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 0 – 39% 40 – 49% 50 – 59% 60 – 69% 70 – 79% 80 – 100%

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Criterion 1 Initiate, plan and design an investigation into an academic area of professional practice
Mark: see Unable to initiate, Inadequately Able to initiate, Clearly initiates, Comprehensively Discerningly
above plan and design initiates, plans and plan and design plans and designs initiates, plans and initiates, plans and
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into an academic investigation into into an academic into an academic investigation into investigation into an
area of an academic area area of area of an academic area academic area of
professional of professional professional professional of professional professional practice
practice practice practice practice practice

Criterion 2 Conduct an academic study considering its theoretical underpinning and offer insight into an
area of professional practice
Mark: see
above
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an academic study conducts an conducts an academic study conduct s an an academic study
and does not academic study academic study well considering its academic study considering its
consider its and does not considering its theoretical considering its theoretical
theoretical consider theoretical underpinning and theoretical underpinning and
underpinning nor adequately its underpinning and offers insight into underpinning and offers insight into an
offers insight into theoretical offers insight into an area of offers insight into area of professional
an area of underpinning nor an area of professional an area of practice
professional offers insight into professional practice professional
practice an area of practice practice
professional
practice

Criterion 3 Demonstrate the ability to analyse, synthesise and evaluate findings appropriate to the study
undertaken
Mark: see
above
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ability to analyse, ability to analyse, analyse, analyse, analyse, analyse, synthesise,
synthesise, and synthesise, and synthesise, and synthesise, and synthesise, and and evaluate
evaluate findings evaluate findings evaluate findings evaluate findings evaluate findings findings appropriate
appropriate to the appropriate to the appropriate to the appropriate to the appropriate to the to the study
study undertaken. study undertaken. study undertaken. study undertaken. study undertaken. undertaken.

Criterion 4 Critically reflect on the processes undertaken as part of the study and offer creative solutions
for future studies
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above
reflect on the critically reflects critically reflects good ability to good ability to outstanding ability to
processes on the processes on the processes critically reflect on critically reflect on critically reflect on
undertaken as part undertaken as part undertaken as part the processes the processes the processes
of the study nor of the study nor of the study and undertaken as part undertaken as part undertaken as part
offers creative offers creative offers creative of the study and of the study and of the study and
solutions for future solutions for future solutions for future offers creative offers creative offers creative
studies. studies studies solutions for future solutions for future solutions for future
studies studies studies.

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Name: Mehak Sabtain

Programme: Masters of Public Health
Course code: LBR7337

The Association between Diabetes and Oral Health Outcomes in

Populations from Developing Countries: A Qualitative Systematic
Review

A dissertation submitted to Birmingham City University in partial fulfillment for the Master’s
degree in “public health”

Supervisor: Kate Thompson

Academic year: 2023/24
Date: 12/April/2024

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Table of Contents

Abstract............................................................................................................................................6
Chapter 1: Introduction....................................................................................................................7
Introduction......................................................................................................................................7
Systematic Review Question.......................................................................................................8
Study Aim and Objectives...........................................................................................................8
Relevance and Justification of the Study.....................................................................................8
Outline of the Dissertation.........................................................................................................10
Chapter 2: Literature Review.........................................................................................................11
Chapter Overview......................................................................................................................11
Epidemiology of Diabetes and Oral Health Issues in Developing Countries............................11
Biological Mechanisms Linking Diabetes and Oral Health......................................................12
Socio-economic and Cultural Factors Affecting Diabetes and Oral Health..............................13
Public Health and Policy Implications......................................................................................14
Theoretical Analysis..................................................................................................................15
Biopsychosocial Model.........................................................................................................15
Health Belief Model..............................................................................................................15
Literature Gap............................................................................................................................16
Chapter Summary......................................................................................................................16
Chapter 3: Methodology................................................................................................................17
Chapter overview.......................................................................................................................17
Systematic Review Perspective.................................................................................................17
Systematic Review Framework.................................................................................................18
Search Strategy..........................................................................................................................19
Eligibility Criteria and Article Screening..................................................................................20
Quality Assessment and Critical Appraisal...............................................................................22
Data Extraction..........................................................................................................................22
Analysis.....................................................................................................................................23
Chapter 4: Results..........................................................................................................................25
Chapter Overview......................................................................................................................25
Article Search Screen and Appraisal.........................................................................................25
Results of Extracted Data..........................................................................................................26
Article Study Analysis...........................................................................................................26
Thematic Analysis.................................................................................................................28
Results........................................................................................................................................29
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Theme 1: Socio-economic Influences on Oral Health...........................................................29
Theme 2: Oral Health Knowledge and Practices among Diabetics.......................................30
Theme 3: Association between Diabetes and Periodontal Disease.......................................31
Theme 4: Role of Healthcare Providers in Oral Health Promotion.......................................32
Theme 5: Global Challenges in Oral Health Improvement...................................................33
Theme 6: Oral Health Disparities and Disease Management................................................33
Chapter Summary......................................................................................................................34
Chapter 5: Discussion............................................................................................................36
Analysis of Findings............................................................................................................36
Analysis by Linking with Literature Review...............................................................37
Reflection on the Study's Objectives...........................................................................44
Chapter 6: Conclusion...........................................................................................................43
Recommendations..............................................................................................................40
Healthcare Policy and Practice Recommendations............................................40
Recommendations for Future Research.................................................................41
Consideration of Socio-economic and Cultural Contexts.................................41
Practical and Theoretical Contribution........................................................................42
Limitations and Future Research..................................................................................42
References......................................................................................................................................45

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Abstract
The complex relationship between diabetes and oral health outcomes in underdeveloped countries
is thoroughly examined in this dissertation. The increasing global prevalence of diabetes and its substanti
al impact on oral health make this an issue of great concern. Worsening oral health disparities in these pl
aces are investigated by the study in relation to socio-economic determinants, healthcare accessibility, an
d educational deficiencies in diabetes treatment. This study integrates and evaluates results from particula
r studies released after 2015 using a qualitative systematic review approach. An exhaustive review of the
relevant literature is what we are shooting for. Finding relevant research, this review used the Population,
Exposure, Outcomes (PEO) paradigm. It focused on studies that exposed people with diabetes living in l
ow-income countries to various oral health problems.

After a comprehensive review, the data were thematically analysed to reveal commonalities and d
ifferences across the studies. The findings highlight significant challenges to effective oral healthcare pr
ovision, including insufficient funding, outdated healthcare infrastructure, and a general ignorance regard
ing the link between diabetes and dental health on the part of both patients and healthcare providers. Thes
e challenges add complexity to diabetes management and lead to negative oral health outcomes. The rese
arch contributes to the field by highlighting the critical need for all-encompassing healthcare policies that
integrate dental health into diabetes care protocols, individualised awareness-raising educational activitie
s, and enhanced interdisciplinary healthcare collaboration. The socioeconomic status of diabetic patients i
n underdeveloped countries must be considered in any holistic healthcare strategy, as this research argues.
The end goal is better oral health and better management of diabetes.

Keywords: Diabetes, Oral Health, Developing Countries, Systematic Review, Health Disparities

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Chapter 1: Introduction
Introduction
Large numbers of individuals worldwide have diabetes mellitus, a metabolic disorder which
results in extremely high blood glucose levels. Its incidence has been rising sharply in developing nations
which lack health care funding and facilities (Sahoo et al., 2021). Based on the International diabetes
Federation, the number of individuals with Diabetes will grow from 463 million in 2019 to 700 million
by 2045. Comprehensive initiatives to deal with the increasing diabetes cases in these areas are urgently
needed. This epidemic could have causes including urbanisation, lifestyle modifications and genetics.
Just like the diabetes epidemic, bad oral health is widespread in underdeveloped countries where
individuals lack access to quality dentistry treatment (Ramos-Gomez et al., 2020). Dental caries,
periodontal problems or tooth loss impact numerous individuals and lower quality of life while bringing
down the burden of non-infectious diseases. Probably the most regular oral Health issue is caries of
permanent teeth, impacting almost 3.5 billion people globally, the World health Organisation states. Oral
health is a public health problem worldwide (Soluk-Tekkesin and Wright, 2022). Still, it's very bad in
developing countries in which the water is inadequately fluoridated, the topic poorly understood and
dentists aren't offered.
There's a two-way and complex interaction between dental health and diabetes. Research
indicates that diabetes raises the chance of periodontal disease, increases the seriousness of gum
infections and also slows the healing period following tooth operations (Ray, 2023). Since blood sugar
levels in diabetes are high, oral infections are more frequent. Diabetes also causes it to be much more
likely that gum disease and tooth decay are going to happen as saliva production reduces - an ailment
called dry mouth. Conversely, diabetes might worsen with poor dental health, like periodontitis. The
more severe and rapid form of periodontal disease seen in people with diabetes is an inflammatory
chronic disorder of the supporting cells of teeth (gums and bones) (Gruenthal-Rankin, 2021). The
inflammation brought on by periodontal disease could impact glycemic control and insulin resistance and
consequently demands effective dental healthcare for diabetes management.
Multiple studies indicate that diabetes is related to poor dental health and warrant coordinated
therapy. For instance, a systemic review of Journal of Periodontology reported that periodontal disease is
linked with increased risk of developing diabetes than untreated individuals (Borgnakke and Genco,
2020). Additionally, periodontal infection management continues to be linked with better glycemic
control in diabetics, indicating the possibility for oral health treatments in the control of diabetes. No
matter these results, it remains unknown just how best to deal with comorbidities in underdeveloped
nations and which processes bind the disorders. This particular link is especially important in
underdeveloped countries where diabetes and bad dental health are more prevalent. Lack of
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understanding of its importance, limited ability to access dentistry and not enough coordinated medical
services further complicates maintaining good oral health among individuals with diabetes (Uguru et al.,
2020). Public health initiatives must support integrated care techniques to deal with oral health and
diabetes as this example shows how these 2 interrelated health concerns might be best addressed
together.
Concerns regarding the connection between dental health and diabetes have risen in recent years
particularly in developing nations where both diseases are rising. As the interaction between both health
problems is two-way, an extensive treatment strategy is required; this includes addressing the dental and
diabetic aspects of a patient's condition (Kapila, 2021). Additional analysis is required to learn these
relationships to figure out appropriate prevention, treatment and management of diabetes and oral health
problems to be able to build proper prevention, management and treatment methods in these very poor
countries where these 2 health issues comprise a dual burden (Briggs et al., 2020). Governments,
communities, healthcare providers, and individuals will have to come together to get over these obstacles
and improve health outcomes and life expectancy for individuals with diabetes and oral health
complications.
Systematic Review Question
What is the association between diabetes and oral health outcomes in populations from
developing countries, and what factors influence this relationship?
Study Aim and Objectives
The study aims to systematically review and synthesise existing research on the association between
diabetes and oral health outcomes in populations from developing countries. The study has the following
objectives.
 To identify and evaluate studies investigating the relationship between diabetes and oral health
outcomes in developing countries.
 To analyse the prevalence and types of oral health issues among people with diabetes in
developing countries.
 To examine the impact of diabetes management on oral health outcomes in these populations.
 To explore potential socioeconomic, cultural, and systemic factors influencing the association
between diabetes and oral health in developing countries
Relevance and Justification of the Study
A pressing public health concern that necessitates thorough examination and intervention is the
growing incidence of diabetes and its association with problems related to oral health in underdeveloped
nations. This work fills a need in the literature and addresses a serious health problem that impacts
millions of people; it is also highly relevant and warranted because it focuses on a comprehensive
evaluation of the correlation between diabetes and oral health outcomes in these areas (Genco and Sanz,
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2020). A rise in non-communicable diseases, such as diabetes, is a hallmark of the fast epidemiological
change now affecting developing nations. According to the International Diabetes Federation, these areas
are expected to see the highest increase in the prevalence of diabetes in the coming decades.
Additionally, these populations continue to bear a disproportionate share of the burden associated with
oral health disorders, which remain a serious concern overall (Fleming et al., 2022). In the context of
developing nations, there has not been enough exploration of the complicated health nexus, which is the
relationship between diabetes and dental health, especially how each condition might worsen the other.
In a context characterised by particular socioeconomic, cultural, as well healthcare hurdles, this
research might highlight the particular processes and dynamics of the link between oral health and
diabetes. There is a substantial discrepancy between the health systems and population health profiles of
industrialised nations from what most existing research flows (Apergis et al., 2021). Healthcare
accessibility, dietary habits, educational attainment and public health regulations vary widely throughout
developing nations, so these studies' conclusions might not immediately hold there. By focusing on
developing-world peoples this project fills a knowledge vacuum. This will produce culturally relevant
insights which could be a little more helpful for the most at risk communities. Further, the study's ability
to highlight public health initiatives and interventions is fundamental to its justification (Domnguez et al.,
2020). Given the bidirectional interaction between dental health and diabetes, understanding the link can
inform integrated healthcare approaches which simultaneously manage both disorders. For instance,
excellent dental care for diabetic patients may aid with diabetes management and enhance health and
quality of life. Such coordinated efforts might be economical approaches to utilizing health resources in
developing countries.
Possible policy implications further emphasize the study's importance. Knowing the precise oral
health difficulties and requirements of diabetic patients in poor nations helps policymakers to develop
and implement focused public health programmes and policies. This kind of efforts could include
boosting access to dental treatment, which includes dental education of diabetes control programmes and
rules promoting cooperation between healthcare specialists (Gill et al., 2022). This particular study might
also inform future research by identifying data gaps and highlighting effective interventions which may
be replicated or modified to be used in some other settings. It might also trigger a bigger debate
regarding how oral health operates in the treatment of illnesses including diabetes, that is under-reported
in public health planning (Ghanem and Nagy, 2024). This particular systematic review is justified
because it might highlight the connection between dental health and diabetes in developing nations where
both diseases are big hurdles to healthcare. This particular work addresses a literature need and has
implications for healthcare policy, practice and future research; Additionally, it improves academic
understanding (Secundo et al., 2020). Such research might enhance the lives of huge numbers of people

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with diabetes in poor nations and contribute to global health equity by guiding far more adapted health
interventions based on context.

Outline of the Dissertation

This dissertation uses a systematic review approach to investigate the link between diabetes and
oral health outcomes in low-income regions. Chapter 1: Introduction provides background information
by describing the study's rationale, objectives, and methodology; it stresses the importance of
investigating the connection between diabetes and dental health in marginalised communities. Presenting
the research topic, aims, and rationale behind the study gives a firm framework. In Chapter 2, "Literature
Review," the authors thoroughly examine prior studies and theoretical frameworks, providing a critical
evaluation of those works to fill in knowledge gaps and prove the study's significance to the scientific
community. In this section, the standing point of things is ensured, and the special contribution of the
systematic review is emphasised. The search tactics, inclusion and exclusion criteria, and data extraction
and analysis methodologies used in the systematic review are laid out in Chapter 3: Methodology. The
goal of this chapter is to make sure the research method is open and reproducible. Chapter 4: Results
summarise the findings from careful data analysis and shed light on the relationship between diabetes
and dental health in developing nations. Chap 5 and 6: Discussion and Conclusion on study weaknesses,
future research recommendations and consequences for public health policy and practice are talked
about. This particular very last chapter summarizes the results and their significance for overall health
outcomes in developing countries.

