Diabetes mellitus and associated oral manifestations: a review

Evaluation of Oral Microflora-Related to Dental Caries and Salivary pH in type II Diabetic Patients

Background

Diabetes mellitus is one of the chronic diseases and a group of metabolic disorders characterized by a high blood sugar level over a prolonged period. The present study aimed to evaluate and correlate HbA1c, salivary pH, and oral bacterial microflora (streptococcus and lactobacillus colony-forming unit (CFU)) related to dental caries in normal, controlled, and uncontrolled type II diabetic patients.

Materials and Methods

A total of 90 samples were taken for this study. The HbA1c test was recorded and grouped into three (normal, prediabetic, and diabetic). CFUs (streptococcus and lactobacillus) were evaluated by the spit-and-swab method. Salivary pH was measured with a pH strip with color coding. By using the post hoc test, the P-value was significant.

Results

The CFU of streptococcus and lactobacillus in the saliva spit and swab method is statistically significant for P <0.005 and P <0.01 among normal, prediabetic, and diabetic groups. In diabetic patients, there is a higher incidence of dental caries (s.d. 6.7), a higher CFU (s.d. 6194.5) in the bacterial microflora, and a lower salivary pH (s.d. 0.6) than in prediabetic and normal patients.

Conclusion

From the present study, we conclude that there is a slight increase in the CFU of Streptococcus mutans in diabetic patients compared to non-diabetic patients. This CFU increase and decrease in salivary PH were strongly associated with increased dental caries in diabetic patients.

Can hyperglycemia be associated with caries activity and root caries in adults?

AIMS

A previous meta-analysis showed that individuals with Type 2 diabetes mellitus (T2D) have a greater chance of developing both coronal caries and root caries than systemically healthy ones, which can be influenced by hyperglycemia per se. This study aimed to associate blood and salivary glucose levels with caries.

METHODS

This research is a subset of a cross-sectional study. N = 39 individuals underwent a dental examination and salivary glucose, fasting blood glucose (FBG) and glycated hemoglobin (A1c) measurements.

RESULTS

The prevalence of active coronal caries was 10.2%, and that of root caries was 20.5%. A1c and FBG averages were higher in individuals with root caries (9.75 ± 1.71 and 186.3 ± 62.5) than without (7.01 ± 2.23 and 115.1 ± 48.6; p < 0.05). Individuals with T2D showed weak correlation of salivary glucose and number of active coronal caries. Significant correlations were observed between salivary and blood glucose. There was relevance of A1c (0.53; CI=0.124-0.941; p = 0.01) and FBG (0.019; CI=0.006-0.033; p = 0.006) toward the increased number of root caries lesions, even after adjustment for salivary flow and age.

CONCLUSION

Blood glucose levels are associated with an increased number of root caries in adults with or without T2D. In individuals with T2D, salivary glucose was correlated with active coronal caries. Additional studies are needed to support this association.

Changes in saliva characteristics and carious status related to metabolic control in patients with type 2 diabetes mellitus

OBJECTIVES

This cross-sectional study aimed: 1) to compare the saliva characteristics and the occurrence of caries in patients with type 2 diabetes mellitus (T2DM) and patients without T2DM, 2) to study the impact of inadequate glycemic control on saliva and caries prevalence.

METHODS

23 adults with T2DM and 18 controls participated. Patients with T2DM were divided depending on their metabolic control: a) well-controlled (W.C.): HbA1c≤7 %, and b) poorly-controlled (P.C.): HbA1c> 7 %). The examined clinical parameters were: 1) number of natural teeth, 2) DMFT index of coronal caries, 3) saliva pH, 4) saliva flow and buffering capacity, and 5) subjective feeling of dry mouth.

RESULTS

The groups W.C and P.C showed significant differences in the number of teeth, the saliva flow, and DMFT. The C and P.C groups presented differences in pH, saliva flow, buffer capacity, and DMFT. Finally, the W.C and C groups indicated differences in the buffer capacity, saliva flow, and DMFT. The subjective feeling of dry mouth is related to the duration of the disease. The DMFT value correlated negatively with the status of metabolic regulation. Multiple linear regression revealed that the DMFT value was positively associated with serum HbA1c levels.

CONCLUSIONS

1) Adults with T2DM present a lower saliva flow rate and buffering capacity, as well as higher caries prevalence than controls; 2) The metabolic control of T2DM is essential for the maintenance of saliva flow rate and buffering capacity, and caries prevalence; 3) The duration of T2DM is of importance for the subjective sense of dry mouth.

CLINICAL SIGNIFICANCE

The duration and metabolic control of T2DM are important clinical parameters for oral complications. Awareness and co-operation of diabetologists and dentists are needed to detect oral lesions in patients with diabetes and be treated timely and effectively.

Association between Diabetes and the Use of Removable Dental Prostheses among the Korean Population

BACKGROUND

A balanced nutrient intake is important for patients with diabetes. Even if individuals have the same number of residual natural teeth, there are large differences in the masticatory performance between edentulous sites restored with a fixed dental prosthesis, including dental implants, and those restored with a removable dental prosthesis. This study assessed whether the prevalence and control of diabetes differed based on the use of removable dental prostheses through an analysis of nationally representative data.

METHODS

Overall, 8,155 individuals (3,525 men and 4,630 women) aged ≥ 50 years were included in this study and were classified into the following 3 groups: group 1, did not use any removable dental prostheses (NF); group 2, used removable partial dentures (RPD); and group 3, used removable complete dentures on at least 1 jaw (CD). The characterization of diabetic patients and glycemic control were analyzed and compared among groups. To determine the relationship between diabetes and the use of dental prostheses, multivariable logistic regression analysis was performed (P < 0.05).

RESULTS

The adjusted odds ratios and 95% confidence intervals for diabetes in men participants in groups NF, RPD, and CD were 1 (reference), 1.165 (0.878-1.544), and 1.491 (1.034-2.151), respectively, after adjusting for confounding factors. Diabetes and glycemic control were significantly associated with the use of removable dental prostheses among men.

