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Year : 2021  |  Volume : 32  |  Issue : 2  |  Page : 140-146
Oral health status and self- assessment of oral health risk factors among South Indian diabetic patients

Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Research Centre, Hyderabad, Telangana, India

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Date of Submission20-Jun-2018
Date of Decision13-Oct-2018
Date of Acceptance18-Jul-2019
Date of Web Publication22-Nov-2021


Background: The disease profile of the world is changing at an astonishingly fast rate. It is essential that the impending nature of chronic disease is recognized and acted on urgently. India leads the world with the largest number of diabetics earning the dubious distinction of being termed the “diabetic capital” of the world. Aim: To assess and compare the oral health status and related oral health risk factors among diabetic patients in Hyderabad and Secunderabad. Settings: A cross sectional study was carried out in various diagnostic centers among 801 patients aged 30 years and above. Methods and Materials: Oral health status and self-assessed data on related oral risk factors were measured using modified World Health Organization (WHO) assessment form and oral health questionnaire for adults 2013. Statistical Analysis: Comparison of mean scores of the variables based on gender was assessed using ANOVA. Statistical significance was set at p < 0.05. Results: Females had higher proportion of untreated caries (362; 85%) and DMFT (Decayed, Missing and Filled Teeth; 375; 88%) compared to males. On the basis of loss of attachment, the mean number of sextants with no loss of attachment was mostly noted among female subjects. Conclusion: In the present study, though gingivitis was seen in higher percentage (82%), the presence of periodontal disease was relatively low (68.3%). It can be concluded that diabetic subjects may have poor oral health.

Keywords: Dentition status, diabetes, gingival status, loss of attachment

How to cite this article:
Madhuri M, Kulkarni S, Doshi D, Reddy S, Adepu S, Reddy S. Oral health status and self- assessment of oral health risk factors among South Indian diabetic patients. Indian J Dent Res 2021;32:140-6

How to cite this URL:
Madhuri M, Kulkarni S, Doshi D, Reddy S, Adepu S, Reddy S. Oral health status and self- assessment of oral health risk factors among South Indian diabetic patients. Indian J Dent Res [serial online] 2021 [cited 2022 Aug 8];32:140-6. Available from:

   Introduction Top

The disease profile of the world is changing at an astonishingly fast rate, especially in low- and middle-income countries.[1] Long-held notions about the nature of chronic diseases, their occurrence, the risk factors underlying them and the populations at risk are no longer valid. It is very essential that the impending nature of chronic disease is recognized, understood, and acted on urgently.[2] Long standing diseases such as heart disease, cancer, stroke, diabetes and respiratory diseases share common risk factors such as tobacco use, unhealthy diet, physical inactivity, and lack of access to preventive care.[1]

Among such persistent diseases, diabetes is a major global health problem affecting millions of people around the world.[3] It has an ice-berg phenomenon and is one of the most frequent chronic diseases affecting the society. Diabetes Mellitus is a group of metabolic diseases characterized by hyperglycemia resulting from defects in insulin secretion, insulin action, or both.[4]

India leads the world with the largest number of diabetic subjects earning the dubious distinction of being termed the “diabetic capital of the world”.[5] The National Urban Diabetes Survey (NUDS) in India, conducted a population based study in six metropolitan cities revealed that the prevalence of diabetes in the southern part of India was found to be greater with 13.5% in Chennai, 12.4% in Bangalore and 16.6% in Hyderabad as compared to other cities.[5],[6]

The American Diabetes Association has classified diabetes into Type 1 or Insulin –Dependent Diabetes Mellitus (IDDM), Type 2 or Non-Insulin-Dependent Diabetes Mellitus (NIDDM).[7] Type 1 diabetes, usually manifests in childhood or adolescence in which the patients require exogenous insulin because of destruction of insulin-producing β cells in the pancreas by autoimmune reactions. Type 2 is the result of insulin resistance and impaired insulin secretion. Lastly, gestational diabetes is a condition of abnormal glucose tolerance observed during pregnancy.[7] Long-term poor glycemic control in both Type I and Type II can lead to major complications, like diabetic neuropathy, nephropathy, retinopathy, coronary heart diseases and strokes.[8] Apart from affecting the systemic health, diabetes also has an influence on the oral health.[9]

