Oral Complications of Diabetes Mellitus
Oral Complications of Diabetic Mellitus
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| Dry mouth in diabetic patient |
Diabetes mellitus (DM) is associated with several microvascular and macrovascular complications, such as retinopathy, nephropathy, neuropathy, and cardiovascular diseases. The pathogenesis of these complications is complex, and involves metabolic and hemodynamic disturbances, including hyperglycemia, insulin resistance, dyslipidemia, hypertension, and immune dysfunction. These disturbances initiate several damaging processes, such as increased reactive oxygen species (ROS) production, inflammation, and ischemia. These processes mainly exert their damaging effect on endothelial and nerve cells, hence the susceptibility of densely vascularized and innervated sites, such as the eyes, kidneys, and nerves. Since the oral cavity is also highly vascularized and innervated, oral complications can be expected as well. The relationship between DM and oral diseases has received considerable attention in the past few decades. However, most studies only focus on periodontitis, and still approach DM from the limited perspective of elevated blood glucose levels only. In this review, we will assess other potential oral complications as well, including: dental caries, dry mouth, oral mucosal lesions, oral cancer, taste disturbances,TMJ disorders, burning mouth syndrome, apical periodontitis, and peri-implant diseases. Each oral complication will be briefly introduced, followed by an assessment of the literature studying epidemiological associations with DM. We will also elaborate on pathogenic mechanisms that might explain associations between DM and oral complications.
Potential Oral Complications of Diabetes Mellitus
Only a limited number of studies investigated the direct effect of hyperglycemia on dental caries.
Insulin resistance
One study compared the decayed, missing, and filled teeth (DMFT) index—a marker for experienced and current caries—between obese, insulin-resistant (OB-IR) patients and healthy controls. The DMFT index, as well as one of its components (decayed teeth), were increased in patients with insulin resistance
In general, patients with poor glycemic control present significantly lower salivary flow rate
and higher prevalence of xerostomia, compared to subjects with well-controlled DM
Hyperglycemia in patients with DM can cause polyuria and osmotic diuresis, possibly leading to dehydration, which is associated with hyposalivation
Immune dysfunction: impaired immune response and proinflammatory state
DM and its metabolic disturbances could be associated with dry mouth, sometimes mediated by inflammatory processes.
Several studies found that the increased prevalence of Candida-related oral lesions was associated with poor metabolic control, indicating that hyperglycemia is important for this association
Immune dysfunction: impaired immune response and proinflammatory state
As we discussed before, patients with DM are susceptible for hyposalivation. Saliva has several innate immune defensive mechanisms to protect the oral mucosa against microorganisms such as Candida. Examples are mechanical washing, its buffering capacity and the presence of antifungal components such as histatins and mucins
Hyperglycemia
Although it is likely that hyperglycemia is important for the increased risk of oral cancer in patients with DM, there is only limited evidence for that hypothesis
Temporomandibular Disorders (TMD)
Burning Mouth Syndrome
Pulp Necrosis and Apical Periodontitis
Peri-implant Disease
From the pictures ..
The previous section explained that chronic complications of DM are the result of persistent metabolic and hemodynamic disturbances that mainly target endothelial cells, typically affecting specific regions in the body. It has been proposed in literature that the oral cavity of patients with DM might be one of those regions, with
an increased susceptibility for oral complications as a result
Dental Caries
HyperglycemiaOnly a limited number of studies investigated the direct effect of hyperglycemia on dental caries.
Insulin resistance
One study compared the decayed, missing, and filled teeth (DMFT) index—a marker for experienced and current caries—between obese, insulin-resistant (OB-IR) patients and healthy controls. The DMFT index, as well as one of its components (decayed teeth), were increased in patients with insulin resistance
Dry Mouth
HyperglycemiaIn general, patients with poor glycemic control present significantly lower salivary flow rate
and higher prevalence of xerostomia, compared to subjects with well-controlled DM
Hyperglycemia in patients with DM can cause polyuria and osmotic diuresis, possibly leading to dehydration, which is associated with hyposalivation
Immune dysfunction: impaired immune response and proinflammatory state
DM and its metabolic disturbances could be associated with dry mouth, sometimes mediated by inflammatory processes.
Oral Mucosal Lesions
HyperglycemiaSeveral studies found that the increased prevalence of Candida-related oral lesions was associated with poor metabolic control, indicating that hyperglycemia is important for this association
Immune dysfunction: impaired immune response and proinflammatory state
As we discussed before, patients with DM are susceptible for hyposalivation. Saliva has several innate immune defensive mechanisms to protect the oral mucosa against microorganisms such as Candida. Examples are mechanical washing, its buffering capacity and the presence of antifungal components such as histatins and mucins
Oral Cancer
Hyperglycemia
Although it is likely that hyperglycemia is important for the increased risk of oral cancer in patients with DM, there is only limited evidence for that hypothesis
Taste Disturbance
Unfortunately, there is no literature available that investigated the same pathogenic pathways we have been using throughout this report. However, a few explanations why patients with DM more frequently suffer from taste impairment have been proposed. For example, the increased susceptibility for dry mouth we discussed in section Dry Mouth, might increase the risk for taste disturbances. One study found that, of all patients with a subjective complaint of taste disturbance, 63% also had a sensation of oral dryness, often regardless of the actual salivary flow . Another study showed that hyposalivation was indeed associated with hypogeusia in a general elderly population
Other Oral Complications
Temporomandibular Disorders (TMD)
Burning Mouth Syndrome
Pulp Necrosis and Apical Periodontitis
Peri-implant Disease
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Oral complications of diabetes mellitus. 1A & 1B: Periodontitis. Dental caries. Image 2A displays a clinical view of dental caries, observed from the occlusal view. Picture 2B is a radiograph of an example of a deep carious lesion, marked by the red circle. 3.
Hyposalivation. The photo in image 3 shows a clinical view of fissured tongue, caused by severe hyposalivation. 4.
Oral candidiasis. Image 4 displays a clinical view of oral candidiasis, located at the palate. 5A & 5B: Oral cancer. At image 5, a clinical representation of leukoplakia and oral cancer is shown at the buccal (5A) and palatal (5B) site. 6A & 6B: Apical periodontitis. Figure 6A shows a fistula, caused by apical periodontitis, with image 6B as the corresponding radiograph, where the lesion at the apex of the tooth is marked by the red circle. 7A & 7B: Temporomandibular disorders. Image 7A indicates the location of pain often seen in patients with temporomandibular disorders, while 7B shows a measurement of limited jaw opening, another symptom of temporomandibular disorders. 8A & 8B: Peri-implantitis. At figure 8A, a clinical view of peri-implantitis is presented, with 8B as the corresponding radiograph. Again, the red dots indicate where ideally, the bone level should be, while the red dots show the actual reduced bone level as a result of the inflammatory process
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