|Year : 2022 | Volume
| Issue : 1 | Page : 34-42
Oral health status among type 2 diabetic versus nondiabetic adult population of muradnagar: A cross-sectional comparative study
Dipshikha Das, Ritu Gupta, Ipseeta Menon, Anubhav Sharma, Vikram Arora, Iram Ahsan
Department of Public Health Dentistry, I.T.S Centre for Dental Studies and Research, Ghaziabad, Uttar Pradesh, India
|Date of Submission||17-Oct-2021|
|Date of Decision||20-Jan-2022|
|Date of Acceptance||22-Jan-2022|
|Date of Web Publication||14-Mar-2022|
Department of Public Health Dentistry, I.T.S Centre for Dental Studies and Research, Delhi-Meerut Road, Murad Nagar, Ghaziabad - 201 206, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Background: Diabetes mellitus is a rising public health concern in India. It has become one of the most prevalent diseases in the world. Aim: This study aimed to assess and correlate oral health status, socioeconomic status (SES), and oral hygiene practices among Type 2 Diabetic and nondiabetic adult population of Muradnagar. Materials and Methods: A cross-sectional comparative study was conducted in the Community Health Center of Muradnagar among 250 (Type 2 diabetic) and 250 (nondiabetic) adult study subjects from October 2019 to March 2020. A interview-based questionnaire assessed demographic details, body mass index, and SES of study subjects. The family history, type, and duration of diabetes as well as knowledge on diabetes, its systemic and oral manifestations, and medications were assessed among diabetic study subjects. WHO Oral Health Assessment Questionnaire 2013 was used. Oral Hygiene Index-Simplified and Community Periodontal Index using WHO Oral Health 2013 Criteria were also used. Results: The mean age of diabetic study subjects was found to be 45.81 ± 5.05 years, whereas of nondiabetic study subjects, it was 40.85 ± 7.7 years. The mean decayed, missing, and filled teeth is statistically higher among diabetics (10.23 ± 4.73) than nondiabetics (5.34 ± 3.316). Periodontal pocket was present among 67.2% of diabetic study subjects with a mean number of teeth affected, with a pocket depth of about 4–5 mm in 4.68 ± 2.94 and 6 mm or more in 3.76 ± 2.83 which was comparatively higher than the nondiabetic study subjects. The prevalence of attachment loss among diabetic study subjects was noted as 28.4%, whereas among nondiabetic study subjects, it was 18%. Conclusion: The study concluded a strong association between diabetes and poor periodontal conditions and leaves an impact on overall oral health status of diabetic study subjects compared to the nondiabetics.
Keywords: Dental caries, diabetes, oral health status, oral hygiene, periodontal disease
|How to cite this article:|
Das D, Gupta R, Menon I, Sharma A, Arora V, Ahsan I. Oral health status among type 2 diabetic versus nondiabetic adult population of muradnagar: A cross-sectional comparative study. Asian J Pharm Res Health Care 2022;14:34-42
|How to cite this URL:|
Das D, Gupta R, Menon I, Sharma A, Arora V, Ahsan I. Oral health status among type 2 diabetic versus nondiabetic adult population of muradnagar: A cross-sectional comparative study. Asian J Pharm Res Health Care [serial online] 2022 [cited 2022 May 25];14:34-42. Available from: http://www.ajprhc.com/text.asp?2022/14/1/34/339408
| Introduction|| |
Diabetes mellitus (DM) is a rising public health concern in India. It is a metabolic disorder characterized by chronic hyperglycemia and disturbed carbohydrate, fat, and protein metabolism caused by defective insulin secretion, action, or both. According to the International Diabetes Federation of the year 2020, 463 million have diabetes in the world, and out of them, 88 million people are from the Southeast Asia region. Surprisingly out of these 88 million people, 77 million diabetics belong to India. The probable reason for such an increased prevalence of diabetes might be due to high urbanization, industrialization, and change in lifestyle patterns among the people. Diabetes is also associated with a lot of medical as well as oral complications. Therefore, it is imperative to diagnose this disease at an early stage, as it will be easier to treat it effectively. It will further reduce the chances of avoiding the development of serious complications due to it. Moreover, the economic burden related to the management of this disease will also be reduced.
Periodontitis is referred to as the sixth complication of DM. According to a report of Expert Committee on Diagnosis and Classification of Diabetes Mellitus, periodontitis was cited as one of the pathological conditions often found among diabetics. Indeed, multiple studies have provided conclusive evidence that the prevalence, severity, and progression of periodontal disease are significantly increased in patients with diabetes. If left untreated, periodontitis can lead to tooth loss, thereby compromising a patient's ability to maintain a proper diet and affecting the quality of life.
