Self-reported oral health and quality of life in patients with type 2 diabetes mellitus in primary care: a multi-center cross-sectional study

Figures & data

Figure 1 Flowchart of recruitment of family physician offices and inclusion of patients with diabetes mellitus type 2. ^aInclusion criteria: 1) ≥18 years; 2) diagnosed with T2DM; 3) follows the standardized primary care protocol, including an annual examination; 4) understands spoken and written Dutch. ^bMain reasons for not participating in the study: lack of time and routine of the nurse practitioners and/or family physicians; financial issues for certain patients; disinterest and lack of motivation of certain patients; dental anxiety.

Table 1 Patient characteristics (total study population, n=764)

Characteristic
Age (years) (n=763)			65.9±10.7
Age groups (n=763)
	30–39		7 (0.9)
	40–41		49 (6.4)
	50–59		145 (19.0)
	60–69		262 (34.3)
	≥70		300 (39.3)
Sex (n=763)
	Male		426 (55.8)
	Female		337 (44.2)
Ethnicity (n=518)
	Western-European		400 (77.2)
		Dutch	396 (76.4)
		Other	4 (0.8)
	Other		118 (22.8)
		Surinamese	59 (11.4)
		Indonesian	18 (3.5)
		Moroccan	14 (2.7)
		Other	27 (5.2)
Education (n=518)
	Primary		50 (9.7)
	Secondary		196 (37.8)
	Higher		272 (52.5)
Smoking (n=707)
	Yes		112 (15.8)
	No		595 (84.2)
Metabolic control (HbA1c) (n=715)
	Good (≤53 mmol/mol)		479 (67.0)
	Moderate (54–63 mmol/mol)		161 (22.5)
	Poor (≥64 mmol/mol)		75 (10.5)
Obesity (BMI ≥30 kg/m^2) (n=729)
	Yes		287 (39.4)
	No		444 (60.7)
Hypertension (SBP ≥140 mmHg) (n=729)
	Yes		269 (36.9)
	No		460 (63.1)
Dyslipidemia (LDL >2.5 mmol/L) (n=690)
	Yes		300 (43.5)
	No		390 (56.5)
Kidney dysfunction (eGFR <60 mL/min/1.73m^2) (n=682)
	Yes		142 (20.8)
	No		540 (79.2)
Retinopathy (n=450)
	Yes		18 (4.0)
	No		432 (96.0)
Diabetic foot risk (n=639)
	None (Simm’s 0)		457 (71.5)
	Moderate (Simm’s 1)		90 (14.1)
	High (Simm’s 2)		80 (12.5)
	Very high (Simm’s 3)		12 (1.9)

Notes: For each parameter, the number of subjects with available data is provided. Data are presented as mean±SD or n (%). Note: When the n for a variable differs from the overall patient population, this is the result of missing data. Percentages represent only non-missing data.

Abbreviations: SPB, systolic blood pressure; LDL, low-density lipoprotein; eGFR, estimated glomerular filtration rate.

Table 2 Self-reported oral health: dental care utilization and oral health complaints (n=764)

Question		n (%)
Do you have a dentist? (n=764)
	Yes	639 (83.6)
	No	125 (16.4)
Do you visit your dentist regularly? (at least once a year) (n=762)
	Yes	582 (76.2)
	No	180 (23.6)
Do you have dental insurance? (n=757)
	Yes	525 (68.7)
	No	232 (30.4)
How many teeth do you have? (n=757)
	More than 18	410 (53.7)
	±13–18	111 (14.5)
	±7–12	79 (10.3)
	±1–6	36 (4.7)
	None	121 (15.8)
Do you have a partial or full prosthesis? (n=759)
	No	414 (54.2)
	Partial	221 (28.9)
	Full	124 (16.2)
Do you sometimes suffer from pain in mouth? (n=764)
	Yes	113 (14.8)
	No	651 (85.2)
Do you sometimes suffer from a dry mouth? (n=764)
	Yes	285 (37.3)
	No	479 (62.7)
Do you sometimes suffer from bad breath? (n=764)
	Yes	90 (11.8)
	No	674 (88.2)
Any of the above (pain, dry mouth, bad breath) (n=764)
	Yes	378 (49.5)
	No	386 (50.5)

Notes: Data are presented as n (%). When the n for a variable differs from the overall patient population, this is the result of missing data. Percentages represent only non-missing data.

