Oral health complications in type 2 diabetes: A hospital-based observational study among beneficiaries of employees state insurance in Puducherry, India

Palash Kumar Sanyal; Pramod Srirammohan; Sirshendu Chaudhuri

doi:10.4103/injms.injms_8_21

ORIGINAL ARTICLE

Year : 2021 | Volume : 12 | Issue : 4 | Page : 222-227

Oral health complications in type 2 diabetes: A hospital-based observational study among beneficiaries of employees state insurance in Puducherry, India

Palash Kumar Sanyal¹, Pramod Srirammohan¹, Sirshendu Chaudhuri²
¹ ESI Hospital, Puducherry, India
² Department of Community Medicine, Apollo Institute of Medical Sciences and Research, Chittoor, Andhra Pradesh, India

Date of Submission	23-Jan-2021
Date of Acceptance	17-Jun-2021
Date of Web Publication	26-Oct-2021

Correspondence Address:
Dr. Sirshendu Chaudhuri
Apollo Institute of Medical Sciences and Research, Chittoor, Andhra Pradesh
India

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/injms.injms_8_21

Abstract

Background: Oral health evaluation is one aspect of diabetes care, that is usually not practised in majority of health care settings in India. Aims: To-identify the various complications related to oral health among Type 2 diabetics in a secondary care hospital in South India; and to identify the various determinants associated with it. Methods: In this cross-sectional study among the employees state insurance beneficiaries, we conveniently sampled the Type 2 diabetes patients attending the outpatient department for routine diabetic care and evaluated for some preidentified oral health conditions. Results: We recruited 124 participants, 76 (61.3%) males. The average duration of diabetes was 6.5 years (inter-quartile range-3–7 years). Gingivitis (n = 97, 78.2%) was the most common complication. Other important complications include-loss of functionality (n = 88, 71%), calculous (n = 87, 70.2%), and gingival recession (n = 56, 45.2%). In multivariate logistics regression modeling, young diabetics (adjusted odds ratio [AOR] −6.2; 95% confidence interval [CI] −2.2,17.6) and male populations (AOR − 2.6; 95% CI − 1.1, 6.0) were at higher risk of developing multiple complications. Conclusions: Diabetic population frequently suffers with oral complications. Health care professionals can include the importance of dental health care in the routine health education session for diabetics. In addition, clinicians can recommend dental evaluation to the diabetics apart from other clinical biochemical evaluation.

Keywords: Dental health, India, type 2 diabetes

How to cite this article:
Sanyal PK, Srirammohan P, Chaudhuri S. Oral health complications in type 2 diabetes: A hospital-based observational study among beneficiaries of employees state insurance in Puducherry, India. Indian J Med Spec 2021;12:222-7

How to cite this URL:
Sanyal PK, Srirammohan P, Chaudhuri S. Oral health complications in type 2 diabetes: A hospital-based observational study among beneficiaries of employees state insurance in Puducherry, India. Indian J Med Spec [serial online] 2021 [cited 2022 Aug 16];12:222-7. Available from: http://www.ijms.in/text.asp?2021/12/4/222/329299

Introduction

Oral health has remained an ignored aspect of diabetes care.^[1] To achieve the glycemic goals, the major strategy that has been put forward include lifestyle modifications like-diet control and increase in physical activity apart from the pharmacological management to reduce blood sugar level.^[2] Evidence from different parts of the world suggests that diabetics often face wide range of oral health complications such as periodontitis, gingivitis, early loss of attachment of tooth, loss of tooth at early age, abscesses related to gums, and dental caries related to oral health when compared to the nondiabetics.^[3] Even, complications like periodontitis could be an early sign of diabetes.^[4]

The possible autoimmune mechanism has been proposed behind the oral complications among diabetics.^[5],[6] Due to prevailing diabetes in these patients, their oral complications take longer time to resolve and are more difficult to manage than in a nondiabetic patient.^[4] Conversely, diabetic people with such oral complications may find it difficult to achieve the glycemic goals despite following the standard recommendations. The American Diabetes Association emphasized that diabetics with oral conditions like periodontitis can lead to substantially affect the treatment outcome.^[7] Growing evidence suggests that there is a two-way relationship between glycemic status and periodontitis. While poor glycemic control predisposes to periodontitis; the latter in turn negatively affects the glycemic control and thereby increase the incidence of micro- and macro-vascular complications like end-stage renal disease and cardio-renal mortality.^[8]

India has remained as one of the countries with high burden of diabetes and its complications for a long period.^[9] Fortunately, at the same time, people started developing awareness about the condition, and the importance of lifestyle modification.^[10] However, there is only meager evidence in the country on oral health complications on diabetics. Reporting from various health care facilities is needed to improve the evidence on oral health among diabetics in India. As a matter of fact, majority of health institutions including government hospitals, both teaching and nonteaching, private institutions and even practicing diabetologists, physicians and endocrinologists usually do not include oral health evaluation as part of the diabetes management protocol. This leaves many patients with undiagnosed dental and periodontal complications. On this background, the objectives of the study were to identify the various complications related to oral health among Type 2 diabetics in a secondary care hospital in South India; and to identify the various determinants associated with poor oral health among the diabetics.

