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
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 prevalence increases with age.15 It is also well established that patients with diabetes are more likely to develop periodontal diseases (inflammatory disorders affecting the supporting structures of the teeth) than are nondiabetic individuals.6 In 1993, Loe called periodontitis the sixth complication of diabetes mellitus.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 diseases,8,9 and dentists can help reduce this risk by assessing, advising, and closely monitoring the diabetic patient.10,11 Through such officebased activities, dentists assume functions characteristic of primary and preventive health care clinicians. We think of this expanded role as having 3 phases of involvement: assessment, discussion, and active management. Assessment constitutes dentists asking the diabetic patient about the type and severity of disease (regimen used to control blood glucose, duration of disease, and presence of any complications). Discussion represents their communication with the patient (about importance of tight blood glucose control, association of diabetes with oral health, and, conversely, association of dental treatment with blood glucose control). Active management reflects actions taken to ameliorate the diabetic patients oral health care (monitoring blood glucose level, communicating with the patients physician, adjusting the frequency of dental visits). In this study, we (1) measured general dentists 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 status, discussion of pertinent issues, and active management of patientsand identified 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 American Academy of Periodontology Directory. Responses were received from 105 of 132 eligible general dentists (response rate = 80%) and from 103 of 142 eligible 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 interventions 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) high performer in 1 area and high performance in other areas, and (3) investigated the extent to which attitudes and orientations suggested by theories of behavioral change, especially the Theory of Planned Behavior,12,13 predict general dentists and periodontists active management of the diabetic patient. By including general dentistsapproximately 80% of all dental practitionerswe cast the broadest possible net in terms of access to oral health care.14 By including periodontists, we examined dental specialists whose postgraduate training emphasized the dental and medical management of patients with periodontal disease, including those with diabetes. Maryland. Two random samples (general dentists = 180, periodontists = 180) were drawn from lists supplied by the American Dental Association for general dentists15 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%; periodontist response rate = 73%). Respondents were classified as eligible if (1) their primary professional activity was the practice of general dentistry or periodontics and (2) they practiced in the designated geographic area. The proportional state-based, random sampling strategy we used and the postal survey data collection approach we implemented, have been previously described.17,18

METHODS
Data were collected through a postal survey of actively practicing dentists identified as general dentists or periodontists in the northeastern United States: Massachusetts, Rhode Island, Connecticut, New York, New Jersey, Pennsylvania, Delaware, Washington, DC, and

Measures
We created 3 scalesassessment (rated on a 6-point scale), discussion (rated on a 4-point scale), and active management (rated on a 4point scale)to measure dentists management

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of the diabetic patient. For each scale, we used Likert-type questionnaire items. The assessment scale comprised the following items: for a new diabetic patient, do you routinely ask about (1) the patients type of diabetes, (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 management of a diabetic patient: (1) discuss how well controlled the patient is, (2) discuss postoperative medications or infection control, (3) discuss 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 evaluation 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 participant, 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 behavior, resulting in a percentage value representing level of activity in each area. The percentage 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 categories based on the decile score ranges for each scale. The decile cutpoint closest to a cumulative 50% for each clinician group for each scale, as presented in Table 1, was used to divide clinician performance into highperformance 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 differences between group mean scale scores within each of the 3 behavioral realms. Multiple 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 correlation to examine associations among the 3 behavior scales and selected demographic and practice structure characteristics. Crosstabular analyses were conducted to examine the association between level of discussion and level of active management for each clinician group. Logistic regression was used to assess the potential confounding effect of significantly correlated demographic, practice structure, and provider characteristic variables on the respective associations between high and low performance levels.

TABLE 1General Dentists and Periodontists Scoring on Assessment, Discussion, and Active Management Scales: Northeastern United States, 2002
Assessment Scale General Dentists Scale Score 060 6170 7180 8190 9199 100 Group scale mean Grand mean (95% CI)e (n = 103) No. (%) 19 (18.4) 13 (12.6) 15 (14.6) 15 (14.6) 15 (14.6) 26 (25.2) Cumulative % 18.4 31.1 45.6 60.2a 74.8a 100a 0.86 84.37b 84.64 (81.9, 87.4) Periodontists (n = 102) No. (%) 8 (7.8) 3 (2.9) 10 (9.8) 13 (12.7) 11 (10.8) 57 (55.9) 0.87 83.63b Cumulative % 7.8 10.8 20.6 33.3 44.1 100a (n = 102) No. (%) 3 (2.9) 7 (6.9) 15 (14.7) 27 (26.5) 15 (14.7) 35 (34.3) Discussion Scale General Dentists Cumulative % 2.9 9.8 24.5 51.0 65.7a 100a Periodontists (n = 102) No. (%) ... ... 2 (2.0) 15 (14.7) 13 (12.7) 72 (70.6) 0.63 96.10c 92.25 (90.7, 93.8) Cumulative % ... ... 2.0 16.7 29.4 100a (n = 103) No. (%) 48 (46.6) 13 (12.6) 17 (16.5) 11 (10.7) 11 (10.7) 3 (2.9) Active Management Scale General Dentists Cumulative % 46.6 59.2a 75.7a 86.4a 97.1a 100a Periodontists (n = 101) No. (%) 14 (13.9) 16 (15.8) 27 (26.7) 12 (11.9) 17 (16.8) 15 (14.9) 0.61 75.84d 72.82 (70.5, 75.1) Cumulative % 13.9 29.7 56.4 68.3a 85.1a 100a