Table 3 Self-reported oral health: periodontitis related items (only dentate subjects; n=636)

Question		n (%)
Do you think you might have gum disease? (n=589)
	Yes	118 (20.0)
	No	471 (80.0)
Overall, how would you rate the health of your teeth and gums? (n=628)
	Poor	31 (4.9)
	Fair	199 (31.7)
	Good	320 (51.0)
	Very good	59 (9.4)
	Excellent	19 (3.0)
Have you ever had treatment for gum disease such as scaling and root planing, sometimes called “deep cleaning”? (n=606)
	Yes	188 (31.0)
	No	418 (69.0)
Have you ever had any teeth become loose on their own, without an injury? (n=628)
	Yes	111 (17.7)
	No	517 (82.3)
Have you ever been told by a dental professional that you lost bone around your teeth? (n=612)
	Yes	69 (11.3)
	No	543 (88.7)
During the past 3months, have you noticed a tooth that does not look right? (n=623)
	Yes	50 (8.0)
	No	573 (92.0)
Aside from brushing your teeth with a toothbrush, in the last 7days, how many times did you use dental floss or any other device to clean between your teeth? (n=626)
	1–7 days	482 (77.0)
	Never	144 (23.0)
Aside from brushing your teeth with a toothbrush, in the last 7days, how many times did you use mouthwash or other dental rinse product that you use to treat dental disease or dental problems? (n=626)
	1–7 days	227 (36.3)
	Never	399 (63.7)
Periodontitis screening tool
Periodontitis*
	Yes	407 (69.3)
	No	180 (30.7)

Notes: Data are presented as n (%). Note: When the n for a variable differs from the overall patient population, this is the result of missing data. Percentages represent only non-missing data. The questions presented here are the original questions developed by Eke et al.²⁶ The Dutch translations can be found in Appendix 2. *Estimated by applying screening tool.²⁸

Table 4 General health-related QoL (SF-36) of the study population (n=544), and compared to the general population from the Netherlands (n=1,742) and Amsterdam (n=4,172)

SF-36 concept scales	Current study^a	General population the Netherlands^b	General population Amsterdam^b
Physical functioning	75.0±23.5	83.0±22.8**	85.2±23.1
Social functioning	81.1±21.8	84.0±22.4*	85.1±21.5
Role limitations due to physical health problems	68.3±40.2	76.4±36.3**	79.5±35.4
Role limitations due to emotional problems	77.7±36.5	82.3±32.9*	83.1±32.7
General mental health	76.0±18.5	76.8±17.4	75.9±17.6
Vitality	64.8±19.8	68.6±19.3**	68.6±19.2
Bodily pain	74.4±24.3	74.9±23.4	80.5±24.4
General health perceptions	58.5±19.1	70.7±20.7**	71.3±20.8
Changes in health over time	52.7±19.9	n/a	n/a

Notes: Data are presented as mean±SD. Concept scales according to Ware et al.³¹ aBased on 544 participants that have filled in the SF-36 questionnaire completely. Partially completed and empty questionnaires were omitted from the analysis. ^bOne-sample t-tests were used to analyze differences between our study population and the general population from the Netherlands (n=1,742) and Amsterdam (n=4,172).³⁰ *p<0.01, **p<0.001

Table 5 Oral health-related QoL (OHIP-NL14) (n=640)

OHIP-NL14 subdomain^a	Mean ± SD^b	Impact, n (%)^b,c
Functional limitation	0.3±0.8	27 (4.2)
Physical pain	0.8±1.4	77 (12.0)
Psychological discomfort	0.5±1.2	44 (6.9)
Physical disability	0.3±0.9	28 (4.4)
Psychological disability	0.3±0.9	23 (3.6)
Social disability	0.2±0.7	19 (3.0)
Handicap	0.2±0.7	18 (2.8)
OHIP-NL14 total score	2.5±5.2	122 (19.1)

Notes: Data are presented as mean±SD or n (%). ^aSubdomains according to Slade.³³ bBased on 640 participants that have filled in the OHIP-NL14 questionnaire completely. Partially completed and empty questionnaires were omitted from the analysis. ^cFor the OHIP-NL14, an impact is defined as a response of at least “occasionally” within the specific subdomain.