Literature studies[9],[10],[11] reveal the oral health manifestations associated with diabetes which include periodontitis, xerostomia, tooth loss, gingivitis, odontogenic abscess, dental caries, and oral mucosal lesions such as lichen planus, candidiasis etc. According to the American Diabetes Association (ADA), periodontal disease has been recently recognized as the sixth complication of diabetes mellitus and there appears to be a bidirectional relationship between periodontal disease and glycemic levels.[12] The main mechanisms by which diabetes and periodontitis are related via alterations in host and collagen metabolism wherein prolonged tissue exposure to hyperglycaemia results in the production of advanced glycation end products (AGEs) leading to an increase in collagen cross-linking and the generation of reactive oxygen intermediates, such as free radicals.[13]

Studies[14],[15],[16] conducted worldwide have shown oral health complications of diabetes can be prevented by improving the knowledge. With this background, the present study aims to determine the oral health status and self-assessment of oral health and risk factors among the diabetic patients in Hyderabad and Secunderabad cities, thereby creating awareness regarding the oral health-related problems in diabetic patients.

   Methods Top

Ethical clearance was obtained from the Institutional Review Board of Panineeya Institute of Dental Sciences and Research Centre. After the explanation of the study procedures, subjects aged 30 years and above, diagnosed with diabetes mellitus for the past 2 years and who signed the informed consent form were recruited in the present study. Subjects having type I and gestational diabetes, with history of antibiotics usage in the last one week and who underwent periodontal therapy in the last three months were excluded from the study. Participation was voluntary and anonymous. Confidentiality of the respondents was also maintained. The study was conducted for a period of four months from February 2016 to May 2016 at all the four branches of Life span diabetic centers and Vanaja Hospital.

A pilot study was conducted among 50 diabetic patients to assess the feasibility of the study, for the sample size estimation and to finalize the study proforma. With a confidence level of 99, standard deviation of 0.761 and sampling error at 1%, the estimated sample size obtained as minimum of 755 subjects. However, final sample of 801 was considered to increase the precision of the study, excluding the subjects from the pilot study. The clinical examination of all the subjects was done by a single pre-trained, pre-calibrated examiner to limit intra-examiner variability (Cronbach's α value of 0.9). The training and calibration was done in the Department of Public Health Dentistry (Panineeya Mahavidyalaya Institute of Dental Sciences and Research Centre) under the guidance of a senior faculty. This study complied with the STROBE guidelines.[17]

Oral health status and self-assessed data on related oral risk factors in adults were measured in English language using modified World Health Organization (WHO) assessment form[18] and self-reported standardized oral health questionnaire for adults 2013.[18]


The procedures followed were in accordance with the Helsinki Declaration of 1975, as revised in 2000.[19]


Statistical analysis was done utilizing Statistical Package for Social Sciences Software (SPSS version 20.0), statistical data 2011 SPSS, Inc., an IBM company, Armonk, New York, USA.[20] Descriptive statistics were carried out for the demographic variables. Chi-square test was used to associate the prevalence of dental caries and periodontal disease of study population with variables. Comparison of mean scores of the variables based on gender was assessed using ANOVA. Statistical significance was set at p < 0.05.

   Results Top

A total of 801 diabetic patients, comprising of 375 (46.8%) males and 426 (53.1%) females formed the study population. A majority of the study subjects were residing in urban area (94%) and belonged to the age group of 50-59 years (24.7%). Based on the years in school, 358 (44.7%) subjects had 11+ years of schooling. However, a considerable number of subjects (24.7%) did not attend the school.

