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 Table of Contents  
Year : 2022  |  Volume : 9  |  Issue : 3  |  Page : 249-256

Bidirectional Relationship between Oral Health and Diabetes Mellitus: A Knowledge, Attitude, and Practice Survey

1 Faculty of Dentistry, Jamia Millia Islamia, New Delhi, India
2 Department of Oral Pathology and Microbiology, Faculty of Dentistry, Jamia Millia Islamia, New Delhi, India

Date of Submission29-Jul-2022
Date of Decision25-Sep-2022
Date of Acceptance10-Oct-2022
Date of Web Publication14-Nov-2022

Correspondence Address:
Deepika Bablani Popli
Department of Oral Pathology, Faculty of Dentistry, Jamia Millia Islamia, Maulana Mohammad Ali Jauhar Marg, Jamia Nagar, New Delhi - 110 025
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jdrr.jdrr_113_22

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Background: Diabetes mellitus is a chronic disease, known to be associated with several oral complications. A less well-known, but proven bidirectional relationship exists between diabetes and oral health, where one affects the other. Previous studies have shown a lack of awareness about this two-way relationship. This Knowledge, Attitude, and Practice (KAP) study was undertaken to identify the gaps in awareness about diabetes mellitus and its association with oral health. Objectives: The objective of this study was to evaluate and compare the KAPs of diabetics and nondiabetics (ND) regarding the bidirectional relationship between diabetes and oral health. Methodology: This study was conducted at a tertiary dental care institute wherein 75 diabetics, both Type I and II and 75 ND were enrolled. A questionnaire was administered by the investigators, in which responses to various questions regarding their demographics, KAPs in the context of oral health and diabetes were collected. The Chi-Square test was utilized for statistical analysis. Results: 27.3% of respondents had no knowledge about the bidirectional relationship between diabetes and oral health. Although the majority (69.3%) considered regular dental check-ups to be important for good oral health, they were found to be lacking in their practices, where 51.3% followed once a day brushing routine and 71.3% did not know about flossing or interdental cleaning. Conclusion: The study highlights the gaps in KAPs of people regarding the bidirectional relationship between diabetes and oral health and thus emphasizes the need for educational interventions at the community level.

Keywords: Attitude, Bidirectional relationship, diabetes mellitus, knowledge, attitude, and practices, oral health, practice

How to cite this article:
Shrivastava PK, Uppal S, Popli DB, Sircar K. Bidirectional Relationship between Oral Health and Diabetes Mellitus: A Knowledge, Attitude, and Practice Survey. J Dent Res Rev 2022;9:249-56

How to cite this URL:
Shrivastava PK, Uppal S, Popli DB, Sircar K. Bidirectional Relationship between Oral Health and Diabetes Mellitus: A Knowledge, Attitude, and Practice Survey. J Dent Res Rev [serial online] 2022 [cited 2023 Jan 30];9:249-56. Available from: https://www.jdrr.org/text.asp?2022/9/3/249/361133

  Introduction Top

Diabetes mellitus (DM) is a chronic debilitating disease affecting 366 million people around the world.[1] With a prevalence of 10.4% as per World Bank data in 2019, India is the Diabetes capital of the world.[2] It is estimated that the prevalence of DM will touch the 69.9 million mark by 2025 and 80 million by 2030.[3] Diabetes, particularly uncontrolled DM is associated with several systemic complications such as cataracts, nephropathy, peripheral neuropathy, and delayed wound healing.[4] Apart from the systemic complications, diabetes is also known to negatively impact affect the oral health of an individual.[5]

A bidirectional or dual adverse relationship has been reported between periodontal disease and DM. According to this theory, poor glycemic control in diabetic patients is related to increased severity of periodontal diseases and on the other hand, periodontal disease can derange glycemic status, aggravating the diabetic status of an individual.[6],[7] Therefore, maintaining good oral hygiene and periodontal health can contribute toward good glycemic control in diabetics.[5],[8]

A brief review of the literature revealed that public awareness about the relationship between oral health status and glycemic control in DM is limited. Therefore, this study was planned to evaluate the knowledge, attitude, and practices (KAP) among people with respect to the association of oral health and DM. The evidence generated by this study will form a basis for planning intervention programs, to increase awareness among people regarding the bidirectional relationship between oral health and diabetes.

  Methodology Top

This was an observational cross-sectional study carried out in a tertiary dental care institute over a period of 3 months after obtaining the approval of the Institutional Ethics Committee (1/9/342/JMI/IEC/2021). Written informed consent was obtained from all the participants.

