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 Table of Contents  
Year : 2020  |  Volume : 11  |  Issue : 1  |  Page : 32-38

Prevalence of oral lesions in patients with type 2 diabetes in north Kerala population

1 Department of Oral Medicine and Radiology, Government Dental College, Kozhikode, Kerala, India
2 Department of Oral Medicine and Radiology, Government Dental College, Thrissur, Kerala, India
3 Department of oral medicine and radiology, Government Dental College, Thiruvananthapuram, Kerala, India
4 Department of General Medicine, Government Medical College, Kozhikode, Kerala, India
5 Department of Oral Medicine and Radiology, Government Medical College, Kozhikode, Kerala, India

Date of Submission07-Feb-2019
Date of Decision26-Mar-2019
Date of Acceptance25-Jun-2019
Date of Web Publication18-Dec-2019

Correspondence Address:
Dr. Jinisha Madathil
Department of Oral Medicine and Radiology, Government Dental College, Kozhikode, Kerala.
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jod.jod_7_19

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Objective: To assess the prevalence of oral lesions in Type 2 Diabetic patients. Methods: The study was conducted in Outpatient Department and Diabetic Clinic of Government Medical College, Kozhikode and Department of Oral Medicine and Radiology, Government Dental College, Kozhikode over a period of 1 year. A total of 800 individuals 400 Type 2 Diabetes Mellitus patients and 400 healthy individuals were enrolled in this study. An oral clinical examination was carried out for all participants using a mouth mirror, visible light source and cotton gauze. Results: Prevalence of oral lesions was significantly high P<0.05 in Type 2 DM patients than the controls in the study sample. In the present study ,the prevalence of oral mucosal lesions was significantly higher in Type 2 Diabetic Patients (38%) than in control subjects (25%) (P=0.000). No significant (P>0.05) association was found between Type 2 Diabetes Mellitus and Potentially malignant oral mucosal lesions and also no association was found between oral lesions and metabolic control of the disease. Conclusion: This study showed that the prevalence of oral lesions was higher in Type 2 diabetic than non - diabetics and provides evidence that diabetes can have a negative influence on oral health.

Keywords: Diabetes mellitus, oral lesions, oral mucosal lesions, potentially malignant disorders, type 2 diabetes mellitus

How to cite this article:
Madathil J, Salim HP, Balan A, Radhakrishnan C, Kumar NR. Prevalence of oral lesions in patients with type 2 diabetes in north Kerala population. J Diabetol 2020;11:32-8

How to cite this URL:
Madathil J, Salim HP, Balan A, Radhakrishnan C, Kumar NR. Prevalence of oral lesions in patients with type 2 diabetes in north Kerala population. J Diabetol [serial online] 2020 [cited 2022 Nov 29];11:32-8. Available from: https://www.journalofdiabetology.org/text.asp?2020/11/1/32/273088

  Introduction Top

Diabetes mellitus (DM) is considered as a major public health concern worldwide and is the single most important metabolic disease that can affect nearly every organ system in the body and 5% of all deaths is attributable to it.[1] The prevalence of diabetes for all age groups worldwide was estimated to be 2.8% in 2000 and 4.4% in 2030.[2] The countries with the largest number of people with diabetes are India, China, and the United States, with India regarded as the diabetic capital of the world.[3] Diabetes frequently predisposes an individual to oral health complications.[4] Oral diseases have a direct adverse effect on the quality of life and may have serious impact on individual’s well-being, self-esteem, financial status, and social interaction.[5]

Epidemiological studies on oral mucosal lesions are rare globally in comparison with the studies on dental caries and periodontal diseases. It has not been proven whether oral mucosal lesions in patients with diabetes occur more frequently than in those without diabetes.[6],[7] This study was carried out to assess the type and frequency of oral lesions in patients with type 2 diabetes compared with that of nondiabetic controls and to find whether there is any association of such lesions with metabolic control of the disease and to provide additional information to the existing literature.

