Tooth Loss Associated with Morbidity and Mortality

The impact of impaired healing in those with diabetes mellitus (DM) contributes to their higher risk of developing periodontitis, leading to tooth loss (TL).  

An estimated 463 million people are affected by diabetes, and the number continues to grow globally. Because a complication of diabetes is impaired healing, those with diabetes can see the destruction of the soft tissues that help support their teeth. In addition, there has been evidence to show that periodontitis, with its inflammatory mediators, can hinder glycemic control and lead to insulin resistance. With the increasing number of individuals with diabetes, information is needed to pinpoint the exact mechanism of severe tooth loss (having less than nine permanent teeth) and the association with diabetes status. According to the Centers for Disease Control and Prevention (CDC), there was more than a 50% chance of developing TL in those with uncontrolled diabetes compared to those who did not have diabetes. In addition to tooth loss, different health conditions come up in uncontrolled diabetes, like heart problems, retinopathy, and metabolic syndrome. 

This review was done with a comprehensive literature search between January 2000 and April 2021 and included key terms such as diabetes, morbidity, mortality, tooth loss, and aging. The inclusion criteria included controlled trials, cohorts, case-control, and cross-sectional studies that showed an association between tooth loss and morbidity and mortality by diabetes in an aged population group of 50 years and older, even though the age definition for older adults exceeds 60 years of age. Of 1,089 abstracts that the authors reviewed themselves after exclusions were applied and duplicates taken out, the systematic review had a total of thirteen studies.  

The studies that looked at diabetes incidence and prevalence (as outcomes) reached statistical significance. They found in three articles that a loss of twenty teeth, more than nine teeth, and more than eight teeth, were associated with an odds ratio (OR 1.7), hazard ratio (HR 1.37), and odds ratio (OR 1.74), respectively, showing the prevalence of diabetes in those with TL. In terms of analyzing the HbA1c in those with tooth loss, they found that HbA1c was inversely correlated with how many teeth were left. If the individual had fewer teeth, the HbA1c would be more significant and vice versa. Other complications due to diabetes were also looked at to determine if they also had extensive teeth loss. TL was also seen in those who had diabetic retinopathy and metabolic syndrome. Heart disease was not as prevalent in those who had more healthy teeth. While there was data for HbA1c and diabetes incidence and prevalence, there were no statistically significant results of predicting mortality in people with teeth loss and diabetes. 

To conclude, this systematic review showed an association in older adults with TL and the incidence and prevalence of diabetes and other diabetes-related health issues. Loss of more than eight teeth showed in several articles that diabetes was present and could be attributed to the inflammatory system. This study was adjusted for some confounders, but the diet was not controlled and significantly affected diabetes and TL. Lost to follow up was high in one of the studies and was not included in another. Further limitations included that each study differed in the number of teeth lost as their baseline, some did not have reliable tests, and the patient could self-report their missing teeth. The longer the individual has had diabetes, the worse it can become without the proper medications, diet, and lifestyle modifications, and thus can potentially lead to worse outcomes for TL. However, the temporality of the diabetes outcome and tooth loss exposure was not found due to the lack of a large number of studies in this review. Future studies should include the diagnosis of diabetes onset in terms of years to determine if the progression of diabetes causes tooth loss or if the severity of diabetes is the main culprit of extensive tooth loss. There is a need for high-quality studies with different assessments to show the association between diabetes and tooth loss and the possible steps to add dental care into diabetes education. Dental professionals and healthcare providers need to educate their patients on the importance of teeth cleanings and teeth retention. Studies have shown the decline of quality of life even if a few teeth are lost. Dental hygiene should be stressed as an essential preventative step in their daily life, like checking their feet or blood sugar is.  

Practice Pearls: 

• There is a 50% chance of developing tooth loss in those with uncontrolled diabetes compared to those who did not have diabetes. 
• As the number of teeth lost increases, the outcome for diabetes grows poorer. 
• Insulin resistance can be linked to periodontitis due to the inflammatory mediators. 

Raju, Karen, et al. “Association of Tooth Loss with Morbidity and Mortality by Diabetes Status in Older Adults: A Systematic Review.” BMC Endocrine Disorders, vol. 21, no. 1, 2021, https://doi.org/10.1186/s12902-021-00830-6.  

Helal, Omar et al. “Predictors for tooth loss in periodontitis patients: Systematic review and meta-analysis.” Journal of clinical periodontology vol. 46,7 (2019): 699-712. doi:10.1111/jcpe.13118 

Megan Jane, PharmD Candidate 2022, USF Taneja College of Pharmacy 

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