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Oral Health and Diabetes Complications

Apr 10, 2021
Editor: David L. Joffe, BSPharm, CDE, FACA

Author: Sameen Khan, Pharm.D. Candidate, USF College of Pharmacy

Better oral health may be linked to better outcomes in patients with diabetes, but which comes first — gum disease or diabetes? 

Researchers have proposed a bidirectional link between oral health and diabetes, which may be related to an inflammatory mechanism. Periodontal disease, characterized by oral tissue destruction, produces a weak immune response that stimulates systemic inflammation. Diabetes also creates excessive inflammatory markers and altered cell function, oxidative stress, and defective neutrophil apoptosis. It may also cause acute complications such as hyperglycemia or hypoglycemia and chronic complications, including cardiovascular diseases, kidney failure, retinopathy, and neuropathy. 


A Canadian retrospective cohort study’s objective was to relate the incidence of acute or chronic diabetes-related conditions to self-reported oral health status. The study, which took place in Ontario, Canada, obtained participants from a pool of those who had taken either the 2003 or 2007-08 Canadian Community Health Survey (CCHS), a national survey representative of 98% of the Canadian population. Inclusion criteria required that patients have a definite diabetes diagnosis, are 40 years of age or older, and are from Ontario, Canada. Participants were excluded from the study if their electronic medical records were inaccessible, they became ineligible for the Ontario Health Insurance Plan (OHIP) in the follow-up period or failed to respond to the survey questions. The final study group had a total of 5,183 participants from a variety of backgrounds with covariates, including income, race, sex, education, presence of chronic disease, smoking, and alcohol use. 

Selected participants self-reported their oral health by responding to the question, “would you say the health of your teeth and mouth is: excellent, very good, good, fair, or poor?” Upon answering the question, participants were categorized into two groups, “good to excellent” and “poor to fair.” OHIP data was then used to track health encounters to compare the incidences of acute and chronic diabetes-related complications between the two groups. Acute conditions for this study included non-specific hypoglycemia and hyperglycemia. Chronic complications included stroke, myocardial infarction, retinopathy, amputation, skin infection, and dialysis.   

The study concluded with a 95% confidence interval (0.81, 1.51) that the odds of an acute complication occurring as opposed to no complication were 10% greater in patients with self-reported “poor to fair” oral health. The odds of a chronic complication occurring instead of no complication were 34% greater in those with self-reported “poor to fair” oral health, reported with a confidence interval of 95% (1.11, 1.61). Covariates in the study population were also analyzed. It was found that participants who had less education, smoked, and had fewer dental visits had more incidences of both acute and chronic diabetes-related complications. Ethnic minorities reported higher incidences of acute complications but lower incidences of chronic complications. 

Conversely, those living in rural areas had higher odds of developing chronic complications and were less likely to present with acute complications. It was determined that income level, sex, and age had no impact on developing acute or chronic complications. Still, patients who had regular contact with general physicians had a decreased likelihood of experiencing either complication. 

Though the study reported many statistically significant results, it also had many limitations that require further research before definitive recommendations can be made. Researchers themselves acknowledged that the self-reported oral health score is a significant limitation, and the study’s power would have been increased if clinical evaluations had been performed. It is unknown whether the participants received any training or reference for determining this score, making incorrect self-assessments possible. Another limitation of the study is that the Canadian database from which participants were chosen does not differentiate between type 1 or type 2 diabetes, which may have caused an overestimation of results.  

Practice Pearls:  

  • Improving oral health can lead to better diabetes-related outcomes in all patients. 
  • Patient demographics affect the occurrence of acute or chronic diabetes-related complications. 
  • Regular contact with general physicians is positively correlated with a decreased likelihood of experiencing complications. 


Parbhakar, Kamini Kaura, et al. “Acute and Chronic Diabetes Complications Associated with Self-Reported Oral Health: a Retrospective Cohort Study.” BMC Oral Health, vol. 20, no. 1, July 2020 


Sameen Khan, Pharm.D. Candidate, USF College of Pharmacy