The total mean DMFT (Decayed, Missing Filled teeth) and root caries recorded for the study subjects was found to be 13.25 ± 11.0 and 3.12 ± 7.4, respectively. Gender wise distribution revealed that, though females (9.83 ± 9.4) had higher mean score for decayed component compared to males (8.88 ± 9.5), it was not statistically significant. On the other hand, higher mean scores were noticed for missing (5.1 ± 8.8) and filled components (0.27 ± 1.0) among male subjects compared to females (2.38 ± 5.5; 0.16 ± 0.8, respectively). Furthermore, it was noticed that only the missing component of DMFT was significant based on gender. When root caries was taken into consideration, it was noted that females had significantly higher mean scores compared to males (4.44 ± 9.0, 1.63 ± 4.6, respectively P = 0.0001*) [Table 1].
Table 1: Distribution of study subjects based on mean scores of Decayed, Missing, and Filled teeth (DMFT) and Root caries according to the gender

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Around 82% and 68% of study population had gingival bleeding and periodontal disease, respectively. Gender wise distribution revealed significant difference for gingival bleeding with females (87.3%) having a higher score (P = 0.0001*). On the other side, a comparable number of both males and females had healthy periodontium [Table 2]. On the basis of loss of attachment, the mean number of sextants with no loss of attachment was mostly noted among female subjects (20.30 ± 11.5) and was statistically significant (P = 0.01*). Likewise, except for Code “3” (9-11 mm), the attachment loss was also higher among females, it was not statistically significant [Table 3].
Table 2: Number and percentage of study subjects with healthy gingival and periodontal conditions based on gender

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Table 3: Distribution of mean number of teeth present with loss of attachment according to gender

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In this study, 95% of subjects did not have any oral mucosal conditions. The most common oral mucosal condition observed among both males (3.5%) and females (2.8%) was leukoplakia. A low but comparable number of males (0.2%) and females (0.2%) had candidiasis. Furthermore, on a positive note none of the female subjects and only 0.2% of male subjects reported having ulceration and abscess, respectively [Table 4].
Table 4: Distribution of study subjects based on oral mucosal conditions according to gender

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On a significant note, more than half of the study population experienced difficulty in biting or chewing food (81.7%), embarrassed about the appearance of teeth (70.1%), felt tensed (61.6%), and avoided smiling (60.5%) because of the problem with the teeth. Based on gender, significantly higher proportion of male subjects felt it often (54.9%, 36.5%, 28.7%, 22.9% respectively) in comparison to females (45.5%, 21.3%, 17.3%, 13.1%, respectively) [Table 5]. Similarly, more than half of the study population also experienced interrupted sleep (55.7%), loss of days at work (55.6%), difficulty in undertaking usual activities (57.2%) and social activities (63.5%) because of their teeth, wherein significantly higher proportion of males experienced the above problems [Table 6].
Table 5: Percentage of respondents experiencing difficulty biting/chewing foods, embarrassed about the appearance of teeth, felt tense mouth, and avoided smiling because of their teeth during the past 12 months

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Table 6: Percentage of respondents experiencing interrupted sleep, days not at work, experiencing difficulty in undertaking usual activities and diminished participation in social activities because of their teeth during the past 12 months

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Most of the study subjects perceived their teeth and gums status as being “average” (27.7%, 22.6%, respectively) and very few study subjects reported them to be excellent (1.4%, 0.7%, respectively). In comparison with their counterparts, significantly higher proportion of males perceived their teeth and gums to be good (17.9%, 19%, respectively). Majority of the study subjects (86.6%) claimed using toothbrush as their main oral hygiene aid, 18.2% reported using wooden toothpicks, 16.5% of subjects used charcoal and 15.6% of study subjects used chewsticks/miswak, respectively. Based on gender, significantly higher percentage of males (90.9%) reported the use of toothbrush and wooden toothpicks (19.2%) compared to females (82.9%, 17.4%, respectively) (P = 0.001*). On the other hand, significantly higher percentage of females (18.5%) used chewstick/miswak compared to males (12.3%) (P = 0.01*).

Amongst the population, most of the subjects (105; 13.1%) didn't visit the dentist for the last five years. Around 9.6% of study subjects visited dentist in the last six months. Furthermore, 8.1% of the subjects visited dentist between 1 and 2 years, with a higher representation of males (10.9%).

Tobacco usage was more predominantly seen among males (31.2%) in this study population. Likewise, a higher proportion of males consumed cigarettes (31%), several times in a day compared to their counterparts (15.7%). Around 4.5% of males and 2.5% of females reported using pipe several times in a month. Furthermore, snuff was not consumed on daily basis by the present study population.