0.71 87.78c

0.64 69.32d

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.

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TABLE 2Correlations Between Dentists Scores Evaluating Management of Diabetic Patients and Selected Personal and Practice Characteristics: Northeastern United States, 2002
General Dentists Assessment Scale Respondents age in years No. hours in typical week respondent spends in direct patient care No. patients respondent sees in typical week No. full-time and part-time dentists in office No. staff in office with respondent No. years of postdoctoral training Respondents patients who pay with Medicaid, % Estimated % of practice neighborhood on welfare No. times in average week respondent consults with dental specialist No. times in average week respondent consults with medical specialist Note. Units are Pearson product moment correlation coefficients. *P .05; ** P .01. 0.23* 0.17 0.19 0.14 0.02 0.27** 0.09 0.13 0.23* 0.21* Discussion Scale 0.14 0.07 0.09 0.15 0.10 0.17 0.04 0.03 0.23* 0.23* Active Management Scale 0.08 0.02 0.05 0.19 0.11 0.25* 0.29** 0.24* 0.12 0.32** Assessment Scale 0.08 0.02 0.01 0.11 0.09 0.14 0.06 0.19 0.01 0.16 Periodontists Discussion Scale 0.04 0.07 0.09 0.19 0.01 0.03 0.06 0.04 <.01 <.01 Active Management Scale 0.11 0.12 0.09 0.30** 0.19 0.05 0.07 0.01 0.15 0.28**

In the regression model, we included the independent variables discussion activity, practice 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 retained for use in the final model. For all statistical analyses, we used the program SPSS version 11.0 (SPSS Inc, Chicago, Ill).

RESULTS
The education and sociodemographic characteristics of the 2 samples have been described previously.18 Although clinician group was significantly associated with years of postdoctoral training, as expected, it was not significantly associated with any of the other sociodemographic variables considered. Level of postdoctoral training was 2 years for 53% of periodontists, 3 years for 47% of periodontists, 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 periodontists 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 distributions, 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 dentists 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 correlated with the assessment scale for both practitioner groups, estimated mean scale scores are 84.4 for general dentists and 83.6 for periodontists (Table 1). The effect of clinician group membership is not significant when adjusted for potential confounders. The grand mean for assessment, when adjusted for covariates, was 84.6. On the discussion scale, 51.0% of general dentists, scoring 90 or less, and 29.4% of periodontists, 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 correlated with the discussion scale for both practitioner 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 discussion, 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 categorized 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 demographic and practice structure variables significantly correlated with the active management scale for both practitioner groups, estimated mean scale scores were 69.3 for general dentists and 75.8 for periodontists (Table 1). The effect of clinician group membership was not significant when adjusted for potential confounders. The grand mean for active management, 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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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 Active Management Scale Low score 60 High score 61 Total Low score 80 High score 81 Total
a

Periodontists, No. (%)b Low Score< 100 High Score = 100

Low Score 90 35 (67.3) 17 (32.7) 52 (100.0)

High Score 91 13 (26.0) 37 (74.0) 50 (100.0)

support from others (colleagues expectations, patients expectations), and perceived relevance of the activity (view activity as the responsibility of others). Except for number of consultations with medical specialists, significant 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.

