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


This study's findings indicate that "poor to fair" self-reported oral health is associated with a greater likelihood for chronic complications than acute complications, after adjusting for an extensive range of covariates. This is in line with studies that have found that diabetics with periodontal disease or those who do not receive periodontal treatment, incur higher medical costs and a greater number of hospitalizations, and supports the association between periodontal disease and chronic diabetes complications.[24,25,34–37] This study provides insights about the likelihood for complications among diabetics in Ontario, Canada.

Over the last century, many hypotheses have been developed to explain the oral-systemic link, based on the microbial dysbiosis of periodontal disease.[38] Oral pathogens are thought to impact systemic health by either direct invasion or the indirect stimulation of immune-inflammatory responses.[38,39] The inconsistency of evidence on direct invasion lead scientists to find more support for the hypothesis of indirect invasion, which may explain the bidirectional impact of periodontal disease.[36,38,39] Although our study does not seek to support one hypothesis over the other, nor does it claim causation, the greater likelihood of chronic complications in this study may be explained by the proposition that indirectly exaggerated immune inflammatory responses link periodontal disease to diabetes.[40–42]

However, in order to interpret the greater odds of chronic complications than acute complications observed among diabetics reporting "poor to fair" oral health status, it is important to understand the difference between the mechanism of acute and chronic diabetes complications. The literature suggests that the basis of acute diabetes complications is metabolic imbalances and hyperglycemia.[13,17]Chronic complications are further characterized by insulin resistance that can lead to micro- and macrovascular damage.[13,16,17,43] Although clinical trials have explored the impact of periodontal treatment on the reduction of blood sugar levels, only a few have explored the reduction of lipid markers such as cholesterol, triglycerides and high-density lipids, which are important contributors of insulin resistance and are associated with greater chronic complications.[44–48] Some studies also support the use of BMI as a predictive measure for insulin resistance, however, BMI was not found to have a significant effect on either acute or chronic complications in this current study.[49] As insulin resistance may be the connecting factor for periodontal disease and chronic diabetes complications, further research into this component of the putative bidirectional link may provide insight into preventive measures. At the public health level, for instance, where health outcomes, health expenditures and improved quality of life is of concern, this may provide support for concurrent demands for improvements in access to dental care in Canada and better management of diabetes, reductions in inefficient healthcare costs, such as physician and emergency department use for oral health-related complaints,[50,51] and improvements to the quality of life of diabetics.[52]

This study presents with several strengths. Primarily, it has been conducted at the population level, allowing for population-based inferences for diabetics over the age of 40. Second is the use of a validated diabetes diagnosis, which contrasts most of the current literature.[24,25] In comparison with observational studies, our retrospective selection of participants and longitudinal follow-up allows for arguments beyond a simple association between self-reported oral health and diabetes complications. The use of self-reported oral health also presents as a strength in this study. As self-reported oral health is multi-faceted in nature, representing the social, psychosocial, economic and cultural components of oral health, it presents as a convenient measure for exploring the diabetes health experience.[53–55] Notably, studies have found that self-reported oral health status is consistent with the clinical need for oral treatment.[56] Among diabetics, this measure can thus arguably be used to assess the odds of diabetes complications and provide a means to improve health literacy and expand the referral network for diabetics in need of dental care.[57]

Despite these strengths, there are also important limitations to consider. Although self-reported oral health status can be an effective measure to predict oral health needs, it may not be a competent measure for clinical periodontitis.[54] The evidence shows that self-reported oral health can be highly specific but not sensitive.[56] Thus, the current study's participants may be able to report that they do not have periodontal disease with greater accuracy that those with the condition.[56] However, the evidence also suggests that diabetics may be more aware of their periodontal disease status.[58,59] Although clinical measures of periodontal disease and diabetes control would provide greater power to our study, such measures have not been linked to electronic medical records in Canada. Using the ODD also presents with the limitation that this database does not differentiate between type 1 or 2 diabetics.[29] As the periodontal disease-diabetes link is based on the pathological mechanism of adult onset diabetes, this limitation may overestimate results; however, as more than 95% of the ODD is made up of type 2 diabetics and the sample was restricted to participants over the age of 40, the impact of type 1 diabetics is minimal and does not arguably impact the study results.