  Materials and Methods Top

The study was approved by the ethics research committee of Government Dental College, Kozhikode, Kerala, India. This hospital-based cross-sectional study conducted over 1 year included 400 patients with type 2 DM and 400 nondiabetic control subjects. The sample size of the study was calculated using a single formula, n = (Zα+Zβ)2Pq × 2/d2, where Zα = 1.96, Zβ = 0.84, P is the expected prevalence (p1+p2/2), q = 100 − P, and d = margin of error, which was based on the proportion of oral lesions in patients with diabetes from a previous study.[8] The precision was set at 0.05 with a 95% confidence interval.

Previously diagnosed Under treatment patients with type 2 diabetes who were reported with glycosylated hemoglobin (HbA1C) were recruited from diabetic outpatient department, and nondiabetic control group assessed by HbA1C was recruited from the outpatient department of general medicine. Only patients who were willing to participate in the study were recruited. Patients with type 1 diabetes and immunocompromised patients were excluded from the study. All volunteers were informed of the aims and methods of this study, and written consent was obtained from them. Data collection sheets were used to gather demographic data, medical and dental history, subjective xerostomia, and past and current use of medications. Data on the duration of disease, type of diabetes, HbA1C values, any major complications, and type of diabetes therapy were retrieved from medical records. The patient was categorized into three groups according to mean HbA1C values recorded in the past year.[8] These were as follows:

  • Well-controlled HbA1C < 7.5%

  • Moderately controlled HbA1C 7.6%–8.9%

  • Poorly controlled HbA1C > 9%

  •   Oral Examination Top

    Subjects underwent systematic clinical examination of oral mucosa by a single examiner, and examination was performed under electrical overhead lights using a mouth mirror, tweezers, gauze, and a wooden tongue depressor. Oral hygiene status of the patient was assessed by Simplified Oral Hygiene Index and caries index by decayed missing filled teeth scoring criteria. The gingival and periodontal status of the patients was assessed by gingival index and community periodontal index of treatment needs, respectively. Cytologic smear from the tongue was taken for a microscopic count of Candida pseudohyphae. Patients with oral lesions were referred to Government Dental College, Kozhikode, Kerala, India, for appropriate treatment.

      Statistical Analysis Top

    All the collected data were analyzed using the Statistical Package for the Social Sciences (SPSS, IBM Corporation, Microsoft 7) software, version 18.0, for Microsoft Windows. A descriptive study was made for clinically relevant variables. The association between the different qualitative variables was examined using Pearson chi-squared coefficient. A P < 0.05 was considered statistically significant.

      Results Top

    A total of 5880 patients who reported to the outpatient department of diabetic clinic, Government Medical College, Kozhikode, Kerala, India, during the July 2015 to July 2016, were screened. A total of 146 were patients with type 1 diabetes and 5734 were patients with type 2 diabetes. The male-to-female ratio of patients with type 2 diabetes was 1:1.8. There were more women than men among both cases (63.8%) and control subjects (61.8%). The demographic characteristics are presented in [Table 1].
    Table 1: Demographic data and characteristics of the study groups

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    The age of cases ranged from 23 to 75 years with a mean age of 54.84 ± 10.81 years. The age of controls ranged from 25 to 76 years with a mean age of 54.13 ± 11.2 years. The controls and cases were age matched. The patients were divided into five age groups. Majority were in the age group of above 60 years [Graph 1].
    Graph 1: Distribution of case and control groups according to age

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    More cases (22.1%) than control subjects (16.3%) were on medications for indications other than diabetes. Diabetes-related variables among patients with type 2 DM are presented in [Table 2]. A total of 68.5% of subjects were having DM for more than 10 years. The mean (standard deviation [SD]) value of HbA1C%, indicative of metabolic control, was 9.5 (2.26) with 42% of the subjects having moderately or well-controlled disease. Most patients (72%) were prescribed a combination of insulin and oral hypoglycemic drugs, whereas 18.5% were prescribed oral hypoglycemic drugs and 9.5% of patients were prescribed insulin alone.
    Table 2: Description of diabetes variables among patients with diabetes