CONCLUSION

The use of removable dental prostheses is a potential risk indicator for uncontrolled diabetes in Korean men adults, suggesting the need for a comprehensive approach to minimize the complications of diabetes mellitus.

Prevalence of Candida albicans in primary endodontic infections associated with a higher frequency of apical periodontitis in type two diabetes mellitus patients

To identify the prevalence of C. albicans in primary endodontic infections of type two diabetes mellitus (T2DM) patients and compare their clinical and radiographical characteristics with a non-diabetic control group, establishing the possible relationship between primary endodontic infection, T2DM, and C. albicans, since diabetes mellitus (DM), influences the development, course, and response to the treatment of apical periodontitis, but the presence of Candida albicans (C. albicans) has not been considered before. A total of 120 patients were selected and divided into two groups: 60 T2DM diagnosed patients and 60 non-diabetic controls. A clinical examination and radiographic analysis were performed to establish a periapical index score (PAI). Root canal samples were taken. Deoxyribonucleic acid (DNA) was extracted, and specific primers were used to identify C. albicans by polymerase chain reaction (PCR). A twofold increase in the prevalence of C. albicans in T2DM patients was observed in contrast to control patients (p = 0.0251). Sixty-five percent of T2DM patients with positive C. albicans scored a ≥ 3 PAI, while only 27% of the patients without C. albicans had a ≥ 3 PAI score (p = 0.0065). Long-term DM patients presented C. albicans more frequently (p < 0.0001). In this study, long-term T2DM patients carried C. albicans in their root canals more frequently when having a primary endodontic infection. Furthermore, this C. albicans presence seems to be related to a higher frequency of apical periodontitis.

A rare case report and appraisal of the literature on spontaneous tooth exfoliation associated with trigeminal herpes zoster

BACKGROUND

Reports of post herpetic maxillofacial complications have been very rarely documented in the literature that includes periapical lesions, calcified and devitalized pulps, resorption of roots, osteonecrosis, and spontaneous exfoliation of teeth. The atypical feature of the case of concern to the dental surgeon is the rare complication of spontaneous tooth exfoliation following herpes zoster.

CASE REPORT

This case reports a male patient of age 47 years who reported to the Department of Periodontology with the chief complaint of mobility in the left upper central incisor. Patient history revealed herpes zoster infection that began 11 days earlier along with underlying diabetes mellitus condition. We hereby report a known diabetic patient with history of herpes zoster infection who presented with rare complication of spontaneous tooth exfoliation involving the maxillary division of the trigeminal nerve.

DISCUSSION

Limited number of cases has been reported in the literature regarding spontaneous teeth exfoliation secondary to herpes zoster. The exact pathogenesis regarding the spontaneous exfoliation of teeth in herpes zoster patient is still controversial. Thus, an oral health care provider should be aware of this rare complication while managing a case of tooth mobility with the previous history of herpes zoster of trigeminal nerve.

Comparison of salivary and serum glucose levels in diabetic patients

Diabetes mellitus is a noncommunicable disease with a rising prevalence worldwide and in developing countries. The most commonly used diagnostic biofluid for detection of glucose levels is blood, but sample collection is an invasive and painful procedure. Thus, there arises a need for a noninvasive and painless technique to detect glucose levels. The objectives of the present study were to estimate the glucose levels of saliva, to assess if any significant correlation existed between the serum and salivary glucose levels, and to correlate salivary glucose levels with regard to duration of diabetes, age, and gender. In the present study, serum and salivary glucose levels of 200 subjects (100 diabetic subjects and 100 nondiabetic subjects) were estimated by glucose oxidase method. Glycosylated hemoglobin levels were also measured in randomly selected 40 diabetic subjects. The findings of present study revealed a significant correlation between salivary and serum glucose levels in both diabetic and nondiabetic subjects. No significant relationship was observed between salivary glucose levels and gender or age in both diabetics and nondiabetics and between salivary glucose levels and duration of diabetes in diabetics. On the basis of the findings, it was concluded that salivary glucose levels could serve as a potentially noninvasive adjunct to monitor glycemic control in diabetic patients.

A comparative study of oral candidal species carriage in patients with type1 and type2 diabetes mellitus

Context:

Diabetes mellitus can have profound effects upon the oral tissues especially in patients with poor glycemic control being prone to severe and/or recurrent infections particularly candidiasis. The main aim was to study the association between Type 1 and Type 2 diabetes mellitus and candidal carriage.

Materials and Methods:

The study design comprised of previously diagnosed 30 patients each with type 1 diabetes mellitus (Group A) and type 2 diabetes mellitus (Group B) and 30 age-, sex- and dental status-matched healthy non-diabetic individuals as controls (Group C). The saliva samples were collected and inoculated onto Sabouraud dextrose agar (SDA) and chromogenic agar culture medium. Candidal colony forming units per ml (CFU/ml) values were determined.

Statistical Analysis:

Data were analyzed by χ² test, Mann-Whitney U-test, Spearman's rank correlation and Karl Pearson's correlation coefficient.

Results:

Data analysis showed statistically significant higher positive candidal growth in Group A and Group B when compared to Group C. The CFU/ml values were significantly higher in Groups A and B as compared with Group C. Significant positive correlation of CFU/ml with fasting blood sugar level and HbA1c% in both Groups A and B was seen. Oral signs and symptoms observed in diabetics were dry mouth, burning sensation, fissuring and atrophic changes of tongue and erythematous areas, which positively correlated with candidal load.

Conclusion:

The glycemic control status of the diabetic patients may directly influence candidal colonization. The quantitative and biochemical characterization allows better insight into the study of association of diabetes mellitus and candida.

Efficacy of Ankaferd Blood Stopper on bone healing in diabetic rats: a stereological and histopathological study

We evaluated the effects of Ankaferd Blood Stopper (ABS) and routine antibiotic prophylaxis (AP) on early healing of bone defects in diabetic rats. We used 48 rats in the study. Diabetes was induced in 24 rats using streptozotocin; the remaining 24 healthy untreated rats served as controls. Twelve of the diabetic rats and 12 of the healthy rats were treated with AP for 3 days before surgery. Bilateral bone defects were created in the mandible of all animals. ABS was applied to the defects on the left sides of the mandibles, while nothing was applied to the right sides. Animals were sacrificed on days 7 and 14 after operation and examined for histopathology and by stereology. The volume of newly formed bone was significantly less in the diabetic rats on both days 7 and 14. Local administration of ABS significantly increased the mean volume of newly formed bone in both diabetic and nondiabetic rats at days 7 and 14. No significant difference in new bone formation was found between AP and ABS treatment in diabetic rats. Both AP and local administration of ABS have beneficial effects on bone healing in diabetic animals.

