Effects of periodontal health intervention program on oral health-related outcomes in older patients with type 2 diabetes: a randomized controlled trial

Effects of periodontal health intervention program on oral health-related outcomes in older patients with type 2 diabetes: a randomized controlled trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Effects of periodontal health intervention program on oral health-related outcomes in older patients with type 2 diabetes: a randomized controlled trial Chunxiu Xiao, Lan Zhang, Zhaoxi Li, Qingnv Xu, Suping Lin, Siyu Zheng, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6068876/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 31 Jul, 2025 Read the published version in Scientific Reports → Version 1 posted 10 You are reading this latest preprint version Abstract As the sixth complication of diabetes, periodontitis interacts with diabetes to form a vicious circle. Periodontal health interventions can improve periodontal health and the quality of life in older patients with type 2 diabetes mellitus (T2DM). This study aimed to explore the effect of periodontal health interventions based on the Pender Health Promotion Model on periodontal outcome index and quality of life in this patient population. This randomized controlled trial enrolled 108 patients with T2DM from the endocrine and metabolism department of a tertiary hospital. Participants were randomly assigned to either an experimental group or a control group. The control group received routine health interventions, while the experimental group underwent a periodontal health intervention program in addition to the routine health interventions. Relevant outcome measures were assessed at baseline and after 12 weeks of intervention. Data from 103 participants were analyzed. Following the intervention, significant differences were identified between the groups in Plaque Index (PLI), Oral Hygiene Index-Simplified (OHI-S), and periodontal health knowledge, attitude, and behavior. The periodontal health intervention program can enhances periodontal health knowledge, attitudes, and behaviors while positively impacting the oral health index and quality of life of older patients with T2DM. Health sciences/Diseases/Dental diseases Health sciences/Diseases/Endocrine system and metabolic diseases Type 2 diabetes Pender Health Promotion Model Periodontal health Quality of life Oral hygiene Knowledge-attitude-behavior Figures Figure 1 Introduction Diabetes encompasses a group of metabolic disorders characterized by chronic hyperglycemia, influenced by both genetic and environmental factors. In China, where the aging population is expanding, approximately 260 million individuals are aged ≥ 60 years, representing 18.7% of the national population. Among this demographic, nearly 30% are affected by diabetes, with > 95% diagnosed with type 2 diabetes mellitus (T2DM) [ 1 , 2 ]. Periodontitis, recognized as the sixth most common complication of diabetes, is a chronic inflammatory condition triggered by dental plaque that leads to the progressive destruction of periodontal tissue [ 3 ]. Persistent periodontal infections exacerbate the systemic microinflammatory state, complicating glycemic control [ 4 ]. A consensus report from the International Diabetes Federation and the European Federation of Periodontology [ 5 ] highlights the critical role of periodontal health in diabetes management. Age significantly influences the prevalence of periodontitis [ 6 ], particularly in older patients with diabetes, who often lack sufficient knowledge about oral health. This gap leads to underestimating the risk posed by periodontitis and its impact on diabetes management. Awareness and education are essential for promoting behavioral changes, as adopting proper oral hygiene practices can mitigate the risk of periodontitis. Consequently, health interventions aimed at improving periodontal care and promoting effective dental plaque control are vital for preventing periodontitis and enhancing overall diabetes care. Numerous studies, both domestic and international, have demonstrated that oral health interventions can improve the oral quality of life and periodontal indices in patients with diabetes. These interventions include oral health education [ 7 – 10 ], comprehensive healthcare [ 11 ], oral nursing combined with exercise guidance [ 12 ], and strategies to maintain the stability of the oral environment [ 13 ]. For instance, one study focused on older patients with T2DM in an intervention group who received a 20-minute lifestyle modification and dental care intervention plan supplemented by personalized lifestyle counseling. During the intervention, nurses guided patients in goal setting and reinforced these goals through 15-minute health education videos in the first and second months. The control group, by contrast, received routine care. Results revealed significant improvements in both periodontal condition and blood glucose levels in the intervention group after 3 months. However, the quasi-experimental study was limited by selection bias and insufficient rigor [ 14 ]. Similarly, a randomized controlled trial examined the impact of educational interventions based on health belief models in patients with T2DM. Participants in the trial group attended four educational sessions within 1 month, covering topics such as oral health risks, potential complications, benefits of preventive behavior, and disorders associated with poor oral health. They were subsequently encouraged to practice oral care. The control group received routine care. After 3 months, the experimental group exhibited heightened awareness of oral nursing practices. However, this study was limited by its reliance on a self-designed questionnaire as the sole outcome measure, lacking objective oral health indicators to evaluate intervention effectiveness [ 15 ]. Several studies have explored oral health education for older patients with diabetes in China. In one study, the experimental group received nursing interventions that included education on oral health knowledge, covering a diverse range of topics such as theoretical training in oral healthcare, oral nursing skills, timely oral examinations, and the prompt use of necessary treatment. Meanwhile, the control group received routine nursing care. The results demonstrated improvements in oral health and quality of life among patients in the experimental group following the intervention. However, it remains unclear whether the baseline characteristics of the participants in these studies were comparable [ 16 ]. Another study examined the effect of health education based on behavior change theory on the oral health of older patients with diabetes. The experimental group underwent an intervention that incorporated education on diabetes, oral health knowledge, and psychological support, structured through the stages of pre-intention, intention, preparation, action, and maintenance. The findings revealed that such interventions effectively improved patients’ oral health awareness and behavioral habits, improved their quality of life, and contributed to better blood sugar control. Nevertheless, the study's extended duration limits its applicability to short-term hospitalization settings. Both research interventions primarily focused on theoretical knowledge education across various stages, with insufficient training in oral health protection skills [ 17 ]. In summary, several studies have demonstrated that oral health interventions can improve the oral quality of life and enhance the periodontal index in patients with diabetes. However, few intervention programs fully account for the unique needs of the older adult population. Most interventions focus predominantly on preventing oral problems in patients with diabetes, lack behavioral components for oral health, and demonstrate insufficient scientific rigor. Additionally, personalized interventions tailored to individual patient conditions are notably absent. The Health Promotion Model (HPM), developed by Pender, a prominent American nursing scholar of the 20th century, provides a comprehensive theoretical framework for analyzing factors that affect health behaviors. This model serves as a robust theoretical foundation for understanding and explaining lifestyle choices and specific health-related behaviors. The HPM consists of three primary components: personal characteristics and experiences, specific behavioral cognition and emotions, and behavioral outcomes. Personal characteristics and experiences are subdivided into prior related behaviors and personal factors. Prior related behaviors refer to an individual's past behaviors, including their nature and characteristics, which can serve as predictors of current behaviors across physical, psychological, social, and cultural dimensions. Specific behavioral cognitions and emotions encompass perceived benefits of behavior, perceived barriers to action, cognitive self-efficacy, emotional responses to actions, interpersonal influences, and situational factors. Behavioral outcomes include planned health-promoting actions, immediate needs and preferences, and health-enhancing behaviors [ 18 , 19 ]. The HPM has been widely used in clinical settings and has demonstrated effectiveness in improving patients’ self-management skills, health behaviors, knowledge, and quality of life [ 20 , 21 ]. However, there is a lack of health intervention studies that utilize the HPM to address oral health among older patients with T2DM. This study aims to apply the HPM to develop a periodontal health program for older patients with T2DM, emphasizing the relationship between diabetes and periodontitis, the risk factors contributing to periodontal problems, and the influence of poor oral hygiene habits. By evaluating the knowledge, attitudes, behaviors, and personal factors associated with periodontal health, the program seeks to enhance patients’ understanding of proper periodontal care, overcome barriers to oral health practices, and improve self-efficacy. Ultimately, the goal is to encourage patients to commit to periodontal health plans and adopt sustainable oral health behaviors. This clinical randomized controlled trial aimed to evaluate the effectiveness of a periodontal health intervention program designed for older patients with T2DM using the Pender HPM. The findings aim to offer a theoretical foundation for the clinical advancement of periodontal health interventions tailored to this population. Methods Study design, setting, and participants This study was approved by the Ethics Committee of Fujian Medical University Union Hospital (2023KY071). All patients signed informed consent, and all experiments were conducted in accordance with the Declaration of Helsinki. The trial was registered (ChiCTR2300073533, 13/07/2023) with the China Clinical Trial Registry prior to its commencement. This single-blind, single-center, randomized controlled trial was conducted at Fujian Medical University Union Hospital, China, from August 2023 to February 2024. The study employed quantitative research methods, incorporating clinical reagent tests and internationally recognized scales to assess outcomes. Additionally, a previously developed self-made scale was used for evaluation purposes., and written informed consent was obtained from all participants. Participants aged 60 years or older with T2DM were recruited from the Department of Endocrinology and Metabolism at a tertiary hospital in Fujian Province. Eligibility criteria included the following: (1) diagnosis of T2DM based on the World Health Organization (WHO) diabetes diagnostic criteria of 1999 [ 22 , 23 ]; (2) ability to communicate effectively in Chinese; (3) capability to complete the questionnaire independently or with assistance from the researcher; (4) possession of at least 16 natural teeth; and (5) ability to perform self-care, including brushing and mouth rinsing. Exclusion criteria were as follows: (1) presence of severe complications; (2) mental illnesses or emotional disorders; (3) use of hormones or antibiotics for more than 2 weeks within the past 3 months or recent scaling or scraping; and (4) history of systematic periodontal treatment within the previous year. Additionally, participants were excluded during the study if they: (1) demonstrated poor compliance during follow-up or were unable to adhere to long-term follow-up; (2) required the use of hormones or antibiotics for more than 2 weeks during the intervention period; (3) were unable to continue participation due to changes in their medical condition; or (4) withdrew or died during the study. Study randomization To address the challenge of a socially dispersed patient population and the limited number of hospital visitors meeting the minimum sample size requirements within a short timeframe, patients were enrolled consecutively into the study. Participants who fulfilled the inclusion and exclusion criteria and were officially included in the trial were sequentially numbered. A set of random sequences was generated in advance by external individuals not involved in the study using a randomization website. These random numbers, ranging from 1 to 108, were placed in sequentially numbered, sealed, and opaque envelopes, which