|
 
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| REVIEW ARTICLE |
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| Year : 2022 | Volume
: 12
| Issue : 1 | Page : 10-14 |
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Diabetes as it affects the oral cavity
Olufemi A Fasanmade1, Adekunmi A Fasanmade2, Anthonia O Ogbera3, Patricia O Ayanbadejo4, Richard A Adewole5
1 Department of Medicine, Faculty of Clinical Sciences, College of Medicine, University of Lagos (CMUL), Idiaraba, Lagos, Nigeria
2 Department of Oral and Maxillofacial Surgery, Oxford University Hospitals, NHS Foundation Trust, Oxford, UK
3 Department of Medicine, Lagos State University Teaching Hospital (LASUTH), Ikeja, Lagos, Nigeria
4 Department of Preventive Dentistry, Faculty of Dental Sciences, CMUL School of Dentistry, CMUL/LUTH, Nigeria
5 Department of Oral and Maxillofacial Surgery, Dental School, CMUL, Lagos, Nigeria
| Date of Submission | 06-May-2022 |
| Date of Decision | 05-Aug-2022 |
| Date of Acceptance | 09-Jul-2022 |
| Date of Web Publication | 02-Sep-2022 |
Correspondence Address:
Prof. Olufemi A Fasanmade
Department of Medicine, Faculty of Clinical Sciences, College of Medicine, University of Lagos (CMUL), Idiaraba, PMB 12003, Lagos
Nigeria
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/ajem.ajem_7_22
Background: Diabetes is one of the commonest noncommunicable diseases and often affects various organs. The oral cavity is a commonly affected area, which is not given due attention. Objective: The objective of this review article was to highlight often overlooked dental, oral, and maxillofacial comorbidities in patients with diabetes mellitus (DM). Design: Review article. Setting: Clinical. Materials and Methods: Articles on the oral manifestations of DM were collated through studies done by other clinical researchers over the past three decades to highlight different oral conditions that complicate or are associated with DM. The databases of PubMed and Google Scholar were searched, and the key words used were oral manifestations, DM, and oral health. Results: About 100 articles on the subject were identified, several of which were perused and used for this review. Many oral comorbidities exist in patients with DM including periodontal diseases, caries, tongue lesions, buccal lesions, abnormalities of taste, and orodental infections. These conditions affected glycemic control, and poor glycemic control led to several of these manifestations. Conclusion: Comprehensive oral and dental screening should be incorporated into medical examination of patients with DM. Also, we recommend that patients visiting dental surgeries for rapidly advancing periodontal disease and orodental infections should be screened for DM among other immunosuppressive states. Keywords: Diabetes mellitus, mouth, oral cavity
How to cite this article:
Fasanmade OA, Fasanmade AA, Ogbera AO, Ayanbadejo PO, Adewole RA. Diabetes as it affects the oral cavity. Afr J Endocrinol Metab 2022;12:10-4 |
| Introduction | |  |
Diabetes mellitus (DM) is defined as a metabolic disorder characterized by chronic hyperglycemia secondary to relative or absolute insulin deficiency.[1] The prevalence of the condition is rapidly increasing worldwide, and currently there are 537 million people affected globally, and it is one of the commonest noncommunicable diseases seen in adult outpatient clinics.[2],[3] Hence, it is common to find hitherto undiagnosed DM in patients being managed for diverse acute or chronic medical or surgical conditions. It is for this reason that patients are often screened for DM while investigating various conditions. Oral healthcare is not an exception as patients presenting with orofacial and dental conditions are routinely screened for DM before embarking on most kinds of treatment.[4] DM has been associated with several oral manifestations, which will subsequently be discussed.
| Oral comorbidities of dm | | |
DM has been found to be associated with some oral diseases. Some oral abnormalities are also known to be common in DM and some dental conditions are often pointers to the existence of previously undiagnosed DM. These will be listed and described below.
- Dental caries and sequelae
- Periodontal diseases
- Salivary abnormalities
- Taste abnormalities
- Mouth ulcers
- Fordyce’s granules
- Infections
- Halitosis
- Diseases of the jaw bones.
