“We need to pay attention to the complications of poor oral health (eg, periodontal disease and tooth loss) and diabetes,” said study coauthor Bei Wu, PhD, Pauline Gratz Professor of Nursing and Professor of Global Health, Duke University School of Nursing, Durham, NC. “There is a potential bidirectional relationship between poor oral health and diabetes. Diabetes can cause the inflammation of the periodontal disease. On the other hand, if a patient has periodontal disease, which is manifested by infection and inflammation, he/she will run into difficulty with glycemic control.”
Tooth Loss Rates Increased Faster in Non-Hispanic Blacks
The study sample included 37,609 patients (aged ≥25 years) with at least 1 permanent tooth. Tooth loss increased with age (Figure 1), but the rate of increase was higher among people with diabetes and varied by race/ethnicity. Among people with diabetes, tooth loss increased faster in non-Hispanic blacks than in non-Hispanic whites (z=4.05, P<0.001) or in Mexican Americans (z=4.38, P<0.001).
The rate of tooth loss increased faster with age among non-Hispanic whites with diabetes than among their counterparts without diabetes (z = 2.73, P=0.01). In contrast, no significant difference was found between those with and without diabetes among non-Hispanic blacks and Mexican Americans.
Emphasizing the Importance of Oral Health in Diabetes Care Is Essential to Care
“In the words of the former Surgeon General C. Everett Koop, ‘You are not healthy without good oral health,’” Dr. Wu noted. “Oral health problems can cause pain and suffering and make speaking, chewing and swallowing difficult.”
“It is important to improve patients’ oral health knowledge, improve self oral hygiene care, and establish a pattern for regular dental visit,” Dr. Wu said. “It would be great if physicians can think about referring diabetic patients to seek dental care.”
Call for More Research
“The relationship between oral health and diabetes is complex,” Dr. Wu noted. “Our study is not a longitudinal study, and therefore, we can only examine the association between tooth retention and diabetes. More research is needed to further examine this complex causal relationship. In the future, we hope that dental care will be an integrated part of medical care, and dental insurance will become a part of the medical insurance.
Commentary by Edmond R. Hewlett, DDS
Spokesperson from the American Dental Association
Professor, Section of Restorative Dentistry & Associate Dean of Outreach and Diversity, UCLA School Of Dentistry
Los Angeles, California
Researchers at Duke University have shed light on two important and timely health issues: (1) the connections between oral (dental) health and overall health, and (2) health disparities—the degree to which diseases can affect some racial/ethnic groups more severely than others. This study specifically examines and compares tooth loss between adults with and without diabetes among samples of non-Hispanic white, non-Hispanic black, and Mexican-American populations. The researchers correctly point out that the number of adults in the United States with diabetes has increased rapidly over the past two decades, and that the disease is far more common among non-Hispanic blacks and Hispanics than non-Hispanic whites. In addition, other studies have indicated a two-way relationship between diabetes and periodontal (gum) disease, ie diabetes can increase the risk of having periodontal disease (which can result in tooth loss), and periodontal disease can complicate the control of diabetes in people with diabetes.
The Duke research team analyzed large sets of data from multiple U.S. national health surveys (NHANES), which included oral examinations on over 37,000 individuals conducted between 1971 and 2012. Several noteworthy findings were reported that were consistent with trends suggested by earlier studies with smaller sample sizes: higher rates of diabetes were found among non-Hispanic blacks and Mexican-Americans vs. non-Hispanic whites; adults with diabetes were more likely to have lower income and education levels than those without diabetes; adults with diabetes were generally older than those without diabetes. With respect to tooth loss, the results showed that having diabetes does indeed increase the risk of losing teeth, with non-Hispanic blacks having higher risk of tooth loss than non-Hispanic whites and Mexican-Americans. Other studies suggest that a number of factors, including access to dental services, attitudes about the importance of routine dental care, limited awareness about dental care, and overall health contribute to the challenges facing non-Hispanic blacks. Lower access to dental care may be a contributing factor in the higher tooth loss and, by extension, potential for more difficult management of diabetes, among non-Hispanic blacks.
The findings of this study illustrate the importance of regular dental visits and good home care of the teeth and gums in the management of diabetes—good oral health is part of good overall health. The study also reflects the importance of access to dental services as a matter of public health.
January 12, 2016
Luo H, Pan W, Sloan F, Feinglos M, Wu B. Forty-year trends in tooth loss among American adults with and without diabetes mellitus: an age-period-cohort analysis. Prev Chronic Dis. 2015;12:150309.