24 (82.8) 5 (17.2) 29 (100.0)

33 (45.8) 39 (54.2) 72 (100.0)

DISCUSSION
Our analysis demonstrates the importance of deconstructing and measuring dentists management of the diabetic patient according to the 3 areas of activity consideredassessment, 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 dentists 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

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 practice characteristics. Among general dentists, level of assessment was positively and significantly associated with years of postdoctoral training, number of dental specialist consultations, 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 consultations with medical specialists. Among periodontists, level of active management was positively and significantly associated with number of dentists in the office as well as number of consultations with medical specialists. As shown in Table 3, 74% of general dentists 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 associated multivariate logistic regression models were also statistically significant. In Table 4, 2 regression models are presented, 1 for general dentists and 1 for

periodontists. To assess the role of each in influencing the active management scale (the dependent variable), we included the following independent variables in both models: involvement in discussion activity with diabetic patients (the discussion scale), demographic and practice characteristics, variables informed by the Theory of Planned Behavior focusing on feelings of mastery or control (assessment of confidence level), perceived

TABLE 4Results of Multivariate Regression Models Predicting Active Management of Diabetic Patients by General Dentists and Periodontists: Northeastern United States, 2002
General Dentists Standard Coefficient Score on discussion scale Confidence in ability to manage patient with diabetes in officea How strongly agree: My colleagues expect me to take more active role in diabetes controlb How strongly agree: My patients expect me to take more active role in diabetes controlb Likelihood that viewing active management as responsibility of others will hinder my active managementc No. consultations with medical specialist in average week % of patients who pay through Medicaid Years of postdoctoral study R2 df F (P)
a

Periodontists P Standard Coefficient 0.086 0.263 0.284 0.220 0.325 0.244 0.133 0.007 P .407 .009 .020 .090 .003 .007 .150 .934

0.419 0.076 0.041 0.270 -0.013 0.215 0.258 0.143

<.001 .397 .742 .031 .887 .014 .002 .111

0.548 8, 73 11.081 (<.001)

0.456 8, 74 7.763 (<.001)

Values range from not at all (1) to very (4). Values range from disagree strongly (1) to agree strongly (4). c Values range from very likely (1) to not at all likely (4).
b

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The data also demonstrate the importance of considering demographic, practice structure, and postdoctoral education variables in understanding levels of generalist and specialist activity in the management of diabetic patients. When such variables were considered, differences between the 2 groups in terms of assessment 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 understanding of the structure and dynamics of practices of these 2 groups21 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, although levels of activity were high for both groups. Because periodontists are referralbased practitioners, they may be more likely to see patients with more advanced periodontal disease and to engage in more invasive procedures, making them more conscious of the need to explain the basis for and consequences of the procedures they will be doing, particularly in relation to the medical condition of the patientin this case, the diabetic patient. Also, because periodontics is a referralbased practice, there may be more emphasis on establishing a relation or basis of understanding 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 comparable figure for periodontists was 54%. Perhaps periodontists, as referral-based specialists, believe their relationship with the patient should be focused on the particulars of the specialized matter for which the patient was referred. 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 management 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 interprofessional relations (with medical specialists). Missing as influences were variables pertaining to patient relations, such as discussion with patients, 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 discussion, their perceptions of patient expectations, and the socioeconomic level of their patientswhereas periodontists were more influenced by their colleagues and their ability to perform what they perceived to be their professional role. Among general dentists, the percentage of patients who paid for services through Medicaid was also an influential predictor of active management of diabetic patients. Diabetes disproportionately affects socially and materially disadvantaged adults25,26; payment for health care through Medicaid is an indicator of such status. Dentists who see more Medicaid 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 investigation 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, discussion inspires in the patient trust in the dentists 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 legitimizing expertise is unnecessary or that the general dentist, who is usually the referral source, has already performed this step. Instead, as indicated by the model, periodontists were influenced by their sense of confidence in their ability 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 interdisciplinary, medical orientation regarding management of the diabetic patient and of ease on the part of the dentist in seeking and obtaining medical consultations.28

Limitations
We recognize the limitations inherent in selfreported data. If social desirability bias, that is, bias toward reporting or overreporting a behavior that one feels is held in high regard or expected by others, was present in this selfreported 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 patients. Although our study was restricted to respondents from the northeastern United States, we see no reason to suspect that respondents were less likely than were dentists in other regions of the country to engage in active management of diabetic patients. In addition, although our sample sizes were rather small, several steps were taken to ensure that the samples were representative. We used a proportional, state-based, random sampling strategy in which the number of randomly selected periodontists and general dentists from each state was proportional to the percentage of periodontists and general dentists 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 intervention strategiesfor general dentists and periodontists, respectivelyto achieve the goal of fostering dentists active management of the diabetic patient. For periodontists, our results suggest a strategy that features (1) professional

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endorsements capable of convincing the periodontist that active management of the diabetic patient is supported by his or her professional leadership at the national, regional, and local levels, and (2) didactic training emphasizing that the scope of practice for a specialist should include active management of both the systemic and the oral health of the patients referred 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 outcomesand trained to communicate and discuss 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 involvement in the management of the diabetic patient, thereby contributing to the improvement of the dental patients oral and systemic health. Approximately 5% of all patients seen in dental offices are estimated to have diabetes.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 general dentists and periodontists will be treating greater numbers of patients, and older patients with this disease owing in part to the increasing 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 patients with diabetes.

