Periodontal diseases are chronic inflammatory conditions caused by microbial dysbiosis and an impaired host response that affect the periodontium. Poorly controlled diabetes increases the risk, severity and progression of periodontitis through mechanisms involving oral microbial dysbiosis, chronic inflammation, immune dysregulation and altered bone metabolism. The relationship is also important in the opposite direction: periodontal disease can contribute to poor glycemic control and may affect the onset and progression of diabetes complications, including retinopathy, neuropathy, nephropathy and cardiovascular disease. Research cited by the study reports that many people with diabetes have insufficient awareness of oral-health management and rarely consult dental professionals unless symptoms such as gingival bleeding, swelling, pain or tooth mobility appear.

Certified diabetes nurse educators are nurses with broad expertise in providing diabetes self-management education to outpatients. Their contact with patients during routine diabetes care offers opportunities to reinforce oral-health messages, including oral hygiene, maintenance of adequate oral moisture and denture care. However, the study notes that these nurses can face limited training opportunities, uncertainty about suitable teaching content, and insufficient collaboration with dental professionals. The research team had previously developed a written nursing guide for oral-health management in diabetes outpatient clinics. That guide was evaluated positively, but user feedback indicated that written material alone did not fully convey practical assessment procedures, patient-communication techniques or step-by-step guidance for educational sessions. The audiovisual resource was therefore developed as a supplement to the existing guide rather than as a replacement.

The material was produced through a three-phase development process. In the first phase, nursing researchers specializing in diabetes care and oral-health management, along with dentists and dental hygienists, collaboratively determined the learning content. In the second, researchers discussed the video’s length, purpose, scenario and narration with a professional video-production company, drafted the script and revised it after review by dentists and nurses working in outpatient diabetes care. In the third, the company created a storyboard, reviewed illustrations and checked the final video and audio. The completed program used animation, oral-cavity photographs supplied by dentists and a local dental hygienists’ association with appropriate permissions, and narrated instruction. It was divided into an introduction, key assessment points, teaching moments and an ending.

The program’s learning objectives were centered on practical application. Its introduction explained the importance of oral-health education delivered by nurses in diabetes care and used a true-or-false quiz to test common management practices. The assessment section used photographs to explain how to examine overall oral condition, oral hygiene, dry mouth, halitosis, subjective symptoms of periodontal disease and the number of remaining teeth. A visually presented nurse–patient scenario then demonstrated the sequence for approaching a patient, observing the oral cavity and communicating during assessment. The ending highlighted the importance of regular dental visits and medical–dental collaboration and offered encouragement to nurses considering implementation. For this study, oral-health management included observation and assessment of the oral cavity, education on hygiene, oral moisture and denture care, and documentation to support determination of an appropriate course of action.

The investigators recruited certified diabetes nurse educators working in outpatient departments in Japan’s Kanto region. They identified 122 institutions where both certified diabetologists and certified diabetes nurse educators provided outpatient diabetes care by matching databases maintained by the Japan Diabetes Society and the Certification Board for Diabetes Educators in Japan. Following purposive sampling, invitations were mailed to an eligible nurse at each institution. Eight of the 122 nurses provided written informed consent, received a QR code linking to the audiovisual material and were included in the analysis. Participants ranged from their 30s to their 60s, with more than half in their 40s, and had worked as certified diabetes nurse educators for four to 20 years. Half reported having received prior education on oral-health management for patients with diabetes.

Two to three months after using the material in patient education, each participant completed a 40- to 60-minute semistructured interview by Zoom. The interview guide explored learning, the application of oral observation and assessment, patient responses and implementation of oral-health management. Interviews were audio-recorded, automatically transcribed and manually checked for accuracy. A nursing researcher with expertise in oral-health management identified relevant passages and organized them into subcategories, categories and themes. A second researcher with expertise in diabetes care independently reviewed and recoded portions of the transcripts, and disagreements were resolved by discussion. MAXQDA software was used to organize and retrieve coded data. The researchers used the term “effect” to mean perceived changes in nurses’ knowledge, attitudes and practices, rather than direct effects on patients.