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    Pain and decayed tooth were the main complaints among both groups, 33 (8.3%) and 18 (4.5%) among cases and 11 (2.8%) and 22 (5.5%) among controls, respectively. A total of 16 (4%) cases and 5 (1.25%) controls complained of mobility of tooth. Burning sensation of oral mucosa was present among nine (2.25%) cases and one (0.25%) control. Patients had other complaints such as bleeding from gingiva, sensitivity, halitosis, broken tooth, and ulcer. More than half of the subjects in both groups were either completely edentulous or partially edentulous but only 11.75% of cases and 5.75% of controls were wearing dentures. There were more number of dentulous persons in the control group (35.75%) compared to that in the cases (16%), and the loss of teeth was significantly more among the cases (P < 0.05). The dentition status for both groups is presented in [Table 3]. More than half of the cases showed poor oral hygiene, whereas good oral hygiene was observed more in control subjects.
    Table 3: Oral health status among cases and controls

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    The caries index was higher in the case group (90.25%) compared to that in the controls (76.25%) (P = 0.000). On examining 800 subjects including both cases and controls, 60 were found to be edentulous, 38 (9.5%) among cases and 22 (5.5%) among controls and had a decayed missing filled (DMF) score of 32. Among dentate subjects, the minimum DMF score was 0 among cases and controls and maximum was 24 among cases and 26 among controls. Only 39 cases showed a DMF score of 0, whereas 95 controls had a score of 0. A DMF score between 1 and 10 was observed among 255 cases and 237 controls. Score between 11 and 20 was observed among 52 cases and 41 controls and between 20 and 30 was seen among 13 cases and 6 controls, respectively. DMF score of above 30 was observed among 41 cases and 21 controls. Periodontitis and gingivitis seem to be higher in cases (85.5% and 82.25%, respectively) than that in control group (P = 0.000). Periodontal status was assessed by taking into consideration the factors such as bleeding, calculus and other plaque retentive factors, and the presence of periodontal pockets. Subjects without any periodontal disease were significantly lower among cases, whereas bleeding on probing, calculus, and pocket depth of 4–5mm was more among cases compared to that among controls [Table 3].

    On questioning and examining patients, it was observed that more than half of the cases (78.75%) than controls were affected with xerostomia with a significant P value of <0.05. A total of 19.5% cases were presented with more discomfort compared to 3.25% control subjects. Candidiasis was observed in 58% of cases.

    Oral mucosal lesions were significantly higher in cases (38.25%) than those in control subjects (25%) (P = 0.000). Oral lesions, which were found in higher frequency and significantly associated with cases, included coated tongue, fissured tongue, lingual varicosity, and traumatic keratosis. Oral mucosal lesions observed in cases and control subjects are shown in [Table 4]. Coated tongue was seen in 89.25% of cases. Other than coated tongue, 13 different types of oral mucosal lesions were observed in both cases and controls and were categorized into six main groups: tongue lesions, denture-related lesions, white lesions, ulcerative lesions, and precancerous lesions. The most common lesions in cases were fissured tongue (16%), lingual varicosity (9%), and melanin pigmentation (10.25%). The prevalence of melanin pigmentation was higher in cases than in control subjects, but this difference was not statistically significant (P = 0.549). A statistically significant association was found between poor metabolic control and fissured tongue (P = 0.002).
    Table 4: Comparison of the prevalence of oral mucosal lesions in diabetics and controls

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      Discussion Top

    DM is a complex and pernicious syndrome characterized by abnormalities in carbohydrate, lipid, and protein metabolism, resulting from either a profound or an absolute deficiency of insulin. Many studies had discussed diabetes as a risk factor for oral diseases.[8],[10] This study also showed an increased prevalence of oral lesions in patients with type 2 diabetes as compared to nondiabetic patients. This highlights the importance of monitoring the oral health of patients with DM, as a high incidence of lesions indicates a need for urgent treatment.

