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Year : 2020  |  Volume : 18  |  Issue : 4  |  Page : 290-295

Association of oral health status and oral health-related quality of life among adult patients with type 2 diabetes mellitus: A cross-sectional study

Department of Public Health Dentistry, V.S. Dental College and Hospital, Bengaluru, Karnataka, India

Date of Submission18-Feb-2020
Date of Decision27-Oct-2020
Date of Acceptance29-Nov-2020
Date of Web Publication16-Dec-2020

Correspondence Address:
Nagashree Savanur Ravindranath
No. 86/3, 6th Cross, Ashoknagar, Bengaluru - 560 050, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiaphd.jiaphd_31_20

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Background: The growing burden of noncommunicable diseases like type II diabetes mellitus is a challenge worldwide. Type II diabetes mellitus has a number complications which includes oral conditions like periodontitis, tooth loss, dry mouth, and taste alterations. However, it is unclear if these oral conditions affect the oral health-related quality of life (OHRQoL) in diabetic patients. Aim: The aim of this study was to explore the association between oral health status and OHRQoL in adult type II diabetes patients. Materials and Methods: A cross-sectional study was done in a teaching dental hospital setting on a convenient sample of 350 participants. The WHO Oral Health Survey Proforma 2013 was used to assess oral health status, and Oral Health Impact Profile-20 (OHIP-20) questionnaire was used to collect information on OHRQoL. The mean OHIP score of the participants was compared between the different categories of the oral health status variables using independent t-test and Chi-square test. P < 0.05 was considered statistically significant. The Statistical Package for the Social Sciences version 19 was used for analysis. Results: Decayed, Missing, and Filled Teeth score, bleeding on probing, loss of attachment, and presence of denture were significantly associated with high OHIP scores as compared to the absence of these conditions (P < 0.001). The presence of oral mucosal lesions was not associated with OHIP scores (P = 0.099). Conclusion: The present study found an association between oral health status and OHRQoL in type II diabetes mellitus patients.

Keywords: Cross-sectional study, diabetes mellitus, oral health, quality of life

How to cite this article:
Ravindranath NS, Raju R. Association of oral health status and oral health-related quality of life among adult patients with type 2 diabetes mellitus: A cross-sectional study. J Indian Assoc Public Health Dent 2020;18:290-5

How to cite this URL:
Ravindranath NS, Raju R. Association of oral health status and oral health-related quality of life among adult patients with type 2 diabetes mellitus: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2020 [cited 2022 Aug 17];18:290-5. Available from: https://www.jiaphd.org/text.asp?2020/18/4/290/303637

  Introduction Top

Noninsulin-dependent diabetes mellitus has reached epidemic proportions affecting large sections of the world's population and its prevalence is on the rise every generation.[1] India is poised to be the diabetic capital of the world, with an ever-increasing number of people reported to be diabetic every year.[2] This is only the tip of the iceberg. Type II diabetes is associated with an increased risk for macrovascular complications including cardiovascular disease and for microvascular complications including diabetic nephropathy, peripheral vascular disease, neuropathy, and retinopathy.[3]

Diabetic patients display a higher prevalence of oral disorders including xerostomia, taste impairment, sialosis, oral candidiasis, and oral lichen planus. Studies indicate that diabetic patients are two to three times more likely to develop periodontal disease and display a greater severity of periodontal disease, the severity of which is related to the long-term metabolic control of diabetes.[4]

The impact of disease status on overall life experience is an important consideration in the management of patients with diabetes. Health-related quality of life (HRQL) is affected in diabetic patients who have macrovascular complications, such as cardiovascular disease.[5] The impact of oral health on HRQL in diabetic patients is not clear.

Oral health-related quality of life (OHRQoL) is defined as the person's assessment of factors that affect his or her well-being. It includes functional aspects such as mastication and speech, psychological aspects such as appearance and self-esteem, social aspects such as intimacy, communications, and social interactions as well as aspects of pain and discomfort. It is a multidimensional construct with far-reaching applications in epidemiological and clinical research.[6]

OHRQoL has a role to play both at the individual level and population level. At the patient level, quality of life considerations have to be paid attention during diagnosis, selecting treatment options, and evaluating the outcomes of the treatment. At the population level, OHRQoL should be considered during monitoring oral health trends, evaluating oral health policies, and during resource allocation.[7]

In view of the growing importance of OHRQoL and the ever-increasing burden of type II diabetes mellitus,[4],[6],[7]it is imperative to study OHRQoL in type II diabetes mellitus patients. The aim of this study was to explore the association between oral health and quality of life in type II diabetes patients, which is the ultimate desired outcome of health services.