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Chapter 2: Literature Review

Chapter Overview

The literature review chapter is essential to determine the boundaries of research concerning oral
health outcomes and diabetes in developing nations. It acts as an appraisal of present academic
discussions and a snapshot of the breadth of research completed in this specific area. This literature
review investigates theme areas which individually contribute to the understanding of the reciprocal
relationship between diabetes and dental health. In particular, it analyses the epidemiological information
on diabetes and its associations to dental health problems including periodontitis and dental caries in
intermediate and low income countries.
Moreover, it reviews mechanisms underlying how diabetes and oral health interact and how each
illness might intensify the other. The article also reviews cultural and social factors impacting diabetes
management and access to oral health care, especially the disparities and difficulties of populations in
poor countries. The literature review also reviews public health consequences from this connection by
assessing current policies and treatments to relieve the combined effects of diabetes and poor dental
health. This chapter systematically studies unmet areas in the literature. It also defines the research issues
in which this dissertation is based, on which additional analysis and debate will be based.
Epidemiology of Diabetes and Oral Health Issues in Developing Countries

An astonishing rise of prevalence and a complicated interaction of socio-economic factors

aggravated health outcomes characterise the epidemiology of diabetes and oral health disorders in
developing nations as a public health burden. Urbanization, dietitian modifications and sedentary
lifestyles are mostly to blame for escalating diabetes prevalence in these countries based on the World
Health Organisation (2016). It seems that urban lifestyle is contributing to the diabetes epidemic as
prevalence rates are higher in cities than in outlying ones (Ranasinghe et al., 2021). Developing-world
diabetic populations bear a dual burden of illness with periodontal disease, dental caries and loss of tooth.
Diabetes increases periodontal disease frequency and periodontal inflammation adversely impacts
glycemic control (Rapone et al., 2021). No matter this connection, diabetic patients suffer a severe lack
of oral healthcare. This is usually because of an absence of coordinated healthcare providers and people
usually don't value the role of excellent oral health in diabetes treatment.
Types of diabetes along with various other typical oral health issues in these populations are also
systematically analyzed. The greatest prevalence of T2DM (associated with morbid obesity and lifestyle
factors) occurs in emerging nations. Genco and Borgnakke (2020) reported increased severity of
periodontitis in type 2 diabetic subjects than in controls. This might make diabetes treatment harder and
create a cascading sequence of health issues if not treated. Socio-economic constraints and inequality in

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healthcare access and quality even more compound the challenges of managing chronic ailments. There's
a social-economic gradient, research indicates. Those of lower socio economic origin are at increased
risk for diabetes and poorer oral health aggravated by ignorance and lack of access to healthcare
(Rahmah, 2021). An evaluation of present research demonstrates a complicated interaction of natural,
socio economic and healthcare system variables forms the epidemiological profile of diabetes and oral
health issues in emerging nations. Full, situation-specific epidemiological statistics remain critical for
discovering much more about the scope and causes of these health problems (Chen et al., 2024).
Specifically, oral health epidemiology and diabetes in these contexts are urgently must bridge this
knowledge gap and alleviate the burden of these related diseases in developing nations.
Biological Mechanisms Linking Diabetes and Oral Health

To address the compounded health problems observed in populations globally requires an

understanding of the complex molecular pathways linking diabetes to dental overall health. This link is
based on complicated biochemical and physiological processes which worsen each other's symptoms and
must be considered critically not only in association studies (Rocca and Anjum, 2020). Probably the most
frequent oral problem in diabetes is periodontitis. Simultaneously, insufficient insulin or insulin
resistance production results in a cascading sequence of metabolic disturbances which promote oral
health risks. The inflammatory response is crucial to this relationship; Periodontal disease is far more
widespread and serious in diabetes as it brings about much more systemic inflammation and impacts
immune function (Graves et al., 2020). A condition whereby proteins could be glycated can happen,
called superior glycation end products (AGEs), can develop when blood sugar is elevated. Receptors for
AGEs (RAGE) on many cell types including endothelial cells and monocytes enable AGEs to help with
periodontal disease and diabetes afflictions (Chavakis and Hajishengallis, 2021). This particular contract
promotes a pro-inflammatory ailment by promoting much more serious periodontal deterioration with the
release of pro-inflammatory cytokines and adhesion molecules.
This imbalanced oral microbiota and more biofilm development happens in a hyperglycemic
atmosphere owing to the more proliferation of periodontopathogenic bacteria on sugars. An even much
more vicious cycle happens when poor oral health worsens glycemic control as this particular microbial
dysbiosis encourages further host inflammatory response aggravating periodontal damage (Negrini et al.,
2021). The bidirectional nature of the association is illustrated by research demonstrating that periodontal
treatment may enhance glycemic management. The impaired salivary function and composition due to
diabetes is another important consideration. Modifications in salivary composition and decreased salivary
flow rate are linked with diabetes mellitus and higher chances of xerostomia (Al-Maweri et al., 2021).
These changes impair saliva's inherent antibacterial properties and worsen dental health. Since saliva

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plays vital functions in oral health (acid buffering, remineralising tooth enamel and managing microbial
development) diabetic changes in salivary function could cause periodontal disease and dental caries.
Moreover, the cell model of reactive oxygen species (ROS) is an element of oral health issues
connected with oxidative stress characterized by diabetes. Essential pathophysiology variables include
destruction, apoptosis, and inflammation of extracellular matrix. Hyperglycemia-induced oxidative stress
raises these consequences and even damages periodontal cells (Buranasin et al., 2023). Complicated
mechanisms like oxidative stress compared to inflammation pathways need an integrated strategy for the
control and therapy of periodontal disease and diabetes. The ensuing system of biochemical and
physiological pathways uncovered by this in depth examination of the connection between dental health
and diabetes underscores the demand for integrated patient care. There's increasing evidence that
interventional techniques to lessen the influence of diabetes on dental health call for treating systemic
inflammation and microbial dysbiosis. The considerable benefits resulting from interdisciplinary
approaches to the medical needs of diabetic patients are illustrated by the potential for combining dental
care with diabetes control (Obeng and Ogamba, 2021).
Socio-economic and Cultural Factors Affecting Diabetes and Oral Health
A complicated interaction of cultural and socio-economic variables impacts the incidence and
therapy of diabetes and its effects on dental health. In this particular context cultural views, socio
economic status (SES) and healthcare accessibility are probably the most salient factors affecting health
behaviors, healthcare utilization and health outcomes. Research shows that lower socio economic status
is linked to increased rates of oral health issues and diabetes. Reasons for this association include
insufficient dental exams and diabetes treatment, insufficient understanding about utilizing healthcare
facilities correctly and the need to track one's overall health (Chaiban et al., 2022). Additionally, less-
affordable lifestyle choices make lower income people at increased risk for diet-related chronic diseases
like diabetes. This population has already been at greater risk for diabetes and complications since it's
centered in "food deserts," where inexpensive and nutritious food is scarce.
Cultural norms and assumptions shape how people with diabetes and oral health approach care.
Traditional high sugar and carbohydrate heavy diets among some ethnic groups might place members at
increased risk of diabetes and tooth decay (Noakes et al., 2023). The perception that losing teeth is part
of aging might prevent people from getting the proper dental treatment, only one example of just how
cultural differences in understanding oral health care and diabetes may hinder very good management
(Redondo-Fl 'rez et al., 2020). Cultural shame could also delay treatment of some health disorders. The
most crucial factor which crosses cultural beliefs and socioeconomic status will be the availability of
healthcare services. In most developing countries medical and dental treatment could be prohibitively
costly and never provided universally for marginalised and low-income individuals. Lack of healthcare
providers in underserved and rural areas causes it to be already hard for individuals with diabetes to get
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medical treatment including dental health (Castillo et al., 2023). Oral health disorders related to diabetes
management are tough and lack of integration between primary healthcare and oral health services
compound this.
A coordinated healthcare system which considers the larger socio economic factors of health is
necessary due to the complicated relationship between dental health, diabetes and socio economic status.
Culturally related health education, enhanced access to health services and policies that deal with
economic and social barriers to health are parts of any intervention which improves oral health outcomes
and diabetes (Ch'vez et al., 2022). According to Patel et al. (2020) health outcomes could be increased by
adapting health promotion and disease prevention initiatives to the cultural and socio-economic contexts
of some communities. Socio-economic and cultural variables are necessary to control health outcomes,
and this backbreaking research demonstrates the way they meet up with dental health and diabetes in
complicated ways.
Public Health and Policy Implications
Public health strategies and initiatives must consider about the complicated relationship between
oral health and diabetes, especially in developing nations where both disorders are at pandemic levels.
An assessment of recent studies show that coordinated health efforts that think about the two - way
interactions between diabetes and dental health and the wider healthcare system are urgently needed
(Nurminen and Ratto, 2023). Developing nations' public health strategies have always considered dental
health and diabetes as two distinct problems with unique methods and priorities. Consequences of this
compartmentalised approach include inability to use the possible synergies in integrated care models and
links between conditions. One cost-effective strategy for healthcare systems with limited resources is to
incorporate dental health in diabetes treatment as there's growing evidence that this could enhance results
for both disorders (Berini et al., 2022). With consistent periodontal care, individuals with diabetes, for
instance, could enjoy much better oral health and much better blood sugar control, lowering the danger of
these diabetes associated issues.
Nevertheless, substantial systemic barriers must be overcome to deploy integrated care models.
Healthcare systems in many poor nations have to be structured for integrated treatment and national
health insurance programmes don't generally cover dental health. This particular exclusion implies that
the most disadvantaged individuals, already plagued by high rates of diabetes and bad dental Health, are
a lot more in danger of not getting care (World health Organisation, 2017). Additionally, rural and
underserved communities typically lack qualified healthcare providers to provide full care - dental and
diabetes care. Additionally, health promotion and disease prevention initiatives could learn from the
diabetes oral health nexus. Public health interventions targeted at lowering common risk factors for oral
health problems and diabetes include bad eating, smoking and insufficient exercise (Suvan et al., 2022).

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Legislation changes to make health care much more accessible and affordable are required, the
evidence shows. Policies which broaden insurance coverage to include dental care, lower out-of-pocket
expenses, and also improve the amount of health practitioners skilled in integrated care can boost health
outcomes for individuals with diabetes (Jalali et al., 2021). Furthermore, public health policies must
collect and analyse epidemiological data at the diabetes oral health nexus to inform evidence based
interventions and track long term success. The interaction of dental health and diabetes has substantial
intervention and policy consequences for public health in underdeveloped nations. To address this
complicated interplay we require proper care paradigms which bring these 2 diseases together,
acknowledge their symbiotic relationship, and apply that knowledge to our advantage in prevention and
control. A commitment to accessibility and equity must underpin structural changes in health funding,
workforce development and health promotion to facilitate the transition (Barry, 2021).
Theoretical Analysis
Biopsychosocial Model
The complicated connection between diabetes and dental health may be understood from the
Biopsychosocial Model as a process of analysis which incorporates the consequences of social,
biological and psychological variables on overall health outcomes. In this particular model, there exists a
balance between an individual's natural makeup (physical health) and genes, mental makeup (feelings,
ideas, and actions), and cultural makeup (family dynamics, cultural norms, and financial standing),
(Limone andToto, 2022). This idea proposes that social determinants of health and mental stresses can
amplify or perhaps neutralize natural predispositions to diabetes concerning dental health and diabetes.
For example, individuals with diabetes might be much more likely to ignore their mouth health due to the
strain of battling the illness. Societal variables like availability of healthcare and social support systems
also influence the treatment of diabetes and oral health results (El Radad et al., 2023). Integrated care
techniques which consider patients 'psychological and social needs alongside their medical treatments are
emphasized by the Biopsychosocial Model. Public health initiatives and healthcare policies targeting
improved oral health outcomes and diabetes call for a holistic approach in case they're to work,
particularly in underprivileged communities where socio-economic determinants of health are more
prominent.
Health Belief Model
Health Belief Model (HBM): Understanding the impacts of individual beliefs and perceptions
about oral Health consequences and diabetes on health seeking behaviours and management practices.
This psychological framework explains and predicts health behaviours via emphasising attitudes and
beliefs (Ruthig and Kroke, 2022). In this particular model, peoples' perceptions of the gravity of a health
condition, their susceptibility to the issue, the advantages of stopping the issue, and the obstacles to doing
this influence whether they check out the dentist or control their diabetes. Regarding dental health and
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diabetes, the HBM might explain why some individuals skip required dental exams or even don't adhere
to their diabetic treatment regimens (Best, 2021). For instance, individuals might not take preventative
measures against diabetes-related oral health issues unless they're completely conscious of their
vulnerability to such effects or in case they feel the costs, insufficient attention, or fear of tooth
procedures vastly exceed the advantages. This particular model emphasizes the need for specific teaching
programmes aimed at bringing awareness of the hazards of diabetes and of bad dental hygiene and
overcoming the obstacles to therapy accessibility (Ahmad and Haque, 2021).
Literature Gap
Knowledge gaps in the literature are notable particularly for underdeveloped nations and the
complicated relationship between diabetes and dental health. This uncommon aggregation of socio-
economic, cultural, and systemic healthcare components in these settings which impact health outcomes
has garnered little attention from researchers despite bidirectional interaction (Lopez and Batool, 2023).
This particular knowledge gap is crucial as it excludes us from determining the various opportunities and
threats that integrated care interventions face in settings where they're needed most. However, Some
models like Biopsychosocial and Health Belief models offer general perspectives for understanding
complicated health behaviors but they lack wide dissemination of theoretical model analysis and
application in very low income countries' oral health and diabetes. Developing context-specific and
theory-informed strategies gets tougher when data obstacles exist. And when there is no evidence
similarly of the integrated therapies where diabetes and dental health are dealt with together then this
crucial information gap is very urgent because these desired clinical intervention results are restricted in
resource limited settings. By lighting the way around these gaps we can improve the health of diabetic
individuals in developing nations (Flood et al., 2021).

Chapter Summary
The literature review also identified the complicated wider epidemiological context of the
diabetes and its dental health signification in developing nations. As it was proved, socio economic
status, cultural habits and the healthcare system variables all influence the cure and life expectancy of
common illness in various patients. This review examined theoretical Models such as the
Biopsychosocial and health Belief models and found that lots of variables shape Health behaviours and
outcomes. Consequently, it has highlighted the need of integrated care strategies addressing both diabetes
and dental health simultaneously. Evidence on the effect of integrated health interventions, substandard
theoretical frameworks in these contexts and absence of integrated studies on oral health and diabetes in
developing nations would be among the crucial gaps in the literature this assessment identified.