were securely stored. Upon enrollment, researchers contacted the custodians of the random numbers by telephone to determine the participant's group assignment. The custodian opened the corresponding envelope to reveal the group allocation: participants with random numbers 1–54 were assigned to the test group, while those with numbers 55–108 were assigned to the control group. Sample size The sample size for this study was determined using a standard estimation method for experimental studies. The calculation formula is as follows: \(\:n1=n2=2{\left[\left({\mu\:}_{\alpha\:}+{\mu\:}_{\beta\:}\right)\sigma\:/\delta\:\right]}^{2}+1/4{{\mu\:}_{\alpha\:}}^{2}\) , where n1 and n2 represent the required sample sizes for the two groups, σ is the total standard deviation, and δ is the difference between the two population averages. Based on the literature [ 24 ] and accompanying tables, the ratio δ/σ = 0.69, with µ 0.05/2 = 1.96, and µ 0.1 = 1.28. Substituting these values into the formula yields n1 = n2 ≈ 45. Considering the extended duration of the study and an anticipated 20% attrition rate, a minimum of 54 participants per group is required. Therefore, the total expected sample size for this study is 108 participants. Intervention Participants in the control group received standard diabetes health education, information on periodontal health, and routine follow-up care after the intervention. In contrast, participants in the experimental group underwent a periodontal health intervention program designed using the Pender HPM. This program was developed through a structured process involving the formation of a research team, a comprehensive literature review, and expert consultations using the Delphi method. The program consisted of three key components: (1) evaluation of personal characteristics and experience, (2) cognitive and emotional interventions targeting behavioral characteristics, and (3) supervision and reinforcement of committed behaviors. The first component included an assessment of the patient's personal information, oral health factors, and behavioral patterns. The second component comprised five specific activities: recognizing the benefits of health-promoting actions, enhancing theoretical knowledge related to emotional responses, conducting practical skills training to boost self-efficacy, providing feedback and re-evaluation to address cognitive barriers to action, and addressing situational and interpersonal influences. The third component focused on strategies for managing unexpected situations during the intervention period and ensuring adherence to planned behaviors. The intervention was administered directly by the researcher over a 5-day period, with follow-up supervision extending for 12 weeks. An additional table provides more detail (see Supplementary Table S1 ). Outcome measures Main outcomes The main outcome indicators of this study were Plaque Index (PLI) and General Oral Health Assessment Index (GOHAI). Plaque Index (PLI) Plaque Index (PLI) is an evaluation method that assesses the thickness of plaque on the surface of teeth and serves as an indicator of oral hygiene, helping to prevent periodontal disease. In 1962, Quigley and Hein introduced a plaque scoring system with a standard score of 0.5 [ 25 ]. In 1970, Turesky improved this scoring system, making it more objective and specific [ 26 ]. The improved Turesky method of the Quigley–Hein PLI was used in this study. During the examination, the evaluator applies a plaque chromogenic liquid to a cotton swab, which is then used to swab the surface of the lip (cheek) and tongue of the six index teeth, resulting in a total of 12 examination areas. After 5 s, the participant rinses their mouth twice with clear water, allowing the plaque developer to leave pink stains on the areas where the plaque has adhered. The plaque accumulation is scored based on the extent of plaque coverage [ 27 ]. The plaque area is divided into six categories: (1) no plaque on the tooth surface, (2) scattered spot plaque at the gingival margin of the tooth neck, (3) plaque width at the tooth neck of no more than 1 mm, (4) plaque width greater than 1 mm but less than 1/3 of the tooth neck, (5) plaque width between 1/3 and 2/3 of the tooth neck, and (6) plaque width greater than 2/3 of the tooth neck. Scores ranged from 0 to 5, with higher scores indicating poorer oral health. The plaque areas of the 12 regions were quantified using this PLI method. General Oral Health Assessment Index (GOHAI) The General Oral Health Assessment Index (GOHAI), introduced by American scholars in 1990, is a tool designed to measure the subjective oral health status of older individuals [ 28 ]. It comprises 12 items categorized into three domains: functional limitation, psychological discomfort, and pain. The total score ranges from 0 to 48, with higher scores reflecting poorer oral health. The scale demonstrates strong reliability and validity, evidenced by a Cronbach’s α coefficient of 0.88 [ 29 ]. Secondary outcomes The secondary outcomes of this study included assessments using the Periodontal Health Knowledge, Attitude, and Behavior Questionnaire, as well as the Oral Hygiene Index-Simplified (OHI-S). Periodontal health knowledge, attitude, and behavior assessment questionnaire The self-developed questionnaire for assessing periodontal health in older patients with T2DM was organized into three dimensions: knowledge, attitude, and behavior. The knowledge dimension included 29 items, the attitude dimension contained 15 items, and the behavioral dimension comprised 12 items. Oral Hygiene Index-Simplified (OHI-S) Greene and Vermillion (1964) introduced an evaluation method to assess the true status of oral health. This index was designed to be objective, simple, rapid, and reproducible. It comprises two components: Debris Index-Simplified (DI-S) and the Calculus Index-Simplified (CI-S). The examination method involved dividing the tooth surface from the gingival margin to the incisal margin, applying a plaque display agent, and visually assessing the area covered by plaque, soft dirt, pigment, or dental calculus. Only six teeth were examined: the lip and buccal surfaces of 16, 11, 26, and 31 and the tongue surfaces of teeth 36 and 46. Based on the extent of the soft scale coverage, the DI-S was categorized into four groups: no soft scale dirt on the tooth surface, coverage less than 1/3 of the surface, coverage between 1/3 and 2/3, and coverage greater than 2/3. Scores ranged from 0 to 3, with higher scores reflecting poorer oral health. Similarly, the CI-S was categorized based on the extent of dental calculus coverage: no supragingival or subgingival calculus, supragingival calculus covering less than 1/3 of the surface, coverage between 1/3 and 2 /3 or scattered subgingival calculus near the neck of the tooth, and coverage exceeding 2/3 or continuous thick subgingival calculus in the neck of the tooth. Scores for the CI-S ranged from 0 to 3, with higher scores indicating poorer oral health. Other variables Questionnaire The sociodemographic characteristics of the participants were assessed through a survey. The collected data encompassed age, sex, place of origin, disease duration, educational level, marital status, annual family income, smoking history, and alcohol consumption history. Chinese Kayser–Jones Brief Oral Health Status Examination (BOHSE) The scale is a practical tool designed for non-oral health professionals to screen the oral health of older adults. It comprises 10 items: lymph nodes, lips, tongue, mucous membrane, gums, saliva, natural teeth, dentures, logarithm of chewing teeth, and oral cleaning. Each item is scored on a scale from 0 (normal) to 2 (problematic), with higher overall scores reflecting poorer oral health. The scale demonstrates strong reliability and validity, with a Cronbach’s α coefficient of 0.873 [ 30 ]. Data collection The study consisted of a 5-day intervention period, followed by a 12-week maintenance period. Baseline assessments were conducted to evaluate personal characteristics and related behaviors in the early stages. On the second day, participants received training on periodontal health knowledge and oral health protection techniques. Problem-solving feedback was integrated into the learning process and provided on days 2 and 4. Dietary and lifestyle guidance was delivered on day 5. Psychological support, temporary coping strategies, and planned behavior reinforcement were provided throughout the intervention period and continued during follow-up after the intervention. Baseline data were collected by trained data collectors using a custom-designed questionnaire administered directly to participants. Before beginning the surveys, the data collectors explained the study’s purpose to the participants and obtained informed consent. Each questionnaire item was individually explained and completed in real time to ensure the objectivity and validity of the collected data. The PLI and OHI-S were measured with chromogenic reagents by data collectors at baseline and 12 weeks post-intervention. Statistical analysis Statistical analysis was performed using SPSS Statistics software (version 27.0). Continuous data were assessed using descriptive statistics and normality tests. For data following a normal distribution, the mean and standard deviation were used as summary measures. Between-group comparisons for normally distributed data were performed using independent t-tests, while within-group changes were analyzed using paired t-tests. For non-normally distributed data, the median (quartile interval) was reported, and the Wilcoxon signed-rank test was used to analyze the data. Categorical data were summarized as frequencies and constituent ratios, with chi-square and Fisher’s exact tests employed for group comparisons. All statistical tests were two-tailed, and a p-value of < 0.05 was considered statistically significant. Results Characteristics of the patients A total of 108 participants were enrolled in this study and randomized equally into an intervention group (n = 54) and a control group (n = 54). During the study, five participants were lost to follow-up: three from the intervention group (5.56%) and two from the control group (3.70%), resulting in an overall loss to follow-up rate of 4.63%. Consequently, 103 participants completed the study and were included in the final statistical analysis (Fig. 1 ). Among the 108 participants, the mean age was 67.55 ± 5.34 years. The majority of the participants were male (59.26%), while females comprised 40.74% of the cohort. Educational level was predominantly low, with 75% having completed junior high school or less and only 25% achieving a high school education. Furthermore, 96.3% of participants were married. Regarding medical coverage, the primary payment method was provincial or municipal health insurance, accounting for 65.74% of the cases. The median disease duration was 15 years, and the average initial oral examination score was 5.53 ± 1.65. No statistically significant differences in general demographics or baseline characteristics were observed between the two groups ( P > 0.05) (Table 1 ). Table 1 Comparison of general data between the two groups Variable Total (n = 108) Experiment (n = 54) Control (n = 54) F/ \(\:{\chi\:}^{2}\) P Age, years 67.0 (63,72) 67.5 (63,72) 67.0 (62,72) -0.308 a 0.758 Sex 0.153 b 0.695 Male 64 (59.26) 31 (57.41) 33 (61.11) Female 44 (40.74) 23 (42.59) 21 (38.89) Education, % 3.391 b 0.335 Elementary school or less 39 (36.11) 15 (27.78) 24 (44.44) Middle school graduate 42 (38.89) 23 (42.59) 19 (35.19) High school or secondary specialized school 15 (13.89) 9 (16.67) 6 (11.11) Junior college or more 12 (11.11) 7 (12.96) 5 (9.26) Marital status, % / 0.745 Unmarried 2 (1.85) 2 (3.70) 0 (0.00) Married 104 (96.30) 51 (94.44) 53 (98.15) Bereaved 2 (1.85) 1 (1.85) 1 (1.85) Smoking, % 1.313 b 0.252 No 94 45 49 Yes 14 9 5 Alcohol consumption, % 1.313 b 0.252 No 94 49 45 Yes 14 5 9 Glycosylated hemoglobin 8.35(7.20, 10.08) 8.30(7.20, 9.83) 8.55(7.28, 10.63) -0.565 a 0.572 Medical payment method, % 2.014 b 0.156 Urban medical insurance 37(34.26) 15(27.78) 22(40.74) Provincial and municipal medical insurance 71(65.74) 39(72.22) 32(59.26) Disease course, years 15.0 (10,20) 15.0 (10,20) 12.5 (8,20) BMI, kg/m 2 5.53 ± 1.65 5.63 ± 1.62 5.43 ± 1.66 0.222 c 0.525 BMI, body mass index; a U-test; b \(\:{\chi\:}^{2}\:\) test; c t-test Comparison of the outcome indicators before intervention No significant differences were observed between the two groups in the following pre-intervention outcome indicators: PLI score ( Z = -0.961, P = 0.337), GOHAI score ( t = 1.020, P = 0.310), DI-S score ( t = 0.219, P = 0.827), CI-S score ( Z = -0.782, P = 0.434), total score of knowledge, attitude, and behavior ( t = 0.645, P = 0.521), knowledge dimension score ( Z = -1.046, P = 0.296), attitude dimension score ( t = -0.250, P = 0.803), behavior dimension score ( t = 0.780, P = 0.437) (Table 2 ). Table 2 Comparison of the outcome indicators before intervention Variable Experiment (n = 54) Control (n = 54) Z/t P PLI 1.75(1.5, 2.08) 1.64 ± 0.41 -0.961 a 0.337 GOHAI 17.69 ± 5.18 16.72 ± 4.52 1.020 b 0.310 DI-S 1.77 ± 0.48 1.75 ± 0.43 0.219 b 0.827 CI-S 1.00 (0.67, 1.33) 0.83 (0.67, 