International Journal of Oral & Maxillofacial Pathology. 2011;2(4):24-27 Available online at http://www.journalgateway.com or www.ijomp.

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Research Article Correlation of Oral Manifestations in Controlled and Uncontrolled Diabetes Mellitus
Lalit Shrimali, Madhusudan Astekar, Sowmya GV

Abstract Diabetes mellitus is a systemic disease and is associated with number of oral manifestations. We studied the oral manifestation in 50 diabetic patient divided in controlled and uncontrolled patients and were compared. Common symptoms observed were Halitosis, taste alteration, burning mouth and the commonest being hyposalivation. Frequent lesions observed was candidiasis which was associated with use of prosthesis. No pathognomic lesion could be observed, but oral manifestations were more in uncontrolled diabetes mellitus patients. Key Words: Hyposalivation. Diabetes Mellitus;Oral Manifestation;Candidiasis;Gingivitis;Periodontitis;

Lalit Shrimali, Madhusudan Astekar, Sowmya GV. Correlation of Oral Manifestations in Controlled and Uncontrolled Diabetes Mellitus. International Journal of Oral & Maxillofacial Pathology; 2011:2(4):24-27. International Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved. Received on: 06/03/2011 Accepted on: 04/04/2011

Introduction Diabetes mellitus is a syndrome of abnormal carbohydrate metabolism that results in acute and chronic complications due to the absolute or relative lack of insulin. Diabetes mellitus is a systemic disease affecting 1 every system of the body. India has now become the diabetic capital. Diabetes mellitus can have profound effects upon oral tissues. In addition to elevated glucose levels, many other pathophysiological changes in diabetics increase the risk of periodontal disease. It has been shown that uncontrolled diabetics have greater incidence of severe recurrent bacterial or fungal infections and periodontal diseases. Various studies have shown that diabetes is associated with hyposalivation or xerostomia, associated with burning mouth, loss of taste, enlargement of salivary glands, candidiasis, lichen planus, and oral 1-4 leukoplakia. Hence this study was conducted on controlled & uncontrolled diabetic patients in order to observe their main symptoms, sign or lesion present and correlated them with the control of diabetes mellitus. Material & Methods The present study included a total of 50 diabetic patients diagnosed with diabetes type 2 from Geetanjali medical college and hospital, Udaipur, India. A customized case history was designed to obtain a good medical and dental history, with special reference to signs and symptoms, detailed examination of oral cavity in relation to dental status and prostheses, as well as the clinical data obtained by physician were also

noted. All the patients were informed about the present study and informed consent was also taken. Only those patients whose fasting blood sugar was >126 mg/dl or random blood sugar >200 mg/dl were selected and divided into two groups. The first group consisted of 25 controlled diabetic patients with treatment in form of oral hypoglycemic agents, insulin or on dietary control. The second group had 25 uncontrolled diabetic patients, who were drug defaulter, or not on treatment and without dietary control. The HbA1c were also estimated in order to differentiate between controlled (<7) and uncontrolled diabetes (>7). Sample material for culture of fungi, were taken with sterilized cotton swabs and was plated onto petridish with sabouraud dextrose agar medium, plus o chloramphenicol and incubated at 37 C for at least 7-10 days. The different morphological colonies were selected & were sub cultured on fresh medium in tubes. Yeast identification was performed using the 5 6 Kreger-van Rij & Lodder criteria. Candidiasis speciation was done by growing the white creamy colonies on chrome agar culture media. Results There was a male predominance in both the groups accounting for about 32 male and 18 female patients with age ranging from 35 to 76 years (Table 1). The study subjects comprised of 60% males and 40% females in controlled group with 68% males and 32% females respectively in uncontrolled group.

2011 International Journal of Oral and Maxillofacial Pathology. Published by Publishing Division, Celesta Software Private Limited. All Rights Reserved

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About 32% in controlled and 40% in uncontrolled group used complete dentures since 15-20 years. The more frequent oral signs and symptoms observed in both controlled and uncontrolled diabetic patients was hyposalivation followed by halitosis gingivitis and periodontitis. Later Taste alteration, aphthous stomatitis was common in uncontrolled diabetes whereas burning mouth sensation in controlled diabetes. Chi-Square test showed a significant difference between the groups (Table 2). On examination of oral cavity, the most common lesion seen in both the groups were Candidiasis, followed by proliferative lesions represented by fibrous hyperplasia possibly associated with the prosthesis, Aphthous ulcers and benign neoplasia (like papilloma). One case of malignant neoplasm and herpetic infection each was only seen in uncontrolled diabetes. Chi-Square test showed a
Diabetic patient Controlled Uncontrolled Total Male (%) 15 (60) 17 (68) 32

significant difference between the groups (Table 3). Culture was positive for candida species in 36% in uncontrolled diabetic, and 28% in controlled diabetic patients as shown in Table 4. Discussion Hyposalivation was the commonest symptom in both controlled & uncontrolled group possibly related to polyuria & substitution of functioning tissue by adipose tissue in major salivary gland, reducing qualitatively & quantitatively saliva production & leading to burning mouth 1 2 symptoms as studied by Russoto , Murrah , 3 7 Gibson and Zachariasen. Some drugs particularly diuretics are also associated with this symptom. When production of saliva is decreased, fungi such as candida albicans & other species can increase in the oral cavity. Similar results were observed by Peters 8-10 Budtz-Jorgensen and Bertran and Oslen.

