Accepted Manuscript

Title: Impact of periodontal status on oral health-related

quality of life in patients with and without type 2 diabetes

Author: FC Irani RR Wassall PM Preshaw

PII: S0300-5712(15)00058-5
DOI: http://dx.doi.org/doi:10.1016/j.jdent.2015.03.001
Reference: JJOD 2435

To appear in: Journal of Dentistry

Received date: 20-2-2015

Revised date: 2-3-2015
Accepted date: 3-3-2015

Please cite this article as: Irani FC, Wassall RR, Preshaw PM, Impact of periodontal
status on oral health-related quality of life in patients with and without type 2 diabetes,
Journal of Dentistry (2015), http://dx.doi.org/10.1016/j.jdent.2015.03.001

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*Title Page with Author Details

Impact of periodontal status on oral health-related quality of life in

patients with and without type 2 diabetes
Irani FC1, Wassall RR1, Preshaw PM1, 2

Institution:
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School of Dental Sciences and Centre for Oral Health Research, Newcastle University, UK

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2
Institute of Cellular Medicine, Newcastle University, UK

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Corresponding Author:

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Professor Philip M. Preshaw

School of Dental Sciences

Framlington Place
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Newcastle University
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NE2 4BW

Email: [email protected]
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Tel: 0191 208 8193 Fax: 0191 208 8191

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Key Words:
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Periodontitis; periodontal diseases; gingivitis

Type 2 diabetes mellitus

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Oral health-related quality of life; OHRQoL

Oral health impact profile-49; OHIP-49

Short Title: Effect of type 2 diabetes and periodontal status on quality of life

Page 1 of 19
Impact of periodontal status on oral health-related quality of life in patients
with and without type 2 diabetes

ABSTRACT
Objectives: To investigate the impact of periodontal status on oral health-related quality of life

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(OHRQoL) in patients with and without type 2 diabetes mellitus (T2DM).

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Methods: 61 patients with T2DM and 74 non-diabetic patients matched for age, gender and

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periodontal status (health, gingivitis, chronic periodontitis) were recruited. The Oral Health

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Impact Profile (OHIP)-49 was self-completed by all participants at baseline and by the patients

with periodontitis at 3 months and 6 months after non-surgical periodontal therapy.

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Results: There were no significant differences in the overall OHIP-49 summary scores between

patients with T2DM (median; interquartile range; 37.0; 19.5-61.0) and without T2DM (30.4;
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16.8-51.0) (p>0.05). Among non-diabetic patients, there were significantly higher OHIP-49

scores (indicating poorer OHRQoL) in patients with gingivitis (41.0; 19.7-75.7) and periodontitis
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(33.0; 19.9-52.5) compared to patients who were periodontally healthy (11.1; 7.1-34.5) (p<0.05),
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though such an effect was not observed in the patients with diabetes. In the non-diabetic patients
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with periodontitis, statistically significant reductions in OHIP-49 scores were noted in the
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psychological discomfort and psychological disability domains following periodontal treatment,

indicating an improvement in OHRQoL. In contrast, there were no statistically significant

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changes in OHIP-49 scores following periodontal treatment in the patients with diabetes.

Conclusion: T2DM does not impact on overall OHRQoL as measured by OHIP-49. Chronic

periodontitis and gingivitis were associated with poorer OHRQoL in non-diabetic patients, with

evidence of improvements following periodontal treatment, but no such effects were observed in

patients with diabetes.

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Clinical Significance: Gingivitis and periodontitis are associated with reduced OHRQoL

compared to periodontal health in non-diabetic patients, with improvements following treatment

of periodontitis. No impact of type 2 diabetes on OHRQoL was noted; this may be related to the

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burden of chronic disease (diabetes) minimising the impact of oral health issues on OHRQoL.