1.17) -0.782 a 0.434 Total score of knowledge, attitude, and behavior 85.43 ± 15.39 83.54 ± 14.77 0.645 b 0.521 Knowledge dimension score 39.00 (32.00,42.00) 37.30 ± 6.74 -1.046 a 0.296 Attitude dimension score 21.98 ± 4.55 22.19 ± 3.82 -0.250 b 0.803 Behavior dimension score 24.93 ± 5.45 24.06 ± 6.03 0.780 b 0.437 PLI, Plaque Index; GOHAI, General Oral Health Assessment Index; DI-S, Debris Index-Simplified; CI-S, Calculus Index-Simplified; a Wilcoxon signed-rank test; b t-test Comparison of the outcome indicators after intervention After the intervention, no significant difference was observed in the GOHAI scores between the two groups ( t = -0.676, P = 0.50). However, significant differences were found in several other measures. The PLI score showed a notable increase ( Z = -6.220, P < 0.001), as did the DI-S score ( Z = -7.167, P < 0.001), and the CI-S score ( Z = -2.724, P = 0.006 < 0.05). Additionally, the total score for knowledge, attitude, and behavior significantly increased ( t = 3.582, P < 0.001), along with improvements in the knowledge dimension score (t = 3.226, P = 0.002), attitude dimension score ( t = 3.235, P = 0.002), and behavior dimension score ( Z = -3.601, P < 0.001) (Table 3 ). Table 3 Comparison of the outcome indicators after intervention Variable Experiment (n = 51) Control (n = 52) Z/t P PLI 1.25 (1.08, 1.42) 1.65 ± 0.39 -6.220 a < 0.001 GOHAI 15.98 ± 5.03 16.62 ± 4.39 -0.676 b 0.500 DI-S 1.00 (0.83, 1.33) 1.71 ± 0.41 -7.167 a < 0.001 CI-S 0.83 (0.50, 1.17) 1.01 ± 0.35 -2.724 a 0.006 Total score of knowledge, attitude, and behavior 94.44 ± 15.30 83.50 ± 15.43 3.582 b < 0.001 Knowledge dimension score 42.13 ± 7.37 37.37 ± 7.17 3.226 b 0.002 Attitude dimension score 25.04 ± 4.54 22.25 ± 4.10 3.235 b 0.002 Behavior dimension score 27.28 ± 5.51 23.00 (19.00, 28.25) -3.601 a < 0.001 PLI, Plaque Index; GOHAI, General Oral Health Assessment Index; DI-S, Debris Index-Simplified; CI-S, Calculus Index-Simplified; a Wilcoxon signed-rank test; b t-test Comparison of the outcome indicators in the experimental group before and after intervention Significant improvements were observed in the experimental group after the intervention across multiple measures: PLI score ( Z = -6.461, P < 0.001), GOHAI score ( t = 11.672, P < 0.001), DI-S score ( Z = -6.415, P < 0.001), CI-S score ( Z = -5.195, P < 0.001), total score of knowledge, attitude, and behavior ( t = -13.640, P < 0.001), knowledge dimension score ( Z = -6.163, P < 0.001), attitude dimension score ( t = -5.009, P < 0.001), behavior dimension score ( t = -8.409, P < 0.001) (Table 4 ) Table 4 Comparison of the outcome indicators in the experimental group before and after intervention Variable Before (n = 54) After (n = 51) Z/t P PLI 1.75 (1.5,2.08) 1.25 (1.08,1.42) -6.461 a < 0.001 GOHAI 17.69 ± 5.18 15.98 ± 5.03 11.672 b < 0.001 DI-S 1.77 ± 0.48 1.00 (0.83,1.33) -6.415 a < 0.001 CI-S 1.00 (0.67,1.33) 0.83 (0.50,1.17) -5.195 a < 0.001 Total score of knowledge, attitude, and behavior 85.43 ± 15.39 94.44 ± 15.30 -13.640 b < 0.001 Knowledge dimension score 39.00 (32.00, 42.00) 42.13 ± 7.37 -6.163 a < 0.001 Attitude dimension score 21.98 ± 4.55 25.04 ± 4.54 -5.009 b < 0.001 Behavior dimension score 24.93 ± 5.45 27.28 ± 5.51 -8.409 b < 0.001 PLI, Plaque Index; GOHAI, General Oral Health Assessment Index; DI-S, Debris Index-Simplified; CI-S, Calculus Index-Simplified; a Wilcoxon signed-rank test; b t-test Comparison of the outcome indicators in the control group before and after intervention No significant differences were observed in the control group before and after the intervention for the PLI score ( t = 1.868, P = 0.068), GOHAI score ( t = 1.983, P = 0.053), DI-S score ( t = 1.958, P = 0.056), total score of knowledge, attitude, and behavior ( t = 0.485, P = 0.630), knowledge dimension score ( t = 0.164, P = 0.870), attitude dimension score ( t = -0.340, P = 0.735), behavior dimension score ( Z = -1.686, P = 0.092). However, a significant improvement was observed in the CI-S score ( Z = -5.195, P < 0.001) (Table 5 ). Table 5 Comparison of the outcome indexes in the control group before and after intervention Variable Before(n = 54) After(n = 52) Z/t P PLI 1.64 ± 0.41 1.65 ± 0.39 1.868 b 0.068 GOHAI 16.72 ± 4.52 16.62 ± 4.39 1.983 b 0.053 DI-S 1.75 ± 0.43 1.71 ± 0.41 1.958 b 0.056 CI-S 0.83 (0.67, 1.17) 1.01 ± 0.35 -5.195 a < 0.001 Total score of knowledge, attitude, and behavior 83.54 ± 14.77 83.50 ± 15.43 0.485 b 0.630 Knowledge dimension score 37.30 ± 6.74 37.37 ± 7.17 0.164 b 0.870 Attitude dimension score 22.19 ± 3.82 22.25 ± 4.10 -0.340 b 0.735 Behavior dimension score 24.06 ± 6.03 23.00 (19.00, 28.25) -1.686 a 0.092 PLI, Plaque Index; GOHAI, General Oral Health Assessment Index; DI-S, Debris Index-Simplified; CI-S, Calculus Index-Simplified; a Wilcoxon signed-rank test; b paired t-test Discussion Periodontal health intervention programs based on the Pender HPM can improve the knowledge, attitude, and behavior of older adults with T2DM regarding oral health. These programs encourage greater attention to oral health, effectively manage plaque build-up to prevent the occurrence or progression of periodontitis, and improve overall oral hygiene. Such interventions are of great significance in improving the oral health status of older individuals. This study demonstrates that periodontal intervention programs can improve periodontal health knowledge, attitudes, and behaviors in older adults with T2DM. These findings align with the conclusions of previous studies [ 31 , 32 ]. The Pender HPM has been instrumental in guiding the development of disease prevention strategies. It helps identify and analyze factors that hinder health-promoting behaviors [ 33 ], emphasizing the importance of evaluation in health promotion. Furthermore, the model underscores the need for a systematic and comprehensive approach to formulating targeted nursing interventions [ 34 ]. In this study, an individualized intervention was designed using the Pender HPM framework, as well as the theory of knowledge, attitude, and behavior. A thorough evaluation of the patient’s existing knowledge, attitude, and behavior was conducted to factor in individual barriers to health behavior and integrate theoretical principles with real-life circumstances. This enabled patients in the experimental group to better understand the relationship between diabetes and periodontitis, recognize the benefits of proper periodontal care, and address behavioral challenges such as mobility disorders. Ultimately, the intervention led to a change in attitudes, encouraging greater attention to periodontal health. Simultaneously, hands-on, face-to-face teaching enhanced patients’ learning retention, improved their oral cleaning skills, boosted their self-efficacy, and fostered consistent adherence to periodontal health behavior. In addition, periodontal health intervention programs have been shown to improve the periodontal health of older individuals with T2DM, aligning with findings from other studies [ 15 , 35 , 36 ]. Research confirms that tooth brushing is associated with a reduced risk of T2DM [ 37 ]. However, long-term adherence to health behaviors, such as proper oral hygiene, depends on patient compliance [ 38 ]. Ensuring good compliance involves increasing factors that promote health behavior while reducing those that hinder it. In this study, a systematic and targeted periodontal health intervention was implemented, which provided older adults with T2DM with a comprehensive understanding of the importance of maintaining periodontal health. The program included skills training on proper brushing techniques (including the Pap brushing method), the use of auxiliary cleaning tools such as dental floss and toothpicks, and correct gargling practices. As a result, individuals improved their oral health-related behaviors and self-efficacy, fostering better compliance. Consequently, the intervention led to a reduction in dental plaque, soft scales, and dental calculus. However, there was no significant difference between the experimental and control groups following the intervention. This lack of difference may be attributed to the fact that the GOHAI scale assesses physiological function, and oral care alone cannot substitute for dental restorative treatments aimed at improving oral physiological function [ 39 ]. Despite this, GOHAI scores in both groups decreased post-intervention. Periodontal interventions can improve oral health and relieve discomfort. Additionally, the correct cleaning method not only results in cleaner teeth and fresher breath but also improves older adults’ satisfaction and self-esteem regarding their oral health. These improvements support their fundamental needs for self-expression and social interaction while also having a positive impact on their psychological and social well-being. Limitations The study has some limitations. First, due to the constraints in time, human resources, and geographic scope, the research was conducted as a single-center study. Participant recruitment was restricted to older self-sufficient adults with T2DM from a tertiary hospital in Fujian Province, which limits the representativeness of the sample and, consequently, the generalizability of the findings. In addition, the study focused solely on periodontal health-related outcome indicators, and no follow-up assessment of periodontal health was performed after the 12-week intervention. Conclusions The intervention program enhances the awareness, attitudes, and behaviors of older individuals with T2DM regarding periodontal health. It motivates them to address oral health proactively, facilitates effective plaque control to prevent the onset or progression of periodontitis, and significantly improves overall oral hygiene quality. Abbreviations T2DM Type 2 diabetes HPM Health Promotion Model PLI Plaque Index PD Periodontitis disease OHI-S Oral Hygiene Index-Simplified GOHAI Geriatric Oral Health Assessment Index DI-S Debris Index-Simplified CI-S Calculus Index-Simplified BOHSE Kayser–Jones Brief Oral Health Status Examination Declarations Ethics approval and consent to participate This study was approved by the Ethics Committee of Grade Tertiary Hospital in Fuzhou City, China (IRB No. 2023KY071), and written informed consent was obtained from all participants. The study protocol was registered with the China Clinical Trial Registry (ChiCTR2300073533) prior to its commencement. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analyzed in the current study are available from the corresponding author upon reasonable request; E-mail: [email protected] . Competing interests The authors declare no competing interests. Funding This work was supported by Fujian Medical University. Authors’ contributions CXX, LZ, and ZXL wrote the first draft. QNX, SPL, and SYZ contributed to data collection. CXX, LZ, and ZXL contributed to all the data, statistical analyses, and data interpretation. HPS contributed to the research concept, supervised the study, and revised the manuscript. All the authors have read and approved the final version of the manuscript. Acknowledgments We thank all the participants for their voluntary participation in this study. We also acknowledge the support from the Department of Endocrinology and Metabolism, a tertiary hospital in Fujian Province, for recruiting the study participants. References National Bureau of Statistics. 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Jiqiang L, Chuanshun Z. Effect of oral health education on elderly patients with diabetes mellitus. Bipedal Health Care . 2018;27:107-8. Lijuan X, Puxin C, Yurui H, Weiyan L. Effect of health education based on behavior change theory on oral health of elderly patients with diabetes mellitus. Qilu J Nurs . 2021;27:92-5. Pender N, Murdaugh C, Parsons M. Health Promotion in vulnerable populations. In: Health Promotion in nursing practice . 4th ed. Upper Saddle River: Prentice Hall; 2002. Xiaomei L, Xianqiong F. Introduction to nursing . 4th ed. Beijing: People’s Medical Publishing House; 2017. Esmaeili Ahangarkolaei M, Taghipour A, Vahedian SM. Improvement of self-care for the elderly with high blood pressure based on Pender’s model: a semi-experimental study. Caspian J Health Aging . 2018;2:52-8. Omidi A, Soltanian A, Esmaili MM. The effect of health-related lifestyle self-management intervention on health promotion behaviors in patients with ischemic heart disease. Avicenna J Nurs Midwif Care . 2016;24:174-83. World Health Organization. Definition and diagnosis of diabetes mellitus and intermediate hyperglycemia: report of a WHO/IDF consultation. 2006. Geneva: WHO Document Production Services; 2006. World Health Organization. Use of glycated haemoglobin(HbA1c)in the diagnosis of diabetes mellitus. Abbreviated report of a WHO consultation; 2011[EB/OL]. (2013-11-12). Zenthöfer A, Dieke R, Dieke A, Wege KC, Rammelsberg P, Hassel AJ. Improving oral hygiene in the long-term care of the elderly--a RCT. Community Dent Oral Epidemiol . 2013;41:261-8. Quigley GA, Hein JW. Comparative cleansing efficiency of manual and power brushing. J Am Dent Assoc . 1962;65:26-9. Turesky S, Gilmore ND, Glickman I. Reduced plaque formation by the chloromethyl analogue of victamine C. J Periodontol . 