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Chapter 3: Methodology
Chapter overview

In the context of developing nations, this particular methodology chapter describes the systematic
strategy adopted to analyze the interaction of interests between diabetes and dental health outcomes. It
can synthesize and integrate present research findings from many different scientific studies, thus a
systematic evaluation was selected as the research format for this examination. This technique extracts
themes, patterns and insights never apparent in individual study to better understand the complex, multi-
factorial interaction of diabetes and oral health. Since socioeconomic conditions in developing countries
are able to differ considerably, variables impacting health outcomes might be rather different, and a
systematic review is thus acceptable (Chan et al., 2021; Cumpston et al. 2022). To bring a single
viewpoint together what's known regarding the subject, data from various studies will be aggregated and
examined. This provides the foundation for future research, informs practice and policy, and also fills
gaps in the literature so individuals who have diabetes in these areas may have greater overall health
outcomes. Following recognized protocols for systematic reviews, the techniques described herein are
meant to be repeatable, transparent, and rigourous.

Systematic Review Perspective

This particular systematic review utilizes a qualitative investigation method since the connection
between oral health and diabetes is complicated, especially in the contexts of developing nations. For
health outcomes impacted by a mix of biological, socioeconomic, cultural, and healthcare system
problems, the qualitative paradigm is well suited to getting rid of the layers of complexity (Leavy, 2022).
This research design offers rich contextual insights that quantitative techniques might miss by evaluating
lived experiences, perceptions, and practices regarding oral health and diabetes.
Qualitative approaches have several reasons. The first step on to comprehending the bigger health
consequences is an awareness of the lived realities of individuals with diabetes in developing nations,
especially when it involves their dental health and obstacles to getting medical treatment (Robertertson,
1988). Qualitative research could therefore provide narratives of these events from the patient
perspective. Such understandings are priceless for determining gaps in healthcare provision,
policymaking and knowledge which impact overall health outcomes.
An additional reason for qualitative approach is that cultural and socio-economic factors also are
applicable to the web of interactions between dental health and diabetes. Cultural norms concerning
sickness and health, financial restrictions on medical treatment, and socioeconomic variables impacting
individual and population health all contribute (Clandinin and Caine, 2013). The interplay amongst these
factors and their effect on overall health decisions and results may be studied using a qualitative design
which is more holistic compared to data relations.
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Oral health and diabetes care management is extremely uneven and restricted in developing
countries because of bumpy allocation of health facilities and limited resources between them.
Qualitative techniques could be utilized to analyze healthcare professionals 'perceptions of challenges
and their methods of overcoming them (Adler, et al., 2016). Such information is critical in guiding and
formulating practical, community - friendly and contextually appropriate policies and initiatives.
And this specific systematic assessment will aggregate outcomes of a number of research papers
using a qualitative methodology of inquiry. This technique will be used to understand the scope and
scope of the issue of knowing the diabetes oral health connection. The method of a study is systematic
study selection, data extraction and theme evaluation (May and Perry, 2021). Diabetes and also the
relation with oral health will be fully understood with the need for patient education, the contribution of
cultures and also the problems confronting the medical systems this particular study will reveal as
themes.
This study reports on a systematic review of questionably complicated but varied relationship
between diabetes and oral health in developing nations, conducted under a qualitative research design
(Pope and Mays, 2006). This technique advocates a rich context for those elements which drive health
outcomes through analyzing events and interrelationships. Data-gathering for the qualitative systematic
review ought to yield ideas for better controlling health problems in less developed places based on
findings in its course.

Systematic Review Framework

The systematic review employs the PEO framework to find, select and appraise relevant papers
based on the primary parts of study subject. Since it could look deeper into the viewpoints, experiences,
and social factors that shape total health outcomes, this particular paradigm lends itself to qualitative
investigation. Concentrating on individuals living with diabetes in countries impacted by economic
inequality (Lockwood et al., 2015). Healthcare issues including insufficient healthcare therapy access,
scarce resources and increased burdens of non-communicable diseases like diabetes have been identified
as its selection for these areas. This research highlights the specific challenges that diabetics experience
regarding their oral health when socioeconomic variables worsen health inequalities in developing
nations. Recent studies investigated the effect of diabetes on dental health. Periodontal disease, tooth
decay along with various other dental health complications are more prevalent among diabetics.

This investigation investigates how long-term health disease diabetes impacts oral health status. It
does this by examining both direct physiological mechanisms and indirect implications from healthcare
accessibility, socioeconomic level and self-care behaviours (Carolan et al., 2015). Since diabetes is such
an intricate relationship with oral health, themes of interest or implications can be several. Important
problems include insufficient funds or availability to receive dental treatment (Arcaya et al., 2015).

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Nguyen et al. (2020) Socioeconomic status is among several factors impacting results of oral health
screenings and the use of diabetic medicines. Other factors are cultural beliefs, poverty and education.
Aim of evaluation Analyzing oral healthcare outcomes for diabetics in developing nations provides
practical insights for programmes, policies and practices. To achieve its stated goals, this review pertains
the PEO framework for methodical literature organisation and analysis (Flemming et al., 2019). This
approach may systematically identify gaps in practice and understanding and guide future studies and
policy changes to enhance lower income populations' diabetes and dental health treatment.

Search Strategy
This systematic review painstakingly covered the literature on diabetes and dental health in poor
nations through crafting its search technique (McGowan et al., 2015). As we understand this is an
interdisciplinary subject matter involving dentistry, social and medical topics we searched across
different databases for related articles. The publication platform of the PsychINFO, PubMed, and
CINAHL hold huge collections of health and mental literature. By utilizing keywords and MeSH
(Medical subject Headings) terminology the vast quantity of research on the subject was gathered.
Developing nations, "socio-economic factors," "dental care," "oral health," "periodontal disease," and
"diabetes" had been selected as keywords to symbolize each study points. They were combined using
Boolean operators to narrow the search. For example, to guarantee that appropriate papers have been
found, search terms included "diabetes and oral health," "periodontal disease and diabetes" and "oral
healthcare access and developing countries." Using Boolean operators such as and, researchers narrowed
down papers which addressed the desired context's particular mixture of dental health and diabetes.
Table 1: Boolean Operator

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To look for literature in the last twenty years of literary reviews, works published between Jan 2015 and
the current day had been limited to the literature search. We selected the time frame to make certain that
results reflected current practices and trends in oral health management and diabetes. It is because
healthcare is moving quickly and worldwide health objectives have changed.

Table 2: Search Strategy

This table summarizes the search strategy along the PEO framework dimensions: It outlines
subjects of investigation, the descriptive emphasis of each search and the terminology used to gather the
literature. We employ word truncations and Boolean operator combinations to broaden the search scope
without losing relevance to the study goals. The literature evaluation will be thorough and contain
research applicable to understanding and addressing the connection between diabetes and dental health in
developing countries due to this method.

Eligibility Criteria and Article Screening

The study set rigorous inclusion criteria to make sure that the systematic review was informed by
relevant and current data on the connection between dental health and diabetes in underdeveloped
countries (Waffenschmidt et al., 2019). A study was eligible for inclusion if published in 2015 or later
and illustrates latest advancements in the area. We selected the time period reflecting current practice and

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to gauge exactly how healthcare dynamics are shifting in developing countries. Prioritising studies in
underdeveloped nations enabled us to draw conclusions relevant to communities facing the twin
whammy of diabetes and oral health inequalities. To maintain a sharp focus, we searched for articles
focusing on exactly how diabetes impacts oral health outcomes (access, dental caries, and periodontal
disease to treatment). The study team's language skills allowed them to conduct a more effective
evaluation by restricting themselves to papers written in English.
By comparison, studies not focused on developing-world diabetics have been excluded to
maintain study context relevance. Articles that included only more general aspects of diabetes care
without any connection to dental health were excluded to keep the review focused on this two key areas.
The exact same logic was applied to non-English publications exclusions: Translational constraints
meant they couldn't be included and studies before 2015 were not even assessed so we knew our data
were current.
The screening articles started by reviewing their abstracts and titles. This removed papers which
plainly did not meet the inclusion criteria and enabled fast discovery of potentially relevant research. The
research questions and also the criteria were then read through the full-text articles to ensure they were
relevant. This particular two-step screening was guaranteed to guarantee an objective selection of
publications performed independently by various members of the research team. Final article selection
was conducted using a consensus approach in case reviewers disagreed at any point. This specific
painstaking process was needed to select relevant literature research and then to lay the basis for the
subsequent in depth study.
Table 3: Eligibility Criteria and Article Screening

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Table 1 research inclusion and exclusion criteria in systematic review. And so we know that
publications we read will highlight the interconnectedness of diabetes and dental health in developing
nations. Using the PEO framework to systematically categorise the research and defining broad criteria
allows an effective targeted evaluation.

Quality Assessment and Critical Appraisal

The systematic review on qualitative research on diabetes and oral health in developing nations
needed to verify the studies given. Due to this reason, the Critical Appraisal Skills Programme (CASP)
Qualitative Checklist was created (Long 1and1 al., 2020). This particular checklist is typical for
evaluating the merit, significance, and dependability of qualitative research. We used the ten questions of
the CASP checklist to evaluate methodology clarity, relevance to our study problems and research ethics.
First things first in an evaluation: Ensured study objectives were defined and the qualitative
approach was topic-appropriate. This was crucial for our review in determining study significance. After
that, the research approach was validated for collecting participants' complex thoughts and feelings about
diabetes and oral health. Results must be generalizable and comprehensive if the recruiting technique can
collect a representative sample. The evaluation also evaluated just how well data collection processes
provided meaningful, detailed information. To uncover biases and measures to lessen them, researchers
also examined the researchers' relationship with the participants to make sure credible data (Nardi, 2018).
Assessing whether studies met ethical norms in qualitative research included informed permission and
participant anonymity. Results were assessed according to just how effectively and clearly the data
analysis technique reached its conclusions.
Part of the evaluation was evaluating the evidence to allow for the researchers 'conclusions and
the way they determined themes and patterns within the data. The results further enhance our
understanding of the connection between dental health and diabetes, particularly in developing countries
- that will be the last point in the research significance area. We excluded studies with inadequate
methodology using a quality evaluation and critical appraisal procedure according to the CASP
Qualitative Checklist for this particular systematic review. Our trustworthy and appropriate evidence
synthesis for the study of diabetes and oral health problems in poor nations is guided by thorough
evaluations of the qualitative research 'validity and dependability.

Data Extraction
Data extraction was planned to guarantee an extensive coverage of each study in the systematic
review handling the qualitative analysis of the connection of oral health and diabetes in developing
countries (Chapman et al., 2015). This step was only completed if evidence synthesis was insightful and
consistent with the study aims. We used a standardised data extraction form to ensure consistent and
complete investigations throughout all investigations.

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Starting with study design, data retrieved dealt with numerous important domains of each study.
This included the qualitative method (grounded concept, ethnography or phenomenology) which resulted
in understanding the findings and context. Demographic data and diabetes status in addition to other
pertinent socio-economic or cultural circumstances which might have impacted the study's application to
the review's focus on developing nations were meticulously recorded as population characteristics. Data
extraction was centered on diabetes and dental health discoveries. Specifically, we documented stories,
themes and patterns from studies which illuminated oral health methods, socioeconomic factors and lived
experiences of individuals with diabetes and barriers to accessing dental care (Liao and Hitchcock,
2018). We also gathered healthcare providers 'thoughts and feelings about dealing with dental health and
diabetes.

Additionally, information on original research' suggestions or insights in addition to data on

consequences of these results for diabetic treatment and dental health was retrieved. This knowledge is
required to enhance health outcomes in the target groups and understand the research's practical
consequences. At every stage, many reviewers independently extracted data to limit bias and make
certain that all pertinent data was captured. This systematic review was collaborative in nature with
disagreements about data extraction settled by consensus after much debate. This method of data
extraction allowed a deep examination of the incorporated qualitative studies and laid the basis for
synthesis of nuanced and credible evidence, adding to our understanding of the interaction of oral health
and diabetes in developing nations.

Analysis
This study build upon qualitative evidence in systematic review by explaining the specificities of
diabetes and oral health in developing nations. This method is needed to obtain a deep understanding of
the subject with the systematic reporting and cataloguing of recurring patterns (themes) throughout
selected qualitative studies (Terry et al., 2017). Thematic analysis requires reading and rereading the data
retrieved from each research and doing the qualitative information to get a fundamental grasp of the
subject. To prepare for a more in depth study, you must understand how broad and deep the content is
during this particular immersion stage.

Then we systematically code the data. That's, picking passages from the text that highlight the
study's objectives is coding. Annotating these segments with short labels describing the main substance
or relevance groups the data into bite sized chunks for later analysis. Thematic analysis is adaptable
enough to use both inductive codes generated naturally out of the data and deductive codes based on the
study aims and previously published works. The next step is sorting codes into possible themes (or
groups of codes with similar stories or ideas). Themes are continuously revised and refined in this

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iterative phase to reflect the facts. Our synthesis of findings will be guided by a thematic framework
established once themes are reviewed and defined more fully (Braun and Clarke, 2017). This narrative
synthesis places the results within the larger socio economic and healthcare systems of developing
nations and highlights the similarities and differences among the research. We expose qualitative
material about experiences, difficulties and wants of individuals with diabetes with regards to their dental
healthcare through thematic analysis. With our robust methodology, we contribute to the literature and
inform future research, practice and policy.

Ethical Considerations

Ethics issues when conducting a systematic review combining qualitative studies on dental health
and diabetes in underdeveloped countries are imperative to ensure honesty and dignity all through the
study process. Using published data is a crucial ethical consideration in doing systematic reviews. This
requires a reevaluation of the initial study circumstances, participant consent and anonymization, Arifin
(2018) states. We excluded studies which met ethical approval and ethical norms in methodology to
avoid any possible infringement of the subjects 'rights and dignity early in the investigation. A second
ethical concern is publication bias that may change the review findings and conclusions (Cacciattolo,
2015).
Still, we searched through databases and also included studies with or without results as proof.
This method reduces the danger of favouring results which are advantageous or those published in high
impact journals, while enhancing the representation of current knowledge. Search tactics, inclusion and
exclusion criteria and analysis methods were documented to enable a replicable systematic review. Being
accessible and open helps with ethics, because we can let others check and replicate our work which
helps with an equitable evidence base. Following these guidelines can assure a truthful review which is
respectful of the initial study and its participants and that our synthesis of results belongs to an ethical
and positive contribution to the area.

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Chapter 4: Results
Chapter Overview
This particular chapter details the complicated connection between oral health outcomes and
diabetes as discovered by a systematic literature review of developing country populations. It offers an
organised discussion of themes emerging out of the synthesis of evidence collected using rigorous
methodology. This particular analysis is crucial since it identifies the personal, educational, and systemic
hurdles to appropriate treatment and control of diabetes and shows the interplay of dental health and
diseases. This chapter seeks to expand existing knowledge by examining the findings. It hopes to offer
lessons for future research, legislation and medical practice to address these interconnected health
challenges.