Female (%) 10 (40) 8 (32) 18

Edentulous(%) 14 (56) 17 (68) 31

Prosthesis (%) 8 (32) 10 (40) 18

Table 1: The Gender status and Clinical Characteristics of the study Groups. Sign & Symptoms Controlled Uncontrolled Chi Value P-value Hyposalivation 17 (68%) 21 (84%) 7.017 0.008* Halitosis 13 (52%) 19 (76%) 12.500 0.000** Gingivitis 10 (40%) 12 (48%) 1.299 0.254 Periodontitis 8 (32%) 12 (48%) 5.333 0.021* Taste alteration 7 (28%) 11 (44%) 5.556 0.018* Aphthous stomatitis 4 (16%) 7 (28%) 4.196 0.041* Burning mouth sensation 8 (32%) 6 (24%) 1.587 0.208 Sialorrhea 3 (12%) 4 (16%) 0.664 0.415 Table 2: Signs and Symptoms observed in number of both controlled and uncontrolled diabetic patients. (* Significant, ** Highly Significant) Lesion Controlled Uncontrolled Chi Value 1.471 1.587 4.196 0.664 4.082 4.082 P- value 0.225 0.208 0.041* 0.415 0.043* 0.043*

Candidiasis 7 (28%) 9 (36%) Proliferative lesion 6 (24%) 8 (32%) Aphthous ulcers 4 (16%) 7 (28%) Benign neoplasia 3 (12%) 4 (16%) Malignant neoplasia 0(0%) 1 (4%) Herpes 0 (0%) 1 (4%) Table 3: Intra Oral Manifestations Diabetic Patients. (* Significant) Diabetic patient Candidal Carriers Patient with lesion 3 (12%) 4 (16%)

Positive culture 7 (28%) 9 (36%)

Controlled 4 (16%) Uncontrolled 5 (20%) Table 4: Candidiasis in Diabetic Patients.

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Burning mouth sensation observed more frequently in controlled diabetes possibly because of neuropathy. Similar results were 11 observed by Quirino et al . Dentures can induce proliferation of fungi, due to decreased local vascular circulation associated with compression of prosthesis 10,12 with deficient hygienic habits. Candidiasis associated with atrophic lesion 13 has been described by Farman & Nutt , 14 Lamey . Diabetics have predisposed local factors causing damage to microvascularization, suggesting that reduced blood supply can predispose to candidiasis. In our study major frequency of candidosis was not observed even in uncontrolled diabetics, similar results were 15 16 17 observed by Odds , Fisher & Quirino and the association between diabetes and candidosis is still controversial, and needs further study. Lamey also observed no significant difference in relation to microorganism in treated diabetics, duration of disease or even age of the patient with relation to local factors such as wearing of prosthesis, 14 hyposalivation and smoking. Lamey , 15 18 Odds and Darwazeh found that increase of glucose in saliva promotes greater adherence of fungi to epithelial cells, which also interfere with the defense mechanism of neutrophils facilitating possible candidiasis in the presence of local predisposing factor. 19 Taylor and Borgnakke identified periodontal disease may lead to poor metabolic control in diabetic patients. After periodontal therapy improvement in glycemic control has been seen in some patient of 20 diabetes as seen by Mealey. It clearly indicates that all diabetic patients should have regular dental checkup and periodontal 3 treatment if necessary. Gibson studied the correlation of oral lichen planus to diabetes and observed that Lichen planus lesions are mainly of erosive or ulcerative type in 21 4 diabetes. Albrecht has observed that some anti-diabetic drugs also causes lesion similar to Lichen planus called as Lichenoid reactions. Conclusion Hyposalivation was most frequent symptom especially in uncontrolled Diabetics; others were alteration of taste, burning mouth and halitosis. Candidal lesions were correlated with the presence of prosthesis. No characteristics and pathognomonic lesion could be associated with diabetes mellitus but oral manifestations are more common in
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uncontrolled diabetes. Since we have studied 50 patients of diabetes, more studies with large number of patients is required to draw definitive conclusions.
Author Affiliation 1. Dr.Lalit Shrimali, Assistant Professor, Department of General Medicine, Geetanjali Medical College and Hospital, 2. Dr.Madhusudan S Astekar, Professor, Department of Oral and Maxillofacial Pathology, 3. Dr.Sowmya GV, Post Graduate Student, Department of Oral Medicine and Radiology, Pacific Dental College and Hospital, Udaipur, Rajasthan State, India. Acknowledgement We would like to thank all the staff members from Geetanjali Medical College and Pacific Dental College and Hospital for helping us.

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Corresponding Author Dr. Lalit Shrimali, General Physician, Opposite B N College, Subhash Nagar, Udaipur-313002, Rajasthan State, India. Ph: 09414166465 Email: drlalitshrimali@yahoo.co.in

Source of Support: Nil, Conflict of Interest: None Declared.