1970;41:41-3. Deyu H. Oral preventive medicine. People’s Medical Publishing House ; 2012 Pluto. p. 30-1. Atchison KA, Dolan TA. Development of the geriatric Oral Health assessment index. J Dent Educ . 1990;54:680-7. Weini X, Junyi L. A comparative study of OHIP-14 Chinese version and GOHAI Chinese version. J Oral Sci Res . 2014;03:252257. Caijun Z, Fu D. Study on the Sinicization, reliability and validity of Kayser-Jones concise oral health checklist. Nursing Management in China . 2016;16:38-41. Feng N. Observation and evaluation of oral health education for patients with diabetic periodontitis. Diabetes New World . 2020;23:135-7. Cinar AB, Freeman R, Schou L. A new complementary approach for oral health and diabetes management: health coaching. Int Dent J . 2018;68:54-64. Junwen L, Ying C, Songmei C, Xinwen Y, Liu Z, Xia C, et al. Qualitative study on influencing factors of dietary compliance in patients with chronic liver disease based on Pender health promotion model. Chin Evid-Based Nurs . 2023;9:3336-40. Poudel P, Griffiths R, Wong VW, Arora A, Flack JR, Khoo CL, et al. Oral health knowledge, attitudes and care practices of people with diabetes: a systematic review. BMC Public Health . 2018;18:577. Yuan W, Chunmei Z, Xiaoyan G. Effect of comprehensive nursing intervention on oral treatment of diabetic patients with chronic periodontitis. Chin Mod Med . 2020;27:228-30, 234. Ping Z, Kui W. Effect of intensive oral exercise on oral health of diabetic patients with periodontitis. Chin Gen Pract Nurs . 2022;20:1531-3. Wang Y, Jiang Y, Chen Y, Yu L, Zhou J, Wang N, et al. Associations of oral hygiene with incident hypertension and type 2 diabetes mellitus: A population based cohort study in Southwest ChinaJ. J Clin Hypertens (Greenwich) . 2022;24:483-92. Eckerd Lambe C. Complementary and alternative therapy use in breast cancer: Notable findings. J Christian Nurs . 2013;30:218-25. Yufei L. Study on the Effect of Comprehensive Oral Nursing Intervention for the Elderly in Pension Institutions. Jilin University ; 2019. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTableS1.pdf Title: Periodontal health intervention program Description: Periodontal health intervention program adopted by the experimental group, including intervention factors, time, theme, content, and forms. 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study\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-6068876/v1/bc28ab9dc6d66addd6b8311f.png"},{"id":88268470,"identity":"9fa98848-2633-4c76-9d9f-7386b4d63fc4","added_by":"auto","created_at":"2025-08-04 16:51:57","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1223237,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6068876/v1/32a78008-192e-4a93-9997-e902edd99dd5.pdf"},{"id":78224106,"identity":"d07dd4a5-5690-4b86-b84a-a4e8377fd9af","added_by":"auto","created_at":"2025-03-11 06:41:57","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":150837,"visible":true,"origin":"","legend":"\u003cp\u003eTitle: Periodontal health intervention program\u003c/p\u003e\n\u003cp\u003eDescription: Periodontal health intervention program adopted by the experimental group, including intervention factors, time, theme, content, and forms.\u003c/p\u003e","description":"","filename":"SupplementaryTableS1.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6068876/v1/8448c703af690459337fe8a2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Effects of periodontal health intervention program on oral health-related outcomes in older patients with type 2 diabetes: a randomized controlled trial","fulltext":[{"header":"Introduction","content":"\u003cp\u003eDiabetes encompasses a group of metabolic disorders characterized by chronic hyperglycemia, influenced by both genetic and environmental factors. In China, where the aging population is expanding, approximately 260\u0026nbsp;million individuals are aged\u0026thinsp;\u0026ge;\u0026thinsp;60 years, representing 18.7% of the national population. Among this demographic, nearly 30% are affected by diabetes, with \u0026gt;\u0026thinsp;95% diagnosed with type 2 diabetes mellitus (T2DM) [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Periodontitis, recognized as the sixth most common complication of diabetes, is a chronic inflammatory condition triggered by dental plaque that leads to the progressive destruction of periodontal tissue [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Persistent periodontal infections exacerbate the systemic microinflammatory state, complicating glycemic control [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. A consensus report from the International Diabetes Federation and the European Federation of Periodontology [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e] highlights the critical role of periodontal health in diabetes management. Age significantly influences the prevalence of periodontitis [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], particularly in older patients with diabetes, who often lack sufficient knowledge about oral health. This gap leads to underestimating the risk posed by periodontitis and its impact on diabetes management. Awareness and education are essential for promoting behavioral changes, as adopting proper oral hygiene practices can mitigate the risk of periodontitis. Consequently, health interventions aimed at improving periodontal care and promoting effective dental plaque control are vital for preventing periodontitis and enhancing overall diabetes care.\u003c/p\u003e \u003cp\u003e Numerous studies, both domestic and international, have demonstrated that oral health interventions can improve the oral quality of life and periodontal indices in patients with diabetes. These interventions include oral health education [\u003cspan additionalcitationids=\"CR8 CR9\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e], comprehensive healthcare [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e], oral nursing combined with exercise guidance [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], and strategies to maintain the stability of the oral environment [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. For instance, one study focused on older patients with T2DM in an intervention group who received a 20-minute lifestyle modification and dental care intervention plan supplemented by personalized lifestyle counseling. During the intervention, nurses guided patients in goal setting and reinforced these goals through 15-minute health education videos in the first and second months. The control group, by contrast, received routine care. Results revealed significant improvements in both periodontal condition and blood glucose levels in the intervention group after 3 months. However, the quasi-experimental study was limited by selection bias and insufficient rigor [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Similarly, a randomized controlled trial examined the impact of educational interventions based on health belief models in patients with T2DM. Participants in the trial group attended four educational sessions within 1 month, covering topics such as oral health risks, potential complications, benefits of preventive behavior, and disorders associated with poor oral health. They were subsequently encouraged to practice oral care. The control group received routine care. After 3 months, the experimental group exhibited heightened awareness of oral nursing practices. However, this study was limited by its reliance on a self-designed questionnaire as the sole outcome measure, lacking objective oral health indicators to evaluate intervention effectiveness [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSeveral studies have explored oral health education for older patients with diabetes in China. In one study, the experimental group received nursing interventions that included education on oral health knowledge, covering a diverse range of topics such as theoretical training in oral healthcare, oral nursing skills, timely oral examinations, and the prompt use of necessary treatment. Meanwhile, the control group received routine nursing care. The results demonstrated improvements in oral health and quality of life among patients in the experimental group following the intervention. However, it remains unclear whether the baseline characteristics of the participants in these studies were comparable [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Another study examined the effect of health education based on behavior change theory on the oral health of older patients with diabetes. The experimental group underwent an intervention that incorporated education on diabetes, oral health knowledge, and psychological support, structured through the stages of pre-intention, intention, preparation, action, and maintenance. The findings revealed that such interventions effectively improved patients\u0026rsquo; oral health awareness and behavioral habits, improved their quality of life, and contributed to better blood sugar control. Nevertheless, the study's extended duration limits its applicability to short-term hospitalization settings. Both research interventions primarily focused on theoretical knowledge education across various stages, with insufficient training in oral health protection skills [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. In summary, several studies have demonstrated that oral health interventions can improve the oral quality of life and enhance the periodontal index in patients with diabetes. However, few intervention programs fully account for the unique needs of the older adult population. Most interventions focus predominantly on preventing oral problems in patients with diabetes, lack behavioral components for oral health, and demonstrate insufficient scientific rigor. Additionally, personalized interventions tailored to individual patient conditions are notably absent.\u003c/p\u003e \u003cp\u003eThe Health Promotion Model (HPM), developed by Pender, a prominent American nursing scholar of the 20th century, provides a comprehensive theoretical framework for analyzing factors that affect health behaviors. This model serves as a robust theoretical foundation for understanding and explaining lifestyle choices and specific health-related behaviors. The HPM consists of three primary components: personal characteristics and experiences, specific behavioral cognition and emotions, and behavioral outcomes. Personal characteristics and experiences are subdivided into prior related behaviors and personal factors. Prior related behaviors refer to an individual's past behaviors, including their nature and characteristics, which can serve as predictors of current behaviors across physical, psychological, social, and cultural dimensions. Specific behavioral cognitions and emotions encompass perceived benefits of behavior, perceived barriers to action, cognitive self-efficacy, emotional responses to actions, interpersonal influences, and situational factors. Behavioral outcomes include planned health-promoting actions, immediate needs and preferences, and health-enhancing behaviors [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. The HPM has been widely used in clinical settings and has demonstrated effectiveness in improving patients\u0026rsquo; self-management skills, health behaviors, knowledge, and quality of life [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. However, there is a lack of health intervention studies that utilize the HPM to address oral health among older patients with T2DM. This study aims to apply the HPM to develop a periodontal health program for older patients with T2DM, emphasizing the relationship between diabetes and periodontitis, the risk factors contributing to periodontal problems, and the influence of poor oral hygiene habits. By evaluating the knowledge, attitudes, behaviors, and personal factors associated with periodontal health, the program seeks to enhance patients\u0026rsquo; understanding of proper periodontal care, overcome barriers to oral health practices, and improve self-efficacy. Ultimately, the goal is to encourage patients to commit to periodontal health plans and adopt sustainable oral health behaviors.\u003c/p\u003e \u003cp\u003eThis clinical randomized controlled trial aimed to evaluate the effectiveness of a periodontal health intervention program designed for older patients with T2DM using the Pender HPM. The findings aim to offer a theoretical foundation for the clinical advancement of periodontal health interventions tailored to this population.