   Discussion Top

The World Health Organization (WHO) Executive Board has acknowledged the intrinsic link between oral health, general health, and quality of life. It has been suggested that oral health is a neglected area of global health.[21] A healthy oral cavity not only enables nutrition of the physical body, but also enhances social interaction and promotes self-esteem and feelings of well-being.[22] In recent times, chronic diseases have emerged as the major cluster of health concerns that are driven by forces which include ageing, rapid unplanned urbanization, and globalization of unhealthy lifestyles.[23] According to the United Nations resolution, Diabetes Mellitus has been marked as the most common and one of the major public health challenges of the twenty-first century.[24]

Literature review[8],[9],[10],[11] has shown the detrimental effects of diabetes on systemic as well as on the oral health. Evidence supports a dose-dependent role between periodontitis and diabetes mellitus with a bidirectional relationship.[25] For example, diabetes increases the risk and hastens the progression of periodontal disease, and on the other hand, periodontal disease hinders glycemic control, creating a vicious cycle that may worsen both the diseases.[26] Research has revealed that in diabetic patients the risk of periodontitis is 2-3 times more than their healthy counterparts.[26]

Very few studies[27],[28] have investigated the prevalence of dental caries and root caries in diabetic patients exclusively. Recognizing this importance, the present study was undertaken to assess and compare the oral health status and related oral health risk factors among diabetic patients in Hyderabad and Secunderabad.

In order to maintain standardization and permit international comparisons, WHO proforma[18] was utilized. It also provides the essential information on self-assessment of oral health and socio behavioral risk factors.

The current study revealed that more than half of the study population (83.8%) had more than 20 natural teeth with mean number of 28.35 ± 7.3, which was higher compared to the southern Thailand diabetic population[27] (21.7 ± 0.5).

In the present study, high prevalence of dental caries (87%) was observed among the study population. These findings support the research done among diabetics in United States (81%)[29] and southern Thailand[27] (83.8%). This could be because diabetic patients may have high salivary glucose level favoring the propagation and accumulation of microorganisms on tooth surface. Also, in the diabetes, the executing tendency of neutrophils is lowered, thereby accelerating the microbial activity and thus maximizing the risk of tooth decay.[25]

The mean DMFT of the study population was 13.25 ± 11.0. On the other hand, a slightly higher DMFT score was observed in a study done by Bacic M et al. among Zagreb diabetic population[28] (17.7 ± 6.9) which could be due to the differences in the life styles, dietary habits and socio-cultural activities. Diabetic patients may have frequent meals than the normal subjects and repeated intakes of even small amounts of carbohydrates might be cariogenic.[30] This could account for higher mean score for the decayed component (9.38 ± 9.7) in the present study. On the contrary, a lower mean score for the decayed component was observed by Hinato et al. among southern Thailand diabetic population[27] (3.8 ± 0.2).

Literature studies[27],[31],[32] have suggested that exposed root surface are more vulnerable to demineralization indicating a higher incidence of root caries in type 2 diabetic subjects. These may be related to higher glucose level in secretory fluids, e.g. saliva and gingival crevicular fluid (GCF), stimulating the root surface plaque to an increased saccharolytic activity and acid production.[32] Thus, in the present study, significantly higher root caries mean score (3.12 ± 7.4; P > 0.0001*) was obtained. However, in study done among Gullah African diabetic population[32] (1.3 ± 2.5), lower mean scores for the root caries were observed.

Dental literature has shown diabetes as a risk factor for gingivitis due to impaired synthesis of collagen and glycosaminoglycans by gingival fibroblasts, increased crevicular fluid collagenolytic activity and reduced function of granular neutrophils.[33] The above could be the reason for the higher prevalence for gingivitis (84%) in the present study.

Numerous studies[26],[31],[32] have found a higher prevalence of periodontal disease among diabetic patients than among healthy controls. An increase in micro vascular permeability and more extensive signs of gingival inflammation and long-term cytokine—mediated immune response can lead to severe periodontitis among diabetics. In the present study, around 22% of the total population reported having 4–5 mm of pocket depth. This was in accordance with the study done by Perrson RE[34] among US population (21.1%).