Pterygomaxillary implants: a graftless solution to deficient maxillary bone

Edentulism is one of the common dental problems in the aging population. Implant therapy has emerged as one the valid and effective solutions to this problem. However in the maxilla, posterior part presents with several anatomic obstacles in the form of bone quality, quantity, size of maxillary antrum and poor accessibility. There are various options like sinus lift with graft and pterygomaxillary implant options available. Option like ptergomaxillary implants requires lot of skill of technic sensitivity and skill of the surgeon and also is proven to be statistically superior. Case reports of pterygomaxillary implants for both partially edentulous and fully edentulous conditions are hereby described in the article.

Morphologic and cytomorphometric analysis of exfoliated buccal mucosal cells in diabetes patients

BACKGROUND

It is now known that the disease process of diabetes has effects on various tissues of the body. The following study was done to analyze the effects of diabetes on oral tissues.

AIMS

To study the morphology and cytomorphometry of the cells obtained in cytologic smears from the buccal mucosa of diabetic patients.

MATERIALS AND METHODS

Smears were obtained from clinically normal buccal mucosa of 50 randomly selected diabetic patients attending the diabetic clinic and the out-patient department and of five healthy subjects as control. Smears were stained using Papanicolaou method, and using a micrometer mean values of nuclear diameter (ND), cell diameter (CD), cytoplasmic diameter (CyD) and nucleus: cytoplasm ratio (N: C ratio) were obtained for each patient. Diabetic patients were divided into four groups based on the glycosylated hemoglobin (GHb) values for comparison.

STATISTICAL ANALYSIS USED

Student's T-test and Fisher's F-test.

RESULTS

Statistically significant increase in ND (P=0.0367) was found in diabetic patients compared to controls. Degree of glycemic control significantly affected ND (P=0.0042) and N: C ratio (P=0.0055). In general, as the severity of diabetes increases, ND and N: C ratio rise gradually.

CONCLUSIONS

Diabetes produces definite morphologic and cytomorphometric changes in the buccal mucosa of patients. However, further research in this direction is indicated, to analyze the significance of these findings as a tool for diabetes detection, as well as to obtain deeper insights into its effects on various tissues.

Diabetic patients: their knowledge and perception of oral health

Objectives

The objectives of the study were to: (1) assess the knowledge and awareness of diabetic patients of their risk for systemic and oral diseases as complications associated with diabetes, (2) to assess their attitudes toward sustaining good oral health through proper oral hygiene and regular dental check-ups, and (3) to the extent that they are aware, to determine how they became aware.

Methods

Two hundred self-administered questionnaires were distributed to assess the main objectives of the study. Only completed questionnaires were used in the current study data analysis.

Results

A majority of the participants had Type 2 diabetes (58%). The awareness of diabetic patients of their increased risk for oral diseases is low compared to their awareness of systemic diseases. Their attitude toward maintaining good oral health was also not to desired standard. Of the participants, 50% brushed their teeth once daily and 66% never used dental floss. Regarding participants’ sources of awareness, 37% learned from dentists and 45% through other media sources.

Conclusions

Diabetic patients are found to have little knowledge of their increased risk for oral diseases. In order to promote proper oral health and to reduce the risk of oral diseases, health professionals in both the dental and medical fields need to take the responsibility to develop programs to educate the public about the oral manifestations of diabetes and its complications on oral health.

Na+-glucose cotransporter SGLT1 protein in salivary glands: potential involvement in the diabetes-induced decrease in salivary flow

Oral health complications in diabetes include decreased salivary secretion. The SLC5A1 gene encodes the Na(+)-glucose cotransporter SGLT1 protein, which not only transports glucose, but also acts as a water channel. Since SLC5A1 expression is altered in kidneys of diabetic subjects, we hypothesize that it could also be altered in salivary glands, contributing to diabetic dysfunction. The present study shows a diabetes-induced decrease (p < 0.001) in salivary secretion, which was accompanied by enhanced (p < 0.05) SGLT1 mRNA expression in parotid (50%) and submandibular (30%) glands. Immunohistochemical analysis of parotid gland of diabetic rats revealed that SGLT1 protein expression increased in the luminal membrane of ductal cells, which can stimulate water reabsorption from primary saliva. Furthermore, SGLT1 protein was reduced in myoepithelial cells of the parotid from diabetic animals, and that, by reducing cellular contractile activity, might also be related to reduced salivary flux. Six-day insulin-treated diabetic rats reversed all alterations. In conclusion, diabetes increases SLC5A1 gene expression in salivary glands, increasing the SGLT1 protein content in the luminal membrane of ductal cells, which, by increasing water reabsorption, might explain the diabetes-induced decrease in salivary secretion.

Relationship Between Periodontitis and Diabetes: Lessons From Rodent Studies

BACKGROUND

A great amount of investigations have provided evidence that both type 1 and type 2 diabetes increase the risk and severity of periodontitis; several alterations in the diabetic periodontium are likely to be involved. Conversely, periodontitis has been shown to have an impact on diabetes, although less evidence is available on the underlying mechanisms. The association between periodontitis and diabetes has been discussed in several reviews over the past years; however, none has focused on the use and contribution of rodent models.

METHODS

This review describes the most commonly used rodent models of diabetes, periodontitis, and the association between the two diseases. Further, we summarize the influence of diabetes in the periodontium as well as the effect of periodontitis on diabetes status with special focus on evidence from experimental studies.

RESULTS

Rodent studies have confirmed human findings and further increased our knowledge on the alterations in the diabetic periodontium. On the other hand, few rodent investigations have explored the consequences of periodontitis for diabetes. Their results clearly indicate that periodontitis can become a health hazard not only for diabetes but also for prediabetes; the exact mechanisms are still to be unraveled.