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStudy design, setting, and participants\u003c/h2\u003e \u003cp\u003e This study was approved by the Ethics Committee of Fujian Medical University Union Hospital (2023KY071). All patients signed informed consent, and all experiments were conducted in accordance with the Declaration of Helsinki. The trial was registered (ChiCTR2300073533, 13/07/2023) with the China Clinical Trial Registry prior to its commencement. This single-blind, single-center, randomized controlled trial was conducted at Fujian Medical University Union Hospital, China, from August 2023 to February 2024. The study employed quantitative research methods, incorporating clinical reagent tests and internationally recognized scales to assess outcomes. Additionally, a previously developed self-made scale was used for evaluation purposes., and written informed consent was obtained from all participants. Participants aged 60 years or older with T2DM were recruited from the Department of Endocrinology and Metabolism at a tertiary hospital in Fujian Province. Eligibility criteria included the following: (1) diagnosis of T2DM based on the World Health Organization (WHO) diabetes diagnostic criteria of 1999 [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]; (2) ability to communicate effectively in Chinese; (3) capability to complete the questionnaire independently or with assistance from the researcher; (4) possession of at least 16 natural teeth; and (5) ability to perform self-care, including brushing and mouth rinsing. Exclusion criteria were as follows: (1) presence of severe complications; (2) mental illnesses or emotional disorders; (3) use of hormones or antibiotics for more than 2 weeks within the past 3 months or recent scaling or scraping; and (4) history of systematic periodontal treatment within the previous year. Additionally, participants were excluded during the study if they: (1) demonstrated poor compliance during follow-up or were unable to adhere to long-term follow-up; (2) required the use of hormones or antibiotics for more than 2 weeks during the intervention period; (3) were unable to continue participation due to changes in their medical condition; or (4) withdrew or died during the study.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy randomization\u003c/h3\u003e\n\u003cp\u003eTo address the challenge of a socially dispersed patient population and the limited number of hospital visitors meeting the minimum sample size requirements within a short timeframe, patients were enrolled consecutively into the study. Participants who fulfilled the inclusion and exclusion criteria and were officially included in the trial were sequentially numbered. A set of random sequences was generated in advance by external individuals not involved in the study using a randomization website. These random numbers, ranging from 1 to 108, were placed in sequentially numbered, sealed, and opaque envelopes, which were securely stored. Upon enrollment, researchers contacted the custodians of the random numbers by telephone to determine the participant's group assignment. The custodian opened the corresponding envelope to reveal the group allocation: participants with random numbers 1\u0026ndash;54 were assigned to the test group, while those with numbers 55\u0026ndash;108 were assigned to the control group.\u003c/p\u003e\n\u003ch3\u003eSample size\u003c/h3\u003e\n\u003cp\u003eThe sample size for this study was determined using a standard estimation method for experimental studies. The calculation formula is as follows: \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:n1=n2=2{\\left[\\left({\\mu\\:}_{\\alpha\\:}+{\\mu\\:}_{\\beta\\:}\\right)\\sigma\\:/\\delta\\:\\right]}^{2}+1/4{{\\mu\\:}_{\\alpha\\:}}^{2}\\)\u003c/span\u003e\u003c/span\u003e, where n1 and n2 represent the required sample sizes for the two groups, σ is the total standard deviation, and δ is the difference between the two population averages. Based on the literature [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e] and accompanying tables, the ratio δ/σ\u0026thinsp;=\u0026thinsp;0.69, with \u0026micro;\u003csub\u003e0.05/2\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;1.96, and \u0026micro;\u003csub\u003e0.1\u003c/sub\u003e\u0026thinsp;=\u0026thinsp;1.28. Substituting these values into the formula yields n1\u0026thinsp;=\u0026thinsp;n2\u0026thinsp;\u0026asymp;\u0026thinsp;45. Considering the extended duration of the study and an anticipated 20% attrition rate, a minimum of 54 participants per group is required. Therefore, the total expected sample size for this study is 108 participants.\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eParticipants in the control group received standard diabetes health education, information on periodontal health, and routine follow-up care after the intervention.\u003c/p\u003e \u003cp\u003eIn contrast, participants in the experimental group underwent a periodontal health intervention program designed using the Pender HPM. This program was developed through a structured process involving the formation of a research team, a comprehensive literature review, and expert consultations using the Delphi method. The program consisted of three key components: (1) evaluation of personal characteristics and experience, (2) cognitive and emotional interventions targeting behavioral characteristics, and (3) supervision and reinforcement of committed behaviors. The first component included an assessment of the patient's personal information, oral health factors, and behavioral patterns. The second component comprised five specific activities: recognizing the benefits of health-promoting actions, enhancing theoretical knowledge related to emotional responses, conducting practical skills training to boost self-efficacy, providing feedback and re-evaluation to address cognitive barriers to action, and addressing situational and interpersonal influences. The third component focused on strategies for managing unexpected situations during the intervention period and ensuring adherence to planned behaviors. The intervention was administered directly by the researcher over a 5-day period, with follow-up supervision extending for 12 weeks. An additional table provides more detail (see Supplementary Table \u003cspan refid=\"MOESM1\" class=\"InternalRef\"\u003eS1\u003c/span\u003e).\u003c/p\u003e\n\u003ch3\u003eOutcome measures\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMain outcomes\u003c/h2\u003e \u003cp\u003eThe main outcome indicators of this study were Plaque Index (PLI) and General Oral Health Assessment Index (GOHAI).\u003c/p\u003e \u003cp\u003ePlaque Index (PLI)\u003c/p\u003e \u003cp\u003ePlaque Index (PLI) is an evaluation method that assesses the thickness of plaque on the surface of teeth and serves as an indicator of oral hygiene, helping to prevent periodontal disease. In 1962, Quigley and Hein introduced a plaque scoring system with a standard score of 0.5 [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. In 1970, Turesky improved this scoring system, making it more objective and specific [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. The improved Turesky method of the Quigley\u0026ndash;Hein PLI was used in this study. During the examination, the evaluator applies a plaque chromogenic liquid to a cotton swab, which is then used to swab the surface of the lip (cheek) and tongue of the six index teeth, resulting in a total of 12 examination areas. After 5 s, the participant rinses their mouth twice with clear water, allowing the plaque developer to leave pink stains on the areas where the plaque has adhered. The plaque accumulation is scored based on the extent of plaque coverage [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. The plaque area is divided into six categories: (1) no plaque on the tooth surface, (2) scattered spot plaque at the gingival margin of the tooth neck, (3) plaque width at the tooth neck of no more than 1 mm, (4) plaque width greater than 1 mm but less than 1/3 of the tooth neck, (5) plaque width between 1/3 and 2/3 of the tooth neck, and (6) plaque width greater than 2/3 of the tooth neck. Scores ranged from 0 to 5, with higher scores indicating poorer oral health. The plaque areas of the 12 regions were quantified using this PLI method.\u003c/p\u003e \u003cp\u003eGeneral Oral Health Assessment Index (GOHAI)\u003c/p\u003e \u003cp\u003eThe General Oral Health Assessment Index (GOHAI), introduced by American scholars in 1990, is a tool designed to measure the subjective oral health status of older individuals [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. It comprises 12 items categorized into three domains: functional limitation, psychological discomfort, and pain. The total score ranges from 0 to 48, with higher scores reflecting poorer oral health. The scale demonstrates strong reliability and validity, evidenced by a Cronbach\u0026rsquo;s α coefficient of 0.88 [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eSecondary outcomes\u003c/h3\u003e\n\u003cp\u003eThe secondary outcomes of this study included assessments using the Periodontal Health Knowledge, Attitude, and Behavior Questionnaire, as well as the Oral Hygiene Index-Simplified (OHI-S).\u003c/p\u003e \u003cp\u003ePeriodontal health knowledge, attitude, and behavior assessment questionnaire\u003c/p\u003e \u003cp\u003eThe self-developed questionnaire for assessing periodontal health in older patients with T2DM was organized into three dimensions: knowledge, attitude, and behavior. The knowledge dimension included 29 items, the attitude dimension contained 15 items, and the behavioral dimension comprised 12 items.\u003c/p\u003e \u003cp\u003eOral Hygiene Index-Simplified (OHI-S)\u003c/p\u003e \u003cp\u003e Greene and Vermillion (1964) introduced an evaluation method to assess the true status of oral health. This index was designed to be objective, simple, rapid, and reproducible. It comprises two components: Debris Index-Simplified (DI-S) and the Calculus Index-Simplified (CI-S). The examination method involved dividing the tooth surface from the gingival margin to the incisal margin, applying a plaque display agent, and visually assessing the area covered by plaque, soft dirt, pigment, or dental calculus. Only six teeth were examined: the lip and buccal surfaces of 16, 11, 26, and 31 and the tongue surfaces of teeth 36 and 46. Based on the extent of the soft scale coverage, the DI-S was categorized into four groups: no soft scale dirt on the tooth surface, coverage less than 1/3 of the surface, coverage between 1/3 and 2/3, and coverage greater than 2/3. Scores ranged from 0 to 3, with higher scores reflecting poorer oral health. Similarly, the CI-S was categorized based on the extent of dental calculus coverage: no supragingival or subgingival calculus, supragingival calculus covering less than 1/3 of the surface, coverage between 1/3 and 2 /3 or scattered subgingival calculus near the neck of the tooth, and coverage exceeding 2/3 or continuous thick subgingival calculus in the neck of the tooth. Scores for the CI-S ranged from 0 to 3, with higher scores indicating poorer oral health.\u003c/p\u003e\n\u003ch3\u003eOther variables\u003c/h3\u003e\n\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eQuestionnaire\u003c/h2\u003e \u003cp\u003eThe sociodemographic characteristics of the participants were assessed through a survey. The collected data encompassed age, sex, place of origin, disease duration, educational level, marital status, annual family income, smoking history, and alcohol consumption history.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eChinese Kayser\u0026ndash;Jones Brief Oral Health Status Examination (BOHSE)\u003c/h2\u003e \u003cp\u003eThe scale is a practical tool designed for non-oral health professionals to screen the oral health of older adults. It comprises 10 items: lymph nodes, lips, tongue, mucous membrane, gums, saliva, natural teeth, dentures, logarithm of chewing teeth, and oral cleaning. Each item is scored on a scale from 0 (normal) to 2 (problematic), with higher overall scores reflecting poorer oral health. The scale demonstrates strong reliability and validity, with a Cronbach\u0026rsquo;s α coefficient of 0.873 [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eData collection\u003c/h2\u003e \u003cp\u003eThe study consisted of a 5-day intervention period, followed by a 12-week maintenance period. Baseline assessments were conducted to evaluate personal characteristics and related behaviors in the early stages. On the second day, participants received training on periodontal health knowledge and oral health protection techniques. Problem-solving feedback was integrated into the learning process and provided on days 2 and 4. Dietary and lifestyle guidance was delivered on day 5. Psychological support, temporary coping strategies, and planned behavior reinforcement were provided throughout the intervention period and continued during follow-up after the intervention. Baseline data were collected by trained data collectors using a custom-designed questionnaire administered directly to participants. Before beginning the surveys, the data collectors explained the study\u0026rsquo;s purpose to the participants and obtained informed consent. Each questionnaire item was individually explained and completed in real time to ensure the objectivity and validity of the collected data. The PLI and OHI-S were measured with chromogenic reagents by data collectors at baseline and 12 weeks post-intervention.