  Materials and Methods Top

A cross-sectional study in a hospital-based setting was conducted in the outpatient department of a dental teaching hospital in India. Diabetic patients aged 30–60 years of age and those who gave informed consent to participate in the study were included. Patients with other systemic diseases and those with intellectual impairments were excluded.

Data were collected between May 2017 and November 2017 from a convenient sample of 350 patients. The sample size was estimated by the formula n = z2pq/d2, where “p,” the estimated population proportion, was taken as 34% anticipated burden of periodontal disease,[8]d,” the tolerated margin of error, as 5%, and “z” to be 1.96 for confidence interval at 95%. Ethical approval from the Research Ethics Committee of the institution was obtained in the meeting held on November 17, 2016 (VSDCH/1195/16-17). Written informed consent was taken from all the study participants.

Data regarding OHRQoL of the participants were obtained by a shortened version of Oral Health Impact Profile-20 (OHIP-20).[9] The questionnaire was translated into the local language Kannada, and a pilot study was conducted to check for feasibility of questionnaire administration and understandability of the items. Pilot testing was done in a sample of 40 persons who fulfilled the eligibility criteria, and the same was not included in the final sample. The 20-item questionnaire contains validated measures to assess oral health-related outcomes in seven conceptual domains: functional limitation, pain, psychological discomfort, physical disability, psychological disability, social disability, and handicap. A six-point scale ranging from “never” to “all the time” was used to record the responses. The scores given to the different responses on the OHIP questionnaire were as follows: never = 1, seldom = 2, sometimes = 3, fairly often = 4, very often = 5, and all the time = 6.

Oral and written instructions were provided to the study participants on questionnaire completion together with assurances of confidentiality. The self-administered questionnaire was given to the subjects in the waiting area of the outpatient department. The Oral Health Survey Proforma by the WHO (2013) was used for recording the oral health findings.[10]Oral examination was done by calibrated examiners in the outpatient department of the teaching dental hospital. Calibration of the two examiners was done in the department of public health dentistry. The kappa coefficient for inter-examiner reliability was 0.84 for periodontal status assessment according to the Oral Health Survey Proforma by the WHO (2013).

Data were analyzed using the statistical software Statistical Package for the Social Sciences version 19. (IBM SPSS Statistics for Windows, Version 19.0. Armonk, NY: IBM Corp.). Independent t-test was used to test the difference in mean OHIP scores of different oral health status categories. Chi-square test was used to assess the association between oral health status and OHIP.

  Results Top

In this cross-sectional study out of 350 participants, 193 (55.1%) participants were male and 157 (44.9%) were female. 170 (48.6%) were of the 30–39 year age group, 109 (31.1) were of the 40–49 year age group, and 71 (20.3%) were 50–60 years old.

Responses “seldom,” “never,” and “sometimes” were categorized as low OHIP and responses “all the time,” “very often,” and “fairly often” were categorized as high OHIP. This method is the simple scoring method which allows the calculation of the prevalence of impact on the population for a threshold.[11] “Functional limitation” domain questions showed the highest mean OHIP scores (4.59) as well as high percentage of high impact (76.3%). This domain was followed by questions of “psychological discomfort” domain with higher impact (76.1%). “Physical pain” is another domain which showed higher OHIP scores (3.91). The other domains did not exhibit such high impacts on OHRQoL. The mean scores for each question of OHIP-20 questionnaire are depicted in [Table 1].
Table 1: Mean Oral Health Impact Profile scores for each question of Oral Health Impact Profile-20 questionnaire and percentage of participants with high impact and low impact

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One or more decayed teeth were seen in 34.6% of the participants, and one or more teeth were lost in 39.7% of the participants. Filled teeth (FT) were seen in 71.1% of participants. Decayed, Missing, and FT (DMFT) score was 0 in 39.1% of the participants, 1–16 in 45.8% of participants, and 32 in 53 participants. The oral health status and OHRQoL scores of the participants are shown in [Table 2].
Table 2: Oral health status and mean Oral Health Impact Profile score of the participants