Dental caries and sequelae
DM is associated with an increased frequency of dental diseases. These range from dental caries to its complications as toothache, tooth decay, and tooth loss.[5] Dental caries itself is a localized progressively destructive disease of the teeth, which often begins at the inorganic external surface usually due to demineralization that comes from the actions of microbes on carbohydrate food residue. It eventually progresses to involve the organic matrix.[6] Caries can either affect the crown or the root of the teeth or both. Cavitation, pulp infection, toothache, abscesses and tooth mobility, and the eventual tooth loss are the outcomes if untreated. Key factors in the development of this process include oral hygiene and DM control.[7] Dental infections secondary to caries can lead to the deterioration of glycemic control, and many studies have demonstrated that dental caries is common in older DM patients, especially those with poor control.[8],[9] The association of dental caries with glycemic control is however inconsistent. For instance, a study of dental status in a group of adult diabetics (n = 222) when compared with the control group (n = 189), using WHO criteria, revealed no difference in the prevalence of caries in the diabetic and control groups. Neither was any significant difference found in the mean number of teeth with fillings, but the number of extracted teeth per subject was significantly higher in the diabetic group (12.3) than the control group (9.7), P < 0.01. In addition, those with type 1 diabetes were found to have a significantly higher number of teeth filled (4.05 vs 2.22) than those with type 2 diabetes (P < 0.001). Also, type 2 diabetic patients had a significantly higher number of extracted teeth (14.1 vs 10.1), P < 0.001.[10]
Periodontal diseases
Chronic periodontal disease is the most prevalent oral comorbidity of DM. This is a chronic inflammation of the periodontium, which occurs due to the accumulation of bacterial plaque near the teeth. It is characterized by gingivitis, destruction of the alveolar bone, and ligament. This leads to the exposure of the tooth roots and apparent lengthening of the teeth. Early features include easy bruisability, swelling, and bleeding. This bears semblance to vitamin C deficiency (scurvy) and may be related to deficiency of this vitamin, which is commonly seen in DM. Later, periodontal disease leads to the development of periodontal pockets, loosening, and finally loss of the teeth.[11],[12] The exact cause of the accelerated periodontal disease is unknown, but it could be due to basement membrane thickening in the periodontal tissue, microangiopathic and neuropathic changes, and the alteration of the mouth microflora. The altered microflora may be due to an increased salivary glucose and xerostomia.[13] Other hypotheses include the well-documented leukocyte dysfunction seen in DM, reduced healing capacity, and altered collagen metabolism.[14],[15] Periodontal disease is reported to affect a large proportion of middle-aged or elderly people with diabetes.[16],[17] Children with DM are not spared as those with less than optimum glycemic control often have higher gingival scores using the Community Index of Periodontal needs (CPITN) index.[18],[19] Overall, periodontal disease is two to three times common in people with DM.[20] Periodontal disease shows an almost linear relationship with elevated blood glucose levels.[21] Good glycemic control, regular oral home care, and frequent dental checkups are vital to controlling periodontal diseases. Antibiotics and surgical intervention are sometimes also required.
Salivary abnormalities
The alteration of salivary quantity and quality is frequently seen in DM. This ranges from sialorrhea to xerostomia. In xerostomia, there is a dryness of the mouth, which could arise from autonomic neuropathy, dehydration, or parotid calculi. Where there are calculi, the parotid gland is found to be enlarged and may be tender. Medications such as diuretics, phenothiazines, etc., could also cause or worsen xerostomia. Some xerostomias are so severe that speech and mastication become impaired and others develop a severe burning pain in the mouth referred to as “burning mouth syndrome.”[22],[23] The treatment of burning mouth syndrome, which is common in elderly women, is with benzodiazepines, alpha lipoic acid, or gabapentin. In other individuals, sialorrhea (excessive salivation) may be the first sign of DM.[24] Treatment is with botulinum toxin in severe cases.
Taste abnormalities
Some patients may have abnormal sense of taste (dysgeusia) lasting for a few days to several months, which could range from sour to metallic. A few patients also complain of sugary taste of their saliva sensation.[25],[26],[27]
Mouth ulcers
Mouth ulcers are common in DM patients and may be the first symptom of DM.[28] The varied causes include aphthous ulcers, drug reactions, oral candidiasis, vitamin deficiency, and less commonly cancers. Lichen planus may antedate or coexist with DM, the lesions being on the skin and mouth or the mouth only.[29] Mouth ulcers may be on the tongue, palate, or buccal mucosa. Improving oral hygiene and improving glycemic control are vital steps to the management of these ulcers in addition to specific treatment of the underlying condition.