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INTRODUCTION

Periodontitis is a common chronic inflammatory disease that affects the supporting structures of

the teeth. Periodontal inflammation is initiated and perpetuated by the subgingival bacterial

biofilm, but the tissue damage which occurs derives mainly from the host immune-inflammatory

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response to the bacterial challenge. Certain systemic diseases are associated with increased

susceptibility to periodontitis, for example, the presence of diabetes is associated with a 2-3-fold

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increased risk, particularly if poorly controlled (1). The rise in the prevalence of diabetes in most

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populations, including in the UK, is mainly attributed to an increase in type 2 diabetes mellitus

(T2DM) (2). T2DM is associated with insulin resistance i.e. the inability of the body to respond

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normally to insulin and inability of the β-cells of the pancreas to produce sufficient insulin. The

multifactorial aetiology and chronic inflammatory nature of both diabetes and periodontitis
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highlight the complexity of the relationship between the two conditions (3).
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Both periodontitis (4, 5) and diabetes (6, 7) have been reported to have negative impacts on

aspects of daily living and health-related quality of life. Evidence suggests that oral health
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problems can adversely affect an individual’s physical functioning, social standing and
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wellbeing, and that it can be difficult to dissociate oral health from general health with regards to
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impacts on quality of life (8-10). Oral health-related quality of life (OHRQoL) can be assessed

using the Oral Health Impact Profile-49 (OHIP-49) questionnaire (11). This contains 49 items

within 7 domains (functional limitation, physical pain, psychological discomfort, physical

disability, psychological disability, social disability, handicap), with responses ranging from

score 0 indicating ‘never’ to score 4 indicating ‘very often’. Domain scores are generated by

summing the response scores to the items within the domain, and an overall summary score is

generated by summing the response scores to all 49 items. A higher score is indicative of poorer
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Page 4 of 19
OHRQoL. Our group has previously identified, when using OHIP-49, that patients with chronic

periodontitis report significantly poorer OHRQoL compared to patients without periodontitis,

with significant functional, social and psychological impacts on OHRQoL (12).

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Considering that OHRQoL measures are increasingly used in assessing patient-centred outcomes

of disease and treatment, and in view of the close inter-relationship between periodontitis and

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T2DM, it is important to explore the impact of periodontal status and treatment on OHRQoL in

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patients with T2DM. The aim of this study was to use OHIP-49 to assess OHRQoL in patients

with diabetes and periodontitis, and to evaluate any impact of periodontal treatment.

MATERIALS AND METHODS an

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Adult participants with T2DM were recruited from primary and secondary care diabetes clinics
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in Newcastle upon Tyne, UK. Written informed consent was obtained from all participants prior
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to recruitment. The non-diabetic control group was recruited from patients attending Newcastle

Dental Hospital, UK, matched according to age, gender and periodontal status. Participants were
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assigned a diagnosis of periodontal health (no probing depths >4mm, bleeding on probing (BOP)
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≤15%, no attachment loss), gingivitis (no probing depths > 4 mm, BOP >15%, no attachment
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loss), or chronic periodontitis (≥6 sites with probing depths ≥5 mm on separate teeth, with

attachment loss and alveolar bone loss confirmed on x-ray). Exclusion criteria included

immunosuppression, pregnancy, conditions requiring prophylactic antibiotic treatment prior to

dental treatment, bleeding disorders, and any prior non-surgical treatment for periodontal disease

in the past 6 weeks. Ethical approval was granted by the UK National Research Ethics Service

(ref. 06/Q0904/8).

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The periodontal examination was performed by a single examiner using a UNC PCP15 manual

periodontal probe. Parameters recorded included plaque index (PI) (13), modified gingival index

(mGI) (14), probing depth (PD), and percent BOP. Patients with periodontitis received standard

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non-surgical periodontal therapy utilising a full mouth debridement approach with local

anaesthetic typically over 2 visits, together with oral hygiene instruction personalised to their

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clinical situation. Early periodontal maintenance follow up appointments were provided at 3 and

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6 weeks, including further prophylaxis to disrupt the biofilm and reinforcement of oral hygiene

instructions. Definitive periodontal maintenance care appointments were provided at 3 months

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and 6 months healing. Patients with periodontal health or gingivitis received oral hygiene

instruction and prophylaxis at the screening appointment only, and were not followed up
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thereafter.
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OHIP-49 was used to assess OHRQoL. All participants self-completed the questionnaire at the

screening appointment prior to any treatment being provided. The patients with periodontitis
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additionally completed the questionnaire again at 3 months and 6 months following the
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periodontal therapy.
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The null hypotheses in this study were that (i) there would be no differences in OHRQoL

between diabetic and non-diabetic patients with different periodontal conditions (health,

gingivitis, chronic periodontitis), and (ii) that there would be no impact of periodontal treatment

on OHRQoL. All data were analysed using SPSS 21.0 statistical software. Patients who had not

responded to ≥ 10% of the items in OHIP-49 were eliminated from the study. For patients who

had <10% missing responses, the answers to the missing items were derived using group mean
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Page 6 of 19
score imputation for each item in order to calculate the individual domain scores and the

summary scores as reported previously (12, 15). Data were tested for normality using the

