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 Table of Contents  
Year : 2022  |  Volume : 12  |  Issue : 1  |  Page : 10-14

Diabetes as it affects the oral cavity

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 Submission06-May-2022
Date of Decision05-Aug-2022
Date of Acceptance09-Jul-2022
Date of Web Publication02-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
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ajem.ajem_7_22

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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

How to cite this URL:
Fasanmade OA, Fasanmade AA, Ogbera AO, Ayanbadejo PO, Adewole RA. Diabetes as it affects the oral cavity. Afr J Endocrinol Metab [serial online] 2022 [cited 2023 Jun 10];12:10-4. Available from: http://www.ajemjournal.org/text.asp?2022/12/1/10/355338

  Introduction Top

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 Top

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.

  1. Dental caries and sequelae

  2. Periodontal diseases

  3. Salivary abnormalities

  4. Taste abnormalities

  5. Mouth ulcers

  6. Fordyce’s granules

  7. Infections

  8. Halitosis

  9. 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.


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 Top

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 Top

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.

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Conflicts of interest

There are no conflicts of interest.

  References Top

Report of WHO/IDF Consultation. Definition and diagnosis and of diabetes mellitus and intermediate hyperglycemia. WHO/IDF 2006 report. Available from: www.who.int. [Last accessed on 2022 Apr 20].  Back to cited text no. 1
International Diabetes Federation. IDF Diabetes Atlas (Executive Summary). 10th ed.; 2021. Available from: www.diabetesatlas.org. [Last accessed on 2022 Apr 20].  Back to cited text no. 2
Ikimi NU, Onigbinde OO, Sorunke ME, Adetoye JO, Enebong DJ A study of periodontal disease and diabetes mellitus in Abuja, Nigeria. J Dent Med Sci 2017;10:65-70.  Back to cited text no. 3
Oyapero A, Ogbera AO Awareness and oral self-care practices of diabetes patients at a tertiary hospital in Lagos, Nigeria. Ann Med Health Sci Res 2017;7:36-43.  Back to cited text no. 4
Coelho AS, Amaro IF, Caramelo F, Paula A, Marto CM, Ferreira MM, et al. Dental caries, diabetes mellitus, metabolic control and diabetes duration: A systematic review and meta-analysis. J Esthet Restor Dent 2020;32:291-309.  Back to cited text no. 5
Miralles L, Silvestre FJ, Hernández-Mijares A, Bautista D, Llambes F, Grau D Dental caries in type 1 diabetics: Influence of systemic factors of the disease upon the development of dental caries. Med Oral Patol Oral Cir Bucal 2006;11:E256-60.  Back to cited text no. 6
Pohjamo L, Knuuttila M, Tervonen T, Haukipuro K Caries prevalence related to the control of diabetes. Proc Finn Dent Soc 1988;84:247-52.  Back to cited text no. 7
Lai S, Cagetti MG, Cocco F, Cossellu D, Meloni G, Campus G, et al. Evaluation of the difference in caries experience in diabetic and non-diabetic children—A case control study. Plos One 2017;12:e0188451.  Back to cited text no. 8
Oliver RC, Tervonen T, Bereuter J, Flynn D Diabetes—A risk factor for periodontitis? Northwest Dent 1991;70:26-7.  Back to cited text no. 9
Bissong M, Azodo CC, Agbor MA, Nkuo-Akenji T, Fon PN Oral health status of diabetes mellitus patients in Southwest Cameroon. Odontostomatol Trop 2015;38:49-57.  Back to cited text no. 10