Article Search Screen and Appraisal

Following the PRISMA flow diagram as a guide, the systematic review technique started by searc
hing various databases and locating 300 publications. Following duplicate removal the number of papers
was reduced to 250. Titles and abstracts were subsequently reviewed. Fifty articles were identified at this
stage as possibly included. Fifteen articles have been selected for detailed examination after full-text revi
ews using inclusion and exclusion criteria. A methodological quality Critical Appraisal was performed o
n each one of these papers using the qualitative research compatible crucial appraisal Skills Programme
(CASP) checklist. Following strict criteria for study integrity and importance, this evaluation procedure i
dentified studies that would shed light on exactly how diabetes impacts oral health in developing nations.
The selection and evaluation procedure was transparent and rigorous using PRISMA flow chart.

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Identification of studies via databases and registers

Identification
Records identified from*: Records removed before
screening:
Databases (n =363)
Duplicate records removed
PubMED (n = 100) (n = 20)
PsychInfo (n=55) Records marked as ineligible
by automation tools (n =60 )
CINAHL(n=208)

Screening Records excluded

Records screened
(n = 25)
(n = 283)

Reports sought for retrieval Reports not retrieved

(n = 258) (n =80)

Reports excluded:
Reports assessed for eligibility
Did not meet the criteria of
(n =178) inclusion (n=163)

Reason 1: Not reported in the

developing countries
Included
Reason 2: Not qualitative
studies

Studies included in review

(n =15)

Fig 4.1 PRISMA Flow Diagram

Results of Extracted Data

Article Study Analysis
Article Yea Key Findings Focus Area

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r
Poudel et al., 2018 2018 Reviewed oral health knowledge among people Knowledge and
with diabetes, stressing the importance of Attitudes
integrated health education.
Schwendicke et al., 2015 Found significant socio-economic disparities Socio-economic
2015 affecting caries incidence. Factors
Kipkemoi et al., 2020 2020 Explored socio-economic factors affecting oral Socio-economic
health in diabetic patients in Kenya. Factors
Taylor & Borgnakke, 2008 Discussed the link between periodontal disease Disease
2008 and diabetes complications. Association
Rawal et al., 2019 2019 Association between oral health and diabetes in Disease
Indian adults, suggesting integration with Association
NCDs.
Poudel et al., 2022 2022 Scoped oral health practices in South Asian Knowledge and
diabetics, highlighting educational gaps. Practices
Albright et al., 2013 2013 Investigated the interaction between obesity, Disease
poor oral health, and diabetes. Association
Petersen, 2004 2004 Discussed global challenges in improving oral Global Health
health.
Chávarry et al., 2009 2009 Systematic review on the relationship between Disease
diabetes and periodontal disease. Association
Agarwal et al., 2010 2010 Survey on the prevalence of periodontal diseases Disease
in India. Prevalence
Lalla & Papapanou, 2011 Reviewed the interrelation of diabetes mellitus Disease
2011 and periodontitis. Association
Poudel et al., 2017 2017 Reviewed diabetes care providers' role in oral Healthcare
health, suggesting potential for health Provider Role
promotion.
Nazir et al., 2018 2018 Discussed diabetes' oral complications and their Disease
management. Management
González-Moles & 2021 Reviewed oral health problems in diabetic Disease
Ramos-García, 2021 patients, emphasising the need for Management
comprehensive care.
Das et al., 2022 2022 Comparing oral health status between diabetic Disease
and non-diabetic populations. Comparison
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Thematic Analysis

This review thematically analyses several themes including dental health and diabetes in
underdeveloped nations. To begin with, socio-economic variables decide the prevalence and
management of oral health disorders in diabetic individuals. It's seen in discrepancies in income and
access to healthcare services. This particular study calls for steps to end these disparities and guarantee
equal access to high quality healthcare services. Next, the review says that individuals with diabetes
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understand almost nothing about oral health. Targeted teaching programmes empowering patients to
manage their dental health efficiently are urgently needed to enhance overall diabetes treatment due to
knowledge deficit and bad health practices.

Additionally, the analysed investigation revealed a high correlated of diabetes with periodontal
disease, suggesting a two way connection wherein treatment of a single disorder might influence the
outcome of the other. Inspired by a holistic approach to patient care, it stresses the benefits of integrating
dental healthcare into diabetic treatment regimes. Health outcomes in diabetes populations are likewise
linked to healthcare practitioners'engagement to promote oral health. Nevertheless, global hurdles to oral
health promotion include systemic hurdles and insufficient knowledge.

Lastly, a disease plan for treatment which mirrors the differences between diabetes and non-
diabetic individuals is warranted due to disparate results in oral health. Collectively these suggestions
compliment the problem by suggesting interdisciplinary approaches to enhancing the oral health of
individuals with diabetes in low income settings. Such approaches must encompass healthcare policy,
patient education and clinical practice.

Results
Theme 1: Socio-economic Influences on Oral Health
Results from the extensive evaluation suggest that SES influences the performance of individuals
with diabetes in underdeveloped countries on their dental health. Oral health concerns are more prevalent
and ability to access dental care more restricted for lower socioeconomic class (Schwendicke et al.,
2015). Based on Kapkemoi et al. (2020), lower socioeconomic position was linked with greater
proportion of periodontal disease and oral caries than with higher socioeconomic status. Problems of
preventive dental care access, insufficient understanding of oral health techniques and economic burden
of therapy are but some of the causes of inequality. For lower income groups, dental operations might be
way too costly and so they may not have access to dental care. Geographic restrictions add to the
problem too : Access to dental treatment is restricted in remote and rural regions (Kipkemoi et al., 2020).
Geographical inequality also means individuals travel for long distances to get dental care, which adds
time and money to existing obstacles to timely accessing dental therapies (Schwendicke et al., 2015).

As for preventive measures, community based oral health programmes offering reduced or free
dentistry care may benefit low income communities. Success was achieved by educational campaigns
highlighting oral health's importance and its impact on diabetes control (Schwendicke et al., 2015).
Education as a way to encourage individuals to control their well being and these programmes commonly
incorporate information on economical home care that could lessen the risk of oral health disorders

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(Kipkemoi et al., 2020),These results help support the analysis goal of explaining the complicated
interaction between dental health and diabetes and diabetes, focusing on the role of socio-economic
factors. Together, attempts to deal with these social inequalities will likely be required to improve oral
health outcomes of diabetes in developing countries (Schwendicke et al., 2015). Include provision of
low-cost medical attention and creation of holistic educational programmes adapted to the needs of
economically disadvantaged groups. In the context of socio-economic reality of diabetic patients,
inclusive healthcare models and policy interventions are warranted to enhance general diabetes in
general. This will make certain that everybody will have a chance to access dental healthcare regardless
of diabetes.

Theme 2: Oral Health Knowledge and Practices among Diabetics

The systematic review discovered a gap in oral health education and practice which directly
affects oral health outcomes in developing world diabetic populations. The significance of oral health is
poorly known among individuals with diabetes; For instance, very not many people realise that diabetes
can worsen oral health and that bad oral health can worsen diabetes (Poudel et al., 2018; Poudel et al.
2022). The absence of routine dental examinations, insufficient usage of toothfloss and occasional
brushing are signs of this dearth of care. Along with raising the risk of dental caries and periodontal
disease, these activities are able to make diabetes management hard, a vicious circle which can decrease
quality of life.

Additional research indicates an enhancement in the oral health awareness gap in individuals with
diabetes. Good outcomes are observed in programmes which teach diabetic patients on the need for
routine dental hygiene, the association between oral health and diabetes and particular oral hygiene
habits (Poudel et al., 2018; Poudel et al. 2022). These interventions have enhanced oral health methods,
more dentistry care utilisation and self-efficacy in managing oral health among individuals with diabetes,
delivered through workshops, leaflets and electronic media (Poudel et al., 2018; Poudel et al. 2022). The
paper states that dental professionals must promote oral health education. The relationship between
diabetes with oral health is complicated. Nevertheless, individuals with diabetes that get oral health
education in their standard meetings tend to be more likely to take preventive actions to help keep their
mouths well (Poudel et al., 2018; Poudel et al. 2022). This holistic method of diabetes management
includes dental health for a diabetic patient.

These results support the study goals of investigating how diabetes related knowledge and habits
affect oral health outcomes of the population. We urgently require thorough educational initiatives to
deal with the correlation between poor oral health awareness and bad oral health habits among diabetics
(Poudel et al., 2018; Poudel et al. 2022). Moreover, these therapies are helpful and necessary in diabetes
care, as the results reveal. This particular evidence indicates that oral health education should be standard
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practice in diabetes management courses. It will educate individuals with diabetes on ways to keep good
oral health.

Theme 3: Association between Diabetes and Periodontal Disease

This particular extensive review determines that diabetes is related to periodontal disease, a
connection which considerably impacts the treatment and prognosis of both diseases. Periodontal disease
is much more common in diabetics than in non - diabetic individuals, based on information from the
analyzed studies (Taylor and Borgnakke, 2008; Rawal et al., 2019; Chávarry et al., 2009; Lalla &
Papapanou, 2011; González-Moles & Ramos-García, 2021). This particular connection is primarily
because of the hyperglycemic condition of diabetic people, and that offers a world for the spread of
periodontal germs leading to even worse periodontal inflammation and tissue damage (Taylor &
Borgnakke, 2008; Rawal et al., 2019; Chávarry et al., 2009; Lalla & Papapanou, 2011; González-Moles
& Ramos-García, 2021). The evaluation additionally mentions which glycemic management is related to
the seriousness of periodontal disease in diabetic individuals. It seems that inadequate glycemic
management plays a role in periodontal issues, setting up a feedback loop wherein diabetic issues raises
periodontal threat plus severe periodontal disease makes diabetes control complicated (Taylor &
Borgnakke, 2008; Rawal et al., 2019; Chávarry et al., 2009; Lalla & Papapanou, 2011; González-Moles
& Ramos-García, 2021). This cycle might adversely influence the individual's overall health as well as
quality of life by way of a a chain reaction of issues associated with both health issues.

This specific connection has implications for diabetic care. Results highlight the significance of
dental health assessments as well as treatments in common diabetes treatment programmes. Regular
periodontal examinations and therapies are crucial steps toward managing blood glucose and also
avoiding diabetes(Taylor & Borgnakke, 2008; Rawal et al., 2019; Chávarry et al., 2009; Lalla &
Papapanou, 2011; González-Moles & Ramos-García, 2021). Furthermore, dental health providers and
diabetes treatment specialists must put into action a multidisciplinary attention strategy. This kind of
interdependence may be handled by prevention, early diagnosis and timely treatment of periodontal
issues(Taylor & Borgnakke, 2008; Rawal et al., 2019; Chávarry et al., 2009; Lalla & Papapanou, 2011;
González-Moles & Ramos-García, 2021).

These results confirm the research assumptions that periodontal disease is related to diabetic
issues and this link has essential control implications for diabetes. The study reveals just how much
diabetes impacts periodontal wellness along with other dental health problems and just how
comprehensive medical care is required for much better outcomes for diabetic individuals (Taylor &
Borgnakke, 2008; Rawal et al., 2019; Chávarry et al., 2009; Lalla & Papapanou, 2011; González-Moles
& Ramos-García, 2021). Advocating for the job of dental health of diabetes control methods as well as

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patient results, this particular job offers new insights into optimizing care for diabetic patients by
showcasing the connection between periodontal disease and diabetes as well as its management
implications.

Theme 4: Role of Healthcare Providers in Oral Health Promotion

The systematic study offers crucial information about how health professionals practice oral
health promotion in diabetic therapy. Results reveal a patchwork of practices with a few physicians
ensuring their diabetes patients get dental health advice in their regular therapy and others ignoring it
(Poudel et al., 2017; Nazir et al., 2018). This instance illustrates a weakness of current diabetes care
policies which are poorly thought out in terms of dental health matters contributing to overall health and
diabetes outcome control. Medical providers can promote healthier mouth outcomes for their patients by
talking about oral health openly, promoting preventive dental habits and advocating for regular dental
visits (Poudel et al., 2017; Nazir et al., 2018). With these beneficial activities, both diabetes management
and early treatment and detection of people with periodontal diseases are possible ; This shows the
interdependent relation between oral health and diabetes management. Moreover, the review points to the
absence of doctors - coordination of treatment with dentists, not being appropriately timed with patients
when conversing with them and not realizing the linkage between dental health and diabetes management
as barriers in integrating tooth health into the diabetes treatment (Poudel et al. 2017; Nazir et al., 2018).
Because the diabetes concern is multifaceted, attending doctors that educate their patients on dental
health must be well trained in this respect (Poudel et al., 2017; Nazir et al., 2018). From these results, the
research suggests many approaches to including dental health in diabetic care plans. For starters, medical
professionals must learn on diabetes and oral health in order to promote dental wellness among patients.
Next, regular dental check ups and recommendations to specialists must be a part of a comprehensive
plan for diabetes treatment (Poudel et al., 2017; Nazir et al., 2018). Third, increased patient outcomes
through multidisciplinary dental and medical cooperation can be achieved. This will allow more detailed
treatment plans addressing oral health of diabetes management.

These findings support the study objectives of examining healthcare providers 'roles in promoting
oral health and integrating it into diabetes management. Results suggest the need for a more holistic
approach to diabetic treatment by highlighting the key yet undervalued link between dental health and
diabetes (Poudel et al., 2017; Nazir et al., 2018). Including the recommended measures could enhance the
oral and overall health of diabetics and also make promotion of excellent oral health a crucial element of
diabetic management plans.

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Theme 5: Global Challenges in Oral Health Improvement
The systematic review investigates worldwide programmes aimed at improving the oral health of
diabetics and also determines what those programmes accomplished and what hurdles remain. The
analysis indicates that several global health initiatives focused on enhancing oral health and lowering the
burden of oral diseases aren't working as intended in developing countries (Petersen, 2004; González-
Moles & Ramos-García, 2021). Several systemic, socio-economic and logistical barriers prevent these
projects from attaining their goals. Importantly, despite worldwide campaigns promoting the benefits of
dental health, not many initiatives have succeeded in enhancing the dental health of diabetics. For
various reasons this disparity is present, such as a unprepared healthcare system, limited ability to access
dental treatment and lack of coordination between diabetes prevention initiatives and overall health
programmes (Petersen, 2004; González-Moles & Ramos-García, 2021). The assessment also
recommends much better policy enforcement and execution because a lot of developing nations lack the
infrastructure and resources to carry out the worldwide recommendations for oral health.