In contrast to the study done by Alhabashneh et al.[35] among Jordan diabetic population, the results of present study revealed no significant difference based on gender with regard to the loss of attachment. Furthermore, around 68% of the study subjects had an attachment loss of >5 mm which may be due to the fact that the glucose-mediated advanced glycation end products (AGEs) accumulation, thereby impairing the chemotactic and phagocytic function of polymorphonuclear leukocytes. Additionally, when AGE-protein binds to its macrophage receptors, the production of IL-1 and TNFα is induced, thereby leading to periodontal attachment loss among diabetics.[36]

Patients with diabetes have an increased incidence of oral mucosal lesions, which may be explained by the immunocompromised state, reduced salivary flow and salivary buffering capacity.[37] Surprisingly, only 1% of study subjects of the existing study had candidiasis. Similar results were observed in a study conducted by Arrieta-Blanco JJ et al. among Madrid diabetic population[38] (1%).

The present study results reported that most of the diabetic subjects had brushed their teeth twice daily (71.8%). This was similar to the study conducted by Commisso L et al.[33] among Italian diabetic population where 72% of the subjects brushed twice daily. However, a lower frequency of tooth brushing was observed among diabetic population of Michigan (31.5%)[37] and Mangalore[39] (62%).

A significant difference was observed with regard to the dental visit (P = 0.01), wherein, around 56% of the study subjects did not visit dentist in the last one year. For majority of the participants, the main reason for visiting a dentist was due to pain (23.7%) followed by the treatment (19.2%). This reflects a treatment-based visit rather than a preventive care.

In the present study, a significant proportion of the respondents (86%, P = 0.001) used toothbrush as their oral hygiene aid and significantly higher percentage of females reported the usage of fluoridated toothpaste (17.8%) compared to their male counterparts (P = 0.013*). On the other hand, only 7% of the study subjects used dental floss indicating a lapse in the knowledge regarding the inter proximal cleaning or inadequate efforts to maintain their oral hygiene.[35] These findings were in congruence with Jordan[35] and Warwickshire[29] diabetic population where the usage of dental floss was 7% and 6.3%, respectively.

Alarmingly, about half of the study population had smoking habit (47.2%) which could be an increased risk for periodontal disease in this study. This was in agreement with a study conducted by Jansson H et al.[40] among Swedish diabetic population (67%).

Though, the present study tried to establish a relationship between diabetes and poor oral health, it has certain limitations such as cross-sectional study design and the self-reporting nature of the questionnaire. The current study did not include the duration of diabetes among the study subjects, as well as the assessments of blood sugar levels (i.e. HbA1c levels), thus the level of diabetic control could not be confirmed.

   Conclusion Top

In the present study, gingivitis was seen in higher percentage (82%) among the study population whereas the presence of periodontal disease was found to be relatively low (68.3%). Likewise, an attachment loss of > 5 mm was recorded among small proportion of population (36.3%). On a positive note, 95% of subjects did not have any oral mucosal conditions. Gender wise distribution revealed higher mean scores for untreated caries (9.83 ± 9.4) and root caries (4.44 ± 9.0) among female diabetic patients. On the contrary, male subjects had higher mean scores for missing (5.1 ± 8.8) and filled components (0.27 ± 1.0). Based on the present study results, it can be concluded that diabetic subjects may have poor oral health.


I would like to thank all the subjects who willingly participated in the study.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Full text]  
Jansson H, Lindholm E, Lindh C, Groop L, Bratthall G. Type 2 diabetes and risk for periodontal disease: A role for dental health awareness. J Clin Periodontol 2006;33:408-14.  Back to cited text no. 40

Correspondence Address:
Dr. Mukkavilli Madhuri
Department of Public Health Dentistry, Panineeya Institute of Dental Sciences and Research Centre, Road No. 5, Kamala Nagar, Hyderabad, Telangana - 500 044
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijdr.IJDR_508_18

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  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]


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