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003eStatistical analysis\u003c/h2\u003e \u003cp\u003eStatistical analysis was performed using SPSS Statistics software (version 27.0). Continuous data were assessed using descriptive statistics and normality tests. For data following a normal distribution, the mean and standard deviation were used as summary measures. Between-group comparisons for normally distributed data were performed using independent t-tests, while within-group changes were analyzed using paired t-tests. For non-normally distributed data, the median (quartile interval) was reported, and the Wilcoxon signed-rank test was used to analyze the data. Categorical data were summarized as frequencies and constituent ratios, with chi-square and Fisher\u0026rsquo;s exact tests employed for group comparisons. All statistical tests were two-tailed, and a p-value of \u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e \u003ch2\u003eCharacteristics of the patients\u003c/h2\u003e \u003cp\u003eA total of 108 participants were enrolled in this study and randomized equally into an intervention group (n\u0026thinsp;=\u0026thinsp;54) and a control group (n\u0026thinsp;=\u0026thinsp;54). During the study, five participants were lost to follow-up: three from the intervention group (5.56%) and two from the control group (3.70%), resulting in an overall loss to follow-up rate of 4.63%. Consequently, 103 participants completed the study and were included in the final statistical analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eAmong the 108 participants, the mean age was 67.55\u0026thinsp;\u0026plusmn;\u0026thinsp;5.34 years. The majority of the participants were male (59.26%), while females comprised 40.74% of the cohort. Educational level was predominantly low, with 75% having completed junior high school or less and only 25% achieving a high school education. Furthermore, 96.3% of participants were married. Regarding medical coverage, the primary payment method was provincial or municipal health insurance, accounting for 65.74% of the cases. The median disease duration was 15 years, and the average initial oral examination score was 5.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.65. No statistically significant differences in general demographics or baseline characteristics were observed between the two groups (\u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026gt;\u0026thinsp;0.05) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of general data between the two groups\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTotal (n\u0026thinsp;=\u0026thinsp;108)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eExperiment (n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eF/\u003c/em\u003e\u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\chi\\:}^{2}\\)\u003c/span\u003e\u003c/span\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAge, years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.0 (63,72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e67.5 (63,72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e67.0 (62,72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.308\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.758\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSex\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.153\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.695\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e64 (59.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31 (57.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e33 (61.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e44 (40.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (42.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e21 (38.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eEducation, %\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.391\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.335\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eElementary school or less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e39 (36.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15 (27.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e24 (44.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMiddle school graduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42 (38.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (42.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e19 (35.19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school or secondary specialized school\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (13.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9 (16.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e6 (11.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eJunior college or more\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (11.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7 (12.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5 (9.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMarital status, %\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.745\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUnmarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2 (3.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0 (0.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMarried\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e104 (96.30)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51 (94.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e53 (98.15)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBereaved\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 (1.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1 (1.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1 (1.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eSmoking, %\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.313\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.252\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eAlcohol consumption, %\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.313\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.252\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e49\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eGlycosylated hemoglobin\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e8.35(7.20, 10.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e8.30(7.20, 9.83)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e8.55(7.28, 10.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e-0.565\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.572\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMedical payment method, %\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.014\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.156\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUrban medical insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37(34.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15(27.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22(40.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProvincial and municipal medical insurance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71(65.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e39(72.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e32(59.26)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eDisease course, years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15.0 (10,20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e15.0 (10,20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e12.5 (8,20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eBMI, kg/m\u003c/b\u003e\u003csup\u003e\u003cb\u003e2\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.53\u0026thinsp;\u0026plusmn;\u0026thinsp;1.65\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.63\u0026thinsp;\u0026plusmn;\u0026thinsp;1.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e5.43\u0026thinsp;\u0026plusmn;\u0026thinsp;1.66\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.222\u003csup\u003ec\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c6\"\u003e \u003cp\u003e0.525\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBMI, body mass index; \u003csup\u003ea\u003c/sup\u003e U-test; \u003csup\u003eb\u003c/sup\u003e \u003cspan class=\"InlineEquation\"\u003e\u003cspan class=\"mathinline\"\u003e\\(\\:{\\chi\\:}^{2}\\:\\)\u003c/span\u003e\u003c/span\u003etest; \u003csup\u003ec\u003c/sup\u003e t-test\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec17\" class=\"Section2\"\u003e \u003ch2\u003eComparison of the outcome indicators before intervention\u003c/h2\u003e \u003cp\u003eNo significant differences were observed between the two groups in the following pre-intervention outcome indicators: PLI score (\u003cem\u003eZ\u003c/em\u003e = -0.961, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.337), GOHAI score (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.020, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.310), DI-S score (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.219, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.827), CI-S score (\u003cem\u003eZ\u003c/em\u003e = -0.782, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.434), total score of knowledge, attitude, and behavior (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.645, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.521), knowledge dimension score (\u003cem\u003eZ\u003c/em\u003e = -1.046, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.296), attitude dimension score (\u003cem\u003et\u003c/em\u003e = -0.250, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.803), behavior dimension score (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.780, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.437) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the outcome indicators before intervention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperiment (n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eZ/t\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePLI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.75(1.5, 2.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.961\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.337\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGOHAI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17.69\u0026thinsp;\u0026plusmn;\u0026thinsp;5.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.72\u0026thinsp;\u0026plusmn;\u0026thinsp;4.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.020\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.310\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDI-S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.219\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.827\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCI-S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00 (0.67, 1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.83 (0.67, 1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.782\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.434\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score of knowledge, attitude, and behavior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85.43\u0026thinsp;\u0026plusmn;\u0026thinsp;15.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.54\u0026thinsp;\u0026plusmn;\u0026thinsp;14.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.645\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.521\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge dimension score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39.00 (32.00,42.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.30\u0026thinsp;\u0026plusmn;\u0026thinsp;6.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.046\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.296\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitude dimension score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21.98\u0026thinsp;\u0026plusmn;\u0026thinsp;4.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.19\u0026thinsp;\u0026plusmn;\u0026thinsp;3.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.250\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.803\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBehavior dimension score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.93\u0026thinsp;\u0026plusmn;\u0026thinsp;5.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e24.06\u0026thinsp;\u0026plusmn;\u0026thinsp;6.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.780\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.437\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePLI, Plaque Index; GOHAI, General Oral Health Assessment Index; DI-S, Debris Index-Simplified; CI-S, Calculus Index-Simplified; \u003csup\u003ea\u003c/sup\u003e Wilcoxon signed-rank test; \u003csup\u003eb\u003c/sup\u003e t-test\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec18\" class=\"Section2\"\u003e \u003ch2\u003eComparison of the outcome indicators after intervention\u003c/h2\u003e \u003cp\u003eAfter the intervention, no significant difference was observed in the GOHAI scores between the two groups (\u003cem\u003et\u003c/em\u003e = -0.676, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.50). However, significant differences were found in several other measures. The PLI score showed a notable increase (\u003cem\u003eZ\u003c/em\u003e = -6.220, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), as did the DI-S score (\u003cem\u003eZ\u003c/em\u003e = -7.167, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and the CI-S score (\u003cem\u003eZ\u003c/em\u003e = -2.724, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.006\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Additionally, the total score for knowledge, attitude, and behavior significantly increased (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.582, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), along with improvements in the knowledge dimension score (t\u0026thinsp;=\u0026thinsp;3.226, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), attitude dimension score (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;3.235, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002), and behavior dimension score (\u003cem\u003eZ\u003c/em\u003e = -3.601, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the outcome indicators after intervention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eExperiment (n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eControl (n\u0026thinsp;=\u0026thinsp;52)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eZ/t\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePLI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.25 (1.08, 1.