The programmes show gaps, particularly when tailoring and regionalising global health
programmes. Interventions that aren't entirely accessible or acceptable to those most in need happen
because lots of programmes do not take account of the target groups' specific cultural, economic and
social contexts (Petersen, 2004; González-Moles & Ramos-García, 2021). Furthermore, there are no
systematic assessment and monitoring of how these programmes may affect dental health and diabetes
outcomes as time passes (Petersen, 2004; González-Moles & Ramos-García, 2021). These results
confirmed the study goal of examining worldwide barriers to better dental health among diabetes.
Findings indicate a pressing need for more context-specific, individualized strategies to bridge the gap
between international health goals and local conditions (Petersen, 2004; González-Moles & Ramos-
García, 2021).

Future work consisted of more investments in health infrastructure, better coordination of

community, state and federal initiatives and inclusion of dental health into existing diabetic treatment
models. It's broader to bring down the prevalence of non-communicable illnesses and closing these
policy and programmatic gaps might greatly improve oral health outcomes for diabetics worldwide.

Theme 6: Oral Health Disparities and Disease Management

This systematic review examines differences in dental health outcomes among individuals with
diabetes and unaffected patients. It identifies a gap demonstrating the effect of systemic disorders on
dental health. Periodontal disease, tooth cavities and tooth damage tend to be more common in
individuals with diabetes than in non diabetics and dental health results for individuals with diabetes are
usually worse (Albright et al., 2013; Das et al., 2022). Bigger systemic factors including socio-economic

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status, health literacy, and access to medical care amplify these inequalities more for individuals with
chronic illnesses like diabetes.

Oral health is under-valued in the overall diabetes care framework and represents a challenge in
disease management approaches, the review indicates. As glycemic management and oral health have
mutual influences, the absence of integrated treatment methods doesn't remedy this overlook that
perpetuates oral health disparities (Albright et al., 2013; Das et al., 2022). Furthermore, these inequalities
are even more exacerbated in developing countries whose healthcare systems are seriously underfunded
and therefore avoid a lot of services including diabetic and dental healthcare (Albright et al., 2013; Das et
al., 2022). In reaction to these gaps, this review proposes that diabetes and dental health make up a part
of a coordinated disease management approach. More frequently, oral health must be evaluated as part of
diabetes care visits; Patient education concerning the relationship between diabetes management and oral
health must be improved; and healthcare providers across specialties must collaborate through integrated
care models (Albright et al., 2013; Das et al., 2022).

Particularly underprivileged and economically disadvantaged individuals require government

steps to enhance their ability to access healthcare. This consists of spending on healthcare infrastructure
and personnel to meet both diabetic and oral health and diabetes needs combined with expanding
insurance to cover dental care for diabetic patients (Albright et al., 2013; Das et al., 2022). Results
support study objectives of highlighting differences in oral health across diabetes groups and practical
solutions for disease management holistically. This kind of discrepancies might be significantly
decreased and health outcomes for individuals with diabetes might be considerably improved with oral
health incorporated in diabetes treatment regimens and systemic obstacles to treatment addressed
(Albright et al., 2013; Das et al., 2022). Health justice and better quality of life for individuals who have
diabetes are wider goals this whole system approach to disease management aligns with best practices in
chronic illness treatment as well.

Chapter Summary
Results of systematic review following analysis yield main themes influencing the interaction
between diabetes and dental health in developing nations are presented. It's demonstrated the need for
health care models with education upgrades and policy driven programmes to close current care gaps.
The following subjects highlight just how socio-economic position, educational attainment and
healthcare system constraints impact oral health outcomes for diabetic people. The research underscores
the need for holistic health approach to creating health initiatives which address the numerous problems
these communities face as they go through these various themes. Findings support future research,
educated policy-making and clinical methods ; additionally they contribute to our existing understanding

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of the diabetes - oral health association. Such efforts seek to enhance health outcomes for individuals
with diabetes in poor countries by guaranteeing better access to care.

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Chapter 5: Discussion
This particular discussion chapter details our systematic study results and
conclusions concerning the association between diabetes and people's dental
health in developing nations. This particular section contextualises our results
within the wider body of research on oral health among diabetes populations,
examining the available data and the shifting relationships between socioeconomic
factors, healthcare practices, along with educational interventions. This particular
research sought to highlight the difficulties and opportunities regarding dental
hygiene and diabetes care in underdeveloped places. The significance of these
themes is that they might form much more integrated healthcare strategies to
enhance the management of oral health and diabetes. We hope this analysis can
direct future studies, policy proposals and community specific healthcare practices.
Analysis of Findings
A key finding of the systematic analysis was the complexity of diabetes and
dental health management in currently challenging poor countries. Vital results
discuss the role of socioeconomic background in dental health outcomes. Additional
barriers to oral healthcare including insufficient insurance and lack of services
make oral health issues more widespread and more serious in diabetes patients of
lower socio economic status (Poudel et al., 2021). Interventions shouldn't be
confined to health settings to address larger social disparities because this
particular stratification is socio-economic status based. Findings regarding
widespread ignorance and neglect of dental hygiene among diabetic people can
also be noteworthy. Poor dental hygiene habits are a leading cause of widespread
public misunderstanding of the diabetes - oral health relationship review ( Ye et al.,
2023). This particular ignorance points out the necessity for constant health
education for the control and prevention of diabetes and also the immediate need
for educational courses targeted to the disease patients.
An increasing issue is the connection of diabetes with periodontal disease;
research indicates that both diseases hurt and then the other way round. A
problem with diabetes is periodontal disease that could bring about hyperglycemia
in case glycemic control is very poor (Genco et al., 2020). There must be a broader
approach to patient care which thinks about both dental and diabetes health in
light of these interconnected concerns. The role of healthcare practitioners in

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closing these inequalities can not be exaggerated. A lot of doctors lack the
knowledge or resources to guide their patients on dealing with their oral health,
leading to disparate approaches to incorporating oral health of diabetes care. This
highlights the need for extensive support by clinicians in managing both illnesses
needing interdisciplinary training and coordination. The evaluation also notes
worldwide challenges for improving the oral health of diabetics, including
insufficient public health programmes and legislation (Chavez et al., 2022). Despite
worldwide efforts on this front, interventions reach and impact are limited,
especially in settings with limited resources due to ongoing policy and programme
gaps. This emphasizes the importance to adapt global ideas to local conditions and
context-relevant strategies.
Lastly, since disease management methods differ, diabetes and non-diabetic
populations demonstrate discrepancies in care delivery and results. Poor oral
healthcare is prevalent amongst diabetes patients and spotlights a bigger
healthcare delivery issue that needs fixing (Ashique et al., 2024). Responses to
these inequalities might include better patient education, more extensive diabetes
management protocols including dental well being, and legislative changes to
guarantee equitable access to healthcare.
Analysis by Linking with Literature Review
Results of the systematic review compared with earlier research build
established trends along with new information concerning diabetes and dental
health in developing countries. Nearly all of the literature confirms our finding that
lower socio economic position is related to worse oral health of diabetes and
supports the hypothesis that socio economic condition impacts oral health decision
making (Souliotis et al., 2021). These findings support the crucial argument that
dealing with the oral health gap requires more than medical treatments. It will
require systemic changes in living and pay. While earlier publications have focused
on apparent obstacles to oral healthcare access, our review highlights more
complicated barriers including geographic inaccessibility and a lack of dental care
professionals (Da Rosa et al., 2020). Logistical difficulties which intensify the
difficulty of healthcare access in resource-limited contexts are described herein and
contribute to the socio-economic debate. Knowledge and practices form an
intriguing pair for the theme analysis.

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While knowledge deficits regarding oral health effects of diabetes in diabetic
populations are usually recognized in the literature, this assessment exposes a
more complicated situation. It suggests that people aren't just ignorant about oral
health and often underestimate it (Barnes, 2021). This means that educational
programs must emphasize the serious consequences of ignoring teeth and gums.
These review articles and the wider literature support the two way connection
between periodontal disease and diabetes. But we provide a critical viewpoint in
our investigation noting the importance of emerging integrated care models. This
demonstrates an increasing recognition of the interdependence of general and
dental health in addition to a trend towards more integrative therapy (Davda et al.,
2023). A new finding of our evaluation is the role of healthcare providers to
promote oral health. Our findings suggest the need for more practical applicability
although provider education is regarded as a subject in the literature. This
particular disparity identifies an opportunity for enhanced health delivery through
focused training and multidisciplinary cooperation that must be explored in future
studies.
Poorer socio economic status is directly connected to much more serious oral
health problems, indicating the centrality of socio economic factors in influencing
oral health results in diabetes. Disparities in dental health exist among developing
nation diabetic populations and are connected to income, education and access to
health services (Gonz 'lez-Moles and Ramos-Garca, 2021). Monetary limitations,
insufficient dental care facilities and ignorance regarding the significance of dental
health maintenance in diabetes control are among the key barriers that lower socio
economic groups face in getting dental treatment. For many individuals, dental
care costs represent a major barrier and financial limitations are a primary reason
(Devinsky et al., 2020). Low incomes might not have the ability to afford dental
care due to the high direct and indirect costs (treatment and time off work). Access
problems are compounded by the scarcity of dental care facilities, particularly in
underprivileged and rural areas. Even if individuals are able and ready to get
treatment, the practical hurdles could be too great a burden because of
geographical inequalities in healthcare system. Education level also influences oral
health results. The more educated individual understands much more about good
oral hygiene habits and they have access to healthcare. On the flip side, less
individuals with lower education understand about dental health, therefore they're
not as likely to brush their teeth regularly and also to wait around to find out the
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dentist (Chebib et al., 2021). Their mitigation requires a holistic strategy addressing
the structural and personal factors triggering these socio-economic gaps. Financial
aid schemes including subsidised dental treatment or insurance which deals with
oral health could be lifesavers for lower income individuals. This geographical gap
of healthcare can be partly filled by boosting dental care services in underserved
areas. This can be accomplished via mobile dental clinics or incentives for dental
practitioners operating in rural areas (Khan et al., 2020). Diabetes and oral health
are interrelated topics which call for awareness of the public and healthcare
professionals. Providers of healthcare can help their patients control diabetes by
getting training on dental health.
The extensive study highlights the need to critically look at diabetic
populations' oral health knowledge and behaviours, highlighting an important
health outcome gap. Lots of people with diabetes, particularly those from
developing nations, don't realize the association between excellent dental health
and diabetes control (Akl et al., 2021). The absence of oral health teaching and
promotion in diabetes care protocols is systemic without individual neglect. This
gap indicates a deeper issue of the system. Full patient education is essential to
diabetes treatment and this particular error highlights the need to reevaluate and
refocus healthcare objectives to incorporate it. These information collected suggest
that most individuals with diabetes don't comprehend simple dentistry hygiene
concepts such as for instance that diabetes raises the risk of periodontal disease
and that worsens diabetes (Graves et al., 2020). These folks also have far more
serious oral health issues as routine brushing and flossing aren't always done. This
creates a vicious cycle of insufficient health management where issues with dental
health can worsen diabetes results and the other way round.
The review additionally talks about the performances of educational
programmes aiming to bridge this gap between theory and practice. Results from
patient-specific educational programmes highlighting the association between
diabetes and dental health are encouraging (Haber and Cipollina, 2024). Various
treatments can reduce risks to oral health. These include digital health platforms,
workshops and instructional brochures on how to brush your teeth, when to see the
dentist and just how to prevent diabetes. This teaching campaign stresses the role
of dental health in diabetes care and transitioning patients from reactive to
proactive management of health (Javaid et al., 2021). Notably, these interventions
work better when incorporated in regular care for individuals who have diabetes.
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Integrating oral health education into patient encounters by healthcare
professionals including endocrinologists, diabetes educators, along with nurses
improves patients 'knowledge and habits. This particular holistic approach reminds
people of the importance to keep oral health and also include it in daily living
activities. This broad analysis spotlights the crucial bidirectional nature of
periodontal disease and diabetes with implications for both diabetes treatment and
gum disease prevention (Pessolano et al., 2020). This particular link is crucial
because of the higher prevalence of periodontal disease and diabetes worldwide
and especially so in probably the poorest countries where healthcare systems face
numerous hurdles. Modified immune responses and increased inflammation
together with diabetes can increase periodontal disease risk along with serious
periodontal disease might worsen diabetes, making glycemic control much more
demanding and chance for diabetic complications, the evidence indicates. Due to
this recursive link, diabetic care must consist of consideration of dental health.
Periodontal disease, associated with loss, bone loss, and gum inflammation of
teeth, is more widespread in poorly controlled diabetes (Ray, 2023). This particular
condition may really impact the quality of life for these people. Complex
interactions between periodontal disease and glycemic control are available;
periodontal inflammation could result in systemic inflammation and hinder
glycemic control. The effects of this two way street extend well beyond the person;
They have systemic implications for healthcare systems and require rethinking of
diabetes management techniques including thorough dental health evaluations and
treatments.
With these results, the evaluation recommends extending conventional
glycemic control methods and implementing a holistic approach to diabetes living.
Including periodontal disease detection and treatment in diabetes treatment plans
might help bring down health risks (AlGhamdi et al., 2023). A second important
strategy is teaching people with diabetes how their oral health impacts overall
diabetes care. Education on diabetes management must emphasize a frequent
dental examination schedule, very good oral hygiene and preparation for
periodontal therapy. The article concludes that diabetologists, dental professionals
and diabetes educators must be an interdisciplinary team to help people with
diabetes and oral health problems gain from holistic treatment. Overall health
results might be optimised when healthcare providers collaborate to offer patients
coordinated treatment plans addressing periodontal health and glucose control
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(Silvestris et al., 2023). In line with the research objectives, outcomes of the
systematic review highlight the key connection between diabetes and periodontal
disease with consequences for controlling diabetes.
In the context of diabetes treatment, the systematic review emphasizes the
benefits of having healthcare practitioners promote dental health. Despite
extensive research linking diabetes to poor dental health, the analysis revealed
that healthcare practitioners' approaches to discussing and treating dental issues in
diabetic patients' daily care varied (Su et al., 2022). Healthcare providers who don't
specialize in dentistry oftentimes neglect the oral health of diabetics. This omission
highlights a crucial need for dental health of diabetes treatment plans along with a
missed opportunity for comprehensive medical care. Individuals who have diabetes
are better served if their healthcare providers frequently question them about their
oral health, send them to dentists and also inform them on the connections
between their oral health and diabetes (Su et al., 2022). These practices result in
enhanced total diabetes management as they raise individuals' awareness of the
importance of dental health care and promote proactive treatment of oral health
complications.
Initiatives to integrate dental health into diabetes care plans are becoming
more crucial. The evaluation suggests that all healthcare personnel doing diabetic
treatment be trained thoroughly (Coronado-V 'zquez et al., 2020). This particular
training should consist of information on dental health, consequences for
neglecting it, along with advantages of preventative oral care. With this
programme, providers can learn to include dental health in diabetes treatment. You
are able to even make oral health a routine part of diabetes treatment by creating
and carrying out standardised care procedures which include referrals and exams.
Examples of possible procedures include standards for screening of diabetes
patients 'oral health before treatment and constantly, referral criteria for dentists
and methods for improving communication and cooperation between dental and
medical staff (Ogamba and Obeng, 2021). People can benefit from an integrated
strategy when multidisciplinary care teams comprising of diabetologists, Oral
health experts, diabetes educators along with others are created. This particular
evaluation is consistent with the study goals in it stresses the need for healthcare
practitioners to promote dental health as part of a multidisciplinary strategy in
diabetic care. Contributing to better knowledge of improving diabetes treatment
protocols, the findings highlight current shortcomings in healthcare practices and
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also suggest practical solutions for change (Catapan et al., 2021). This underscores
the significance of dental health within the context of chronic illness prevention and
structural changes in healthcare delivery models which are essential to enhancing
the health outcomes of diabetes patients.
Recommendations
Outcomes of the systematic review reveal the intricate connection between
diabetes and dental health and light up essential areas for improvement in
healthcare policy and training to benefit populations in developing countries with
diabetes. These findings lay the groundwork for many suggestions that can close
treatment gaps and promote more holistic, integrated approaches to these severe
health issue.
Healthcare Policy and Practice Recommendations
1. Integration of Oral Health into Standard Diabetes Care: Medical policy
must require frequent oral health examinations during diabetes treatment
protocols to maintain optimum oral health for people with diabetes (Patel et
al., 2021). One way in order to integrate is teaching health doctors to view
dental treatment as part of diabetes control and also to refer their diabetic
patients to the best dentist in case of emergency.
2. Development of Targeted Educational Programs for
Diabetics: There's a serious need for creation and distribution of
instructional resources dealing with the role of dental healthcare in diabetes
(Haleem et al., 2022). These programmes ought to be user-friendly and
available via generally used and understood media to their audience
members. Digital platforms and partnerships with local communities might
boost exposure and participation.
3. Strategies for Overcoming Socio-economic Barriers to Care: As a
method to defeat socio-economic barriers to treatment (Karagiannis et al.,
2020) policymakers must think about subsidies or modifications to insurance
to relieve the economic burden of dental healthcare for individuals with
diabetes. If community health schemes or mobile clinics were started in
underprivileged areas to overcome geographic and financial barriers, far
more individuals would get access to care they require.