Kolmogorov-Smirnov test. The medians and interquartile ranges for non-parametric variables

and means and standard deviation for parametric variables were determined. For cross-sectional

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analyses for discrete variables, the chi-squared test was used to compare between groups. The

Mann-Whitney test was used for comparisons of OHIP-49 scores between the groups with and

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without T2DM based on the periodontal status. The Kruskal-Wallis test with post-hoc Mann-

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Whitney tests was used to analyse the OHIP-49 data within the groups with and without T2DM

based on the periodontal status. The Friedman test with post-hoc Wilcoxon Signed Rank tests

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was used for longitudinal comparisons of the effects of periodontal treatment. Cronbach’s alpha

was used to calculate the internal consistency of the questionnaire.

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RESULTS
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63 patients with T2DM and 75 patients without diabetes were recruited to the study. However, 2

patients with T2DM and 1 non-diabetic patient failed to complete a minimum of 90% of the
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items of the OHIP-49 questionnaire, and were removed from the analysis. The final study
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population therefore comprised 61 patients with T2DM and 74 patients without diabetes.
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Demographic characteristics for the groups with and without T2DM are presented in Table 1.

The groups were well matched for gender, age, ethnicity, and smoking status. As expected, the

HbA1c levels of the group with T2DM were significantly higher than the group without diabetes

(p<0.001). The patients were categorised according to diabetes and periodontal status: ND-H (no

diabetes, periodontal health), ND-G (no diabetes, gingivitis), ND-P (no diabetes, periodontitis),

Page 7 of 19
D-H (diabetes, periodontal health), D-G (diabetes, gingivitis) and D-P (diabetes, periodontitis).

Cronbach’s alpha for OHIP-49 was 0.97, indicating good internal consistency.

Periodontal data are presented in Table 2. Within the healthy and gingivitis categories at baseline

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(month 0), the T2DM patients had significantly higher PI, mGI and BOP scores compared to the

non-diabetic patients. Among the patients with periodontitis, no significant differences were

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observed between the T2DM and non-diabetic groups with regards to PI, mGI or BOP scores,

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though a slightly higher mean probing depth was observed in the non-diabetic patients.

Following treatment in the patients with periodontitis (both with and without diabetes),

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statistically significant improvements in all periodontal parameters were noted from month 0 to

month 3, and from month 0 to month 6, with the exception of a non-significant reduction in PI
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from month 0 to month 3 in the diabetes group.
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Table 3 shows the OHIP-49 domain and overall summary scores for the patients with and

without T2DM; there were no statistically significant differences between the two groups,
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indicating no differences in OHRQoL between the patients with T2DM and those without
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diabetes. However, when OHIP-49 domain and overall summary scores for patients with and
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without T2DM were categorised according to periodontal status (Table 4), we identified that,

within the non-diabetic group, patients with gingivitis and periodontitis had significantly higher

OHIP-49 scores (indicating poorer OHRQoL) in every domain as well as the overall summary

score compared to the patients who were periodontally healthy. Within the diabetic group,

however, no such differences in OHRQoL were observed between the periodontal status

categories.

Page 8 of 19
The patients with periodontitis completed OHIP-49 at 3 and 6 months following treatment. Table

5 shows OHIP-49 domain and overall summary scores at each timepoint for the non-diabetic and

diabetic groups. Within the non-diabetic patients, statistically significant reductions in OHIP-49

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scores were noted in the psychological discomfort domain at months 3 and 6, and in the

psychological disability domain at month 6, compared to month 0, indicating an improvement in

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OHRQoL. Furthermore, the overall summary score at month 6 was lower than that at month 0 or

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month 3, though this failed to achieve statistical significance. In contrast, there were no

statistically significant changes in OHIP-49 domain and summary scores at any timepoint in the

patients with diabetes.

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DISCUSSION
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Assessment of the impact of diseases on daily living and quality of life is an important
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component of modern healthcare, and patient-centred outcomes are likely to be more relevant to

patients than traditional clinical measures of disease. Previously, we have identified that (non-
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diabetic) patients with chronic periodontitis have significantly poorer OHRQoL than (non-
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diabetic) patients who do not have periodontitis, with, in particular, functional, physical,
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psychological impacts on their OHRQoL as a result of their periodontitis (12). Given the known

importance of diabetes as a major risk factor for periodontitis, and the nature of the interaction

between these two disease states (3), this study aimed to investigate the impact of periodontal

conditions on OHRQoL in people with type 2 diabetes compared to non-diabetic individuals.