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-6.220\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGOHAI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e15.98\u0026thinsp;\u0026plusmn;\u0026thinsp;5.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.62\u0026thinsp;\u0026plusmn;\u0026thinsp;4.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.676\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.500\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDI-S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00 (0.83, 1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-7.167\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCI-S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.83 (0.50, 1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-2.724\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.006\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score of knowledge, attitude, and behavior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e94.44\u0026thinsp;\u0026plusmn;\u0026thinsp;15.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.50\u0026thinsp;\u0026plusmn;\u0026thinsp;15.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.582\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge dimension score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e42.13\u0026thinsp;\u0026plusmn;\u0026thinsp;7.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.37\u0026thinsp;\u0026plusmn;\u0026thinsp;7.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.226\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitude dimension score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e25.04\u0026thinsp;\u0026plusmn;\u0026thinsp;4.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.25\u0026thinsp;\u0026plusmn;\u0026thinsp;4.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.235\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.002\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBehavior dimension score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e27.28\u0026thinsp;\u0026plusmn;\u0026thinsp;5.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.00 (19.00, 28.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-3.601\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePLI, Plaque Index; GOHAI, General Oral Health Assessment Index; DI-S, Debris Index-Simplified; CI-S, Calculus Index-Simplified; \u003csup\u003ea\u003c/sup\u003e Wilcoxon signed-rank test; \u003csup\u003eb\u003c/sup\u003e t-test\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec19\" class=\"Section2\"\u003e \u003ch2\u003eComparison of the outcome indicators in the experimental group before and after intervention\u003c/h2\u003e \u003cp\u003eSignificant improvements were observed in the experimental group after the intervention across multiple measures: PLI score (\u003cem\u003eZ\u003c/em\u003e = -6.461, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), GOHAI score (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;11.672, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), DI-S score (\u003cem\u003eZ\u003c/em\u003e = -6.415, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), CI-S score (\u003cem\u003eZ\u003c/em\u003e = -5.195, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), total score of knowledge, attitude, and behavior (\u003cem\u003et\u003c/em\u003e = -13.640, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), knowledge dimension score (\u003cem\u003eZ\u003c/em\u003e = -6.163, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), attitude dimension score (\u003cem\u003et\u003c/em\u003e = -5.009, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), behavior dimension score (\u003cem\u003et\u003c/em\u003e = -8.409, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e)\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the outcome indicators in the experimental group before and after intervention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore (n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter (n\u0026thinsp;=\u0026thinsp;51)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eZ/t\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePLI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.75 (1.5,2.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.25 (1.08,1.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-6.461\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGOHAI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17.69\u0026thinsp;\u0026plusmn;\u0026thinsp;5.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e15.98\u0026thinsp;\u0026plusmn;\u0026thinsp;5.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11.672\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDI-S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.77\u0026thinsp;\u0026plusmn;\u0026thinsp;0.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e1.00 (0.83,1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-6.415\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCI-S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.00 (0.67,1.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.83 (0.50,1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-5.195\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score of knowledge, attitude, and behavior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e85.43\u0026thinsp;\u0026plusmn;\u0026thinsp;15.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e94.44\u0026thinsp;\u0026plusmn;\u0026thinsp;15.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-13.640\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge dimension score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e39.00 (32.00, 42.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e42.13\u0026thinsp;\u0026plusmn;\u0026thinsp;7.37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-6.163\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitude dimension score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e21.98\u0026thinsp;\u0026plusmn;\u0026thinsp;4.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e25.04\u0026thinsp;\u0026plusmn;\u0026thinsp;4.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-5.009\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBehavior dimension score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e24.93\u0026thinsp;\u0026plusmn;\u0026thinsp;5.45\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e27.28\u0026thinsp;\u0026plusmn;\u0026thinsp;5.51\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-8.409\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePLI, Plaque Index; GOHAI, General Oral Health Assessment Index; DI-S, Debris Index-Simplified; CI-S, Calculus Index-Simplified; \u003csup\u003ea\u003c/sup\u003e Wilcoxon signed-rank test; \u003csup\u003eb\u003c/sup\u003e t-test\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eComparison of the outcome indicators in the control group before and after intervention\u003c/h2\u003e \u003cp\u003eNo significant differences were observed in the control group before and after the intervention for the PLI score (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.868, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.068), GOHAI score (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.983, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.053), DI-S score (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;1.958, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.056), total score of knowledge, attitude, and behavior (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.485, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.630), knowledge dimension score (\u003cem\u003et\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.164, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.870), attitude dimension score (\u003cem\u003et\u003c/em\u003e = -0.340, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.735), behavior dimension score (\u003cem\u003eZ\u003c/em\u003e = -1.686, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.092). However, a significant improvement was observed in the CI-S score (\u003cem\u003eZ\u003c/em\u003e = -5.195, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eComparison of the outcome indexes in the control group before and after intervention\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eBefore(n\u0026thinsp;=\u0026thinsp;54)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAfter(n\u0026thinsp;=\u0026thinsp;52)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003eZ/t\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cem\u003eP\u003c/em\u003e\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePLI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.64\u0026thinsp;\u0026plusmn;\u0026thinsp;0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.65\u0026thinsp;\u0026plusmn;\u0026thinsp;0.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.868\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.068\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGOHAI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.72\u0026thinsp;\u0026plusmn;\u0026thinsp;4.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.62\u0026thinsp;\u0026plusmn;\u0026thinsp;4.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.983\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.053\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDI-S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.75\u0026thinsp;\u0026plusmn;\u0026thinsp;0.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.71\u0026thinsp;\u0026plusmn;\u0026thinsp;0.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1.958\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.056\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCI-S\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.83 (0.67, 1.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.01\u0026thinsp;\u0026plusmn;\u0026thinsp;0.35\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-5.195\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal score of knowledge, attitude, and behavior\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83.54\u0026thinsp;\u0026plusmn;\u0026thinsp;14.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.50\u0026thinsp;\u0026plusmn;\u0026thinsp;15.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.485\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.630\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eKnowledge dimension score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37.30\u0026thinsp;\u0026plusmn;\u0026thinsp;6.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37.37\u0026thinsp;\u0026plusmn;\u0026thinsp;7.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.164\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.870\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAttitude dimension score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.19\u0026thinsp;\u0026plusmn;\u0026thinsp;3.82\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.25\u0026thinsp;\u0026plusmn;\u0026thinsp;4.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-0.340\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.735\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBehavior dimension score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.06\u0026thinsp;\u0026plusmn;\u0026thinsp;6.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.00 (19.00, 28.25)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e-1.686\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c5\"\u003e \u003cp\u003e0.092\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePLI, Plaque Index; GOHAI, General Oral Health Assessment Index; DI-S, Debris Index-Simplified; CI-S, Calculus Index-Simplified; \u003csup\u003ea\u003c/sup\u003e Wilcoxon signed-rank test; \u003csup\u003eb\u003c/sup\u003e paired t-test\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003ePeriodontal health intervention programs based on the Pender HPM can improve the knowledge, attitude, and behavior of older adults with T2DM regarding oral health. These programs encourage greater attention to oral health, effectively manage plaque build-up to prevent the occurrence or progression of periodontitis, and improve overall oral hygiene. Such interventions are of great significance in improving the oral health status of older individuals.