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Shallow periodontal pockets (4–5 mm) were seen in 174 (49.7%) participants, whereas deep periodontal pockets (>5 mm) were seen in 100 (28.6%) of participants. Loss of attachment of 4–5 mm was seen in 139 (39.7%), 6–8 mm was seen in 85 (24.3%), and more than 9 mm was seen in 56 (16%) participants. Oral mucosal lesions were seen in 33 (6.6%) participants. Partial dentures were used by 84 (24%) and complete dentures were used by 44 (12.6%) participants.

The mean OHIP score of the participants was compared between the different categories of the oral health status variables using independent t-test, as shown in [Table 2]. The difference in the mean OHIP scores of different categories of oral health status variables was found to be statistically different for missing teeth (MT), FT, and DMFT scores. Partially edentulous participants reported a higher mean OHIP score (94.23 ± 10.82) than those who were completely edentulous (70 ± 12.69), and the difference was highly significant with P < 0.001.

The presence of bleeding on probing, periodontal pockets, and loss of attachment showed significantly higher mean OHIP score than those in whom these conditions were absent. Participants with complete denture showed higher mean OHIP scores compared to both participants with partial dentures and those with no dentures. The difference was, however, not significantly different for categories of dental caries and oral mucosal lesions.

The sum of scores obtained on the 20 items was added to obtain a range of scores from 20 to 120.[12] Scores above 80 were considered as high OHIP scores. The number of participants with low OHIP scores and those with high OHIP for each category of the oral health status variables is represented in [Table 3]. These categories of oral health status were tested for association with OHIP scores using Chi-square test. All the components of DMFT score, bleeding on probing, loss of attachment, and presence of denture were associated with high OHIP scores as compared to the absence of these conditions with statistical significance of P < 0.001. The presence of oral mucosal lesions was the only oral health status variable not associated with OHIP scores.
Table 3: Association of oral health status with Oral Health Impact Profile

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  Discussion Top

Type II diabetes is becoming the cause of increasing mortality and morbidity. Oral health complications such as periodontal diseases, dry mouth, tooth loss, taste alterations, and increased risk of fungal infections are among the many complications of this disease.[13],[14] These problems would be likely to impact the OHRQoL of diabetic persons. The present cross-sectional study was done with the aim of finding out if there is an association between oral health status and OHRQoL in adult type II diabetes patients.

Dental caries was seen as a common oral health problem in the study participants, with DMFT score ≥1 observed in 213 (61%) study participants. There were a considerable number of participants (139 [40%]) with tooth loss as a consequence. A similar finding is often put forward by various studies.[14],[15],[16] However, certain studies are inconclusive about the increased burden of dental caries and its sequel among diabetic adults.[17] One review of the literature describes an inconsistent relationship between diabetes and dental caries. It reports increased, decreased, and similar caries experiences in diabetics compared to those without diabetes.[18]

Bleeding on probing was observed in 255 (72.9%) participants, which was expected as there is unanimous reporting of increased gum problems in type II diabetic patients throughout dental literature. A systematic review conducted on the influence of diabetes on periodontal tissues quotes 64% of diabetic adults to be affected by gingivitis.[19]Another oral finding seen was the presence of periodontal pockets with deep pockets seen in 100 (28.6%) and shallow pockets in another 174 (49.7%) participants. Many research studies clearly point out this finding.[14],[16],[19] Loss of attachment was also seen to be present in a large number of participants. This is not surprising as periodontitis is called the sixth complication of diabetes. Research also points out that the relationship between diabetes and periodontal disease is bidirectional, with periodontitis being a modifier of glycemic control.[4]

Oral mucosal lesions were present in a very small number of participants. Hence, it is not a major oral health problem among the study participants. Dentures were worn by almost one-third of the participants. This goes on to show that tooth loss is a significant issue among diabetic adults, with many studies supporting this finding.[18],[20]