Table 6 Oral health problems and oral health-related QoL (n=640)

Self-reported oral health problem		OHIP-NL14
		Severity, mean±SD	Impact, n (%)^a
Pain in mouth (n=640)
	Yes	5.1±7.4***	37 (38.9)***
	No	2.0±4.6	85 (15.6)
Xerostomia (n=640)
	Yes	3.0±5.7*	58 (24.6)**
	No	2.2±4.9	64 (15.8)
Bad breath (n=640)
	Yes	3.5±6.1**	22 (28.9)*
	No	2.3±5.1	100 (17.7)
Periodontitis (n=495)^b
	Yes	2.6±4.7***	77 (22.1)***
	No	0.8±3.4	9 (6.1)
Edentulous (n=634)^c
	Yes	3.6±7.0*	22 (22.2)
	No	2.3±4.8	98 (18.3)

Notes: Data are presented as mean±SD or n (%). Mann–Whitney U and chi-square tests were used to analyze differences between patients with and without self-reported oral health problems regarding OHIP-NL14 severity scores and impact, respectively. ^aFor the OHIP-NL14, an impact is defined as a response of at least “occasionally” within the specific subdomain. ^bBased on 495 participants for whom the periodontitis screening tool could be applied, and who had also filled in the OHIP-NL14 questionnaire completely. Partially completed and empty questionnaires were omitted from the analysis. ^cBased on 634 participants of whom it was known whether they were edentulous or not, and who had also filled in the OHIP-NL14 questionnaire completely. Partially completed and empty questionnaires were omitted from the analysis. *p<0.05, **p<0.01, ***p<0.001

Figure 2 General health-related QoL and oral health-related QoL. The general health-related QoL profile of patients from the current study with and without an impact in oral health-related QoL (defined as a response of at least “occasionally” within at least one OHIP-NL14 subdomain). As reference, the general population of the Netherlands and general Amsterdam population have been added to the figure.³⁰

Abbreviations: PF, physical functioning; SF, social functioning; RP, role limitations due to physical health problems; RE, role limitations due to emotional problems; BP, bodily pain; GH, general health perceptions; VT, vitality; MH, mental health; CH, changes in health over time.

Table S1 Explorative analysis of associations between patient characteristics, self-reported oral health and oral health-related QoL (n=764)