CONCLUSIONS

Findings from rodent studies have been useful in increasing our understanding of periodontitis, diabetes, and their association and hold great promise for future investigations given the wide variety of possibilities for testing biologic hypotheses.

Vascular endothelial growth factor (VEGF) levels of gingiva and gingival crevicular fluid in diabetic and systemically healthy periodontitis patients

It has been demonstrated that diabetes mellitus (DM) may have an inductive effect on the vascular endothelial growth factor (VEGF) levels of periodontium during periodontal disease. The aim of this study is to confirm this phenomenon, investigating whether it is also valid for diabetic periodontitis patients under good metabolic control. Sixteen type II DM patients, all with a glycosylated hemoglobin (HbA1c) value less than 7 (test), and 15 systemically healthy (control) chronic periodontitis patients were included in the study. The VEGF concentrations in the gingival supernatants and gingival crevicular fluid (GCF) samples of the study groups were measured by enzyme-linked immunosorbent assay. The data were analyzed by Student's t test in statistical means. The VEGF levels were significantly higher in the gingival supernatants of the test group (55.89 +/- 8.11 pg/ml) than that of the control group (24.81 +/- 2.04 pg/ml; p < 0.01). However, there was no statistically significant difference in the VEGF levels of GCF between the study groups (38.96 +/- 4.89 pg/ml in the test and 32.20 +/- 4.02 pg/ml in the control group; p > 0.05). Our study confirms that DM affects the VEGF levels of periodontal soft tissues in periodontal disease, and our results also suggest that this effect may not be influenced by the metabolic control of DM.

Characterization of the ultrastructure of gingival mast cells in alloxan-induced diabetic rats

The morphological changes of gingival mast cells of alloxan-induced diabetic rats were studied by electron microscopy. The following observations were made. The cell nucleus and cytoplasm degenerated. The electron density of the granules in the cell cytoplasm clearly decreased. Some granules had dense irregular threads and the granules were surrounded by a thin vacuole. A ghost vacuole formed in some mast cells and disorganized materials accumulated in the cytoplasm. The mast cell nuclei were generally irregular and degenerating mast cells had pyknotic nuclei. General destruction of the cell membrane and granule shedding in some samples was noted and mitochondria with atypical cristae in the cytoplasm of the mast cells were seen. We conclude that the characteristics of the ultrastructure of gingival mast cells in diabetics are distinctive and should be used as criteria for pathogenesis of gingival inflammation.

Mandibular osteomyelitis and tooth exfoliation following zoster-CMV co-infection

Herpes zoster is a common viral infection, the oral soft tissue manifestations of which are widely known and recognized. Reports of spontaneous tooth exfoliation and jaw osteonecrosis following herpes zoster infection in the distribution of the trigeminal nerve are extremely infrequent and sporadic, with only 39 cases being reported in the literature. We report an additional case of mandibular osteomyelitis and spontaneous tooth exfoliation following herpes zoster infection, which occurred in the left mandible of a 70-year-old diabetic man; however, our case also showed CMV co-infection. The role of CMV in the pathogenesis of the osteonecrosis remains uncertain. Awareness of the possibility of CMV co-infection in various oral diseases including oral ulcers, Kaposi's sarcoma, and herpes zoster infections especially in immunocompromised patients is important, since spread of the CMV can easily occur to other sites with potentially fatal consequences. Early diagnosis can lead to effective treatment and prevention of complications.

Candidal overgrowth in diabetic patients: potential predisposing factors

This study was designed to investigate the potential factors that influence the prevalence of the oral carriage of Candida species in patients with type II diabetes mellitus. One hundred and twenty-eight diabetic patients (68 males and 60 females, mean age 54 +/- 7 years) were sequentially enrolled along with 84 (44 males and 40 females mean age 52 +/- 8 years) healthy subjects. Samples were obtained by swabbing the oral mucosa of all participants. Yeast isolates were identified by germ tube test, with API 32 ID system, and by chlamydospore production on 'cornmeal' Tween-80 agar. Candida spp. was recovered from the oral cavity of 64% of the diabetic group, in contrast to 40% of the control group. Candida albicans was the most frequently isolated species in both groups. Potential etiologic factors such as xerostomia, dentures, age, gender and diabetes on oral carriage of Candida spp. were evaluated. The oral carriage of Candida spp. was significantly higher in 'diabetic' patients compared with the healthy subjects but it seems that parameters such as xerostomia, dentures, age, gender and glycemic control cannot be directly associated with Candida growth in the oral cavity in the presence of diabetes.

Update on diabetes mellitus and related oral diseases

Diabetes mellitus (DM) is a group of complex multisystem metabolic disorders characterized by a relative or absolute insufficiency of insulin secretion and/or concomitant resistance to the metabolic action of insulin on target tissues. The chronic hyperglycaemia of diabetes is associated with long-term systemic dysfunction. The present article summarizes current knowledge of DM and details the oral and dental implications of this common endocrine disorder.

Vascular Endothelial Growth Factor in Gingival Tissues and Crevicular Fluids of Diabetic and Healthy Periodontal Patients

BACKGROUND

Periodontal disease is one of the major oral problems encountered in patients with diabetes mellitus (DM). Vascular changes, neutrophil dysfunction, altered collagen synthesis, and genetic predisposition observed in DM may contribute to periodontitis; and the vascular alterations observed in such patients may depend on vascular endothelial growth factor (VEGF) actions. Few reports are available about the mechanism of neovascularization and the angiogenic factors that contribute to the periodontal pathology and the role of VEGF in periodontal diseases. The aim of this study is to compare VEGF expression in healthy and periodontally diseased tissues with gingival crevice fluid (GCF) of healthy persons and diabetic patients.

METHODS

Gingival tissue and GCF samples were collected from sites of periodontitis in 10 healthy subjects and in 10 type 2 diabetic patients, and from the sites of healthy gingiva within the same groups. Therefore, each patient became his/her own control. Additionally, 10 people without any systemic or periodontal diseases were enrolled, forming a negative control group. Thus, a total of 50 tissue and 50 GCF samples were provided.