OHIP-20 is a validated structured questionnaire which has been used in diabetic patients in a multitude of research studies.[21],[22] In the present study, functional limitation, psychological discomfort, and physical pain were the domains which showed high OHIP scores among the participants. In another study conducted by Mohsin et al., among diabetic participants, the same three dimensions showed the highest scores of OHIP.[23] Psychological discomfort and social disability showed a high impact in a few previous studies.[24],[25],[26] A similar study conducted among diabetic patients suggests that oral problems with the potential to cause physical pain and discomfort have the greatest negative impact on quality of life.[27]

Lower OHIP score (76.48 ± 7.98) was seen in participants with DMFT score of 0 compared to those with higher DMFT scores (87.68 ± 5.79) of 1–16, and the difference was highly significant. Participants without dental caries had a higher mean OHIP score (85.34 ± 9.46) than those with dental caries (79.44 ± 6.53) though the difference was not statistically significant. Dental caries is a problem commonly associated with pain and sometimes functional and esthetic implications. There is an agreement regarding the negative impact of dental caries on OHRQoL in an earlier study as well.[27]

The mean OHIP scores of participants with no MT were less than those who had MT. In a previous study done among adults with diabetes, tooth loss had the highest negative impact on quality of life.[28]Jose M et al. opine that the functional and esthetic effects of edentulism contribute to the negative impact on quality of life in diabetic participants.[27] The highest OHIP scores were seen for those with 1–14 teeth missing than for those with all teeth missing. This implies that partial edentulousness affects the quality of life of patients more than complete edentulousness.

Participants with one or more teeth filled had a lower OHIP score (77.86 ± 8.08) than those with no FT (85.51 ± 12.13) with a high statistical difference of P < 0.001. This shows that dental caries if treated promptly results in better quality of life. There was a significant association of all DMFT components and OHIP scores. A similar high impact of dental caries on oral health quality of life was also seen in a study conducted in Sudan.[29]

All the periodontal disease indicators such as bleeding on probing, presence of shallow and deep pockets, and loss of attachment were seen to be significantly associated (P < 0.001) with higher OHIP scores as compared to the absence of these conditions as observed by previous studies.[21],[22],[28] A strong association was found between periodontitis and the quality of life in a previous study done by Mohsin et al.[23] Periodontal disease is the most common oral health condition seen in diabetic adults, and the same condition is also associated with OHRQoL. Hence, oral health professionals should pay attention to the maintenance of periodontal health in diabetic patients.

Higher OHIP scores were also seen in participants who had oral mucosal lesions than those who did not have. However, this difference was not statistically different. Complete denture wearers had higher OHIP scores compared to partial denture wearers. In a study conducted by Alshammari et al., partial denture wearers had a higher impact on OHRQoL than complete denture wearers.[30]The above findings are because dentures do not measure up to natural teeth. It has been shown in previous studies that denture wearers have lower chewing efficiency than persons with natural dentition.[31]

The present study has certain limitations. There was no control group of nondiabetic participants. Hence, the study does not say that the impact of oral health on OHRQoL of diabetic persons is different from that of nondiabetic persons. Another important limitation of the study was that it was conducted in a hospital setting. A community-based study setting would have represented the diabetic adult population better. Nonetheless, the present study highlights that the oral health status of diabetic adults is associated with their OHRQoL.

  Conclusion Top

Oral health status is associated with OHRQoL in type II diabetes mellitus patients, especially in functional limitation, physical pain, and psychological discomfort domains. The presence of oral conditions such as MT, gingival bleeding, periodontal pocket, loss of attachment, and presence of denture is significantly associated with compromised OHRQoL in diabetic adults. Dentists can play an important role in improving diabetic patients' knowledge regarding oral complications and their effect on their quality of life. It is recommended that referring diabetes patients to a dentist could be a part of general physicians' diabetes treatment protocol.


The authors would acknowledge the support of Rajiv Gandhi University of Health Sciences in the form of Advanced Research Grant. The contributions of Dr. Thara Chandran and Dr. Yamini Reddy as research assistants are also acknowledged.

Financial support and sponsorship

This research was supported by the Advanced Research Grant (Project I.D 16D024) from Rajiv Gandhi University of Health Sciences, Bengaluru.

Conflicts of interest

There are no conflicts of interest.

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  [Table 1], [Table 2], [Table 3]


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