Dental Disease, Oral Hygiene Important Determinants of Heart Failure in Patients With Type 2 Diabetes


Study shows that as patients with type 2 diabetes lost more teeth, their risk of heart failure grew.

Among patients with type 2 diabetes, dental diseases and oral hygiene care are important determinants of heart failure (HF) development. Therefore, management of dental diseases and good oral care may prevent HF in these patients, according to the results of a study published in the Journal of the American Heart Association.

Image credit: Maksym Yemelyanov -

Image credit: Maksym Yemelyanov -

Previous studies have shown that dental diseases increase the risk of cardiovascular diseases (CVDs) and that good oral hygiene behaviors can reduce that risk. Despite this, few studies have evaluated representative nationwide data, and there is limited evidence regarding HF risk in relation to dental diseases and oral hygiene behaviors among patients with type 2 diabetes.

In total, 173,927 participants in South Korea with type 2 diabetes were eligible. Among them, 22.6% (n = 39,242) had periodontal diseases. Patients who had periodontal diseases were more likely to have missing teeth, undergo regular dental check-ups and professional dental cleanings, and to brush their teeth frequently.

Of the total participants with type 2 diabetes, 3379 (1.94%) individuals developed HF during a median follow-up of 9.3 years (IQR, 9.1-9.6). Hazard ratios (HRs) for HF increased by 37% in those with 15 or more missing teeth (HR, 1.37; 95% CI, 1.14-1.64) compared with those without missing teeth.

HRs for HF were significantly higher as the number of missing teeth increased (P < 0.001). Among participants who underwent professional dental cleaning 1 or more times per year, HRs of HF decreased by 7% (HR, 0.93; 95% CI, 0.87-0.99) and by 10% among those who brushed their teeth 2 or more times a day (HR, 0.90; 95% CI, 0.82-0.98) compared to those who did undergo regular professional dental cleaning or brushed their teeth more than once per day.

In assessing the associations between the combination of dental diseases or oral hygiene care and the risk of HF, investigators found the HRs for HF increased by 20% among individuals with both periodontal diseases and dental caries (HR, 1.20; 95% CI, 1.01-1.43) compared with those without any of these diseases. Furthermore, HRs for HF increased in participants with both periodontal diseases and a higher number of missing teeth (P = 0.004).

In individuals with periodontal disease and 15 or more missing teeth, HR for HF significantly increased by 46% (HR, 1.46; 95% CI, 1.01-2.13) compared to those without any of those conditions. Investigators observed a similar trend for the combined presence of dental caries and missing teeth.

Further analysis indicated that better oral hygiene care was associated with decreased risk of HF, even when individuals had confounding periodontal diseases (P = 0.047 for daily toothbrushing) or an increasing number of missing teeth (P < 0.001 for professional dental cleaning and daily toothbrushing).

Compared to those without missing teeth but with poor hygiene care, individuals with 15 or more missing teeth and poor oral hygiene care together had an increased HF risk (HR, 1.46; 95% CI, 1.20-1.77 for < 1 time/year of professional dental cleaning; HR, 1.50; 95% CI, 1.09-2.06 for 0-1 time of daily toothbrushing).

Dental diseases can cause systemic inflammation, which can subsequently result in atherosclerotic CVD. Additionally, bacterial toxins in the oral cavity are associated with increased cholesterol and, ultimately, atherosclerotic plaques, attesting to the potential for good oral hygiene to reduce HF risk, according to the study.

Limitations of the study noted by the authors include possible underdiagnosis or overdiagnosis, the exclusion of causality-related conclusions, missing data on inflammation or microbial environment, and the possibility of recall bias due to oral hygiene care being evaluated using a questionnaire.


Huh Y, Yoo JE, Park SH, et al. Association of dental diseases and oral hygiene care with the risk of heart failure in patients with type 2 diabetes: a nationwide cohort study. J Am Heart Assoc. 2023;0:e029207. doi:10.1161/JAHA.122.029207

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