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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.

Aminotransferases and lactate dehydrogenase in saliva of diabetic patients

Although inflammatory or degenerative changes in salivary glands have been demonstrated in genetic animal models of diabetes mellitus and in experimental diabetes, no information is available in diabetics on the possible leakage in saliva of cytosolic enzymes as markers of salivary cell injury. Aspartate (GOT) and alanine (GPT) aminotransferases and lactate dehydrogenase (LDH) were determined in saliva samples collected by the Salivette method from well-controlled insulin-dependent (IDDM n = 11) and non-insulin-dependent (NIDDM n = 18) diabetic patients and from age-cross-matched healthy subjects (n = 33). In IDDM salivary concentrations of GOT (112.55 +/- 23.94 UI/L) and LDH (1120.27 +/- 168.31 UI/L) were similar to those found in the NIDDM (90.94 +/- 19.64, and 1255.43 +/- 221.40 UI/L respectively), but higher (p < 0.05) than those observed in normal subjects (33.09 +/- 3.71, and 423.58 +/- 39.94, UI/L respectively). GPT was higher in NIDDM than IDDM, which in turn was higher than in normal subjects (42.78 +/- 14.72, 16.45 +/- 3.74 and 6.85 +/- 1.52 UI/L respectively). Salivary and serum values of GOT, GPT and LDH were not correlated. Determination of cytosolic enzymes in saliva may be useful for monitoring the diabetic involvement of salivary glands.

Secretion of epidermal growth factor in parotid saliva in diabetic patients: role of autonomic innervation

Parotid saliva was collected over a 12-min period from 24 insulin dependent diabetic patients with varying degrees of autonomic neuropathy and 12 age and sex matched non-diabetic controls. Epidermal growth factor (EGF) concentrations in saliva were measured by radio-immunoassay. The EGF concentrations in diabetics with no autonomic neuropathy or with combined autonomic neuropathy were equivalent but secretion of EGF was significantly elevated at the 6- and 12-min periods of collection in diabetic patients with early or established autonomic neuropathy. It is postulated that when parasympathetic autonomic neuropathy is present a relative "over-activity" of the sympathetic innervation promotes release of salivary EGF. This sympathetic predominance may maintain salivary EGF concentration despite the elevated salivary flow and volume which is associated with parasympathetic autonomic neuropathy.

Some salivary factors in insulin-dependent diabetics

The aim of the study was to compare salivary flow rate, salivary pH, buffer capacity of the saliva, salivary glucose content, and number of Candida albicans, lactobacilli, and Streptococcus mutans in the saliva in age- and sex-matched adult long- and short-duration insulin-dependent diabetics and non-diabetics. Ninety-four long-duration and 86 short-duration diabetics and 86 non-diabetics, aged 20-70 years, participated in the study. Paraffin-stimulated whole saliva was collected. Both long- and short-duration diabetics had a decreased salivary flow rate and an increased salivary glucose content compared with non-diabetics. However, the differences were small. There were no significant differences between the groups in salivary pH, buffer capacity, or bacterial counts.

Diabetes mellitus and associated oral manifestations: a review

Oral research concerning diabetes mellitus has revealed a number of clinical implications. These include, among others, the need for more intense management of the diabetic patient with periodontal disease because tissue destruction may be accelerated, the need for rapid control of oral infection in these patients in order to prevent exacerbation of the existing metabolic imbalance, and the desirability of performing a screening for diabetes mellitus on all patients exhibiting asymptomatic parotid enlargement. Despite the explosion of knowledge concerning diabetes mellitus that has occurred since the discovery of insulin, its definitive etiology continues to elude the scientific community and its treatment remains in the realm of clinical management rather than in that of prevention and cure. In the past, research on diabetes has focused on the role of insulin in seeking the fundamental etiology of diabetes and its complications. With the progression of research, it has become apparent that the initiation and progression of the disease probably involve the interplay of a multiplicity of factors. Hereditary and immunologic factors, as suggested earlier, appear to be operated on by environmental factors, subsequently altering the body's metabolic milieu with widespread primary and secondary effects. Fertile areas for future oral research in diabetes mellitus will include, therefore, genetics, immunology, enzymology, and basement membrane pathology. On the cellular and molecular levels, particularly, the oral cavity and associated structures comprise a somewhat under-investigated area in diabetes mellitus research and, thus, hold great promise for increasing our knowledge of this complex disease.