Methods

Study design

Cross-sectional observational study.

Study setting

This study was conducted in employees state insurance (ESI) Hospital, Pondicherry. This hospital caters to the beneficiaries of ESI Scheme which is governed by the Ministry of Labour. The beneficiaries include insured persons and their dependents who are active subscribers of the ESI scheme. This hospital is a 75-bedded multispecialty hospital. On an average, 4000 patients attend this hospital every month. Approximately 10%–12% of the adult patients attending the outpatient clinic are suffering from diabetes mellitus. The hospital has the facilities for basic laboratory investigations such as complete blood count, blood glucose, blood urea nitrogen, serum creatinine, liver function tests, urine routine, urine ketone bodies.

Study duration

July-2017 to December-2017.

Study participants

Patients diagnosed with Type 2 diabetes for a minimum period of 6 months were eligible for the study. Such patients were enrolled from the outpatient clinic after informed consent. We excluded patients with poor activity of daily living as clinically assessed by the clinicians. All patients with negative consent were excluded from the study; however, they were recommended to follow-up at the dental clinic.

Sample size

Previous hospital-based study^[11] from India showed that the prevalence of periodontitis in India is 60%. At least 119 subjects were needed to detect a 60% of prevalence with a relative precision of 15%.

Sampling method

Based on the technical and administrative feasibility, in OPD, we checked every fifth person with known diabetes for eligibility [Figure 1].

Figure 1: Flowchart showing recruitment of the patients

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Data collection

Initial medical evaluation was done as per the routine protocol for diabetics at the Medicine OPD including history taking, clinical examination, and laboratory investigations. All the enrolled participants were sent to the dental clinic of the same hospital [Figure 1]. The patients underwent dental examination by the Chief Dental Surgeon. The findings of the patients were noted in prescribed format. The format was designed to simplify case recording and standardized for all patients included in this study. Further management on oral conditions was recommended as per the ESI protocol.

Working definitions of the outcome variables

Gingivitis

Inflammation of gums

Clinically manifested by swollen gums, bright red, or purple in color, tender to touch, induced bleed of short duration due to brushing.

Periodontitis

Inflammatory disease of supporting tissues of teeth caused by specific microorganisms or groups of specific microorganisms, resulting in progressive destruction of the periodontal ligament and alveolar bone with periodontal pocket formation, gingival recession, or both.

Plaque

A dense, nonmineralized, highly organized biofilm of microbes, organic and inorganic material derived from the saliva, gingival crevicular fluid (GCF), and bacterial by-products.

Calculus

Hardened dental plaque, caused by the precipitation of minerals from saliva and GCF in plaque on the teeth.

Stain

Tooth discoloration leading to abnormalities in tooth hue, color, and transparency. May be internal or external.

Caries

Decay of tooth, caused by acids made by bacteria leading to the destruction of hard dental tissue like enamel, dentine, or cementum. This manifests in the form of cavities of any depth and size, variable colors like yellow or black. Clinically patient may present with mild to severe pain when the pulp chamber is exposed. Later when dental necrosis sets in this may even become painless. However, the absence of pain often gives a false sense of relief, while the necrotic process continues unabated and may lead to the involvement of sub-alveolar bone and surrounding soft tissue, sometimes leading to life-threatening complications, especially among diabetics.

Gingival recession

Exposure in the roots of the teeth caused by a loss of gum tissue and/or retraction of the gingival margin from the crown of the teeth

Occlusion

Relationship between the maxillary (upper) and mandibular (lower) teeth when they approach each other, as occurs during chewing (dynamic occlusion) or at rest (static occlusion)

Missing tooth

Absence of tooth due to extraction or any other reason

Functionality

Integrated function of teeth, gums, mandible, maxillae, temporomandibular joints for mastication. Defined as normal when the sum of all individual functional components of the anatomical structures of the masticatory apparatus is effective mastication and compromised when there is any functional deficit due to any reason

Periodontal abscess

Localized collection of pus (i.e. an abscess) within the tissues of the periodontium.

Data entry and statistical analysis

Data entry was done in Microsoft Excel. Statistical analysis was performed using Statistical Package for the Social Sciences (IBM SPSS Statistics for Windows, Version 20.0. Armonk, NY: IBM Corp.). All proportions were expressed in percentage with appropriate 95% confidence interval. The continuous variables were expressed with mean with standard deviation (SD), or median with inter-quartile range (IQR). To identify the determinants of poor oral health, univariate analysis followed by multivariate logistic regression model was performed. The factors with P < 0.2 were taken for the final logistic regression model. A value of P < 0.05 was considered statistically significant in the final model.

Human subject protection

The study was approved by the Institutional Ethics Committee. In addition, written informed consent was obtained from all the study participants.

Results

We could recruit 124 participants for the study. The mean age was 54.4 years (SD - 10.1); the age range was 30–79 years. There were 76 males (61.3%) and 48 (38.7%) females. The median duration of diabetes for the study group was 6.5 years (IQR: 3–7 years). We found gingivitis as the most common findings among diabetics [Table 1]. On univariate analysis, we found young population (<50 years) are ten times more prone to develop gingival recession [Table 2]. On an average, we found male gender is two to three times at higher risk in developing occlusion and impaired functionality. [Figure 2] depicts various complications found among diabetic patients. When the duration of diabetes exceeds >5 years, the patients had >3 times higher risk of developing gingival recession and >5 times risk of developing attrition [Table 2].

