Multivariable logistic regression (Adjusted OR).

Climate change is increasingly recognized as a contextual determinant of health in low- and middle-income countries (LMICs). Climate-related stressors such as water scarcity and food insecurity may influence oral health indirectly by disrupting hygiene practices, dietary patterns, and access to care. However, epidemiological evidence examining these relationships remains limited, particularly in resource-limited settings. This study aimed to examine the association between selected climate-related exposures and oral health outcomes among adults residing in climate-vulnerable districts of Pakistan. A cross-sectional analytical study was conducted among 422 adults residing in Charsadda and Peshawar districts of Khyber Pakhtunkhwa, Pakistan. Climate-related exposures assessed over the preceding 12 months included water scarcity, food insecurity, heat stress, and climate-related displacement. Oral health outcomes were evaluated using standardized clinical measures: the Decayed, Missing, and Filled Teeth (DMFT) index and the Community Periodontal Index (CPI). Multivariable binary logistic regression models were used to examine associations between climate-related exposures and oral health outcomes after adjusting for socio-demographic and behavioral confounders. Principal component analysis was performed to explore clustering of environmental and behavioral risk factors. Among the 422 adults, 61.4% had high caries (DMFT ≥ 3) and 47.6% had periodontal disease (CPI ≥ 3). Water scarcity (49.8%) and food insecurity (45.5%) were frequently reported. In adjusted analysis, water scarcity (AOR 1.89;95% CI 1.23-2.9) and food insecurity (AOR 1.74; 95% CI 1.12-2.69) were independently associated with high caries. For periodontal disease, water scarcity (AOR 1.67; 95% CI 1.12-2.48) and food insecurity (AOR 1.59;95% CI 1.05-2.41) were independently associated. Principal component analysis identified clustering of environmental stressors with hygiene- and nutrition-related vulnerabilities. Water scarcity and food insecurity were associated with adverse oral health outcomes in climate-vulnerable districts of Khyber Pakhtunkhwa. Integrating climate resilience with preventive oral health strategies may help in the reduction of emerging environmental health inequalities.