All individuals above the age of 18, visiting the institute, either as patients or as accompanying persons were selected as subjects for the study. The participants were divided into two groups of diabetics and nondiabetics (ND). Individuals who “self-reported” as having been diagnosed with diabetes mellitus were designated “Group A” and the individuals with no previous history of diabetes mellitus were designated as “Group B.” The exclusion criterion was defined as any condition due to which the participants were unable to or not willing to participate in the study. All individuals entering the institute were approached by the investigators in the waiting area of institute between 9:30 am to 10:30 am. This time of the day was selected as an appropriate hour for data collection due to the maximum inflow of patients.

Informed consent was obtained from all the individuals who agreed to participate in the study. The enrolment continued until a target population of 75 self-reported diabetics and 75 ND was reached. A validated close-ended questionnaire was adapted from Gupta et al. and modified as per the requirements for the survey.[9] This four-part questionnaire was administered by the investigators. The first part of the questionnaire contained the demographics, any history of diabetes, and the self-reported average range of blood sugar of the participant. The second part included questions to determine the knowledge of the participant, the third part about attitude, and the fourth part about the practices followed by the participant [Table 1]. Any clarifications needed on the part of the participants were addressed by the investigators.
Table 1: Demographics of participants (n=75)

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The sample size was taken as 150, which included 75 self-reported diabetics, both Type I and Type II, and 75 ND. This calculation was reached using standard statistical formulae based on the prevalence of diabetes in India. The data used were infinite due to the variability of patient encounters on the campus. For a confidence level of 95%, the margin of error encountered for this sample size was ± 4.2%.

For Unlimited population: [INLINEL:1][10]


n = 150

z = 1.96 (for 95% confidence level)

p = 0.078 (based on the WHO data of 2016 on “prevalence of diabetes in India”)[11]

∈ = 4.2%

Since the data were in count form, the responses obtained to the questionnaire were subjected to Chi-square test using Minitab software to compare the responses of diabetics and ND. The level for significance was set at P ≤ 0.05. Descriptive statistics were used to report the individual responses of each group.

  Results Top

Among 150 participants, 75 were diabetics and 75 were ND. Maximum participants (46%) were under the age group 40–59 years, followed by 38.7% under the age group 18–39, and 15.3% were more than 60 years of age. Males were more than females, with a male: female ratio of 89:61. Most of them were graduates and above (57.3%) and with a fasting blood sugar level of 70–100 mg/dl (34%). A detailed demographic status of the participants is represented in [Table 1].

Concerning the knowledge part of the survey, majority of respondents, i.e., 61.3% (n = 92) were aware of the normal fasting blood sugar level (70–110 mg/dl). 16% of participants considered normal blood sugar levels to be below 70–110 mg/dl and 20% were not aware of the normal fasting blood sugar level. Maximum respondents, i.e., 64.7% (n = 97) chose kidney failure as the most common systemic complication of DM, followed by delay in wound healing (63.3%). The least recognized systemic complication was Stroke or cerebrovascular attack (20%). However, 10.7% of the respondents were not sure about the systemic complications of DM [Figure 1]. Regarding the symptoms experienced in diabetes, 67.3% of participants identified increased thirst and hunger as the most common symptom experienced in diabetes, followed by an increased frequency and burning sensation in urine (58%), and effect on vision (54%). About 50.7% of the participants responded that diabetes could cause oral complications and 18.7% responded that diabetes does not cause any oral complications. Moreover, 30.7% were unaware of the potentiality of diabetes to cause oral complications. When asked to identify the oral manifestations of DM, 38% of the participants considered delayed wound healing in the oral cavity as the most common oral symptoms followed by mouth dryness, gum inflammation, and recession [Figure 2].
Figure 1: Responses to the knowledge of participants about systemic complications of diabetes

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Figure 2: Responses to the knowledge of participants about the oral manifestations of diabetes

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Regarding the bidirectional relationship between DM and oral health, most of the respondents (32.7%) were able to identify only a one-way relation between diabetes and oral health that controlling our blood glucose levels could help improve oral health but not the other way around (3.3%), that poor oral health can affect glycemic control. Moreover, 27.3% were completely unaware of any relationship between diabetes and oral health. A significant difference (P = 0.000) between the two groups was found regarding the normal fasting blood sugar level. However, the difference in knowledge between the two groups was not found to be significant for oral complications of diabetes (P = 0.229) and the bidirectional relationship between diabetes and oral health (P = 0.144) [Table 2].
Table 2: Comparison of knowledge of diabetics and nondiabetics through Chi-square test (n=75)

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In relation to the attitude, a vast majority of people (69.3%) believed that one should go for a regular dental check-up and not only when the symptoms were found compelling. For reason to visit a dentist, 52.7% of the respondents felt that diabetics should go for a regular 6-month check-up and 37.3% felt that diabetics should visit a dentist only for dental problems like pain, bleeding gums, etc. Moreover, 78% of the respondents felt that oral complications of diabetes are a cause of concern and one should get it checked by a dentist. A compelling majority (94%) considered the education of oneself and others, an important factor for maintaining good oral hygiene in diabetes. 82% believed that diabetics should be more cautious about their oral health and maintain better oral hygiene than a person without diabetes. A mixed response was observed when the respondents were asked whether brushing twice daily, flossing, and maintaining good oral hygiene could help control diabetes, with 42% in agreement and 30.7% disagreeing with it.