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Recommendations for Future Research
1. Studies on Integrated Care Models: Future Studies should address the
efficacy and results of interdisciplinary approaches to diabetes and dental
health treatment (González-Moles and Ramos-García, 2021). Research along
these lines might find which models enhance health outcomes and which are
best to be used in various cultural and economic settings.
2. Evaluation of Educational Interventions: Second, study evaluating the
impacts of oral health education programmes on diabetes beliefs, behaviours
and understanding levels is needed. Scientific studies must establish which
delivery methods and what content are most conducive to enhancing oral
health outcomes and behaviour change.
3. Assessment of Policy Interventions: The 3rd area of investigation must
be the assessment of policy interventions. Specifically, studies should
investigate just how various policies governing diabetes therapy procedures
impact dental health (Genco and Borgnakke, 2020). Part of this process
includes examining how well-integrated care facilities, insurance
modifications and subsidies enhanced use of and quality of medical
treatment.
Consideration of Socio-economic and Cultural Contexts
All suggestions must be tailored to the target populations socioeconomic and
cultural context. This customization makes the treatments more pertinent and
achievable and raises the possibility that they'll be accepted and utilized by the
community. Health policy and practice interventions might benefit individuals with
diabetes if they find out about and stick to local customs and beliefs concerning
treatment (Babagoli et al., 2021). Healthcare policy, research and practice must
interact to address the complicated issues of dental health and diabetes. Health
and quality of life changes for individuals with diabetes in underdeveloped
countries can be attained from a comprehensive, culturally sensitive strategy which
considers socioeconomic realities of diabetic communities.
Practical and Theoretical Contribution
Policymakers and healthcare providers in underdeveloped nations can apply
the study's evidence-based results to enhance dental health and diabetes control.
Illuminating how socio-economic variables relate to healthcare provider practices
and patient knowledge and behaviours, the findings show the need to integrate oral

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health into diabetes care protocols (Kolossv'ry et al., 2023). All these facts indicate
the need for legislation to enhance access to care, extensive teaching campaigns
and integrated care models adapted to diabetic populations. Theoretic models
which connect better oral hygiene with fewer long-term health complications are
advanced through cyclical evaluation of periodontal disease and diabetes
(Janakiram and Dye, 2020). The complicated connection between socioeconomic
factors of health and health outcomes within the chronic disease management
framework is further examined. This work doubles as it broadens theoretical
approaches and demands more investigation into the complicated relationship
between health inequalities and healthcare access. The results also contribute to
what is known about the connection between dental health and diabetes (Wu &et
al., 2020).
Limitations and Future Research
Caveats concerning interpretation and application of results of this research,
which demonstrates the diabetes oral health nexus in developing nations. The
systematic review process might bias papers with particular outcomes or
techniques (Hunkenschroer and Luetge, 2022). Results may be limited to much
more varied socioeconomic and healthcare contexts because the study is focused
exclusively on developing countries (important to address some healthcare issues).
A second area for improvement would be that the research could only present a
snapshot of socioeconomic determinants and their interactions with overall health
outcomes; it might thus have oversimplified or dismissed complicated interactions
with these elements (Susser et al., 2022). These caveats point out the necessity for
careful application and interpretation of results to various other settings like
policymaking or clinical practice. The findings shouldn't be conclusions but starting
points for further discussion and validation. Future research must overcome these
constraints by incorporating more study types and locations. Longitudinal studies
that follow participants as time passes could clarify the long term effects of
integrated care models on oral health outcomes and diabetes. Medical practice and
policy must be based on the empirical information collected by intervention
research, especially when evaluating the effect of policy and education efforts
(Alvarez et al., 2022).

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Chapter 6: Conclusion
The association between oral health and diabetes in underdeveloped nations
has been examined. The study aimed to catalog the various healthcare systems,
socioeconomic and behavioural variables which constitute this link. As per Masupe
et al. These study questions (2022) point out the challenges that individuals with
diabetes face in integrating healthcare and managing oral health. Oral health
disparities in the public are even more perpetuated by a web of economic and
societal obstacles which prevent people who have diabetes from likewise getting
dental treatment. These problems are compounded by insufficient awareness and
information amongst individuals with diabetes resulting in bad oral hygiene habits.
It also showed that periodontal disease and diabetes are strongly correlated
and can worsen one another. Participation of healthcare practitioners is one way to
fill these gaps (Attaran, 2020). How they promote dental health and also include it
in diabetic care procedures affects the results for their patients. These results were
within the research goals and highlighted the interaction between factors impacting
dental health and diabetes in the developing world healthcare system and
socioeconomic situation. Medical providers must be involved in promoting and
educating patients about oral health since these problems hinder diabetic
populations in accessing and using oral healthcare services (Gonz 'lez-Moles and
Ramos-Garca, 2021). These results have bigger ramifications for healthcare policy
and practice. They champion the recognition and resolution that the
interconnectedness of dental health and diabetes calls for a paradigm shift towards
more holistic, integrated care models. These results ought to prompt lawmakers to
craft inclusive health policies that reduce socioeconomic barriers to healthcare
access and emphasize the role of dental health of frameworks for managing chronic
diseases (Northridge et al., 2020). Consequently, healthcare practices must adjust
to a multidisciplinary, collaborative approach to patient treatment by including
regular dental health examinations and referrals into diabetic care protocols.
The results stimulate additional studies examining the effects of educational
interventions and integrated care models for low income diabetes populations.
They also mention the importance to study novel, low-cost methods to improve
access to dental healthcare, especially in very low resource settings (Ullah et al.,
2023). In terms of developing world diabetes management and oral health, this
research plays a role in the literature. It summarizes the choices and obstacles to
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better dental health outcomes for diabetics. It examines relationships between
socioeconomic status, knowledge and behaviours, and healthcare provider action
(Zimmerman and Shaw Jr, 2020). The findings are consistent with the study goals
and can influence healthcare interventions, legislative reforms and much more
research on oral health and diabetes in developing nations.
Reflection on the Study's Objectives
This particular systematic review highlighted the interconnectedness of
diabetes and dental health with a special emphasis on developing nations. This
particular endeavor sought to highlight the interaction between elements related to
socio economic status, educational attainment, and healthcare system problems
regarding the control and resolution of these related disorders (Ackermann, 2024).
Results suggest that goals were met and new areas for investigation were
revealed. It outlined the complicated interaction among socioeconomic
determinants and diabetics' oral health results while highlighting barriers which
lower socio-economic strata face when looking for dental treatment. This confirms
the study idea that addressing oral health inequities calls for measures beyond the
clinical setting including socio-economic empowerment and legislation reform,
consistent with the study focus on socio-economic influence. A study of diabetic
populations on their oral health knowledge and methods revealed poor awareness
and self care behaviours and the need for educational interventions (Riegel et al.,
2021). This finding supports comprehensive health education as an important
component of controlling oral health and diabetes - the study's stated objective.
Periodontal disease and diabetes interact in both directions, supporting the
study objective of checking out the connection. Findings emphasize the value of
oral health in diabetes treatment and the complexity of the interaction between the
2 (Ahmad and Haque, 2021). Gaps in diabetes care protocols regarding oral health
were identified when the research focused on healthcare practitioners
responsibilities to enhance oral health. This result supports the study aims and
further confirms that oral health education and interdisciplinary treatment methods
must be considered routine in diabetic management. Nagy and Ghanem (2024)
mentioned that socio-economic, educational, as well healthcare attributes added to
their review a far more complex picture of the dental health nexus and diabetes.
This particular article is especially pertinent for developing countries since these

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have probably the most serious issues and the greatest demand for integrated
holistic care techniques.
The systematic review served its purpose in demonstrating that diabetes is
linked with dental health. The results highlight the need for a multidimensional
approach concerning education, the medical system and socioeconomic situation to
change diabetes and also enhance oral health (Palwankar et al., 2021). Continual
studies and policy efforts to deal with these care gaps may utilize insights from this
particular study to inform additional efforts to enhance health outcomes for low
income diabetic communities.

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References
Ackermann, F., (2024). Managing grand challenges: Extending the scope of problem structuring methods
and behavioural operational research. European Journal of Operational Research.
Adler, N.E., Cutler, D.M., Fielding, J.E., Galea, S., Glymour, M.M., Koh, H.K. and Satcher, D., (2016).
Addressing social determinants of health and health disparities: A vital direction for health and
health care. NAM Perspectives.

Agarwal, V., Khatri, M., Singh, G., Gupta, G., Marya, C.M. and Kumar, V., (2010). Prevalence of
periodontal diseases in India. HEALTH CARE, 44(3).

Ahmad, R. and Haque, M., (2021). Oral health messiers: Diabetes mellitus relevance. Diabetes,
Metabolic Syndrome and Obesity, pp.3001-3015.
Akl, S., Ranatunga, M., Long, S., Jennings, E. and Nimmo, A., (2021). A systematic review investigating
patient knowledge and awareness on the association between oral health and their systemic
condition. BMC Public Health, 21, pp.1-13.
Albright, J.W., Woo, P.H., Ji, S., Sun, B., Lang, K. and Albright, J.F., (2013). Synergism between
obesity and poor oral health associated with diabetes in an elderly human population. Southeast
Asian J Trop Med Public Health, 44(2), pp.318-331.

AlGhamdi, A.M., Almubarak, M.M., Al Ghanem, E.J., Alfaraj, Z.S., Alshayib, L.Y., Alghamdi, O.A.,
Huwayz, F.A.B., Hakami, R.Y., Aljehani, W.A., Kaki, A.S. and Bukhsh, A.T., (2023). The
Benefits of Early Dental Disease Detection in Improving the Quality of Life. Journal of Survey in
Fisheries Sciences, 10(5), pp.248-251.
Al-Maweri, S.A., Altayyar, M.O., AlQahtani, K.W., Bamasud, M.S., AlGhamdi, O.Y., Ashraf, S., Eshky,
R., Ba-Hattab, R. and Kassim, S., (2021). Xerostomia, salivary flow, and oral health status among
saudi diabetic patients: A comparative cross-sectional study. Clinical, Cosmetic and
Investigational Dentistry, pp.451-458.
Alvarez, K., Cervantes, P.E., Nelson, K.L., Seag, D.E., Horwitz, S.M. and Hoagwood, K.E., (2022).
Structural racism, children’s mental health service systems, and recommendations for policy and
practice change. Journal of the American Academy of Child & Adolescent Psychiatry, 61(9),
pp.1087-1105.
Apergis, N., Mustafa, G. and Dastidar, S.G., (2021). An analysis of the impact of unconventional oil and
gas activities on public health: New evidence across Oklahoma counties. Energy Economics, 97,
p.105223.
Arcaya, M.C., Arcaya, A.L. and Subramanian, S.V., (2015). Inequalities in health: definitions, concepts,
and theories. Global health action, 8(1), p.27106.

50
 51
Arifin, S.R.M., (2018). Ethical considerations in qualitative study. International journal of care
scholars, 1(2), pp.30-33.

Ashique, S., Mishra, N., Garg, A., Garg, S., Farid, A., Rai, S., Gupta, G., Kamal, D., Paudel, K.R. and
Taghizadeh-Hesary, F., (2024). A Critical Review on the Long-term COVID-19 Impacts on
Patients with Diabetes. The American Journal of Medicine.
Attaran, M., (2020). 3D printing role in filling the critical gap in the medical supply chain during
COVID-19 pandemic. American Journal of Industrial and Business Management, 10(05), p.988.
Babagoli, M.A., Nieto-Martínez, R., González-Rivas, J.P., Sivaramakrishnan, K. and Mechanick, J.I.,
(2021). Roles for community health workers in diabetes prevention and management in low-and
middle-income countries. Cadernos de saude publica, 37, p.e00287120.
Barnes, E., (2021). Understanding dental professionals’ roles in oral health education (Doctoral
dissertation, Cardiff University).
Barry, M.M., (2021). Transformative health promotion: what is needed to advance progress?. Global
health promotion, 28(4), pp.8-16.
Batool, A. and Lopez, A., (2023). Healthcare Access and Regional Connectivity: Bridging the
Gap. Journal of Regional Connectivity and Development, 2(2), pp.260-271.
Berini, C.R., Bonilha, H.S. and Simpson, A.N., (2022). Impact of community health workers on access to
care for rural populations in the United States: a systematic review. Journal of community
health, 47(3), pp.539-553.
Best, C.D., (2021). A Correlational Study of the Relationships of Knowledge of Diabetes, Depression,
Health Belief, Stage of Change and Patient Activation in Adults with Diabetes Mellitus Type
2 (Doctoral dissertation, Adelphi University).
Briggs, A.M., Shiffman, J., Shawar, Y.R., Åkesson, K., Ali, N. and Woolf, A.D., (2020). Global health
policy in the 21st century: challenges and opportunities to arrest the global disability burden from
musculoskeletal health conditions. Best Practice & Research Clinical Rheumatology, 34(5),
p.101549.
Buranasin, P., Kominato, H., Mizutani, K., Mikami, R., Saito, N., Takeda, K. and Iwata, T., (2023).
Influence of Reactive Oxygen Species on Wound Healing and Tissue Regeneration in Periodontal
and Peri-Implant Tissues in Diabetic Patients. Antioxidants, 12(9), p.1787.
Cacciattolo, M., (2015). Ethical considerations in research. In The Praxis of English Language Teaching
and Learning (PELT) (pp. 55-73). Brill.

