Date on Master's Thesis/Doctoral Dissertation


Document Type

Doctoral Dissertation

Degree Name

Ph. D.


Health Management and Systems Sciences

Degree Program

Public Health Sciences with a specialization in Health Management, PhD

Committee Chair

Little, Bert

Committee Co-Chair (if applicable)

Esterhay, Robert

Committee Member

Esterhay, Robert

Committee Member

Jennings, J'Aime

Committee Member

Creel, Liza

Committee Member

Gettleman, Lawrence

Author's Keywords

type 2 diabetes (T2DM); oral health; quality of life; oral health-related quality of life (OHRQoL); United States


This dissertation focused on the relationship between type 2 diabetes (T2DM) and oral health-related quality of life (OHRQoL) and the factors associated with this relationship in the US. The objectives of the dissertation research were a three-part process: (1) to understand the relationships of T2DM with poor OHRQoL, clarify risk and preventive factors that affect this association, and identify research gaps in the literature, (2) to analyze risk factors associated with poor OHRQoL in US adults with T2DM using a nationally representative random probability cluster sample, and (3) to apply structural equation modeling (SEM) to a simplified Andersen’s Behavioral Model (ABM) to analyze the causal effects of T2DM and other factors on OHRQoL in adults from a nationally representative survey in the US. The first, second, and third objectives were met in Aim 1, Aim 2, and Aim 3, respectively. In Aim 1, there were 16 empirical articles included the systematic review that examined the association between T2DM and OHRQoL. Half of the reviewed studies did not include a control or comparison group (participants with non-T2DM). All investigations used samples of convenience, or surveys at the community level outside of the US. No studies were conducted at the national level in the US. Five studies included used only bivariate analysis and did not control for confounders. The remaining 11 studies used multivariate analysis, but none of them used a theoretical framework to guide their approach. Limited evidence supported the association between T2DM and poor OHRQoL. Some data support analyses that an increased susceptibility to periodontal disease, dry mouth, and dental caries may have negative effects on well-being and quality of life among individuals with T2DM. The findings of Aim 1 highlight the need for further research. In Aim 2, the 2003-2004 National Health and Nutrition Examination Survey (NHANES) data set was used. The sample included 2,945 participants aged 20 or older sampled with a probability-based cluster design representing 131,397,654 million persons in the US population. Multiple logistic regression was used to predict severity scores (OHIP-ADD) and prevalence scores (OHIP-SC) with the ABM theoretical framework. We found that OHRQoL was poorer among US adults with T2DM, especially those with uncontrolled glycemia. Risk factors for poor OHRQoL included untreated dental caries, periodontal disease, unmet denture needs, obesity, female gender, African American ethnicity, and low income. Higher education, private dental coverage, and annual dental prophylaxis was associated with higher OHRQoL. In Aim 3, the analysis of a nationally representative sample of 2,798 participants aged 20 or older representing 124,525,899 individuals in the US population was done. We applied SEM to a simplified three-factor Andersen’s model to analyze the causal effects of T2DM and other factors on OHRQoL. Causal pathways of the interrelationships of T2DM, need, personal health practices and use of services with OHRQoL were analyzed in a simplified three-factor ABM. Using SEM, T2DM had an impact on need, which in turn, had direct and indirect effects on OHRQoL. Need also influenced personal health practices and use of services, which in turn, affected OHRQoL. Education and income also affected personal health practices and use of services. In summary, a theory-driven, practice-validated conceptual model with rigorous statistical methodology using a nationally representative sample in the US was used to analyze the association and pathways of T2DM and OHRQoL, as well as factors associated with these relationships. The present research indicates that T2DM negatively affected OHRQoL in US adults. Risk factors for poor OHRQoL (in descending order of importance) were current smoking, untreated dental caries, uncontrolled T2DM, unmet denture need, female gender, obesity, African American ethnicity, and periodontal disease. Protective factors from OHRQoL impairment were private dental insurance, college education, and annual dental prophylaxis. Moreover, need directly and indirectly influenced OHRQoL. Personal health practices and use of services also had affected OHRQoL.