,
duration of the study and smoking. Descriptive statistic has been used for the test.
Randomization had been done reducing the risk of bias. Faber and Fonseca (2014) have stated
that inappropriate sample sizes reduces the power of the study and can compromise the
conclusions that are drawn from the study. Another methodological constraint of the study is that
it was a single blinded study, which increases the risk of bias. Single blinded is a type of study
where the researcher only knows what treatment or intervention has to be given to the
participants until the trial is over. It decreases the likelihood of the bias. However, the
methodological section of the paper provides a detailed account of the outcome measures, the
chosen control groups.
Nakre and Harikiran (2013) is a systematic review, where recommendations for using
appropriate language can be used for providing health education to the patients suffering from
diabetes. The reliability of the methodology used in the paper was supported by several cross
references supporting facts like use of proper phrases free from stigma, using simple languages
that can be used to provide education to common people. In relation to this (Macdonald et al.
(2017) have stated that simple languages can be used while providing education to patients.
Non-verbal education modalities such as application of tele-health for educating patient
have been discussed in the paper by Döğer et al. (2014). The paper has used a randomized
control trial for establishing a relationship between diabetic control and education by using
telehealth. As per the evidence based hierarchy level, this paper belong to the first level. The
ample use of the randomized control trials has increased the generalizability of the study. 82
patients has been recruited for the study, indicating towards a low sample size.

Chrvala, Sherr and Lipman (2016) have assessed the effect of diabetes self-management
education, the support methods, duration, providers and contact time on the glycemic control in
adults. This a systemic search in databases like MEDLINE, CINAHL, EMBASE, ERIC, and
PsycINFO. This a systematic review placing it at the level 1 of the evidence based pyramid. The
review mainly contained randomized control trial papers with unique interventions. All the
studies have been assessed for the presence of the statistically significant difference.
Assess for risk of bias
One of the limitation of the paper Nakre and Harikiran (2013) has found that the search
strategy for this paper is limited to Medline and hence the articles that were found were not much
specialized and some of them are not even peer reviewed due their low circulation. Many of the
good articles that were found in the Medline were only available by payment. The study has
indicated towards the fact that there is an increasing need of systematic review on the studies
evaluating the effectiveness of the educational programs. Not such tools has been used for
assessing the risk of the bias.
The paper by Saengtipbovorn and Taneepanichskul (2014) have stated that one of the
disadvantage of a quasi-experimental study is that, it can cause selection bias, due to the
willingness to participate. Additionally it was not a representation of the entire population of the
elderly people. The paper had also rightfully pointed out that the single blinded technique can
cause the measurement bias.
Raman et al. (2017) does not employ a double blinded trial, hence the risk of bias has not
been assessed. A proper inclusion and exclusion criteria has been used for avoiding any kind of

bias. The risk of bias in the study by Doger et al. (2017) can be due to the short duration of the
study as significant differences has been detected in shorter duration.
In the paper by Chrvala, Sherr and Lipman (2016), retention rates were considered
acceptable to reduce the risk of attrition bias, that is consistent with the Cochrane Collaboration
Criteria that is consistent with the Cochrane Collaboration criteria. The study has also examined
the performance bias for determining the risk of possible contamination. Thus ths study was
considered to be valuable. Saengtipbovorn and Taneepanichskul (2015) have employed a single
mask technique, which has increased the chance of the selection bias.
Interpretation of results and conclusions
It has been well established by several literary sources which proves that communication
between the patients and a health care workers is necessary to make patients adhere to the
guidelines of maintain a sound oral health and glycemic control. It has been stated information
can be imparted to the patients by verbal mode or non-verbal mode (Li et al.2018). Verbal mode
of education can be facilitated by non-verbal teaching or consultation with the doctors. Non –
verbal mode of communication involves using internet based practice such as telehealth to
educate the patients (Macdonald et al. 2013). The clinical implication of the study is that it
indicates towards the fact that internet based teaching can be initiated in the hospitals.
According to Dickinson et al. (2017) stigma has historically been associated with the
diagnosis of the diabetes that contributes to stress and feelings of judgment and fear. It has been
stated that non-handicapping language helps to maintain the integrity of an individual by the
avoidance of language implying that a person as a whole is disabled. The paper has

recommended that while providing verbal instructions to patients with diabetes should be
normal, non-judgmental and should be based on actions, facts or the physiology. It has been
found that judgmental words can promote stigma.
In a study by Raman et al., (2014), it has been found that oral health information in
addition to periodontal therapy has been found to be effective in patients suffering from type 1
diabetes. The difference between the plaque index of the two groups were found to be
significant, wit the P value greater than 1. No significant difference has been found between the
other clinical parameters. Information about patterns of bushing and washing of teeth after each
of the meals are necessary. Similarly, have supported this fact by stating that diabetic patients
should also refrain from the consumption of sweetened food as that will keep them healthy and
glycemic control will be achieved.
According to Nakre and Harikiran (2013), oral health education in patients suffering from
diabetes have shown a reduction in plaque, bleeding and treatment of the dental caries.
Apart from verbal education. Nonverbal education modalities should also be used for
educating patients with type 1 diabetes. Doger et al. (2019) have stated that information
technology and online education can be recommended to teach the patients, families as well as
the health care programs in their graduate and the undergraduate program of nursing. It has been
clearly stated that communication programs that are internet based are mainly are useful for
providing education to the patients residing in the rural areas. Another positive feature of the
program is that patients can receive suggestions in line with the requirements rapidly. In does not
require any face to face direct communication, expenses are saved that could have used in the
transportation.

In the paper by Chrvala, Sherr and Lipman (2016) it was stated that 86 % of the
interventions have achieved significant improvements in the blood sugar level. Most of the
studies have shown a statistically significant reduction of the blood sugar level (P=0.13). All of
the studies have shown that the overall mean reduction to be 0.7 and 0.17 for the intervention
group and the control group. The clinical implication for this study is that there should be
provision for the education to the patients, although the heterogeneity of the intervention, still
needs to be researched.
In the paper by Saengtipbovorn and Taneepanichskul (2015) the analysis had used 95 %
confidence interval with a P value < 0.05, thus increasing the rigor and the validity of the results.
The implication of the paper is that life style intervention programs and interventions needs to be
introduced to spread awareness among elderly people for maintaining the oral health.
Conclusion
In conclusion, it can be stated that dental health education is an important and integral
part of education that can be provided to the patients suffering from diabetes. Both verbal
interactions like consultations and group discussions and non-verbal mode of communications
like mass media campaigns, telehealth education can be effective in promoting a good dental
health among the patients. Both verbal and non-verbal communication has been suggested
alongside medications for ensuring safety to the oral health. The papers chosen for the studies
have been tested for reliability and validity making them suitable for this dissertation. The
outcome measures have been appropriate as per the need clinical question of this paper and have
provided a baseline data in order to compare the intervention in patients.

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Appendix
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