All eight nurses described the audiovisual format as making it easier than text alone to understand how to approach patients, observe the oral cavity, identify oral symptoms and provide education. Participants valued the combination of visual and auditory information, supporting images and realistic demonstrations of patient interaction. Two participants who had used the existing written guide said that combining the guide with the video appeared to deepen their understanding. Five participants also described professional reflection, including recognition by one nurse that necessary oral-health management had not previously been practiced. Their reflections also exposed a perceived weakness in routine medical–dental collaboration. The researchers treated the first two themes—individual learning and professional development or reflection—as direct learning-related experiences, while presenting broader clinical observations and organizational considerations as contextual findings arising as nurses applied the material.

Seven of the eight participants reported gaining new insights into patient care after applying what they had learned. They observed a broad range of oral conditions, and half reported seeing very poor oral hygiene or tooth loss that interfered with eating. Many patients showed limited interest in oral health, regarded existing dental problems as unimportant, or lacked awareness of the relationship between diabetes and periodontal disease. Others delayed seeking dental care until symptoms became severe. Nurses also encountered shame or discomfort when asking patients about oral health or observing their mouths. Some participants speculated that neglected oral care might occur alongside poor foot care or broader disengagement from self-care, but the study did not systematically test that association and did not establish oral status as a predictor of other care behaviors. These patient observations were presented as contextual insights from clinical practice, not as evidence that the audiovisual material changed patient behavior.

Implementation depended on more than individual knowledge. Participants cited limited consultation time, insufficient staffing, variable interest among colleagues, inadequate physical space, and rooms without running water for toothbrushing. All eight emphasized reducing patients’ shame, and most wanted an acceptable way to begin oral observation. Several found that discussions about diet could provide an opening for oral-health education. Suggested resources included private rooms, advance notice of oral-health discussions, more images representing diverse oral conditions, examples of practice in other institutions and opportunities for hands-on consolidation. Participants also proposed patient-facing videos, telenursing and oral-cavity models, none of which were tested in this study. At the time, oral-cavity observation and assessment were not formally defined within the certified scope of practice for diabetes nurse educators, and the audiovisual material encouraged dental consultation without providing a structured pathway for referrals from nursing observation to dental care.

The main limitations were the small, self-selected sample and the exploratory design. Only eight of 122 invited nurses participated, potentially favoring those already interested in oral-health management. The qualitative sample was intended to provide depth rather than statistical power, but the researchers stated that the limited number of interviews did not demonstrate data saturation in the strict methodological sense, so additional interviews might have revealed new concepts. The cross-sectional design could not establish durability. The study also relied on self-reported use of the material rather than direct observation, did not conduct member checking with participants, and excluded patient-centered outcomes. Consequently, the results support claims of perceived usefulness and educational promise rather than demonstrated clinical effectiveness. The authors call for larger and more diverse mixed-methods studies, longitudinal follow-up, observation of how nurses actually use the material, and evaluation of patient-centered outcomes to determine whether combining the written guide with audiovisual instruction can sustainably support oral-health education in diabetes outpatient care.

Subject of Research: Perceived usefulness of audiovisual oral-health education among certified diabetes nurse educators in Japan

Article Title: Nurses’ perceptions of an audiovisual material to support patient education on oral health management in diabetes care

Article References: Kudoh, R., & Shibayama, T. (2026). Nurses’ perceptions of an audiovisual material to support patient education on oral health management in diabetes care. PLOS One, 21(10), e0361280. https://doi.org/10.1371/journal.pone.0361280

Image Credits: AI Generated

DOI: 10.1371/journal.pone.0361280

Keywords: diabetes care, nurse education, oral health, audiovisual learning, patient education, periodontal disease, qualitative research, nursing practice, medical-dental collaboration, Japan, Nurses, perceptions