Karjalainen KM, Knuuttila ML The onset of diabetes and poor metabolic control increases gingival bleeding in children and adolescents with insulin-dependent diabetes mellitus. J Clin Periodontol 1996;23:1060-7.  Back to cited text no. 11
Nishida M, Grossi SG, Dunford RG, Ho AW, Trevisan M, Genco RJ Dietary vitamin C and the risk of periodontal disease. J Periodontol 2000;71: 1215-23.  Back to cited text no. 12
Unür M, Demirez E, Ağaçhan B, Görmüş U, Ergen A, Dalan B, et al. The relationship of oral disturbances of diabetes mellitus patients with paraoxonase gene polymorphisms. Cell Biochem Funct 2008;26:870-3.  Back to cited text no. 13
Manouchehr-Pour M, Spagnuolo PJ, Rodman HM, Bissada NF Comparison of neutrophil chemotactic response in diabetic patients with mild and severe periodontal disease. J Periodontol 1981;52:410-5.  Back to cited text no. 14
Kaplan R, Mulvihill J, Ramamurthy N, Golub L Gingival collagen metabolism in human diabetics. J Dent Res 1982;62:275.  Back to cited text no. 15
Loe H Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care 1993;16:329-34.  Back to cited text no. 16
Ahmad R, Haque M Oral health Messiers: Diabetes mellitus relevance. Diabetes Metab Syndr Obes 2021;14:3001-15.  Back to cited text no. 17
Fakroon S, Arheiam A, Omar S Dental caries experience and periodontal treatment needs of children with autistic spectrum disorder. Eur Arch Paediatr Dent 2015;16:205-9.  Back to cited text no. 18
Wang Y, Xing L, Yu H, Zhao L Prevalence of dental caries in children and adolescents with type 1 diabetes: A systematic review and meta-analysis. BMC Oral Health 2019;19:213.  Back to cited text no. 19
Preshaw PM, Bissett SM Periodontitis and diabetes. Br Dent J 2019;227:577-84.  Back to cited text no. 20
Mealey BL, Oates TW Diabetes and periodontal diseases. J Periodontol 2006;77:1289-303.  Back to cited text no. 21
Moore PA, Guggenheimer J, Orchard T Burning mouth syndrome and peripheral neuropathy in patients with type 1 diabetes mellitus. J Diabetes Complications 2007;21:397-402.  Back to cited text no. 22
Greenspan D Xerostomia: Diagnosis and management. Oncology (Williston Park) 1996;10:7-11.  Back to cited text no. 23
Gibson J, Lamey P-J, Lewis MAO, Frier BM Oral manifestations of previously undiagnosed non-insulin dependent diabetes mellitus. J Oral Pathol Med 1990;19:284-7.  Back to cited text no. 24
Le Floch JP, Le Lievre G, Sadoun J, Perlemuter L, Peynegre R, Hazard J Taste impairment and related factors in type I diabetes mellitus. Diabetes Care 1989;12:173-8.  Back to cited text no. 25
Bajaj S, Prasad S, Gupta A, Singh VB Oral manifestations in type-2 diabetes and related complications. Indian J Endocrinol Metab 2012;16:777-9.  Back to cited text no. 26
Bhandare NN, Keny MS, Nevrekar RP, Bhandare PN Diabetic tongue—Could it be a diagnostic criterion? J Fam Med Pry Care 2014;3:290-1.  Back to cited text no. 27
Mallah N, Ignacio Varela-Centelles P, Seoane-Romero J, Takkouche B Diabetes mellitus and oral lichen planus: A systematic review and meta-analysis. Oral Dis 2021:1-10>. doi: 10.1111/odi.13927.  Back to cited text no. 28
Lundstom IM Incidence of diabetes mellitus in patients with oral lichen planus. Int J Oral Surg 1983;12:147-52.  Back to cited text no. 29
Souza MGM, Costa ALL, Boncalli AG Clinical study of the oral manifestations and related factors in type 2 diabetics patients. Braz J Otorhinolaryngol 2011;77:145-52.  Back to cited text no. 30
Anil S, Remani P, Vijayakumar T, Hari S Cell mediated and humoral immune response in diabetic patients with periodontitis. Oral Surg Oral Med Oral Pathol 1990;70:44-8.  Back to cited text no. 31