Carolan, M., Holman, J. and Ferrari, M., (2015). Experiences of diabetes self‐management: a focus group
study among A ustralians with type 2 diabetes. Journal of clinical nursing, 24(7-8), pp.1011-
1023.

51
 52
Castillo, K.B., Echeto, L. and Schentrup, D., (2023). Barriers to dental care in a rural
community. Journal of Dental Education, 87(5), pp.625-630.
Catapan, S.D.C., Nair, U., Gray, L., Cristina Marino Calvo, M., Bird, D., Janda, M., Fatehi, F., Menon,
A. and Russell, A., (2021). Same goals, different challenges: A systematic review of perspectives
of people with diabetes and healthcare professionals on Type 2 diabetes care. Diabetic
Medicine, 38(9), p.e14625.
Chaiban, L., Benyaich, A., Yaacoub, S., Rawi, H., Truppa, C. and Bardus, M., (2022). Access to primary
and secondary health care services for people living with diabetes and lower-limb amputation
during the COVID-19 pandemic in Lebanon: a qualitative study. BMC Health Services
Research, 22(1), p.593.
Chan, A.K.Y., Tamrakar, M., Jiang, C.M., Lo, E.C.M., Leung, K.C.M. and Chu, C.H., (2021). A
systematic review on caries status of older adults. International Journal of Environmental
Research and Public Health, 18(20), p.10662.

Chapman, A.L., Hadfield, M. and Chapman, C.J., (2015). Qualitative research in healthcare: an
introduction to grounded theory using thematic analysis. Journal of the Royal College of
Physicians of Edinburgh, 45(3), pp.201-205.

Chávarry, N.G., Vettore, M.V., Sansone, C. and Sheiham, A., (2009). The relationship between diabetes
mellitus and destructive periodontal disease: a meta-analysis. Oral health prev dent, 7(2), pp.107-
27.

Chávez, E.M., Kossioni, A. and Fukai, K., (2022). Policies supporting oral health in ageing populations
are needed worldwide. international dental journal, 72(4), pp.S27-S38.
Chebib, N., Waldburger, T.C., Boire, S., Prendki, V., Maniewicz, S., Philippe, M. and Müller, F., (2021).
Oral care knowledge, attitude and practice: Caregivers’ survey and
observation. Gerodontology, 38(1), pp.95-103.
Chen, J., Luo, W.X., Yang, X.F., Xiao, J.L., Zhan, B.X., Liu, Y. and Wu, Y.N., (2024). Self‐management
theories, models and frameworks in patients with chronic heart failure: A scoping
review. Nursing Open, 11(1), p.e2066.
Clandinin, D.J. and Caine, V., (2013). Narrative inquiry. In Reviewing qualitative research in the social
sciences (pp. 166-179). Routledge.

Clarke, V. and Braun, V., (2017). Thematic analysis. The journal of positive psychology, 12(3), pp.297-
298.

Coronado-Vázquez, V., Canet-Fajas, C., Delgado-Marroquín, M.T., Magallón-Botaya, R., Romero-

Martín, M. and Gómez-Salgado, J., (2020). Interventions to facilitate shared decision-making

52
 53
using decision aids with patients in primary health care: a systematic review. Medicine, 99(32),
p.e21389.
Cumpston, M.S., McKenzie, J.E., Welch, V.A. and Brennan, S.E., (2022). Strengthening systematic
reviews in public health: guidance in the Cochrane Handbook for Systematic Reviews of
Interventions. Journal of Public Health, 44(4), pp.e588-e592.

Da Rosa, S.V., Moysés, S.J., Theis, L.C., Soares, R.C., Moysés, S.T., Werneck, R.I. and Rocha, J.S.,
(2020). Barriers in access to dental services hindering the treatment of people with disabilities: a
systematic review. International journal of dentistry, 2020.
Das, D., Gupta, R., Menon, I., Sharma, A., Arora, V. and Ahsan, I., (2022). Oral health status among
type 2 diabetic versus non-diabetic adult population of muradnagar: A cross-sectional
comparative study. Asian Journal of Pharmaceutical Research and Health Care, 14(1), pp.34-42.

Davda, L.S., Gallagher, J.E., Short, S.D. and Balasubramanian, M., (2023). Migrant dentists, health
system responses and future challenges: a case study of the United Kingdom and
Australia. Journal of Ethnic and Migration Studies, pp.1-25.
Devinsky, O., Boyce, D., Robbins, M. and Pressler, M., (2020). Dental health in persons with
disability. Epilepsy & Behavior, 110, p.107174.
Domínguez, D.G., García, D., Martínez, D.A. and Hernandez-Arriaga, B., (2020). Leveraging the power
of mutual aid, coalitions, leadership, and advocacy during COVID-19. American
Psychologist, 75(7), p.909.
El-Radad, H.M., Sayed Ahmed, H.A. and Eldahshan, N.A., (2023). The relationship between self-care
activities, social support, and glycemic control in primary healthcare patients with type 2
diabetes. Diabetology international, 14(1), pp.65-75.
Fleming, E., Burgette, J., Lee, H.H., Buscemi, J. and Smith, P.D., (2022). Oral Health Equity Cannot Be
Achieved Without Racial Equity. Health Affairs Forefront.
Flemming, K., Booth, A., Garside, R., Tunçalp, Ö. and Noyes, J., (2019). Qualitative evidence synthesis
for complex interventions and guideline development: clarification of the purpose, designs and
relevant methods. BMJ global health, 4(Suppl 1), p.e000882.

Flood, D., Seiglie, J.A., Dunn, M., Tschida, S., Theilmann, M., Marcus, M.E., Brian, G., Norov, B.,
Mayige, M.T., Gurung, M.S. and Aryal, K.K., (2021). The state of diabetes treatment coverage in
55 low-income and middle-income countries: a cross-sectional study of nationally representative,
individual-level data in 680 102 adults. The Lancet Healthy Longevity, 2(6), pp.e340-e351.
Genco, R.J. and Borgnakke, W.S., (2020). Diabetes as a potential risk for periodontitis: association
studies. Periodontology 2000, 83(1), pp.40-45.

53
 54
Genco, R.J. and Sanz, M., (2020). Clinical and public health implications of periodontal and systemic
diseases: An overview. Periodontology 2000, 83(1), pp.7-13.
Genco, R.J., Graziani, F. and Hasturk, H.,(2020). Effects of periodontal disease on glycemic control,
complications, and incidence of diabetes mellitus. Periodontology 2000, 83(1), pp.59-65.
Ghanem, A.S. and Nagy, A.C., (2024). Oral health’s role in diabetes risk: a cross-sectional study with
sociodemographic and lifestyle insights. Frontiers in Endocrinology, 15, p.1342783.
Gill, S.A., Quinonez, R.B., Deutchman, M., Conklin, C.E., Rizzolo, D., Rabago, D., Haidet, P. and Silk,
H., (2022). Integrating oral health into health professions school curricula. Medical education
online, 27(1), p.2090308.
González-Moles, M.Á. and Ramos-García, P., (2021). State of evidence on oral health problems in
diabetic patients: a critical review of the literature. Journal of Clinical Medicine, 10(22), p.5383.
Graves, D.T., Ding, Z. and Yang, Y., (2020). The impact of diabetes on periodontal
diseases. Periodontology 2000, 82(1), pp.214-224.
Graves, D.T., Ding, Z. and Yang, Y., (2020). The impact of diabetes on periodontal
diseases. Periodontology 2000, 82(1), pp.214-224.
Gruenthal-Rankin, A.M., (2021). Dietary Dimensions of Early-Life Stress in Medieval Prussia (Doctoral
dissertation, State University of New York at Binghamton).
Haber, J. and Cipollina, J.,(2024). Oral Health Nursing Education and Practice Program: Ten-Year
Outcomes. Policy, Politics, & Nursing Practice, p.15271544231224450.
Hajishengallis, G. and Chavakis, T., (2021). Local and systemic mechanisms linking periodontal disease
and inflammatory comorbidities. Nature Reviews Immunology, 21(7), pp.426-440.
Haleem, A., Javaid, M., Singh, R.P. and Suman, R., (2022). Medical 4.0 technologies for healthcare:
Features, capabilities, and applications. Internet of Things and Cyber-Physical Systems, 2, pp.12-
30.
Hunkenschroer, A.L. and Luetge, C., (2022). Ethics of AI-enabled recruiting and selection: A review and
research agenda. Journal of Business Ethics, 178(4), pp.977-1007.
Jalali, F.S., Bikineh, P. and Delavari, S., (2021). Strategies for reducing out of pocket payments in the
health system: a scoping review. Cost Effectiveness and Resource Allocation, 19, pp.1-22.
Janakiram, C. and Dye, B.A., (2020). A public health approach for prevention of periodontal
disease. Periodontology 2000, 84(1), pp.202-214.
Javaid, M., Haleem, A., Singh, R.P. and Suman, R., (2021). Dentistry 4.0 technologies applications for
dentistry during COVID-19 pandemic. Sustainable Operations and Computers, 2, pp.87-96.
Kapila, Y.L., (2021). Oral health’s inextricable connection to systemic health: Special populations bring
to bear multimodal relationships and factors connecting periodontal disease to systemic diseases
and conditions. Periodontology 2000, 87(1), pp.11-16.

54
 55
Karagiannis, T., Bekiari, E. and Tsapas, A., (2023). Socioeconomic aspects of incretin-based
therapy. Diabetologia, 66(10), pp.1859-1868.
Khan, F., Aziz, A., Hussain, M., Iqbal, S. and Saleem, M., (2020). Review on Portable Dental Services in
Different Regions of America as an Example for Pakistan to Increase Overall Oral
Healthcare. Annals of Abbasi Shaheed Hospital and Karachi Medical & Dental College, 25(01),
pp.51-61.
Kipkemoi, K.K., Some, E.S. and Karonjo, J., (2020). Socio-economic characteristics and factors
associated with oral health status of diabetic patients attending Kikuyu hospital, Kenya. East
African Medical Journal, 97(11).

Kolossváry, E., Farkas, K., Karahan, O., Golledge, J., Schernthaner, G.H., Karplus, T., Bernardo, J.J.,
Marschang, S., Abola, M.T., Heinzmann, M. and Edmonds, M., (2023). The importance of socio-
economic determinants of health in the care of patients with peripheral artery disease: A narrative
review from VAS. Vascular Medicine, 28(3), pp.241-253.
Kroke, A.M. and Ruthig, J.C., (2022). Conspiracy beliefs and the impact on health behaviors. Applied
Psychology: Health and Well‐Being, 14(1), pp.311-328.
Lalla, E. and Papapanou, P.N., (2011). Diabetes mellitus and periodontitis: a tale of two common
interrelated diseases. Nature Reviews Endocrinology, 7(12), pp.738-748.

Leavy, P., (2022). Research design: Quantitative, qualitative, mixed methods, arts-based, and
community-based participatory research approaches. Guilford Publications.

Liao, H. and Hitchcock, J., (2018). Reported credibility techniques in higher education evaluation studies
that use qualitative methods: A research synthesis. Evaluation and program planning, 68,
pp.157-165.

Limone, P. and Toto, G.A., (2022). Factors that predispose undergraduates to mental issues: A
cumulative literature review for future research perspectives. Frontiers in public health, 10,
p.831349.
Lockwood, C., Munn, Z. and Porritt, K., (2015). Qualitative research synthesis: methodological guidance
for systematic reviewers utilizing meta-aggregation. JBI Evidence Implementation, 13(3),
pp.179-187.

Long, H.A., French, D.P. and Brooks, J.M., (2020). Optimising the value of the critical appraisal skills
programme (CASP) tool for quality appraisal in qualitative evidence synthesis. Research
Methods in Medicine & Health Sciences, 1(1), pp.31-42.

55
 56
Masupe, T., Onagbiye, S., Puoane, T., Pilvikki, A., Alvesson, H.M. and Delobelle, P., (2022). Diabetes
self-management: a qualitative study on challenges and solutions from the perspective of South
African patients and health care providers. Global health action, 15(1), p.2090098.
May, T. and Perry, B., (2022). Social research: Issues, methods and process. McGraw-Hill Education
(UK).

McGowan, J., Sampson, M., Salzwedel, D.M., Cogo, E., Foerster, V. and Lefebvre, C., (2016). PRESS
peer review of electronic search strategies: 2015 guideline statement. Journal of clinical
epidemiology, 75, pp.40-46.

Nardi, P.M., (2018). Doing survey research: A guide to quantitative methods. Routledge.

Nazir, M.A., AlGhamdi, L., AlKadi, M., AlBeajan, N., AlRashoudi, L. and AlHussan, M., (2018). The
burden of diabetes, its oral complications and their prevention and management. Open access
Macedonian journal of medical sciences, 6(8), p.1545.

Negrini, T.D.C., Carlos, I.Z., Duque, C., Caiaffa, K.S. and Arthur, R.A., (2021). Interplay among the oral
microbiome, oral cavity conditions, the host immune response, diabetes mellitus, and its
associated-risk factors—An overview. Frontiers in oral health, 2, p.697428.
Nguyen, A.T.M., Akhter, R., Garde, S., Scott, C., Twigg, S.M., Colagiuri, S., Ajwani, S. and Eberhard,
J., (2020). The association of periodontal disease with the complications of diabetes mellitus. A
systematic review. Diabetes research and clinical practice, 165, p.108244.

Noakes, T.D., Crofts, C. and Ben-Dor, M., (2023). Understanding human diet, disease, and insulin
resistance: scientific and evolutionary perspectives. In Ketogenic (pp. 3-69). Academic Press.
Northridge, M.E., Kumar, A. and Kaur, R., (2020). Disparities in access to oral health care. Annual
review of public health, 41, pp.513-535.
Nurminen, M. and Rättö, H., (2023). Impact of diabetes diagnosis on dental care utilization: evidence
from Finland. Health Economics Review, 13(1), p.26.
Obeng, I.S. and Ogamba, I.K., (2021). Service integration for improved diabetic and dental care:
exploring an effective model for optimising health outcomes. Journal of Integrated Care, 29(2),
pp.185-203.
Palwankar, P., Tandon, S., Blaggana, V., Palwankar, D. and Sachdeva, A., (2021). Diabetes and
periodontitis-a socioeconomic disease. J Evolution Med Dent Sci, 10, pp.2320-232.
Patel, A.B., Il'Yasova, D. and Owen-Smith, A., (2020). Sociodemographic and clinical factors associated
with poor oral health outcomes among United States adults. International Journal of Oral Health
Sciences, 10(2), pp.86-93.