Characteristic		Oral complaint				Edentulous^a,b,g,i,j,k	Periodontitis^a	OHIP-NL14
		Pain	Xerostomia^c,e,h	Bad breath^a	Any^c			Severity^c,j	Impact^c
Demographics	Age
	30-39	1 (14.3)	3 (42.9)	4 (57.1)	4 (57.1)	0	2 (28.6)	3.5 ± 4.5	2 (50.0)
	40-49	10 (20.4)	18 (36.7)	14 (28.6)	26 (53.1)	2 (4.1)	27 (65.9)	4.4 ± 7.1	12 (32.4)
	50-59	19 (13.1)	52 (35.9)	22 (15.2)	67 (46.2)	3 (2.1)	91 (70.0)	2.7 ± 5.7	20 (17.7)
	60-69	49 (18.7)	101 (38.5)	30 (11.5)	145 (55.3)	37 (14.3)	157 (75.8)	2.5 ± 4.5	46 (20.4)
	≥70	34 (11.3)	111 (37.0)	20 (6.7)	136 (45.3)	79 (26.5)	130 (64.4)	2.1 ± 5.3	42 (16.2)
	Sex
	Male	55 (12.9)	149 (35.0)	50 (11.7)	205 (48.1)	60 (14.2)	241 (72.2)	2.7 ± 5.6	69 (18.8)
	Female	58 (17.2)	136 (40.4)	40 (11.9)	173 (51.3)	61 (18.3)	166 (65.6)	2.2 ± 4.7	53 (19.6)
	Ethnicity
	Western-European	64 (16.0)	151 (37.8)	39 (9.8)	198 (49.5)	65 (16.3)	215 (68.9)	1.9 ± 4.0	52 (14.5)
	Other	17 (14.4)	48 (40.7)	16 (13.6)	58 (49.2)	7 (6.0)	70 (70.7)	3.4 ± 6.5	26 (27.4)
	Education
	Primary	6 (12.0)	16 (32.0)	7 (14.0)	22 (44.0)	12 (24.5)	23 (69.7)	2.7 ± 6.1	8 (19.0)
	Secondary	28 (14.3)	85 (43.4)	16 (8.2)	97 (49.5)	24 (12.2)	114 (71.7)	2.1 ± 4.8	30 (17.8)
	Higher	44 (16.2)	97 (35.7)	30 (11.0)	136 (50.0)	33 (12.2)	151 (68.6)	2.2 ± 4.4	40 (16.5)
	Smoking
	Yes	18 (16.1)	53 (47.3)	15 (13.4)	66 (58.9)	20 (17.9)	65 (78.3)	3.8 ± 6.1	26 (29.2)
	No	88 (14.8)	197 (33.1)	67 (11.3)	270 (45.4)	95 (16.2)	304 (66.7)	2.2 ± 4.5	86 (17.1)
Diabetes-related parameters	Metabolic control
	Good	69 (14.4)	168 (35.1)	58 (12.1)	230 (48.0)	80 (16.9)	251 (69.7)	2.6 ± 5.5	73 (18.0)
	Moderate	18 (11.2)	58 (36.0)	20 (12.4)	72 (44.7)	28 (17.5)	76 (62.8)	2.0 ± 3.5	25 (18.8)
	Poor	18 (24.0)	33 (44.0)	11 (14.7)	44 (58.7)	9 (12.0)	45 (72.6)	3.8 ± 7.1	19 (31.1)
	Obesity
	No	58 (13.1)	142 (32.0)	44 (9.9)	203 (45.7)	77 (17.4)	222 (65.9)	2.3 ± 5.0	66 (17.9)
	Yes	51 (17.8)	122 (42.5)	43 (15.0)	153 (53.3)	41 (14.5)	160 (71.7)	2.8 ± 5.7	52 (21.3)
	Hypertension
	No	69 (15.0)	171 (37.2)	60 (13.0)	222 (48.3)	62 (13.6)	247 (68.6)	2.7 ± 5.8	77 (19.6)
	Yes	37 (13.8)	95 (35.3)	26 (9.7)	132 (49.1)	54 (20.3)	134 (67.7)	2.2 ± 4.4	42 (19.1)
	Dyslipidemia
	No	51 (13.1)	150 (38.5)	40 (10.3)	183 (46.9)	73 (19.0)	205 (70.7)	2.4 ± 5.0	59 (17.8)
	Yes	50 (16.7)	97 (32.3)	43 (14.3)	146 (48.7)	38 (12.8)	153 (65.1)	2.7 ± 5.8	51 (20.9)
	Kidney dysfunction
	No	89 (16.5)	194 (35.9)	74 (13.7)	268 (49.6)	70 (13.1)	291 (68.3)	2.7 ± 5.7	91 (20.1)
	Yes	17 (12.0)	54 (38.0)	9 (6.3)	62 (43.7)	42 (30.0)	66 (71.7)	2.3 ± 4.1	20 (16.9)
	Retinopathy
	No	68 (15.7)	147 (34.0)	50 (11.6)	202 (46.8)	58 (13.6)	231 (68.8)	2.5 ± 5.2	63 (17.5)
	Yes	4 (22.2)	6 (33.3)	1 (5.6)	9 (50.0)	4 (22.2)	12 (92.3)	2.4 ± 3.1	4 (26.7)
	Diabetic foot risk
	No	70 (15.3)	146 (31.9)	57 (12.5)	207 (45.3)	72 (15.8)	246 (68.9)	2.6 ± 5.1	71 (18.6)
	Yes	30 (16.5)	83 (45.6)	21 (11.5)	102 (56.0)	33 (18.4)	89 (67.9)	2.2 ± 3.9	31 (20.5)
Dental care utilization	Have dentist
	Yes	91 (14.2)	238 (37.2)	80 (12.5)	319 (49.9)	57 (9.0)	363 (68.0)	2.3 ± 5.0	99 (18.1)
	No	22 (17.6)	47 (37.6)	10 (8.0)	59 (47.2)	64 (51.2)	44 (83.0)	3.6 ± 6.3	23 (24.5)
	Dentist visit
	Yes	84 (14.4)	214 (36.8)	74 (12.7)	290 (49.8)	35 (6.1)	343 (68.1)	2.1 ± 4.6	90 (17.9)
	No	29 (16.1)	70 (38.9)	16 (8.9)	87 (48.3)	85 (47.2)	64 (77.1)	3.7 ± 7.0	31 (23.0)
	Dental insurance
	Yes	84 (16.0)	194 (37.0)	65 (12.4)	264 (50.3)	56 (10.8)	301 (70.8)	2.6 ± 5.3	95 (21.3)
	No	29 (12.5)	87 (37.5)	25 (10.8)	110 (47.4)	61 (26.3)	105 (65.6)	2.3 ± 5.2	26 (13.9)