Other oral manifestations related to diabetes include mucosal ulceration, dry mouth, fungal infection, burning mouth syndrome, geographic tongue, oral lichen planus, fissured tongue, delayed wound healing, altered taste, impaired tooth eruption, benign parotid hypertrophy, tooth loss, xerostomia, dental caries, and periodontal disease.
The risk factors of DM are likely to be multifactorial behavioral problems such as cigarette smoking, physical inactivity, intake of saturated fatty acids, and sugar-sweetened beverages. Socioeconomic status (SES) is a total measure of an individual's or family's economic and social position. Some SES factors are also identified as risk factors having an association with DM. Specifically, the socioeconomic factors are gender, age, marital status, level of education, income, occupation, region, residential area, the amount of remaining debt, and current liability. According to a study conducted by Javed et al., a superior SES in individuals with well-controlled T2D may have permitted them to use conventional treatments for diabetes and to maintain their oral health compared to individuals with poorly controlled T2D. Low SES is the major contributing factor in the progression of periodontal conditions in T2D. Poor education and low SES have been linked with a high prevalence of T2D.
However, there is no definite picture and scanty literature search for Type 2 DM and its correlation on oral health aspects among the population in Muradnagar. Second, as diabetes may remain undiagnosed for a long time, dentists could be instrumental in facilitating the early detection of diabetes. Therefore, this study was an attempt to assess and correlate oral health status, SES, and oral hygiene practices among Type 2 diabetic and nondiabetic adult population of Muradnagar.
| Materials and Methods|| |
A cross-sectional comparative study was conducted among 250 Type 2 diabetic and 250 nondiabetic study subjects in the Community Health Center (CHC) of Muradnagar block of Ghaziabad from October 2019 to March 2020.
Source of data
The preconfirmed diabetics who were under treatment of a physician in the CHC of Muradnagar block in Ghaziabad district were considered as diabetic study subjects, whereas persons accompanying the diabetic patients to the center were considered as nondiabetic study subjects. The nondiabetic study subjects were further confirmed for their blood glucose levels using an instant Glucometer. If random plasma glucose level was found to be ≥200 mg/dL (11.1 mmol/L) which is considered to be a sign of diabetes, they were referred to physicians for further confirmation of their condition and were not included in study.
Ethical approval and informed consent
Ethical approval was obtained from the Ethical Committee of I.T.S Center for Dental Studies and Research Muradnagar, Ghaziabad, and from Medical Superintendent of CHC, Muradnagar, prior to conduct of study. Written informed consent was obtained from study subjects and in case of illiterate subjects, the procedure was first explained verbally, and then, thumbprints were obtained prior to conduct of the study.
The pilot study was carried out among 60 study subjects (30 diabetics and 30 nondiabetic controls) to determine the sample size and to check the feasibility of the study.
Sample size determination
The sample size was estimated based on the prevalence of loss of attachment obtained from the pilot study. Substituting the Z α/2 value for 5% level of significance and Z β value for 80% power of the study, Zα = 1.960, Zβ = 0.84, P1 = Prevalence of loss of attachment among diabetic study subjects: 38%, and P2 = Prevalence of loss of attachment among nondiabetic study subjects: 26%.
Which gives a value of n = 234 study subjects rounded off to 250 study subjects. Accordingly, 250 diabetics and 250 nondiabetics were recruited into the study with a total sample size of 500 study subjects.
- Study subjects who were willing to participate
- Diabetic study subjects who were diagnosed with T2D more than 1 year ago
- No medication with antibiotics or steroidal and/or nonsteroidal anti-inflammatory agents over the past 3 weeks
- At least 16 remaining natural teeth
- No immunosuppressive chemotherapy, no current acute illness, no professional periodontal treatment during the last 6 months, and no pregnancy or lactation.
- Edentulous subjects
- Study subjects with any other systemic diseases such as hypertension and epilepsy which can inhibit the clinical examination were excluded
- Study subjects on antimicrobial medication and who had undergone any periodontal therapy during the past 6 months were excluded from the study.
A interview-based questionnaire was administered which is basically divided into two parts. The first part assessed basic demographic details, body mass index (BMI), and SES of study subjects using a modified Kuppuswamy Scale 2019. The second part assessed the basic knowledge on diabetes, family history of diabetes, type and duration of diabetes, their knowledge on the systemic as well as oral manifestations of diabetes, and also about their medication history due to diabetes among the diabetic study subjects.