RESULTS

No VEGF staining was observed in the negative control group or in the systemically healthy people's healthy tissue samples, whereas four samples of diabetic patients showed positive staining (P < 0.05). However, VEGF was revealed in two tissue samples of periodontal sites of systemically healthy people and in six samples of the diabetic patients (P > 0.05). In all test groups, GCF VEGF levels were higher in periodontal sites (P < 0.05) than in healthy sites.

CONCLUSION

The results of this study showed that VEGF is increased in all periodontal tissues of both groups and in the healthy sites of diabetic patients. Additionally, GCF VEGF values increased in periodontal sites of all test groups.

Oral disorders and chronic systemic diseases in very old adults living in institutions

This study evaluated whether oral disorders were associated with chronic systemic diseases in 532 Canadian adults who are old and very old and living in institutions. A brief oral examination documented tooth retention, caries, and periodontal and gingival health. Medical records provided information about chronic systemic conditions. A history of stroke was associated with a higher experience of caries, a higher ratio of decayed-to-present teeth, and more gingival and periodontal problems. Participants with high blood pressure, osteoporosis, or diabetes were more likely to be edentulous or to have fewer teeth than participants who did not have these conditions. Participants who had arthritis retained more teeth with age. Participants who had more diseases also tended to have poorer gingival or periodontal conditions, fewer teeth, and higher risk of edentulousness. The associations between systemic diseases and more severe oral disorders may be direct or may be mediated by underlying factors such as health behaviors.

Implants in the medically compromised patient

Dental clinicians are confronted with an increasing number of medically compromised patients who require implant surgery for their oral rehabilitation. However, there are few guidelines on dental implant therapy in this patient category, so that numerous issues regarding pre- and post-operative management remain unclear to the dental clinician. Therefore, the aim of the present review is to offer a critical evaluation of the literature and to provide the clinician with scientifically based data for implant therapy in the medically compromised patient. This review presents the current knowledge regarding the influence of the most common systemic and local diseases on the outcome of dental implant therapy, e.g., abnormalities in bone metabolism, diabetes mellitus, xerostomia, and ectodermal dysplasias. Specific pathophysiologic aspects of the above-mentioned diseases as well as their potential implications for implant success are critically appraised. In line with these implications, guidelines for pre- and post-operative management that may assist in the successful implant-supported rehabilitation of this patient category are proposed.

The ultrastructure of the capillaries in the gingiva of alloxan-induced diabetic rats

The diabetic effects of alloxan (type I diabetes mellitus) were investigated in 40 Wistar albino rats (18 controls and 22 diabetics). Alloxan in sterile physiological saline was injected into animals intravenously. After the induction of diabetes with alloxan, the ultrastructure of the capillaries in the gingiva was examined by transmission electron microscopy. The thickness of the basement membranes was observed closely adherent to the endothelial cells of the capillary alloxan-diabetic rats. It was greatly thickened owing to the increase in its amorphous, granular and filamentous material with occasional scattered collagen fibres. In some sections, the capillary lumens of the diabetics were closed by epithelial cells. Loss of cytoplasmic material and hyalinization were seen in some smooth muscle cells. In addition, the mitochondrial cristae of smooth muscle cell and epithelial cells disappeared. There was endothelial integrity throughout the smooth muscle cells.

Expression of vascular endothelial growth factor in human periodontal tissues: comparison of healthy and diabetic patients

BACKGROUND

Vascular endothelial growth factor (VEGF) induces proliferation of endothelial cells, stimulates angiogenesis, and increases vascular permeability, but information about its role in periodontal lesions is limited. The aim of this study is to determine the association between VEGF expression in healthy and periodontally diseased tissues of healthy and diabetic patients.

METHODS

Ten systemically healthy and 10 Type 2 diabetic patients (DM) all diagnosed with periodontitis were enrolled into the study. Gingival samples were collected from both periodontal and healthy sites in all patients. Each patient served as his/her own control. Additionally, 10 people without any systemic or periodontal diseases were enrolled as a negative control group.

RESULTS

In the negative control group tissue samples, no VEGF expression was observed. Among the 10 systemically healthy people, no evidence of VEGF was observed in healthy gingival samples, but was found in diseased tissues in 2 cases. In the diabetic patients, VEGF was observed in 4 healthy gingival tissues and in 6 periodontal sites. VEGF was intensely present in monocytes and macrophages.

CONCLUSION

The results of this study show that VEGF is increased in gingival tissues of diabetic patients, especially those with periodontal disease.

Diabetes mellitus and dental implants: a clinical study

Diabetes mellitus is no longer considered to be a contraindication for implant-supported prostheses, provided that the patient's blood sugar is under control, and that there is motivation for oral hygiene procedures. This paper presents the experiences of treating diabetic patients using implants with good success rates.

Glycemic control of type 2 diabetes and severe periodontal disease in the US adult population

OBJECTIVE

We investigated the association between glycemic control of type 2 diabetes mellitus (type 2 DM) and severe periodontal disease in the US adult population ages 45 years and older.

METHODS

Data on 4343 persons ages 45-90 years from the National Health and Nutrition Examination Study III were analyzed using weighted multivariable logistic regression. Severe periodontal disease was defined as 2 + sites with 6 + mm loss of attachment and at least one site with probing pocket depth of 5 + mm. Individuals with fasting plasma glucose > 126 mg/dL were classified as having diabetes; those with poorly controlled diabetes (PCDM) had glycosylated hemoglobin > 9% and those with better-controlled diabetes (BCDM) had glycosylated hemoglobin <or= 9%. Additional variables evaluated in multivariable modeling included age, ethnicity, education, gender, smoking status, and other factors derived from the interview, medical and dental examination, and laboratory assays.

RESULTS

Individuals with PCDM had a significantly higher prevalence of severe periodontitis than those without diabetes (odds ratio = 2.90; 95% CI: 1.40, 6.03), after controlling for age, education, smoking status, and calculus. For the BCDM subjects, there was a tendency for a higher prevalence of severe periodontitis (odds ratio = 1.56; 95% CI: 0.90, 2.68).