Ricciardiello F, Mazzone S, Viola P, Guggino G, Longo G, Napolitano A, et al. Deep neck infections: Decisional algorithm for patients with multiple spaces involvement. Rev Recent Clin Trials 2022;17:46-52.  Back to cited text no. 32
Sykes LM, Sukha A Potential risk of serious infections in the diabetic patient: A clinical report. J Prosth Dent 2001;86:569-73.  Back to cited text no. 33
Doni BR, Peerapur BV, Thotappa LH, Hippargi SB Sequence of oral manifestations in rhino-maxillary mucormycosis. Indian J Dent Res 2011;22:331-5.  Back to cited text no. 34
Barrack HA Hard palate perforation due to mucormycosis: Report of 4 cases. J Laryngol Otol 2007;121:1099-102.  Back to cited text no. 35
Chua JL, Cullen JF Fungal pan-sinusitis with severe visual loss in uncontrolled diabetes. Ann Acad Med Singap 2008;37:964-7.  Back to cited text no. 36
Chambrone L, Palma LF Current status of dental implants survival and peri-implant bone loss in patients with uncontrolled type-2 diabetes mellitus. Curr Opin Endocrinol Diabetes Obes 2019;26:219-22.  Back to cited text no. 37
Darwazeh AMG, MacFarlane TW, McCuish A, Lamey PJ Mixed salivary glucose levels and candidal carriage in patients with diabetes mellitus. J Oral Pathol Med 1989;68:32-6.  Back to cited text no. 38
WHO Scientific Group on Epidemiology Etiology, and Prevention of Periodontal Diseases & World Health Organization. Epidemiology, etiology, and prevention of periodontal diseases: Report of a WHO scientific group, Moscow, 23 November-2 December 1977. Geneva: World Health Organization; 1978. Available from: https://apps.who.int/iris/handle/10665/41313. [Last accessed on 2022 Apr 20].  Back to cited text no. 39
Frantzis TG, Reeve CM, Brown AL Jr. The ultrastructure of capillary basement in the attached gingival of diabetic and non-diabetic patients with periodontal disease. J Periodontol 1971;42:406-11.  Back to cited text no. 40
Listgarten MA, Ricker FH Jr, Laster L, Shapiro J, Cohen DW Vascular basement lamina thickness and the normal and inflamed gingiva of diabetics and non-diabetics. J Periodontol 1974;45:676-86.  Back to cited text no. 41
Taylor GW, Burt BA, Becker MP, Genco RJ, Shlossman M Glycemic control and alveolar bone loss progression in type 2 diabetes. Ann Periodontol 1998;3:30-9.  Back to cited text no. 42
Rocha M, Nava LE, Vazquez de la Torre C, Sanchez-Marin F, Garay-Sevilla ME, Malacara JM Clinical and radiological improvement of periodontal disease in patients with type 2 diabetes mellitus treated with alendronate: A randomized placebo-controlled trial. J Periodontol 2001;72:204-9.  Back to cited text no. 43
Ayanbadejo PO, Savage KO Awareness of periodontal disease amongst Nigeria diabetes. Ondotostomatol Trop 2004;27:13-6.  Back to cited text no. 44
Umeizudike KA, Iwuala SO, Ozoh OB, Ayanbadejo PO, Fasanmade OA Association between periodontal diseases and systemic illness: A survey among internal medicine residents in Nigeria. Saudi Dent J 2016; 28:24-30.  Back to cited text no. 45
Ogunbodede EO, Fatusi OA, Akintomide A, Kolawole K, Ajayi A Oral health status in a population of Nigerian diabetics. J Contemp Dent Pract 2005;6:75-84.  Back to cited text no. 46
Sede MA, Ehizele AO Oral diseases and diabetes: Nigerian medical and dental caregivers’ perspective. Ann Afr Med 2015;14:193-9.  Back to cited text no. 47
Lasisi TJ, Lawal FB, Fasanmade AA Oral health awareness, practices and status of patients with diabetes attending a tertiary health institution in Nigeria. Niger J Med 2016;25:4.  Back to cited text no. 48


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