A WHO Oral Health Assessment Questionnaire 2013 assessed the oral health status and practices among study subjects. Oral Hygiene Index-Simplified (OHI-S) was used to determine oral hygiene and Community Periodontal Index using WHO Oral Health 2013 Criteria was also used.
Data were analyzed using Chicago, IL IBM SPSS Statistics 20.0 for Windows software. Descriptive statistics of the study subjects were depicted using mean percentages and standard deviation. Association was evaluated using Chi-square. Any P < 0.05 was considered significant. Spearman correlation rank test was also assessed to correlate. Independent sample t-test for intragroup comparison was used.
| Results|| |
The mean age of diabetic study subjects was 45.81 ± 5.05 years, whereas of nondiabetic study subjects was 40.85 ± 7.7 years. A majority of 157 (62.8%) diabetic study subjects were male, whereas among nondiabetic study subjects, a majority of 162 (64.8%) subjects were male. A statistically significant difference was found between diabetic and nondiabetic study subjects in respect to their socio economic status, BMI and family history of diabetes (P ≤ 0.05) [Table 1].
|Table 1: Distribution of demographic details among the diabetic and nondiabetic study subjects|
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Among diabetic study subjects, a majority 103 (41.2%) had diabetes for more than 8 years, 224 (89.6%) were under medication for diabetes either oral or inject tables, 168 (75%) diabetic study subjects used oral medications as a treatment modality to keep diabetes under control, and 122 (48.8%) diabetic study subjects surfed Internet as a source of information for diabetes apart from their physician [Table 2].
|Table 2: Distribution of diabetic study subjects based on their duration, treatment, type of treatment modality, and source of information about diabetes|
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Considering the responses to assess the knowledge among the study subjects, a statistically significant difference was found between the diabetic and nondiabetic study subjects on their knowledge about the effect of diabetes on general as well as oral health of an individual (P ≤ 0.05) [Table 3].
|Table 3: Knowledge about oral and general health effects of diabetes among the study subjects|
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Oral hygiene behaviors and practices of diabetics were statistically significant when compared to nondiabetics (P ≤ 0.05). A nonsignificant difference was observed among diabetic and nondiabetic study subjects when compared to the cleaning aids used for cleaning their teeth (P = 0.06) [Table 4].
|Table 4: Comparison of responses of the study subjects based on their oral hygiene behaviors|
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The mean number of sound teeth of diabetics was 21.62 ± 4.73, carious: 2.68 ± 1.84, filled with caries: 0.98 ± 1.64, filled with no caries 1.09 ± 0.81, missing due to any other reason 3.16 ± 3.32, and fixed dental prosthesis/abutment was 0.16 ± 0.47, which had a statistically significant difference when compared to nondiabetics, whereas the mean number of missing teeth due to caries (2.32 ± 2.7) was found to be statistically nonsignificant among both the groups. The mean decayed, missing, and filled teeth (DMFT) status was statistically significantly higher among diabetics (10.23 ± 4.73) The mean number of teeth with periodontal pocket depth of 4–5 mm was noted as 4.68 ± 2.94; sextants affected with loss of attachment score 0–3 mm (2.39 ± 0.88), 4–5 mm (1.72 ± 0.79), 6–8 mm (1.37 ± 0.656), 9–11 mm (0.20 ± 0.465), and 12 mm or more (0.16 ± 0.486) were comparatively statistically significant and higher among diabetic study subjects (P = 0.815) [Table 5].
|Table 5: Comparison of mean dentition status among diabetic and nondiabetic study subject|
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The prevalence of gingival bleeding and periodontal pocket formation among diabetic study subjects in the present study was noted as 33.4% and 33.6%, respectively. The periodontal pockets were seen among a majority (168, 67.2%) diabetic study subjects, whereas among the nondiabetic study subjects, periodontal pockets were seen among a majority 109 (43.6%) study subjects. The prevalence of attachment loss among diabetic study subjects was noted as 28.4%, whereas among nondiabetic study subjects, it was only 18%. On comparison of mean OHI-S scores among both the study groups, it was noted that mean Oral Hygiene-Simplified Index scores were 3.77 ± 1.09 among the diabetic study subjects which is statistically significant and higher compared to nondiabetics. A statistically significant difference was found among diabetic and nondiabetic study subjects and gingival bleeding, periodontal pocket formation, and loss of attachment (P ≥ 0.05) [Table 6].