Notes: Data are presented as mean±SD or n (%). OHIP-NL14 impact is defined as a response of at least “occasionally” within one of the subdomains.

Chi-square, Mann–Whitney U tests or Kruskal–Wallis tests were used to explore significant associations (p<0.01) between oral complaints, edentulousness, periodontitis and oral health-related QoL and: ^aAge groups; ^bEthnicity; ^cSmoking; ^dMetabolic control; ^eObesity; ^fHypertension; ^gKidney dysfunction; ^hDiabetic foot risk; ⁱHaving a dentist; ^jRegularly visiting a dentist; ^kHaving dental insurance coverage. p-values <0.01 were considered as significant. Trends (p<0.05) were observed in the following associations: smoking with periodontitis; obesity with bad breath and with any oral complaint; hypertension with edentulousness; poor metabolic control with pain in the mouth; kidney dysfunction with bad breath; diabetic foot risk with any oral complaint; having a dentist with periodontitis and with impact in oral health-related QoL; having dental insurance coverage with impact in oral health-related QoL.

Table S2 General health-related QoL in patients with and without an impact in oral health-related QoL (n=499), compared to the general Dutch population

SF-36 concept scales	Impact in OHIP-NL14		General population^a
	Yes (n=97)	No (n=402)	The Netherlands (n=1,742)	Amsterdam (n=4,172)
Physical functioning	66.2 ± 21.9^c,d,e	77.1 ± 23.4^b,d,e	83.0 ± 22.8^a,b	85.2 ± 23.1^b,c
Social functioning	70.9 ± 22.7^c,d,e	84.0 ± 20.2^b	84.0 ± 22.4^b	85.1 ± 21.5^b
Role limitations due to physical health problems	50.8 ± 41.1^c,d,e	72.9 ± 38.7^c,e	76.4 ± 36.3^b	79.5 ± 35.4^b,c
Role limitations due to emotional problems	63.9 ± 41.6^c,d,e	82.1 ± 33.5^b	82.3 ± 32.9^b	83.1 ± 32.7^b
General mental health	66.1 ± 18.9^c,d,e	78.6 ± 17.2^b,d,e	76.8 ± 17.4^b,c	75.9 ± 17.6^b,c
Vitality	55.0 ± 19.0^c,d,e	67.4 ± 18.9^b	68.6 ± 19.3^b	68.6 ± 19.2^b
Bodily pain	62.0 ± 25.4^c,d,e	77.6 ± 22.7^b,d,e	74.9 ± 23.4^b,c	80.5 ± 24.4^b,c
General health perceptions	50.6 ± 20.1^c,d,e	60.4 ± 18.0^b,d,e	70.7 ± 20.7^b,c	71.3 ± 20.8^b,c
Changes in health over time	47.7 ± 20.4^c	54.0 ± 18.9^b	n/a	n/a