Page 9 of 19
When considering the data presented in Table 3, it is clear that when considering the overall

diabetic and non-diabetic patient populations (including patients with periodontal health,

gingivitis and chronic periodontitis), that T2DM did not have an impact on OHRQoL. A similar

finding has been reported previously, in which no impact of diabetes (both type 1 and type 2) on

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OHRQoL was noted (16). Although data from epidemiological studies indicate clearly that

diabetes increases the extent and severity of periodontitis (1), the severity of periodontitis in the

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T2DM patients in our study was very similar to that seen in the non-diabetic patients, with a

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slightly lower mean probing depth at baseline being observed in the T2DM group compared to

the non-diabetic patients (Table 2). Furthermore, the level of glycaemic control in the T2DM

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population was good (mean HbA1c 6.9 ± 2.7%). Thus, in our study it is clear that the T2DM

patients were not suffering from more advanced periodontitis than the non-diabetic control
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group, and therefore, it is perhaps unsurprising that OHRQoL scores did not differ between the
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T2DM and non-diabetic groups when considering the population as a whole.

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When the patients were categorised according to periodontal status, we found that, similar to
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previous research (4, 12) OHRQoL was significantly poorer in the non-diabetic patients with
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gingivitis or periodontitis compared to those with periodontal health, in every domain of OHIP-
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49 as well as the overall summary scores (Table 4). However, by contrast, among the T2DM

patients, no significant differences were observed in OHRQoL between those with health,

gingivitis or periodontitis. This may be a function of the relatively small numbers of patients in

the various subgroups, but may potentially also indicate that patients with diabetes are less

concerned about the impact of their periodontal condition than they are about other health issues

that they must manage as part of their diabetes. Potentially, non-diabetic, systemically healthy

Page 10 of 19
individuals may be more concerned about the signs and symptoms of periodontitis than diabetic

individuals who are used to managing other comorbidities (and this may be reflected in the

finding of higher plaque, gingivitis and bleeding scores in the T2DM patients with periodontal

health and gingivitis compared to the corresponding non-diabetes groups). It has been identified

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that as chronic disease states have an increasing impact on individuals, then there is a tendency

for oral health to be prioritised less, particularly if the benefits of attaining oral health are

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perceived to be minimal (17). The need to balance a number of pressing health issues may lead

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to better coping with impacts of periodontitis, or indeed lower expectations of oral health. This

could be a reason for the finding that OHRQoL of patients with T2DM was not worse in people

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with periodontitis or gingivitis compared to those with healthy periodontal tissues. Further

research in this area is warranted.

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A systematic review of the impact of periodontal therapy on OHRQoL has identified that non-
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surgical periodontal therapy can moderately improve OHRQoL (18). In our study, among the

non-diabetic patients, we identified improvements in the psychological discomfort domain of

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OHIP-49 at months 3 and 6, and improvement in the psychological disability domain of OHIP-
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49 at month 6, compared to baseline, but no change in the overall OHIP-49 summary score as a
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result of treatment. This could be a result of many factors such as relatively small number of

patients, moderate periodontal disease at baseline (as opposed to very advanced disease),

relatively short follow-up period, poor sensitivity of the measurement tool to change, or

potentially because of the negative impacts that the requirement for ongoing maintenance and

management of chronic diseases can have on quality of life (19). Patients with chronic conditions

may experience difficulty in integrating everything asked of them by healthcare professionals

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Page 11 of 19
into their daily life (20). The burden of measures they must take to improve their health

condition may prevent them from experiencing the benefits of the treatment they receive. This

may be a reason, at least in part, for the finding that in patients with T2DM, neither periodontal

status nor periodontal treatment had an impact on OHRQoL.

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OHIP-49 has been used for many years to measure the impact of oral health status on quality of

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life. It has been assessed particularly in the context of prosthetic dentistry, but its utility in

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periodontal diseases and its sensitivity to detect meaningful change following treatment are yet

to be fully established. It is conceivable therefore, that use of a different OHRQoL instrument

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may have yielded different results. Further research is warranted to identify whether there are

other tools (potentially yet to be developed) which may have better utility for investigating the
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impact of periodontal diseases on OHRQoL.
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CONCLUSION

T2DM does not impact on overall OHRQoL as measured by OHIP-49. Chronic periodontitis and
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gingivitis were associated with poorer OHRQoL in non-diabetic patients, with evidence of
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improvements following periodontal treatment, but no such effects were observed in patients
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with diabetes.