Medicine, Columbia University, 630 W 168th St, New York, NY 10032 (e-mail: ck60@columbia.edu). This article was accepted August 16, 2006.

14. The 1997 Survey of Dental Practice. Characteristics of Dentists in Private Practice and Their Patients. Chicago, Ill; American Dental Association; November 1998. 15. American Dental Directory. Chicago, Ill: American Dental Association; 2001. 16. Membership Directory. Chicago, Ill: American Academy of Periodontology; 2002. 17. Kunzel C, Lalla E, Albert D, Yin H, Lamster IB. On the primary care frontlines: the role of the general dental practitioner in smoking cessation and diabetes management. J Am Dent Assoc. 2005;136:11441153. 18. Kunzel C, Lalla E, Lamster IB. Management of the patient who smokes and the diabetic patient in the dental office. J Periodontol. 2006;77:331340. 19. Hastreiter RJ, Bakdash B, Roesch MH, Walseth J. Use of tobacco prevention and cessation strategies and techniques in the dental office. J Am Dent Assoc. 1994; 125:14751484. 20. Yellowitz JA, Horowitz AM, Goodman HS, Canto MT, Farooq NS. Knowledge, opinions, and practices of general dentists regarding oral cancer: a pilot study. J Am Dent Assoc. 1998;129:579583. 21. Clark JA, Potter DA, McKinlay JB. Bringing social structure back into clinical decision making. Soc Sci Med. 1991;32:853866. 22. Harrold LR, Field TS, Gurwitz JH. Knowledge, patterns of care, and outcomes of care for generalists and specialists. J Gen Intern Med. 1999;14:459511. 23. Katon W, Von Korff M, Lin E, Simon G. Rethinking practitioner roles in chronic illness: the specialist, primary care physician, and the practice nurse. Gen Hosp Psychiatry. 2001;23:138144. 24. Kujan O, Duxbury AJ, Glenny AM, Thakker NS, Sloan P. Opinions and attitudes of the UKs GDPs and specialists in oral surgery, oral medicine and surgical dentistry on oral cancer screening. Oral Dis. 2005;12:194199. 25. Brown AF, Ettner SL, Piette J, et al. Socioeconomic position and health among persons with diabetes mellitus: a conceptual framework and review of the literature. Epidemiol Rev. 2004;26:6377. 26. Robbins JM, Vaccarino V, Zhang H, et al. Excess type 2 diabetes in African-American women and men aged 4074 and socioeconomic status: evidence from the Third National Health and Nutrition Examination Survey. J Epidemiol Community Health. 2000;54:839845. 27. McKinlay JB, Lin T, Freund K, Moskowitz M. The unexpected influence of physician attributes on clinical decisions: results of an experiment. J Health Soc Behav. 2002;43:92106. 28. Sadowsky D, Kunzel C. Dentists consulting behavior and associated knowledge levels. Am J Public Health. 1987;77:10001001. 29. Fisher RJ. Social desirability bias and the validity of indirect questioning. J Consum Res. 1993;20:303315. 30. Nancarrow C, Brace I. Saying the right thing: coping with social desirability bias in marketing research. Bristol Business School Teaching and Research Review, 2000. Available at: http://www.uwe.ac.uk/bbs/ trr/Is3-cont.html. Accessed December 28, 2006. 31. Mandelblatt JS, Yabroff KR. Effectiveness of interventions designed to increase mammography use: a meta-analysis of provider-targeted strategies. Cancer Epidemiol Biomarkers Prev. 1999;8:759767. 32. Moore PA, Zgibor JC, Dasanayake AP. Diabetes: a growing epidemic of all ages. J Am Dent Assoc. 2003; 134:11S15S.

Contributors
C. Kunzel participated in the conceptualization and design 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 protocol and materials.

Acknowledgments
This work was supported by a National Institute of Dental and Craniofacial Research grant (R01 DE14898; I. Lamster, principal investigator).

References
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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

12. Ajzen I. From intentions to actions: a theory of planned behavior. In: Kuhl J, Beckman J, eds. Action Control: From Cognition to Behavior. Heidelberg, Germany: Springer; 1985:1139. 13. Ajzen I. The theory of planned behavior: some unresolved issues. Organ Behav Hum Decis Process. 1991;50:179191.

730 | Research and Practice | Peer Reviewed | Kunzel et al.

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