Acute and Chronic Diabetes Complications Associated With Self-reported Oral Health

A Retrospective Cohort Study

Kamini Kaura Parbhakar; Laura C. Rosella; Sonica Singhal; Carlos R. Quiñonez


BMC Oral Health. 2020;20(66) 

In This Article


Diabetes is a major public health concern in Canada and worldwide. Characterized by hyperglycemia and the insufficient secretion or action of insulin, diabetes is a metabolic disorder that amplifies inflammatory immune responses resulting in diabetes complications.[1,2] The Canadian prevalence of diabetes currently sits at 3.65 million and is predicted to increase by over 30% within the next decade, and this is coupled with growing health care costs, morbidity, and premature mortality.[3] In Ontario, Canada's most populous province, the current prevalence of diabetes surpasses national estimates, arguably necessitating public health action.[4]

Since the U.S. Surgeon General's Report on oral health in 2000, which placed a heavy emphasis on the relationship between oral health and systemic health, the link between diabetes and periodontal disease has received considerable attention.[5] Periodontal disease is a chronic inflammatory condition characterized by the destruction of oral tissues supporting teeth.[6] Although periodontal disease is most commonly known as a complication of diabetes, the evidence indicates that the link between these two conditions may be bidirectional.[7,8] Initiated by microbial dysbiosis, periodontal disease produces a low grade host immune response that can stimulate systemic inflammation.[9,10] Specifically, the shift in symbiotic microbial communities of the periodontal tissues accounts for an exaggerated immune defense mechanism leading to the destruction of periodontal tissues.[9,10] In turn, among diabetics, hyperglycemia accounts for an alteration in cell function, defective neutrophil apoptosis, oxidative stress, and the excessive production of inflammatory mediators that exacerbate insulin resistance resulting in health complications.[6,11,12] A unified inflammatory mechanism between periodontal disease and diabetics is thought to impact diabetes health outcomes and complications.[13,14]

Diabetes complications are classified as acute and chronic, and chronic complications are further classified as microvascular or macrovascular in nature.[13] Acute complications of diabetes include hyperglycemia and hypoglycemia, and chronic complications include cardiovascular diseases, kidney failure, retinopathy and neuropathy.[13] Diabetes complications with the highest prevalence and greatest cost to the Canadian health care system are predominantly chronic and include stroke, myocardial infarction, kidney failure, lower limb amputations and vision loss.[3,15] Although the biological mechanism of acute and chronic complications has been long debated, there is some consensus on the differences between them and the possibility of a continuum from acute to chronic.[13,16] Acute complications of diabetes have been characterized by changes in metabolic control, specifically hyperglycemia.[13,17] In contrast, chronic hyperglycemia is commonly assumed to be the central determinant in chronic diabetes complications. However, insulin resistance and macrovascular damage are found to play a large role.[13,17]

In the mechanism linking periodontal disease to diabetes, the role of insulin resistance and exaggerated immune inflammatory pathways have been considered the driving force in the "bidirectional" link.[1,2,18–20] To quantify the periodontal impact on diabetic health, studies have explored the effect that periodontal treatment has on blood sugar levels and lipid profile markers.[2,19,21,22] The current evidence for periodontal treatment among diabetics also suggests that periodontal disease may play the role of a risk factor, as periodontal treatment was found to reduce blood sugar levels as well as cholesterol levels and high-density lipids.[21] Periodontal care has also been associated with reductions in health complications, hospital admissions and overall medical and pharmaceutical costs among diabetics.[2,23–25] However, there is no research using Canadian populations in relation to oral health and diabetes, and there is a paucity of population level evidence supporting the epidemiological association between oral and diabetes health generally.[26] This study thus aims to identify the odds of future acute and chronic complications among diabetics who have self-reported oral health status in Canada's most populous province, Ontario.