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2. Massó González EL, Johansson S, Wallander MA, García Rodríguez LA. Trends in the prevalence

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and incidence of diabetes in the UK: 1996-2005. Journal of Epidemiology and Community Health
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3. Preshaw PM, Bissett SM. Periodontitis: oral complication of diabetes. Endocrinology &
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4. Needleman I, McGrath C, Floyd P, Biddle A. Impact of oral health on the life quality of
periodontal patients. Journal of Clinical Periodontology 2004;31:454-7.

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O'Dowd LK, Durham J, McCracken GI, Preshaw PM. Patients' experiences of the impact of
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6. Wandell PE. Quality of life of patients with diabetes mellitus. An overview of research in primary
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7. Goldney RD, Phillips PJ, Fisher LJ, Wilson DH. Diabetes, depression, and quality of life: a
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8. Fontanive V, Abegg C, Tsakos G, Oliveira M. The association between clinical oral health and
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general quality of life: a population-based study of individuals aged 50-74 in Southern Brazil. Community
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health-related quality of life: a systematic review. Journal of Oral Science 2006;48:1-7.

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13. Silness J, Loe H. Periodontal disease in pregnancy II. Correlation between oral hygiene and
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14. Lobene RR, Weatherford T, Ross NM, Lamm RA, Menaker L. A modified gingival index for use in

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clinical trials. Clinical Preventive Dentistry 1986;8:3-6.

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15. Steele JG, Sanders AE, Slade GD, Allen PF, Lahti S, Nuttall N, et al. How do age and tooth loss
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Dentistry & Oral Epidemiology 2004;32:107-14.

16. Allen EM, Ziada HM, O'Halloran D, Clerehugh V, Allen PF. Attitudes, awareness and oral health-

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related quality of life in patients with diabetes. Journal of Oral Rehabilitation 2008;35:218-23.

17. Niesten D, van Mourik K, van der Sanden W. The impact of frailty on oral care behavior of older
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people: a qualitative study. BMC Oral Health 2013;13:61.

18. Shanbhag S, Dahiya M, Croucher R. The impact of periodontal therapy on oral health-related
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quality of life in adults: a systematic review. Journal of Clinical Periodontology 2012;39:725-35.
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19. May CR, Eton DT, Boehmer K, Gallacher K, Hunt K, MacDonald S, et al. Rethinking the patient:
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Research 2014;14:281.
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20. Gallacher K, May CR, Montori VM, Mair FS. Understanding patients' experiences of treatment
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Table

Table 1 Demographic data

No Diabetes T2DM p
n=74 n=61
Gender: male n (%) 43 (58.1%) 40 (65.6%) NS
Age (years) (mean ± SD) 47.7 ±7.4 48.2 ± 6.9 NS

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Ethnicity n (%)

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Caucasian 74 (100 %) 59 (96.7 %)
Black 0 1 (1.6 %) NS

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Asian 0 1 (1.6 %)
HbA1c (%) (mean ± SD) 5.5 ± 0.5 6.9 ± 2.7 < 0.001
Smoking Status n (%)

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Current 8 (10.8 %) 6 (9.8 %)
Ex 22 (29.7 %) 17 (27.9 %) NS
Never 44 (59.5 %) 38 (62.3 %)

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Pack years of smoking 15 (5.0 - 23.7) 15 (4.5 - 40.0) NS
T2DM; type 2 diabetes, NS; not significant.
Data are presented as either means ± SD, or as medians (interquartile range).
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Table 2 Periodontal data according to diabetes and periodontal status

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ND-H D-H p ND-G D-G p ND-P D-P p

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n=17 n=15 n=17 n=20 n=40 n=26
Month 0 PI 0.25 (0.00-0.48) 0.45 (0.41-0.79) <0.01 0.62 (0.47-0.75) 0.83 (0.66-0.90) <0.01 0.64 (0.41-0.80) 0.71 (0.58-0.89) NS
Month 3 PI 0.40 ± 0.37* 0.65 ± 0.31 <0.05