|Table 6: Comparison of periodontal conditions and Oral Hygiene Index score interpretation among diabetic and nondiabetic study subjects|
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Multinomial logistic regression depicts that nondiabetic study subjects are 1.72 times (odds ratio [OR]: 1.72, 95% confidence interval [CI]: 1.064–2.783), 1.27 times (OR: 1.27, 95% CI: 0.77–2.09), and 1.4 times (OR: 1.407, 95% CI: 0.881–2.248) more likely to not have gingival bleeding, periodontal pocket, and loss of attachment, respectively, than the diabetic study subjects.
| Discussion|| |
It is considered that having a systemic illness might increase the risk of other related health issues in the body of an individual. Diabetes lies to be a perfect example of it. Oral implications are a major complication of diabetes since time immemorial which needs to be treated in an early and immediate phase.
In the present study, diabetic study subjects with a mean age of 45.81 ± 5.05 years who visited the CHCand nondiabetic study subjects with a mean age of 40.85 ± 7.7 years who have visited the dental hospital from various parts of Muradnagar were assessed. They represented a considerable fraction of both men and women of Muradnagar as a majority of them visited these health-care settings.
The majority of study subjects in the present study were males among both the diabetic (62.8%) and nondiabetic group (64.8%) which is similar to a study done by Bharateesh et al. where females were 39% and the males were 61% in the study population. A total of 64.4% of diabetic study subjects had a positive history of diabetes in their family which is similar to a study done at Tamil Nadu by Geetha et al. The probable reason for this is that diabetes is a disease that has a strong clustering in families and has a genetic component. The risk of developing Type 2 DM increases approximately two to fourfold when one or both parents are affected., Thus, family history of diabetes may be a useful tool to identify the individuals at increased risk of developing the disease and target behavior modifications that could potentially delay disease onset and improve health outcomes.
A majority 41.2% of the study subjects reported diabetes for more than 3-year duration. A study by Ojehanon et al. conducted in Nigeria reported that about three-tenth (30.6%) of the participants had suffered diabetes for more than 10 years. This indicates that diabetes is a lifelong complication that may remain silent and undiagnosed/unnoticed for a long period of time. Thus the term silent killer is best suited to this disease. A total of 32% of diabetic study subjects were obese which is comparable to a study done at Nepal by Shah et al. where BMI was higher (obesity) in diabetics as compared to nondiabetics. Thus, obesity may be an etiologic factor in the development of DM. These factors are most closely associated with diabetes which includes dietary modifications, extent of physical activity that is a sedentary lifestyle, and genetic susceptibility.
A majority of 56.8% of diabetics and 70.8% of nondiabetics did not know about the effects of diabetes on oral health. This is similar to a study done by Arunkumar et al. which measured patient knowledge and awareness concerning the effects of diabetes on oral health and found that only 10.8% of the study participants were familiar with the effects of diabetes on oral health., The study revealed not much significant difference in oral hygiene practices among diabetic and nondiabetic study subjects. The study subjects majorly used toothbrushes and toothpaste to clean their teeth followed by the use of chewstick/neem stick. Comparable results are found by Attas and Oda where 80% of the study population used toothbrushes and paste to clean their teeth. This may be due to the fact that the present study is conducted in a semiurban area where most of them use toothpaste and toothbrush and growing awareness about use of the proper oral hygiene aid through various oral health programs conducted at the health centers as well as through media. Majority of the diabetic (60%) as well as nondiabetic study subjects (79.2%) in the present study brushed their teeth only once a day and only 28.4% of the diabetics brushed their teeth twice daily. Similar findings are seen in a study conducted by Karikoski et al. in Finland where only 38% brushed their teeth twice, and another study conducted in Jeddah showed that 46% of the study subjects brushed their teeth more than once a day., Considering the results of the present study, emphasizing proper toothbrushing methods and frequency is particularly important among the adult population of Muradnagar.
Duration of diabetes is considered as the main factor when addressing the susceptibility to periodontal disease and other systemic complications, but control of glycemia is one of the principal etiologic mechanisms associated with periodontal breakdown., Thus, the study discusses a strong association between duration of diabetes and periodontal as well as loss of attachment. One of these studies conducted by Cerda et al. concluded that the duration of diabetes was a significant factor for the severity of periodontal disease.