Chi-square test comparing the attitudes of the diabetic and nondiabetic group revealed that the difference in attitude toward diabetics being more cautious about their oral health (P = 0.006), the reason for a diabetic to visit a dentist (P = 0.01), oral complications of diabetes being a cause of concern (P = 0.00), and control in diabetes by the maintenance of a good oral hygiene (P = 0.003) was statistically significant. However, the difference in attitude toward regular dental check-ups was not statistically significant (P = 0.479) [Table 3].
Table 3: Comparison of the attitude of diabetics and nondiabetics through Chi-square test (n=75)

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Regarding practices of diabetics and ND toward oral health, a mixed response was obtained. When asked about their last visit to a dentist, 31.3% of the respondents had last visited the dentist more than a year back. However, 8.7% of the people had never visited a dentist. When asked about the practices that need to be followed by diabetics to maintain their oral health, an overwhelming majority of the participants (89.3%) considered brushing twice daily with fluoride toothpaste as the key practice required to maintain good oral hygiene, followed by rinsing after every meal (54%). However, only a small percentage of the population (24%) considered interdental brushing essential for good oral hygiene [Figure 3].
Figure 3: Responses to the practices that should be followed by diabetics to maintain their oral health

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Regarding the frequency of brushing in a day, 51.3% of the respondents brushed twice daily. However, a large portion (47.3%) followed the practice of brushing only once daily. Most of the participants (71.3%) did not have any idea about flossing, and only 18% of them considered flossing once each day important for oral health. In addition, 49.3%of the respondents changed their toothbrush once every 3–5 months and about 26.7% changed their toothbrush only after it got damaged.

When asked about how diabetics can keep their blood sugar levels under control, the majority of them recognized dietary modifications and exercise/physical activity as crucial for maintaining blood sugar levels. However, only a small portion considered oral hygiene measures as a means to control blood sugar levels [Figure 4].
Figure 4: Responses to the practices that should be followed by diabetics to keep their blood sugar levels in control

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The Chi-square test revealed that the responses of both groups regarding their last visit to a dentist were not statistically significant (P = 0.346). However, a significant difference was found in the practices of the two groups when asked about the frequency of brushing (P = 0.005) in a day [Table 4].
Table 4: Comparison of practices of diabetics and nondiabetics through Chi-square test (n=75)

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  Discussion Top

In 2021, the prevalence of diabetes mellitus across the world was estimated to be around 10.5% of the global adult population. The per capita financial burden due to DM was estimated to be around 12,000 USD in the US and approx. 10,000 INR in India.[12],[13] This data creates a strong case for public health policies, incorporating active programs and educational interventions to reduce the financial burden of the disease and minimize the impact of the disease on the general and oral health of the individual. The bidirectional, dual adverse relationship between DM and periodontal diseases, which proposes a two-way link between DM and periodontal health, wherein one condition affects the other has been reported in several studies.[1],[7],[14],[15] This KAP survey on the bidirectional association of DM and oral health was undertaken with the aim of identifying the gaps in KAPs of diabetic and nondiabetic people so that appropriate public health intervention and education programs can be designed to manage the burden of the disease efficiently at a community level.

Periodontitis is a well-recognized complication of DM.[16] The various mechanisms by which diabetes can aggravate periodontitis include changes in oral microflora, changes in the host response, altered wound healing, and changes in the microvascular integrity in DM which further precipitates periodontitis.[17] It has been observed that diabetic patients show a higher degree of gingival recession, tooth mobility, and other oral manifestations when compared with ND.[18] Earlier studies have also pointed toward increased cariogenic bacteria and plaque formation in diabetes.[19] Several studies have reported that periodontitis is associated with higher HbA1c levels in type-2 diabetes patients as well as in ND.[17],[20] In fact, improved glycemic control in diabetics is reported after undergoing periodontal treatment such as scaling and root planing.[20]