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Month 6 PI 0.35 (0.12-0.62)* 0.58 (0.41-0.72)* <0.05
Month 0 mGI 0.50 (0.25-0.95) 1.33 (0.58-1.83) <0.05 1.33 (0.87-1.64) 2.27 (1.79-2.76) <0.01 2.43 (2.12-2.70) 2.29 (1.68-2.79) NS
Month 3 mGI 1.55 ± 0.73* 1.68 ± 0.71* NS
Month 6 mGI 1.35 ± 0.71* 1.60 ± 0.57* NS

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Month 0 PD (mm) 1.59 ± 0.12 1.72 ± 0.21 NS 1.99 ± 0.29 2.09 ± 0.14 NS 2.97 ± 0.63 2.64 ± 0.56 <0.05
Month 3 PD (mm) 2.53 ±0.51* 2.32 ± 0.42* NS
Month 6 PD (mm) 2.50 ± 0.63* 2.23 ± 0.44* NS

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Month 0 BOP (%) 0.7 (0.0-2.6) 12.2 (0.9-14.0) <0.01 25 (17.7-36.9) 37.1 (25.9-48.6) <0.05 41.0 (28.5-51.4) 33.3 (17.7-51.8) NS
Month 3 BOP (%) 13.5 (9.5-24.9)* 14.2 (6.2-36.0)* NS
Month 6 BOP (%) 10.5 (7.0-23.6)* 8.6 (6.6-20.8)* NS
ND-H; no diabetes, periodontal health, ND-G; no diabetes, gingivitis, ND-P; no diabetes, periodontitis, D-H; diabetes, periodontal health, D-G;
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diabetes, gingivitis, D-P; diabetes, periodontitis, PI; plaque index, mGI; modified gingival index, PD; probing depth, BOP; bleeding on probing,
NS; not significant. Data are presented as either means ± SD, or as medians (interquartile range). P values show cross-sectional comparisons
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between no diabetes and diabetes groups within periodontal status categories. * p<0.05 when comparing scores at Month 3 and Month 6 to those at
Month 0 in the ND-P and D-P groups.
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Page 16 of 19
Table 3 OHIP-49 scores in patients with and without diabetes at baseline (month 0)

OHIP-49 Domains No Diabetes T2DM p

Functional limitation 8.1 (4.8-13.0) 9.0 (6.0-16.5) NS

Physical pain 8.3 (6.0-15.0) 10.0 (6.3-14.5) NS
Psychological discomfort 5.0 (2.0-10.0) 6.0 (2.0-10.5) NS

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Physical disability 3.0 (0.2-6.2) 3.4 (1.8-12.3) NS

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Psychological disability 3.0 (0.8-7.0) 4.0 (1.0-7.5) NS
Social disability 0.0 (0.0-3.3) 0.0 (0.0-2.0) NS

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Handicap 0.0 (0.0-3.0) 1.0 (0.0-4.0) NS
Summary score 30.4 (16.8-51.0) 37.0 (19.5-61.0) NS

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T2DM; type 2 diabetes, NS; not significant.
Data are presented as medians (interquartile range).

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Page 17 of 19
Table 4 OHIP-49 scores in patients with and without diabetes at baseline (month 0)
categorised by periodontal status

OHIP-49 Domains ND-H ND-G ND-P

Functional limitation 4.0 (2.0 - 8.0) 10.0 (6.5 - 14.5)* 9.4 (6.0 - 12.8)**
Physical pain 6.0 (3.1 - 11.5) 10.0 (7.0 - 16.0)* 8.7 (6.3 - 14.8)*

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Psychological discomfort 2.0 (0.0 - 6.5) 7.0 (2.0 - 11.5)* 5.5 (3.0 - 10.0)*

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Physical disability 1.0 (0.0 - 4.0) 4.0 (1.2 - 12.7)* 3.2 (1.0 - 6.2)*
Psychological disability 1.0 (0.0 - 4.0) 4.0 (0.5 - 9.0)* 3.0 (1.0 - 7.0)*
Social disability 0.0 (0.0 - 0.0) 0.2 (0.0 - 4.5)* 1.0 (0.0 - 3.8)*

cr
Handicap 0.0 (0.0 - 0.0) 2.0 (0.0 - 5.5)* 0.5 (0.0 - 3.0)*
Summary score 11.1 (7.1 - 34.5) 41.0 (19.7 - 75.7)* 33.0 (19.9 - 52.5)**