Table 1: List of dental complications (n=124)

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Table 2: Univariate analysis between the oral complications among diabetics and the predictors

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Figure 2: Types of complications seen among patients with type 2 diabetes (a) gingival recession, calculus deposit (crevical), gingivitis. (b) Calculus, stain, gingivitis, gingival recession, (c) Severe crevical teeth, abrasion, stain, gingival recession. (d) Crevical teeth abrasion, gingivitis, teeth attrition (molars), (e) Gingivitis, gingival recession, moderate abrasions, and attrition of molars. (f) Severe attrition (premolars and molar), missing teeth (Picture Source: ESI Hospital, Puducherry)

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Each of the complications was assigned a score of 1 if it is present, and 0 if absent. Therefore, for ten complications listed, maximum score possible was 10 and the minimum 0. The mean score for complications was 4.6 (SD 1.8) and the range was 1–8. We took the median (4.0) to dichotomize the score into “more complication” (score >4) and “less complication” (score ≤4) group. Univariate and multivariate analysis for individual-level risk factors of having more complications was calculated. We found younger population (<50 years) and male gender are at higher risk of developing multiple complications [Table 3].

Table 3: Determinants of oro-dental complications among diabetics

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Discussion

In this hospital-based study, we have identified the various oral complications suffered by diabetic patients. Such complications would have gone unnoticed as the primary reason for visiting the hospital was the treatment of diabetes. We found that the young and male populations are at higher risk of developing multiple complications. In our study, gingivitis was the most common complication reported. In a study by Taylor et al.,^[12] the authors found age as an important covariate with periodontitis. Although this was not exactly found in our study, overall age was a significant determinant. This difference in outcome may have happened due to different study designs. However, in contrast to the finding reported by Taylor et al., we did not find any significant association with other covariates like glycemic control, duration of diabetes.

Every four out of five diabetics are suffering with gingivitis, and gingival recession in approximately 45% of the patients. Taylor et al.^[12] found a similar pattern of the high burden of gingivitis among diabetic patients. However, contrary to our findings, there was a higher reporting of the condition with increasing age. Although not common like gingivitis, roughly one out of four patients suffered from periodontitis. Periodontitis is often reported to be associated with diabetes and poor glycemic control.^{[13],[14],[15],[16]} With the associated microbiological colonization, it can lead to other complications like-tooth loss, and caries tooth.^{[17],[18],[19],[20]} Although, we found that most of the participants had loss of tooth (58.9%), and dental caries (73.33%); such association may not be causal as our study is observational in nature. Nevertheless, longer duration of periodontitis may lead to the increased chance of attachment loss leading to loss of tooth.^[21]

The other noninflammatory conditions like-calculus, stain, occlusion, and functionality were high in our study, ranging between 66% and 71%. Tooth wear like-erosion and abrasion are often reported to be associated with diabetes.^[22] Interestingly, we noticed a strong association of attrition and the duration of diabetes. None of the conditions was statistically associated with glycaemic control status. Nevertheless, we should consider the other external factors that can also cause such findings. For example, attrition can be caused by other factors like diet, chewing pattern, or with the habit of tooth brushing.^{[23],[24],[25],[26]} Functionality represents the total effect of the oral and dental pathology on the proper masticatory functions of teeth supported by their soft and hard tissue. To the best of our knowledge, this relationship between functionality and diabetes has not been explored earlier in the literature. Importantly, we found-the male gender and elderly (>60 years) are strongly associated with functional impairment. Such findings should be investigated further to get conclusive evidence.

In the present study, we found-gingivitis, calculus, stain, and reduced functionality due to loss of teeth due to other reasons such as decayed teeth and loss in the majority of cases leading to the economic burden of replacement, some of them due to mobility and tenderness of teeth associated due to periodontitis and gingivitis. This may have a direct effect on the type and amount of food taken leading to nutritional issues and altered diabetic control.

Limitations

There are few limitations of this study. First, due to lack of funding, we could not compare our findings with the nondiabetic population. Second, as the study is observational in nature, we cannot establish any causal association between the diabetic status with the predictors. Third the observational pro forma was in house created and touched on all essential observational features possible in limited setting. The findings of our study can be considered to develop further hypotheses based on the basic observations we reported.

Conclusion

The diabetic population frequently suffers from oral complications. Such complications are mostly overlooked by them. Hospitals dedicated for employees of any organization and their family members, have excellent opportunity to identify and treat oral health complications among the diabetic population. We strongly recommend for higher-level studies to generate conclusive evidence in our country. Meanwhile, health care professionals including the doctors and the nursing staff can include the importance of dental health care in the routine health education session for diabetics. In addition, clinicians can recommend dental evaluation to diabetics apart from other clinical biochemical evaluations.

Financial support and sponsorship

None.

Conflicts of interest

There are no conflicts of interest.

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