Fordyce’s granules
These are hypertrophied sebaceous cysts on the buccal mucosa. They appear as numerous small, white-yellowish bodies in the mucosal surface of the cheeks and lips as well as in the vermillion border of the lip. They may also be seen in other parts of the body including the penis in males. They are of no particular danger or risk of progression to any other problem but are common in patients with hyperlipidemia and type 2 DM and are twice as common in males than in females.[30]
Oral infection
In general, infections are common in all parts of the body (the mouth inclusive) in people with DM. These infections are often bacterial or fungal and are related to the degree of glycemic control. In the mouth, the alteration of the microflora by the increased salivary glucose, impaired leukocyte function, or xerostomia also plays a big role in infection susceptibility.[31] Life-threatening deep neck infections may occur from innocuous infections in the periodontal tissue in people with diabetes.[32] In addition, infections may spread from adjacent areas such as the paranasal sinuses, the ears, and the tonsils. Rhino-cerebral mucormycosis that extended to the paranasal sinuses, pharynx, palate, orbit, and brain in uncontrolled diabetics has been described by many authors.[33],[34] In addition, four cases of hard-plate perforation due to mucormycosis have been reported by Barrack et al.[35] Two cases of fungal pan-sinusitis with severe visual loss in uncontrolled diabetic patients have been described by other workers.[36] Furthermore, in a retrospective study of dental implants in diabetics, the survival rate in controlled DM patients is lower than that documented in the general population due to peri-implantitis and loss of implants.[37] Some of these infections may become overwhelming leading to great morbidity and mortality.
Halitosis
This is the presence of a foul odor emanating from the mouth. Halitosis may result from various causes including local conditions such as dental caries and abscesses, chronic sinusitis, tonsillitis but could also originate from other remote conditions such as lung abscesses. The use of spices such as garlic and onions may also be responsible. (In contrast, the breath may be sweet smelling in conditions such as ketosis or ketoacidosis.) Very often, simple methods such as the avoidance of spicy, odoriferous food, better hydration, and treatment of any infection are sufficient to eliminate most cases of halitosis. Increased frequency of cleaning the mouth or the use of mouth wash may also be helpful. Others require a more detailed oral, pharyngeal, paranasal sinuses, or pulmonary evaluation to determine the cause and to treat accordingly.[38],[39]
Diseases of the jawbone
In poorly managed or untreated dental caries and periodontitis, there could be an accumulation of calculus and subsequent infection that could lead to mandibular or maxillary osteomyelitis with dire consequences to the architecture of the face. These are common in patients with hyperlipidemia and hyperglycemia, which together are associated with poor perfusion of the bones.[40],[41] Late presentation leads to the need for extensive and costly antibiotics and facial reconstruction. Alveolar bone loss is also a common feature in DM and is assessed by radiographs of the jaw[42] following a detailed examination and scoring of the basic periodontal index. Prevention remains an improved metabolic control though some trials using bisphosphonates show some ability to arrest the disease.[43]
| Increased awareness | | |
Several studies have demonstrated a low awareness of oral diseases in diabetes patients, and this low awareness is seen in both the patients and healthcare practitioners who also are oblivious to the relationship between oral disease and effects on other systems.[44],[45] This poor knowledge of the implication of oral health as it relates to diabetes is widespread among nondental medical staff and even among persons with diabetes themselves leading to a delay in diagnosis/detection, disease progression, and the late presentation for treatment in Nigeria.[46],[47] This narrative requires to be improved both within the medical and dental spheres of healthcare delivery to improve patient wellbeing and health outcomes among the vulnerable people (especially those with DM).[46],[47],[48]
| Conclusion | | |
Oral comorbidities are by no means rare in DM; instead, they are often missed by attending physicians who limit their examination to other areas of the body deemed more vital. Successful maintenance of a good oral health and the management of oral comorbidities of DM revolve around regular oral screening, early detection of the rare and common oral comorbidities, and the establishment of good metabolic control. The importance of multidisciplinary care of the patient with DM cannot be overemphasized, and cooperation between the dental surgeons and physicians is to be encouraged. All diabetic patients for dental extraction or other maxillofacial surgery should be referred to their physicians for glycemic control prior to treatment and should be treated with appropriate precautionary measures including prophylactic antibiotic cover. Appropriate oral health education in DM patients and blood glucose screening were indicated in patients visiting dental clinics, which will go a long way in improving overall health status.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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