The accumulation of hyperglycemia-mediated nonenzymatic advanced glycation end products (AGEs) is believed to underlie the reported bidirectional association of DM and periodontitis. These AGEs affect the migration and phagocytic activity of mononuclear and polymorphonuclear phagocytic cells leading to the establishment of a more pathogenic sub-gingival flora, plaque accumulation and subsequent connective tissue, and alveolar bone degradation.[15] In addition, periodontitis is associated with elevated levels of inflammatory cytokines like C reactive protein, IL-6, and fibrinogen, which have also been reported to adversely affect the glycemic status of an individual. Studies by Teeuw et al. have established that treatment for periodontal disease leads to improvement of the HbA1c levels in Type 2 diabetic patients by resolving the inflammation locally and reducing the serum level of these inflammatory markers that cause insulin resistance.[21] Hence it can be extrapolated that maintaining good periodontal health, through appropriate oral hygiene practices and by treatment of periodontal disease can help diabetics to improve their glycemic control.[22]

The evaluation of knowledge of the topic, among participants in this study, revealed a significant difference (P = 0.000) between the two groups in relation to the normal blood sugar level with diabetics being more aware of the normal fasting blood sugar levels. The most recognized systemic complications of diabetes were “Kidney disease,” and “Delay in wound healing,” whereas “Stroke,” and “Diabetic Ulcers,” which are common complications of DM were the least recognized.[23] Approximately, 40% of the total respondents had no knowledge of any oral manifestations of diabetes. These findings were consistent with the results of another study, where more than half of the total study participants, comprising diabetics and ND, had only a moderate level of awareness about the relationship between oral health and diabetes.[24]

Our study revealed that ND had a more positive attitude toward the role of oral health care with respect to the management of diabetes mellitus, possibly because the ND were younger than the diabetics and thus were more motivated toward adopting healthy lifestyle practices.[25] However, both diabetics (n = 53) and ND (n = 34), were doubtful about the role of oral hygiene practices in controlling blood sugar levels. Gupta et al. observed that only 33% of diabetics brought changes into their lifestyle after being diagnosed with DM.[9]

The results of our study showed that there is a general lack of awareness among study participants about practices, such as interdental cleaning, flossing, etc., that should be followed to maintain good periodontal health. A statistically significant difference (P = 0.005) was noted between the two groups, with respect to the frequency of daily brushing, with only 38.6% ND following the twice daily brushing routine as compared to 64% of diabetics who brushed their teeth twice daily. Some studies have reported that there is no significant difference between diabetics and ND with respect to the practices followed to maintain good oral health, while others have found that diabetics are less likely to brush and floss regularly as compared to the group without diabetes which is consistent with our findings.[18],[24] These studies are in line with our results that reflect a significant lack of knowledge about the importance of maintaining good oral health in diabetics.

Limited awareness about oral health risks in diabetics, inadequate knowledge, poor attitude, and fewer dental visits among diabetics have been reported in studies carried out in Britain and the USA, which highlights the universality of the gap that exists among the general public about the bidirectional relationship of DM and periodontitis and thus mandates future interventions in the area at a global level.[26],[27] Community-level programs by dental health professionals which incorporate general lifestyle changes along with instructions on the maintenance of oral health can play a significant role in increasing awareness. Dental health professionals are a primary source for information related to the association of diabetes and oral health status.[28] Thus, the promotion of appropriate oral health care etiquette by dental surgeons is essential to increase public awareness about the association of periodontitis and diabetes mellitus.

Our study was carried out among people visiting a tertiary dental hospital and hence may not be fully reflective of the KAP status in the community. However, our results seem to suggest, that the KAP status would be even poorer in the general public. We included “self-reported cases” in the diabetic group, and by default may have excluded undiagnosed cases. The study included all self-reported cases of diabetes and no distinction between Type I and Type II DM was made. Our study did not try to analyze the difference in KAP on the basis of differences in socioeconomic status. These limitations of our study may induce a positive bias, but it is evident that there is a significant lack of awareness about the association of DM with oral health, particularly periodontitis.

There is a definite need for public health measures to address the gap in KAPs with respect to the dual adverse association of DM and oral health, specifically periodontitis so that the burden of diabetes, as well as oral diseases in the community, can be reduced.

  Conclusion Top

This KAP study highlights the knowledge gap among both diabetics and ND in the community regarding the bidirectional dual adverse relationship between diabetes mellitus and oral health. This lack of awareness finds reflection in the attitude of the general public toward maintaining good oral health and further in the practices followed to meet that end. As primary health professionals, dental surgeon has a very important role to play in increasing the level of awareness in the community and thus helping to decrease the burden of diabetes mellitus and periodontitis.

Ethical statement

The study was approved by the Institutional Ethics Committee of Jamia Millia Islamia under approval number 1/9/342/ JMI/IEC/2021.


Mr. Dhruv Dar, Former Director, the American Society for Quality (India), contributed to the statistical analysis of the results.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

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  [Figure 1], [Figure 2], [Figure 3], [Figure 4]

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


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