\u003c/p\u003e \u003cp\u003eThis study demonstrates that periodontal intervention programs can improve periodontal health knowledge, attitudes, and behaviors in older adults with T2DM. These findings align with the conclusions of previous studies [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e]. The Pender HPM has been instrumental in guiding the development of disease prevention strategies. It helps identify and analyze factors that hinder health-promoting behaviors [\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], emphasizing the importance of evaluation in health promotion. Furthermore, the model underscores the need for a systematic and comprehensive approach to formulating targeted nursing interventions [\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. In this study, an individualized intervention was designed using the Pender HPM framework, as well as the theory of knowledge, attitude, and behavior. A thorough evaluation of the patient\u0026rsquo;s existing knowledge, attitude, and behavior was conducted to factor in individual barriers to health behavior and integrate theoretical principles with real-life circumstances. This enabled patients in the experimental group to better understand the relationship between diabetes and periodontitis, recognize the benefits of proper periodontal care, and address behavioral challenges such as mobility disorders. Ultimately, the intervention led to a change in attitudes, encouraging greater attention to periodontal health. Simultaneously, hands-on, face-to-face teaching enhanced patients\u0026rsquo; learning retention, improved their oral cleaning skills, boosted their self-efficacy, and fostered consistent adherence to periodontal health behavior.\u003c/p\u003e \u003cp\u003eIn addition, periodontal health intervention programs have been shown to improve the periodontal health of older individuals with T2DM, aligning with findings from other studies [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e, \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. Research confirms that tooth brushing is associated with a reduced risk of T2DM [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. However, long-term adherence to health behaviors, such as proper oral hygiene, depends on patient compliance [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Ensuring good compliance involves increasing factors that promote health behavior while reducing those that hinder it. In this study, a systematic and targeted periodontal health intervention was implemented, which provided older adults with T2DM with a comprehensive understanding of the importance of maintaining periodontal health. The program included skills training on proper brushing techniques (including the Pap brushing method), the use of auxiliary cleaning tools such as dental floss and toothpicks, and correct gargling practices. As a result, individuals improved their oral health-related behaviors and self-efficacy, fostering better compliance. Consequently, the intervention led to a reduction in dental plaque, soft scales, and dental calculus.\u003c/p\u003e \u003cp\u003eHowever, there was no significant difference between the experimental and control groups following the intervention. This lack of difference may be attributed to the fact that the GOHAI scale assesses physiological function, and oral care alone cannot substitute for dental restorative treatments aimed at improving oral physiological function [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Despite this, GOHAI scores in both groups decreased post-intervention. Periodontal interventions can improve oral health and relieve discomfort. Additionally, the correct cleaning method not only results in cleaner teeth and fresher breath but also improves older adults\u0026rsquo; satisfaction and self-esteem regarding their oral health. These improvements support their fundamental needs for self-expression and social interaction while also having a positive impact on their psychological and social well-being.\u003c/p\u003e \u003cdiv id=\"Sec22\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe study has some limitations. First, due to the constraints in time, human resources, and geographic scope, the research was conducted as a single-center study. Participant recruitment was restricted to older self-sufficient adults with T2DM from a tertiary hospital in Fujian Province, which limits the representativeness of the sample and, consequently, the generalizability of the findings. In addition, the study focused solely on periodontal health-related outcome indicators, and no follow-up assessment of periodontal health was performed after the 12-week intervention.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe intervention program enhances the awareness, attitudes, and behaviors of older individuals with T2DM regarding periodontal health. It motivates them to address oral health proactively, facilitates effective plaque control to prevent the onset or progression of periodontitis, and significantly improves overall oral hygiene quality.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eT2DM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eType 2 diabetes\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eHPM\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eHealth Promotion Model\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePLI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePlaque Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003ePD\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003ePeriodontitis disease\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eOHI-S\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eOral Hygiene Index-Simplified\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eGOHAI\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eGeriatric Oral Health Assessment Index\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eDI-S\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eDebris Index-Simplified\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eCI-S\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eCalculus Index-Simplified\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003cdiv class=\"DefinitionListEntry\"\u003e \u003cdiv class=\"Term\"\u003eBOHSE\u003c/div\u003e \u003cdiv class=\"Description\"\u003e \u003cp\u003eKayser\u0026ndash;Jones Brief Oral Health Status Examination\u003c/p\u003e \u003c/div\u003e \u003c/div\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics approval and consent to participate\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Grade Tertiary Hospital in Fuzhou City, China (IRB\u0026nbsp;No. 2023KY071), and written informed consent was obtained from all participants. The study protocol was registered with the China Clinical Trial Registry (ChiCTR2300073533) prior to its commencement.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eConsent for publication\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAvailability of data and materials\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets used and/or analyzed in the current study are available from the corresponding author upon reasonable request; E-mail: [email protected].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eCompeting interests\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eFunding\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis work was supported by Fujian Medical University.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAuthors’ contributions\u0026nbsp;\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eCXX, LZ, and ZXL wrote the first draft. QNX, SPL, and SYZ contributed to data collection. CXX, LZ, and ZXL contributed to all the data, statistical analyses, and data interpretation. HPS contributed to the research concept, supervised the study, and revised the manuscript. All the authors have read and approved the final version of the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAcknowledgments\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all the participants for their voluntary participation in this study. We also acknowledge the support from the Department of Endocrinology and Metabolism, a tertiary hospital in Fujian Province, for recruiting the study participants.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNational Bureau of Statistics. Statistical Bulletin of National Economic and Social Development of the people\u0026rsquo;s Republic of China in 2019 [1] [N]. People\u0026rsquo;s Daily, 2020-02-29 (0.05). 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Complementary and alternative therapy use in breast cancer: Notable findings.\u003cem\u003e J Christian Nurs\u003c/em\u003e. 2013;30:218-25.\u003c/li\u003e\n\u003cli\u003eYufei L. Study on the Effect of Comprehensive Oral Nursing Intervention for the Elderly in Pension Institutions. \u003cem\u003eJilin University\u003c/em\u003e; 2019.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Type 2 diabetes, Pender Health Promotion Model, Periodontal health, Quality of life, Oral hygiene, Knowledge-attitude-behavior","lastPublishedDoi":"10.21203/rs.3.rs-6068876/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6068876/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAs the sixth complication of diabetes, periodontitis interacts with diabetes to form a vicious circle. Periodontal health interventions can improve periodontal health and the quality of life in older patients with type 2 diabetes mellitus (T2DM). This study aimed to explore the effect of periodontal health interventions based on the Pender Health Promotion Model on periodontal outcome index and quality of life in this patient population. This randomized controlled trial enrolled 108 patients with T2DM from the endocrine and metabolism department of a tertiary hospital. Participants were randomly assigned to either an experimental group or a control group. The control group received routine health interventions, while the experimental group underwent a periodontal health intervention program in addition to the routine health interventions. Relevant outcome measures were assessed at baseline and after 12 weeks of intervention. Data from 103 participants were analyzed. Following the intervention, significant differences were identified between the groups in Plaque Index (PLI), Oral Hygiene Index-Simplified (OHI-S), and periodontal health knowledge, attitude, and behavior. The periodontal health intervention program can enhances periodontal health knowledge, attitudes, and behaviors while positively impacting the oral health index and quality of life of older patients with T2DM.\u003c/p\u003e","manuscriptTitle":"Effects of periodontal health intervention program on oral health-related outcomes in older patients with type 2 diabetes: a randomized controlled trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-03-11 06:41:52","doi":"10.21203/rs.3.rs-6068876/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-03-31T06:53:26+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-27T15:16:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-03-26T10:42:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"84231426740207066241604696836162453070","date":"2025-03-18T13:03:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"204378503594287584284088939528313906232","date":"2025-03-18T07:41:42+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-03-18T06:46:37+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-03-18T06:41:21+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-03-05T06:38:11+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-03-03T09:29:55+00:00","index":"","fulltext":""},{"type":"submitted","content":"Scientific Reports","date":"2025-02-20T05:56:06+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"scientific-reports","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"scirep","sideBox":"Learn more about [Scientific Reports](http://www.nature.com/srep/)","snPcode":"","submissionUrl":"","title":"Scientific Reports","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Scientific Reports","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"8cb18201-cbc5-4442-91df-aabb5591eb6d","owner":[],"postedDate":"March 11th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[{"id":45105284,"name":"Health sciences/Diseases/Dental diseases"},{"id":45105285,"name":"Health sciences/Diseases/Endocrine system and metabolic diseases"}],"tags":[],"updatedAt":"2025-08-04T16:46:02+00:00","versionOfRecord":{"articleIdentity":"rs-6068876","link":"https://doi.org/10.1038/s41598-025-13434-0","journal":{"identity":"scientific-reports","isVorOnly":false,"title":"Scientific Reports"},"publishedOn":"2025-07-31 16:38:03","publishedOnDateReadable":"July 31st, 2025"},"versionCreatedAt":"2025-03-11 06:41:52","video":"","vorDoi":"10.1038/s41598-025-13434-0","vorDoiUrl":"https://doi.org/10.1038/s41598-025-13434-0","workflowStages":[]},"version":"v1","identity":"rs-6068876","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6068876","identity":"rs-6068876","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}