56
 57
Patel, J., Wallace, J., Doshi, M., Gadanya, M., Yahya, I.B., Roseman, J. and Srisilapanan, P., (2021).
Oral health for healthy ageing. The Lancet Healthy Longevity, 2(8), pp.e521-e527.
Pessolano, L.G., Kramer, C.D., Simas, A., Weinberg, E.O., Genco, C.A. and Schreiber, B.M., (2020).
Periodontal disease and birth outcomes: are we missing something?. Current Oral Health
Reports, 7, pp.62-71.
Petersen, P.E., (2004). Challenges to improvement of oral health in the 21st century—the approach of the
WHO Global Oral Health Programme. International dental journal, 54, pp.329-343.

Pope, C. and Mays, N., (2006). Qualitative methods in health research. Qualitative research in health
care, pp.1-11.

Poudel, P., Griffiths, R., Arora, A., Wong, V.W., Flack, J.R., Barker, G. and George, A., (2021). Oral
health status, knowledge, and behaviours of people with diabetes in Sydney,
Australia. International journal of environmental research and public health, 18(7), p.3464.
Poudel, P., Griffiths, R., Wong, V.W., Arora, A. and George, A., (2017). Knowledge and practices of
diabetes care providers in oral health care and their potential role in oral health promotion: a
scoping review. Diabetes research and clinical practice, 130, pp.266-277.

Poudel, P., Griffiths, R., Wong, V.W., Arora, A., Flack, J.R., Khoo, C.L. and George, A., (2018). Oral
health knowledge, attitudes and care practices of people with diabetes: a systematic review. BMC
public health, 18, pp.1-12.

Poudel, P., Rawal, L.B., Kong, A., Yadav, U.N., Sousa, M.S., Karmacharya, B., Pradhan, S. and George,
A., (2022). Oral Health Knowledge, Attitudes and Practices of People Living with Diabetes in
South Asia: A Scoping Review. International Journal of Environmental Research and Public
Health, 19(21), p.13851.

Rahmah, A.S., (2021). Socioeconomic inequalities in dental caries. The University of Manchester
(United Kingdom).
Ramos-Gomez, F., Kinsler, J. and Askaryar, H., (2020. Understanding oral health disparities in children
as a global public health issue: how dental health professionals can make a difference. Journal of
public health policy, 41, pp.114-124.
Ranasinghe, P., Jayawardena, R., Gamage, N., Sivanandam, N. and Misra, A., (2021). Prevalence and
trends of the diabetes epidemic in urban and rural India: A pooled systematic review and meta-
analysis of 1.7 million adults. Annals of epidemiology, 58, pp.128-148.
Rapone, B., Ferrara, E., Corsalini, M., Qorri, E., Converti, I., Lorusso, F., Delvecchio, M., Gnoni, A.,
Scacco, S. and Scarano, A., (2021). Inflammatory status and glycemic control level of patients

57
 58
with type 2 diabetes and periodontitis: a randomized clinical trial. International journal of
environmental research and public health, 18(6), p.3018.
Rawal, I., Ghosh, S., Hameed, S.S., Shivashankar, R., Ajay, V.S., Patel, S.A., Goodman, M., Ali, M.K.,
Narayan, K.V., Tandon, N. and Prabhakaran, D., (2019). Association between poor oral health
and diabetes among Indian adult population: potential for integration with NCDs. BMC oral
health, 19, pp.1-10.

Ray, R.R., (2023). Periodontitis: an oral disease with severe consequences. Applied biochemistry and
biotechnology, 195(1), pp.17-32.
Redondo-Flórez, L., Fernández-Lucas, J. and Clemente-Suárez, V.J., (2020). Cultural differences in
stress-related psychological, nutrition, physical activity and oral health factors of
professors. Nutrients, 12(12), p.3644.
Riegel, B., Westland, H., Iovino, P., Barelds, I., Slot, J.B., Stawnychy, M.A., Osokpo, O., Tarbi, E.,
Trappenburg, J.C., Vellone, E. and Strömberg, A., (2021). Characteristics of self-care
interventions for patients with a chronic condition: A scoping review. International journal of
nursing studies, 116, p.103713.
Robertson, L., (1988). Qualitative research methods in occupational therapy. British Journal of
Occupational Therapy, 51(10), pp.344-346.

Rocca, E. and Anjum, R.L., (2020). Complexity, reductionism and the biomedical model. Rethinking
causality, complexity and evidence for the unique patient: A CauseHealth resource for healthcare
professionals and the clinical encounter, pp.75-94.
Sahoo, H., Govil, D., James, K.S. and Prasad, R.D., (2021). Health issues, health care utilization and
health care expenditure among elderly in India: Thematic review of literature. Aging and Health
Research, 1(2), p.100012.
Sandelowski, M. and Barroso, J., (2006). Handbook for synthesizing qualitative research. springer
publishing company.

Schwendicke, F., Dörfer, C.E., Schlattmann, P., Page, L.F., Thomson, W.M. and Paris, S., (2015). Socio-
economic inequality and caries: a systematic review and meta-analysis. Journal of dental
research, 94(1), pp.10-18.

Secundo, G., Ndou, V., Del Vecchio, P. and De Pascale, G., (2020). Sustainable development,
intellectual capital and technology policies: A structured literature review and future research
agenda. Technological Forecasting and Social Change, 153, p.119917.
Silvestris, N., Franchina, T., Gallo, M., Argentiero, A., Avogaro, A., Cirino, G., Colao, A., Danesi, R., Di
Cianni, G., D’Oronzo, S. and Faggiano, A., (2023). Diabetes management in cancer patients. An

58
 59
Italian Association of Medical Oncology, Italian Association of Medical Diabetologists, Italian
Society of Diabetology, Italian Society of Endocrinology and Italian Society of Pharmacology
multidisciplinary consensus position paper. ESMO open, 8(6), p.102062.
Soluk-Tekkesin, M. and Wright, J.M., (2022). The World Health Organization classification of
odontogenic lesions: a summary of the changes of the 2022 (5th) edition. Turkish Journal of
Pathology, 38(2), p.168.
Souliotis, K., Peppou, L.E., Economou, M., Marioli, A., Nikolaidi, S., Saridi, M., Varvaras, D., Paschali,
A. and Syrigos, K.N., (2021). Treatment Adherence in Patients with Lung Cancer from Prospects
of Patients and Physicians. Asian Pacific Journal of Cancer Prevention: APJCP, 22(6), p.1891.
Su, S., Lipsky, M.S., Licari, F.W. and Hung, M., (2022). Comparing oral health behaviours of men and
women in the United States. Journal of Dentistry, 122, p.104157.
Süsser, D., Martin, N., Stavrakas, V., Gaschnig, H., Talens-Peiró, L., Flamos, A., Madrid-López, C. and
Lilliestam, J., (2022). Why energy models should integrate social and environmental factors:
Assessing user needs, omission impacts, and real-word accuracy in the European Union. Energy
research & social science, 92, p.102775.
Suvan, J.E., Sabalic, M., Araújo, M.R. and Ramseier, C.A., (2022). Behavioral strategies for periodontal
health. Periodontology 2000, 90(1), pp.247-261.
Taylor, G.W. and Borgnakke, W.S., (2008). Periodontal disease: associations with diabetes, glycemic
control and complications. Oral diseases, 14(3), pp.191-203.

Terry, G., Hayfield, N., Clarke, V. and Braun, V., (2017). Thematic analysis. The SAGE handbook of
qualitative research in psychology, 2(17-37), p.25.

Uguru, N., Onwujekwe, O., Ogu, U.U. and Uguru, C., (2020). Access to Oral health care: a focus on
dental caries treatment provision in Enugu Nigeria. BMC Oral Health, 20, pp.1-13.
Ullah, H., Manickam, S., Obaidat, M., Laghari, S.U.A. and Uddin, M., (2023). Exploring the potential of
metaverse technology in healthcare: applications, challenges, and future directions. IEEE Access.
Waffenschmidt, S., Knelangen, M., Sieben, W., Bühn, S. and Pieper, D., (2019). Single screening versus
conventional double screening for study selection in systematic reviews: a methodological
systematic review. BMC medical research methodology, 19, pp.1-9.

Wu, C.Z., Yuan, Y.H., Liu, H.H., Li, S.S., Zhang, B.W., Chen, W., An, Z.J., Chen, S.Y., Wu, Y.Z., Han,
B. and Li, C.J., (2020). Epidemiologic relationship between periodontitis and type 2 diabetes
mellitus. BMC Oral Health, 20, pp.1-15.
Ye, X., Huang, S., Wei, J., He, J., Hu, X. and Liu, F., (2023). Understanding the status and associated
factors of oral health behaviors among older Chinese adults with diabetes: A qualitative study.

59
 60
Zimmerman, M.S. and Shaw Jr, G., (2020). Health information seeking behaviour: a concept
analysis. Health Information & Libraries Journal, 37(3), pp.173-191.

60
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Appendix A

CASP Checklist: 10 questions to help you make sense of a Qualitative research

How to use this appraisal tool: Three broad issues need to be considered when appraising
a qualitative study:

Are the results of the study valid? (Section

A) What are the results? (Section
B) Will the results help locally?
(Section C)

The 10 questions on the following pages are designed to help you think about these issues
systematically. The first two questions are screening questions and can be answered
quickly. If the answer to both is “yes”, it is worth proceeding with the remaining questions.
There is some degree of overlap between the questions, you are asked to record a “yes”,
“no” or
“can’t tell” to most of the questions. A number of italicised prompts are given after
each question. These are designed to remind you why the question is important.
Record your reasons for your answers in the spaces provided.

About: These checklists were designed to be used as educational pedagogic tools, as part of
a workshop setting, therefore we do not suggest a scoring system. The core CASP checklists
(randomised controlled trial & systematic review) were based on JAMA 'Users’ guides to the
medical literature 1994 (adapted from Guyatt GH, Sackett DL, and Cook DJ), and piloted with
health care practitioners.
For each new checklist, a group of experts were assembled to develop and pilot the checklist
and the workshop format with which it would be used. Over the years overall adjustments

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have been made to the format, but a recent survey of checklist users reiterated that the
basic format continues to be useful and appropriate.
Referencing: we recommend using the Harvard style citation, i.e.: Critical Appraisal Skills
Programme (2018). CASP (insert name of checklist i.e. Qualitative) Checklist. [online]
Available at: URL. Accessed: Date Accessed.

©CASP this work is licensed under the Creative Commons Attribution – Non-Commercial-
Share A like. To view a copy of this license, visit http://creativecommons.org/licenses/by-
nc- sa/3.0/ www.casp-uk.net

Critical Appraisal Skills Programme (CASP) part of Oxford Centre for Triple Value Healthcare www.casp-uk.net

62
 2

Paper for appraisal and reference:

Section A: Are the results valid?

1. Was there a clear Yes HINT: Consider

statement of the aims of
• what was the goal of the research
the research? Can’t Tell • why it was thought important
• its relevance
No

Comments:

2. Is a qualitative Yes HINT: Consider

methodology
• If the research seeks to interpret or
appropriate? Can’t Tell illuminate the actions and/or subjective
experiences of research participants
No • Is qualitative research the right
methodology for addressing the
research goal

Comments:

Is it worth continuing?

2
 3

3. Was the research Yes HINT: Consider

design appropriate to
• if the researcher has justified the
address the aims of the Can’t Tell research design (e.g. have they
research? discussed how they decided which
method to use)
No

Comments:

3
 4

4. Was the recruitment Yes HINT: Consider

strategy appropriate to
• If the researcher has explained how the
the aims of the Can’t Tell participants were selected
research? • If they explained why the
participants they selected were the
most appropriate to provide access to
No
the type of knowledge sought by the
study
• If there are any discussions
around recruitment (e.g. why
some people chose not to take
part)

Comments:

5. Was the data collected in Yes HINT: Consider

a way that addressed the
• If the setting for the data collection was
research issue? Can’t Tell justified

• If it is clear how data were collected

No (e.g. focus group, semi-structured
interview etc.)

• If the researcher has justified the methods

chosen
• If the researcher has made the methods
explicit (e.g. for interview method, is
there an indication of how interviews are
conducted, or did they use a topic guide)
• If methods were modified during
the study. If so, has the
researcher explained how and
why

4
 5

• If the form of r ecordings, video material, notes etc.)

data is clear
(e.g. tape • If the researcher has discussed
saturation of data

Comments:

5
 6

6. Has the relationship Yes HINT: Consider

between researcher and
• If the researcher critically
participants been
Can’t Tell examined their own role,
adequately considered? potential bias and influence
during (a) formulation of the
research questions (b) data
No collection, including sample
recruitment and choice of
location

• How the researcher responded

to events during the study and
whether they considered the
implications of any changes in the
research design

Comments:

Section B: What are the results?

7. Have ethical issues been Yes HINT: Consider

taken into consideration?
• If there are sufficient details of how the
research was explained to participants
Can’t Tell for the reader to assess whether
ethical standards were maintained

• If the researcher has discussed issues

No raised by the study (e.g. issues around
informed consent or confidentiality or how
they have handled the effects of the study
on the participants during and after the
study)

6
 7

• If approval has been sought from the

ethics committee

Comments:

7
 8

8. Was the data analysis Yes HINT: Consider

sufficiently rigorous?
• If there is an in-depth description of the
Can’t Tell analysis process

• If thematic analysis is used. If so, is it

clear how the categories/themes were
No derived from the data
• Whether the researcher explains how
the data presented were selected from the
original sample to demonstrate the
analysis process

• If sufficient data are presented to

support the
findings
• To what extent contradictory data
are taken into
account

• Whether the researcher critically

examined their own role, potential bias
and influence
during analysis and selection of data for
presentation

Comments:

9. Is there a clear statement Yes HINT: Consider whether

of findings?
• If the findings are explicit
Can’t Tell • If there is adequate discussion of
the evidence both for and against
the researcher’s arguments
No • If the researcher has discussed the
credibility of their findings (e.g.
triangulation, respondent validation,
more than one analyst)
8
 9

• If the findings are discussed in relation to the

original research question

Comments:

9
 10

Section C: Will the results help locally?

10. How valuable is the HINT: Consider
research?
• If the researcher discusses the
contribution the study makes to existing
knowledge or understanding (e.g. do they
consider the findings in relation to current

practice or policy, or relevant research-

based literature

• If they identify new areas where

research is
necessary
• If the researchers have discussed
whether or how the findings can be
transferred to other populations or
considered other ways the research may
be used

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0
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Comments:
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