us
D-H D-G D-P
Functional limitation 6.0 (4.0 - 17.7) 8.7 (6.7 - 12.9) 12.5 (6.8 - 18.0)
Physical pain 10.0 (6.7 - 19.7) 9.2 (5.3 – 13.0) 12.0 (6.8 - 15.3)
Psychological discomfort 5.0 (0.0 - 15.0) 6.0 (3.0 - 8.5) 7.0 (2.0 - 10.3)

an
Physical disability 2.0 (1.0 -12.6) 5.0 (2.0 - 10.0) 3.7 (2.1 - 14.0)
Psychological disability 4.0 (0.0 - 12.0) 4.2 (1.0 - 6.8) 3.5 (1.8 - 7.3)
Social disability 0.0 (0.0 - 5.0) 0.0 (0.0 - 1.0) 0.0 (0.0 - 2.0)
Handicap 1.0 (0.0 - 6.0) 1.0 (0.0 - 2.8) 1.5 (0.0 - 5.0)
M
Summary score 28.0 (13.9 - 93.9) 37.1 (23.8 - 50.7) 44.9 (23.9 - 64.5)
ND-H; no diabetes, periodontal health, ND-G; no diabetes, gingivitis, ND-P; no diabetes, periodontitis,
D-H; diabetes, periodontal health, D-G; diabetes, gingivitis, D-P; diabetes, periodontitis. Data are
d

presented as medians (interquartile range).

* p<0.05 and **p<0.01 when comparing gingivitis and periodontitis groups to healthy groups.
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Table 5 OHIP-49 scores in patients with periodontitis, and with and without diabetes at at
month 0, moth 3 and month 6

OHIP-49 Domains ND-P0 ND-P3 ND-P6

Functional limitation 8.4 (5.0 - 12.9) 9.4 (6.0 - 14.4) 6.4 (4.0 - 11.4)
Physical pain 8.3 (5.8 - 13.3) 9.4 (7.0 - 15.4) 9.1 (5.0 - 11.8)

t
Psychological discomfort 6.0 (3.0 - 9.5) 4.0 (2.0 - 8.0)* 3.0 (1.0 - 7.0)*

ip
Physical disability 3.2 (0.6 - 6.2) 3.2 (1.0 - 8.6) 2.0 (0.4 - 5.1)
Psychological disability 3.0 (1.0 - 7.0) 2.0 (0.0 - 6.5) 1.0 (0.0 - 4.8)*
Social disability 0.0 (0.0 - 3.5) 1.0 (0.0 - 3.5) 0.0 (0.0 - 1.8)

cr
Handicap 0.0 (0.0 - 2.5) 1.0 (0.0 - 2.5) 0.0 (0.0 - 0.0)
Summary score 32.9 (19.9 - 50.9) 34.0 (16.5 - 53.5) 19.9 (12.2 - 38.9)

us
D-P0 D-P3 D-P6
Functional limitation 15.0 (8.0 - 18.0) 12.0 (8.0 - 19.0) 15.0 (5.5 – 16.0)
Physical pain 12.0 (10.0 - 16.0) 13.0 (11.0 - 17.0) 11.0 (7.0 – 13.0)
Psychological discomfort 8.0 (5.0 - 11.0) 7.0 (2.6 - 10.0) 6.0 (1.0 – 7.0)

an
Physical disability 4.0 (3.0 - 14.0) 5.0 (2.0 - 11.0) 5.0 (0.4 - 11.0)
Psychological disability 4.0 (3.0 - 8.0) 4.0 (2.0 - 9.0) 3.0 (0.0 - 9.0)
Social disability 0.0 (0.0 - 2.0) 2.0 (0.0 - 4.0) 0.0 (0.0 - 2.0)
Handicap 1.0 (0.0 - 5.0) 2.0 (0.0 - 6.0) 0.0 (0.0 - 2.0)
M
Summary score 55.0 (30.0 - 60.0) 52.4 (26.0 - 69.0) 40.0 (16.0 - 66.0)
ND-P0; no diabetes, periodontitis month 0, ND-P3; no diabetes, periodontitis month 3, ND-P6; no
diabetes, periodontitis month 6, D-P0; D-P0; diabetes, periodontitis month 0, D-P3; diabetes, periodontitis
d

month 3, D-P6; diabetes, periodontitis month 6. Data are presented as medians (interquartile range).
* p<0.05 for paired comparisons of month 3 and month 6 timepoints to baseline (month 0).
p te
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Page 19 of 19