The mean number of carious lesions was higher among the diabetic study subjects (2.68 ± 1.84) compared to the nondiabetic group.(0.86 ± 1.3). Diabetic patients may have more frequent meals than normal subjects, and repeated intakes of even small amounts of carbohydrates may be cariogenic. A study conducted by Lalla et al. produced similar results where the mean number of carious lesions was identical in both the groups, but the nondiabetic control group had significantly more teeth with restorations.
The mean number of filled teeth was higher in diabetic study subjects (1.09 ± 0.81) compared to nondiabetic study subjects depicting higher oral treatment needs and debilitating oral conditions in them. Contradictory results were shown by a study done by Puranik and Hiremath where the mean number of filled teeth was higher in nondiabetics compared to the diabetic group.
The mean number of teeth missing due to other reasons was slightly higher among diabetics (3.16 ± 3.32) than nondiabetics in the present study. The “other reason” considered in this study was missing due to periodontal conditions. Although the mean number of missing teeth does not give a direct insight into the periodontal status, it is an important factor in estimating oral health.
The mean DMFT status was 8.99 ± 5.27 for diabetic and 3.67 ± 3.10 for nondiabetic study subjects. This is similar to a study done by Sukminingram N et al. where the mean DMFT was 13.52 ± 3.694 in the diabetic group, significantly higher (P < 0.05) than 9.73 ± 2.496 in the nondiabetic group. In contrast, Pohjamo et al. reported only fewer decayed teeth in adults with diabetes compared to controls. A possible explanation for these findings might be due to the loss of protective mechanism of the saliva in diabetics. The cleansing and buffering action of saliva is also impaired. Low salivary pH promotes the growth of aciduric bacteria which then allows the acidogenic bacteria to proliferate creating an inhospitable environment for the protective oral bacteria to cause dental caries.
In the present study, a majority 67.2% of the diabetic study subjects reported with the presence of periodontal pocket compared to the nondiabetic study subjects (43.6%). Comparable results are shown by Botero et al. where the proportion of periodontitis was higher (75.3%) in diabetics than nondiabetics (64.1%). Apart from that, the effect of diabetes on periodontal tissues has been also thoroughly investigated in various observational studies in past demonstrating that diabetes is associated with exaggerated periodontal tissue destruction. A 5-year follow-up study demonstrated that periodontal tissue destruction is associated with poor glycaemic control (HbA1c ≥6.5%) (48 mmol/mol) with an OR of 2.9.
Diabetic study subjects had a higher mean number of 4.68 ± 2.94 teeth with pocket 4–5 mm and 11 ± 5.95 with pocket 6 mm or more compared to nondiabetics, which is comparable to a study done by Kesavan R et al. The presence of loss of attachment was seen in 36% of diabetic and 56.8% of nondiabetic study subjects. Similar findings were observed in studies conducted among other populations by Lalla et al., Hintao et al., and Khader et al. However, a study conducted by Collin et al. showed no significant difference in loss of attachment scores among diabetics and nondiabetic study subjects. Patients with diabetes along with periodontitis presented an increased periodontal loss of attachment as compared to patients without diabetes. Nevertheless, the diagnosis of periodontal disease results from analysis of periodontal disease and attachment loss that represents past destruction of periodontal tissues, and this constitutes one of the main causes of tooth loss.
The oral hygiene status was slightly poorer among diabetics when compared to nondiabetics which is comparable to a study conducted by Hintao et al. where nondiabetics had better oral health status. This might be due to improper removal of dental plaque and debris which adheres to the tooth surface and gingiva leading to caries and gingival inflammation.
Thus, the study discusses a strong association between diabetes and deteriorated poor periodontal conditions as well as leaves an impact on the overall oral health status of the diabetic study subjects when compared to the nondiabetic study subjects. Apart from that, there are various risk factors detected in the present study such as SES, BMI, and duration of diabetes, which eventually lead to poor oral health outcomes among the study subjects. Most of the people in India have a perception that dentistry is an expensive means, which keeps them away from registered professionals on one hand, while on the other hand, turning them into hostages to services of nonregistered lay practitioners sitting on the streets. The main reason behind this is the low level of awareness regarding oral health and hygiene.
| Conclusion|| |
The present study concluded that diabetic study subjects had poorer oral health status when compared to nondiabetics. Furthermore, there is a lack of knowledge about diabetes and its effects on oral health. Diabetes and its impact on oral health status is just a mere beginning to be explored. There is an utmost need of further research in this regard to understand the implication of such common systemic manifestations in the oral cavity of an individual.
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Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]