Notes: Data are presented as mean±SD. Concept scales according to Ware et al.³¹ Comparisons of SF-36 concept scales scores between patients with and without an impact in OHIP-NL14 were analyzed using Mann–Whitney U tests. Comparisons of the SF-36 concept scale scores between the present study population (divided for this analysis in groups with or without an impact in OHIP-NL14) and the general Dutch population were performed by one-sample t-tests. p-values <0.05 were considered significant. ^aGeneral health-related QoL in the general population from the Netherlands and Amsterdam, according to data from Aaronson et al³⁰; ^bsignificantly different from patients with an impact in OHIP-NL14, included in the present study; ^csignificantly different from patients without an impact in OHIP-NL14, included in the present study; ^dsignificantly different from the general population from the Netherlands; ^e significantly different from the general population from Amsterdam.

Table S3 Self-reported oral health questions

Question	Questions and Dutch translations (italic)
1.	Do you have a regular dentist? Heeft u een vaste tandarts?
2.	Do you visit your dentist regularly? (at least once or twice a year) Bezoekt u uw tandarts regelmatig? (minimaal 1 à 2 keer per jaar)
3.	Do you have dental insurance? Heeft u een tandartsverzekering?
4.	How many teeth do you have? Hoeveel eigen tanden en/of kiezen heeft u?
5.	Do you have a partial or full denture? Heeft u een gedeeltelijke/dan wel volledige gebitsprothese?
6.	Do you sometimes suffer from: a) Pain in your mouth? b) A dry mouth? c) Bad breath? Heeft u wel eens last van): a) Pijn in uw mond b) Een droge mond? c) Een slechte adem?

Table S4 Self-reported oral health questions (periodontitis-related questions)

Question	Questions and Dutch translations (italic)
1.	Do you think you might have gum disease? Denkt u dat u een tandvleesaandoening heeft, ook wel gingivitis of parodontitis genoemd?
2.	Overall, how would you rate the health of your teeth and gums? Hoe zou u over het algemeen genomen de gezondheid van uw tanden en tandvlees beoordelen?
3.	Have you ever had treatment for gum disease such as scaling and root planing, sometimes called “deep cleaning”? Bent u wel eens voor een tandvleesaandoening behandeld, soms ook wel “diep schoonmaken” of “pocket behandeling” genoemd?
4.	Have you ever had any teeth become loose on their own, without an injury? Heeft u wel eens last van losstaande tanden gehad, zonder dat daar een ongeluk of trauma aan vooraf ging?
5.	Have you ever been told by a dental professional that you lost bone around your teeth? Heeft een tandheelkundige specialist u wel eens verteld dat u botverlies heeft rondom uw tanden?
6.	During the past 3 months, have you noticed a tooth that doesn’t look right? Heeft u de afgelopen drie maanden wel eens gemerkt dat een tand er niet goed uit zag?
7.	Aside from brushing your teeth with a toothbrush, in the last 7 days, how many times did you use dental floss or any other device to clean between your teeth? Hoe vaak heeft u de laatste zeven dagen, afgezien van tandenpoetsen met een normale tandenborstel, geflost of op een andere manier tussen uw tanden schoongemaakt?
8.	Aside from brushing your teeth with a toothbrush, in the last 7 days, how many times did you use mouthwash or other dental rinse product that you use to treat dental disease or dental problems? Hoe vaak heeft u de laatste zeven dagen, afgezien van tandenpoetsen met een normale tandenborstel, mondspoelmiddel of een ander spoelproduct gebruikt om tandheelkundige ziekte of klachten te behandelen?

Notes: This table presents the original, periodontitis-related self-reported oral health questions from the USA^26, together with their Dutch translations.²⁸

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Data availability

The data supporting the results in the current study are available from the corresponding author on reasonable request.