CONCLUSION

These results provide population-based evidence to support an association between poorly controlled type 2 diabetes mellitus and severe periodontitis.

Oral health in the elderly with non-insulin-dependent diabetes mellitus

Non-insulin-dependent diabetes mellitus (NIDDM) is a common endocrine disease affecting the elderly in particular. Long-term complications involve the vasculature; vision, renal, and neural function; and the periodontium. Knowledge about the oral health of the elderly and the effects of NIDDM is limited. The objective of this study was to compare the oral health of patients aged 60+ years, who have NIDDM, with patients who do not have NIDDM. To evaluate oral health, we recorded retention and condition of the teeth, periodontal health, and condition of the oral mucosa. We also assessed oral hygiene, smoking history, regularity of dental checkups, and medication use. The study group was selected from among patients who came to the ambulatory care clinic at University of Medicine and Dentistry, New Jersey, Center for Aging with a diagnosis of NIDDM. The control group, which did not have NIDDM, was selected from among the same patient group and was matched for age and gender. Patients with severe dementia, those having fewer than 10 teeth or those who were in need of antibiotic prophylaxis were excluded from the study. Patients underwent a short interview and a clinical evaluation. Our study involved 32 elderly adults with NIDDM and 40 elderly adults who did not have NIDDM. Both groups had similar oral hygiene levels and regularity of professional dental care. In addition, the plasma glucose levels among the study group were well controlled. This study did not show statistically significant differences in oral health parameters between participants with diabetes and those in a control group.

Salivary glands and noradrenergic transmission in diabetic rats

1 Type 2 diabetes is associated with diverse oral pathologies in which salivary flow reduction is one of the causes of these oral abnormalities. Scarce literature exists regarding noradrenergic transmission and adrenergic-induced salivary flow in submaxillary and parotid glands of type 2 diabetic rats. 2 We studied noradrenergic transmission as well as the secretory response to alpha1- and beta-adrenoceptor stimulation in the parotid and submaxillary glands of type 2 diabetic rats. 3 Diabetic rats exhibited diminished neuronal uptake, release and endogenous content of noradrenaline (NE) in both salivary glands. Further, NE synthesis was also diminished accompanied by decreased tyrosine hydroxylase activity. Salivary flow responses to alpha1-(methoxamine) and beta-(isoprenaline) adrenoceptor stimulation were reduced in the submaxillary as well as the parotid glands of diabetic rats. 4 Our results suggest that the reduction of noradrenergic transmission in the salivary glands of type 2 diabetic rats is in part responsible for the diminished salivary flow evoked by alpha1- and beta-adrenergic stimulation. Reduced noradrenergic activity may contribute to the pathophysiology of oral abnormalities in diabetic patients.

Biology of oral mucosa and esophagus

The mucosal lining of the oral cavity and esophagus functions to protect the underlying tissue from mechanical damage and from the entry of microorganisms and toxic materials that may be present in the oropharynx. In different regions, the mucosa shows adaptation to differing mechanical demands: Masticatory mucosa consists of a stratified squamous keratinized epithelium tightly attached to the underlying tissues by a collagenous connective tissue, whereas lining mucosa comprises a nonkeratinized epithelium supported by a more elastic and flexible connective tissue. The epithelium is constantly replaced by cell division in the deeper layers, and turnover is faster in the lining than in the masticatory regions. Chemotherapeutic agents and radiation limit proliferation of the epithelium so that it becomes thin or ulcerated; this will first occur in the lining regions. The principal patterns of epithelial differentiation are represented by keratinization and nonkeratinization. As keratinocytes enter into differentiation, they become larger and begin to flatten and to accumulate cytokeratin filaments. In addition to the keratins, the differentiating keratinocytes synthesize and retain a number of specific proteins, including profilaggrin, involucrin, and other precursors of the thickening of the cell envelope in the most superficial layers. The concept of epithelial homeostasis implies that cell production in the deeper layers will be balanced by loss of cells from the surface. There is a rapid clearance of surface cells, which acts as a protective mechanism by limiting colonization and invasion of microorganisms adherent to the mucosal surface.

Bidirectional interrelationships between diabetes and periodontal diseases: an epidemiologic perspective

This review evaluates evidence for a bidirectional relationship between diabetes and periodontal diseases. A comprehensive Medline search of the post-1960 English language literature was employed to identify primary research reports of relationships between diabetes and periodontal diseases. Reports included in the review on the adverse effects of diabetes on periodontal health (DM-->PD) were restricted to those comparing periodontal health in subjects with and without diabetes. Review of adverse affects of periodontal infection on glycemic control included reports of periodontal treatment studies and follow-up observational studies in which changes in glycemic control could be assessed. Observational studies reporting DM-->PD provided consistent evidence of greater prevalence, severity, extent, or progression of at least one manifestation of periodontal diseases in the large majority of reports (supportive evidence in 44/48 total reviewed; 37/41 cross-sectional and 7/7 cohort). Additionally, there were no studies reviewed with superior design features to refute this association. Treatment studies provided direct evidence to support periodontal infection having an adverse, yet modifiable, effect on glycemic control. However, not all investigations reported an improvement in glycemic control after periodontal treatment. Additional evidence to support the effect of severe periodontitis on increased risk for poorer glycemic control comes from 2 follow-up observational studies. The evidence reviewed supports viewing the relationship between diabetes and periodontal diseases as bidirectional. Further rigorous, systematic study is warranted to establish that treating periodontal infections can be influential in contributing to glycemic control management and possibly to the reduction of the burden of complications of diabetes mellitus.

Lowered susceptibility of muscarinic receptor involved in salivary secretion of streptozotocin-induced diabetic rats

We investigated the responses of salivary secretion and the susceptibility of the muscarinic receptors in the salivary glands of the streptozotocin (STZ)-induced diabetic rats (STZ rats). Giving water ad libitum, the amount of whole saliva with no stimulation was similar in the STZ and the control rats. Pilocarpine increased salivary secretion in both groups, although the effect in the STZ rats was two to three fold less than in the control rats. If the animals were restricted from taking water for 6 h, salivary secretion was not slightly changed in the STZ rats in spite of a remarkable increase in the control. An obvious decrease in salivary secretion of the STZ rats was negatively correlated with an increase in urination. Furthermore, salivary secretion from the parotid gland was increased in a dose-dependent manner with pilocarpine in the control rats, but not in the STZ rats. In the [3H]quinuclidinyl benzilate (QNB) binding studies for muscarinic receptor of the STZ rats, Bmax was decreased in the parotid gland and Kd was increased in the submandibular gland. Competitive inhibition of [3H]QNB binding to both glands showed an increase in IC50 of pilocarpine and carbachol. These results suggest that a decrease in salivary secretion of STZ rats is not only induced by a water loss, but also closely associated with the lowered susceptibility of the muscarinic receptors.

Type 1 diabetes mellitus, xerostomia, and salivary flow rates

OBJECTIVE

The Oral Health Science Institute at the University of Pittsburgh has completed a cross-sectional epidemiologic study of 406 subjects with type 1 diabetes and 268 control subjects without diabetes that assessed the associations between oral health and diabetes. This report describes the prevalence of dry-mouth symptoms (xerostomia), the prevalence of hyposalivation in this population, and the possible interrelationships between salivary dysfunction and diabetic complications.

STUDY DESIGN

The subjects with diabetes were participants in the Pittsburgh Epidemiology of Diabetes Complications study who were enrolled in an oral health substudy. Control subjects were spouses or best friends of participants or persons recruited from the community through advertisements in local newspapers. Assessments of salivary function included self-reported xerostomia measures and quantification of resting and stimulated whole saliva flow rates.

RESULTS

Subjects with diabetes reported symptoms of dry mouth more frequently than did control subjects. Salivary flow rates were also impaired in the subjects with diabetes. Regression models of potential predictor variables were created for the 3 self-reported xerostomia measures and 4 salivary flow rate variables. Of the medical diabetic complications studied (ie, retinopathy, peripheral and autonomic neuropathy, nephropathy, and peripheral vascular disease), only neuropathy was found to be associated with xerostomia and decreased salivary flow measures. A report of dry-mouth symptoms was associated with current use of cigarettes, dysgeusia (report of a bad taste), and more frequent snacking behavior. Xerogenic medications and elevated fasting blood glucose concentrations were significantly associated with decreased salivary flow. Resting salivary flow rates less than 0.01 mL/min were associated with a slightly higher prevalence of dental caries. Subjects who reported higher levels of alcohol consumption were less likely to have lower rates of stimulated salivary flow.

CONCLUSIONS

Subjects with type 1 diabetes who had developed neuropathy more often reported symptoms of dry mouth as well as symptoms of decreased salivary flow rates. Because of the importance of saliva in the maintenance and the preservation of oral health, management of oral diseases in diabetic patients should include a comprehensive evaluation of salivary function.

Impact of oral diseases on systemic health in the elderly: diabetes mellitus and aspiration pneumonia

Evidence is increasing that oral health has important impacts on systemic health. This paper presents data from the third National Health and Nutrition Examination Survey (NHANES III) describing the prevalence of dental caries and periodontal diseases in the older adult population. It then evaluates published reports and presents data from clinical and epidemiologic studies on relationships among oral health status, chronic oral infections (of which caries and periodontitis predominate), and certain systemic diseases, specifically focusing on type 2 diabetes and aspiration pneumonia. Both of these diseases increase in occurrence and impact in older age groups. The NHANES III data demonstrate that dental caries and periodontal diseases occur with substantial frequency and represent a burden of unmet treatment need in older adults. Our review found clinical and epidemiologic evidence to support considering periodontal infection a risk factor for poor glycemic control in type 2 diabetes; however, there is limited representation of older adults in reports of this relationship. For aspiration pneumonia, several lines of evidence support oral health status as an important etiologic factor. Additional clinical studies designed specifically to evaluate the effects of treating periodontal infection on glycemic control and improving oral health status in reducing the risk of aspiration pneumonia are warranted. Although further establishing causal relationships among a set of increasingly more frequently demonstrated associations is indicated, there is evidence to support recommending oral care regimens in protocols for managing type 2 diabetes and preventing aspiration pneumonia.

Characterization of the insulin-signaling pathway in lacrimal and salivary glands of rats

PURPOSE

Insulin has been acknowledged as a mediator of several physiological events in lacrimal and salivary glands. We investigated the presence of insulin receptors and of insulin-induced autophosphorylation of the insulin receptor and activation of elements involved in the early steps of insulin signaling in lacrimal and salivary glands of rats.

METHODS

Lacrimal and salivary glands of Wistar rats were removed and processed for immunohistochemistry using anti-insulin receptor and anti-IGF-1 receptor antibodies. The activation of insulin receptors following insulin treatment, and the involvement of insulin receptor substrates-1 and -2, Shc, JAK-2 and STAT-1, were analyzed by immunoprecipitation, followed by SDS-PAGE and immunoblotting of rat lacrimal and salivary glands after exposure to insulin.

RESULTS

Insulin and IGF-1 receptors were present in rat lacrimal and salivary glands and were located predominantly in the cytoplasm and plasma membrane. Functional studies demonstrated that insulin induced a dose-dependent phosphorylation of the insulin receptor, IGF-1R, insulin receptor substrates-1 and -2, Shc, and STAT-1. In rats with streptozotocin-induced diabetes mellitus there was a significant reduction in insulin-induced insulin receptor and STAT-1 phosphorylation in the lacrimal gland but not in the salivary gland; there was no influence on Shc phosphorylation in either tissue.

CONCLUSIONS

The present results indicate that insulin and IGF-1 receptors are expressed in lacrimal and salivary glands, and that insulin can induce the phosphorylation of its receptor and activate elements involved in the early steps of insulin signaling in both tissues.

Insulin-dependent diabetes mellitus and oral soft tissue pathologies. I. Prevalence and characteristics of non-candidal lesions

OBJECTIVE

A large epidemiologic study on oral health has found that several oral soft tissue lesions were more prevalent in subjects with insulin-dependent diabetes mellitus than in control subjects without diabetes. Our objective in part I of this article is to characterize those lesions not associated with Candida.

STUDY DESIGN

This cross-sectional study determined the prevalence and characteristics of oral soft tissue diseases identified during a comprehensive oral evaluation of 405 adult subjects with diabetes and 268 control subjects without diabetes.

RESULTS

Twenty specific oral soft tissue lesions were identified. Nearly twice as many subjects with diabetes as subjects without diabetes were found to have one or more oral soft tissue lesions (44.7% vs 25.0%; P <.0001). Subjects with diabetes also had significantly higher prevalence rates for 7 lesions, 3 of which were non-candidal: fissured tongue, irritation fibroma, and traumatic ulcers. (Four lesions generally associated with Candida infection-median rhomboid glossitis, denture stomatitis, generalized atrophy of the tongue papillae, and angular cheilitis-will be described in part II of this article.) There were no differences found between the subjects with diabetes and the control subjects for lichen planus, gingival hyperplasia, or salivary gland disease.

CONCLUSIONS

Oral soft tissue lesions were seen more frequently in subjects with insulin-dependent diabetes than in the control subjects. Characterization of 3 non-candidal lesions suggests that they are associated with trauma, delayed healing, or both.

Non-insulin dependent diabetes mellitus and alveolar bone loss progression over 2 years

This study tested the hypothesis that persons with non-insulin dependent diabetes mellitus (NIDDM) have greater risk of more severe alveolar bone loss progression over a 2-year period than those without NIDDM. Data from the longitudinal study of the oral health of residents of the Gila River Indian Community were analyzed for 362 subjects, aged 15 to 57, 338 of whom had less than 25% radiographic bone loss at baseline, and who did not develop NIDDM nor lose any teeth during the 2-year study period. The other 24 subjects had NIDDM at baseline, but met the other selection criteria. Bone scores (scale 0-4) from panoramic radiographs corresponded to bone loss of 0%, 1%-24%, 25%-49%, 50%-74%, or 75% and greater. Change in bone score category was computed as the change in worst bone score (WBS) reading after 2 years. Age, calculus, NIDDM status, time to follow-up examination, and baseline WBS were explanatory variables in regression models for ordinal categorical response variables. NIDDM was positively associated with the probability of a change in bone score when the covariates were controlled. The cumulative odds ratio for NIDDM at each threshold of the ordered response was 4.23 (95% C.I. = 1.80, 9.92). In addition to being associated with the incidence of alveolar bone loss (as demonstrated in previous studies), these results suggest an NIDDM-associated increased rate of alveolar bone loss progression.

The relationship between clinical periodontal status and insulin-dependent diabetes mellitus. Results after 5 years

The clinical periodontal status of 44 insulin-dependent diabetic children and adolescents and 20 healthy control subjects was compared for a period of approximately 5 years. Fasting blood glucose, fructosamine, and glycosylated hemoglobin (HbA1) values were determined at baseline and 5 years later. The differences in the clinical and laboratory parameters were compared during the study period. The differences between the two groups were also evaluated. The only statistically significant difference observed in the diabetic group was clinical attachment loss (CAL). The CAL was statistically significantly higher in the diabetic group compared to the controls, and a statistically significantly higher in the diabetic group compared to the controls, and a statistically significant positive correlation was observed between the duration of diabetes and CAL. Fructosamine was also correlated with the gingival index in the diabetic group while there was no correlation in the controls. It may be concluded that diabetes modifies the clinical status of the periodontal tissues and increases clinical attachment loss.

Periodontal disease, oral microbial flora and salivary antibacterial factors in diabetes mellitus type 1 patients

One hundred and thirty-one patients with diabetes mellitus type 1 (IDDM) and 20 healthy controls were checked for the presence of periodontal diseases and for some oral microbiological parameters. Results demonstrated that IDDM patients, who were well compensated from both the metabolic and clinical point of view, showed a prevalence for periodontopathies, which only differed slightly from controls. Only the presence of gingivitis was significantly higher in IDDM patients than in healthy subjects. Both anaerobic and aerobic microbial flora did not show substantial differences for either group. Among the salivary antibacterial factors studied, lysozyme was significantly decreased in diabetic patients compared to controls. It is concluded that IDDM patients undergo periodontal complications with a frequency quite close to that of non-diabetic healthy subjects, when the disease is under strict metabolic and clinical control.

Oral health in the elderly with non-insulin-dependent diabetes mellitus

The purpose of this study was to examine salivary flow rates and selected oral health parameters in 12 patients (aged 76-86 years) with non-insulin-dependent diabetes mellitus (NIDDM) and also in 20 subjects (aged 76-86 years) with NIDDM and cardiovascular diseases (CVD) and to compare them with 32 healthy controls matched for age and gender. Unstimulated salivary flow rates were lower in both groups of NIDDM patients than in the controls, although the differences were not statistically significant. Subjective oral dryness and other oral and non-oral symptoms were more frequently reported by the patients with NIDDM + CVD; however, the differences were usually non-significant. Root-surface caries was more frequently detected in the subjects with NIDDM only, although the difference among groups was not statistically significant. Periodontal treatment need, according to CPITN values, was more frequent in the subjects with NIDDM only, compared with controls or those with NIDDM + CVD, although the differences were again not statistically significant. There were no statistically significant differences in the oral health parameters of the subjects with NIDDM or NIDDM + CVD compared with those of their age- and sex-matched healthy controls.

The relationship between clinical attachment loss and the duration of insulin-dependent diabetes mellitus (IDDM) in children and adolescents

The periodontal status of 77 diabetic children and adolescents, and 77 paired, systemically-healthy, sex- and age-matched control subjects, was clinical examined. Fasting blood glucose, fructosamine and glycosylated haemoglobin (HbA1) values were determined. The mean periodontal pocket depths, clinical attachment levels and the parameters to assess diabetes mellitus from the diabetic group were significantly higher than those of the controls. We found a positive correlation between the duration of diabetes and clinical attachment loss, but not with periodontal probing depth, plaque index and gingival index in the diabetic group. A positive correlation was also assessed between the present serum fructosamine and gingival index in the diabetic group, but not in controls.