    In this study, prevalence of dental caries was found to be significantly higher in diabetics than in nondiabetics (P = 0.000). This was in accordance with other studies on dental caries.[11],[12] However, a study by Bharateesh et al.[13] showed a higher prevalence of dental caries in nondiabetics (32.3%) as compared to that in diabetics (13.6%). Review of literature indicates that there is no clear association between DM and dental caries. Studies have showed higher, similar, or lower caries experience among diabetics than that among nondiabetics.[13],[14],[15] Prevalence of periodontal diseases in this study was more in diabetics (85.5%) than that in nondiabetics (67.75%). The study showed that patients without any periodontal disease were significantly lower among those with diabetes, whereas bleeding on probing, calculus, and pocket depth of 4–5mm was more among diabetics compared to that among nondiabetics. Many authors[16],[17],[18],[19] have reported an increased prevalence of periodontal diseases among patients with diabetes. Campus et al.[11] in their study concluded that the patients with type 2 DM undoubtedly have susceptibility for more severe periodontal disease. Prevalence of periodontal disease was higher in diabetics (92.6%) as compared to that in nondiabetics (83%) in a study by Bharateesh et al.[13] in south Indian population. The increased prevalence and severity of periodontitis typically seen in patients with diabetes, with poor metabolic control, has led to the designation of periodontal diseases as the “sixth complication of diabetes mellitus.”[12] Prevalence of gingivitis was also higher among diabetes (82.25%) when compared to their normal counterpart, which was similar with other studies.[18],[20],[21],[22]

    Xerostomia or subjective dryness of mouth is one of the common complaints among patients with diabetes, which might be associated with the poor salivary flow. Like many other studies,[8],[23],[24],[25] xerostomia was one of the most prevalent conditions (P = 0.000) among diabetics in this study also. Here, the maximum patients were just symptomatic with no effect on speech and food intake, whereas a few were experiencing severe dryness of mouth.

    Prevalence of dental caries, periodontitis, gingivitis, and xerostomia was found to be increased with poor metabolic control but was not significant. This study was similar to other studies, which showed an increased prevalence but not statistically significant.[7],[17] Candidiasis was a common problem noticed in almost all patients with diabetes. In our study, prevalence of Candida carriers was 58%, which was similar to that found in other studies.[21],[26],[27 No significant association was seen between metabolic control and candidiasis in this study. Whereas],[ a study by Mubarak et al.[26] showed that Candida infections were higher among subjects with elevated blood sugar levels (HbA1C > 9) compared to individuals with well-controlled blood sugar levels (HbA1C < 6).

    A number of specific oral mucosal alterations have been associated with type 2 DM,[4],[8],[28] which included coated tongue, lingual varicosities, fissured tongue, geographic tongue, melanin pigmentation, and denture stomatitis. In our study, the prevalence of oral mucosal lesions was significantly higher in patients with type 2 diabetes than that in nondiabetic subjects (P = 0.000). A significantly greater proportion of subjects with DM (38.25%) had one or more oral mucosal lesions compared to nondiabetics (25%). A similar study of 146 patients with type 2 diabetes and 111 nondiabetic control subjects showed that nearly twice the number of patients with diabetes (88%) had one or more oral soft tissue lesions as compared to nondiabetic subjects (45.0%), and the difference was statistically significant (P< 0.001).[29] Another study showed that the prevalence of oral mucosal lesions was significantly higher in patients with type 2 diabetes (45%) than that in nondiabetic subjects (38.3%).[30]

    A highly significant association was observed between coated tongue and type 2 diabetes in this study, which was in accordance with other studies.[5],[29] This finding can be related to decrease in salivary flow and a higher viscosity of saliva that result in reduced action of salivary antimicrobial factors and cleaning capacity of the tongue.[4] An association between diabetes and fissured tongue has been reported in a previous study by de Souza Bastos et al.[29] with a prevalence of 17.8% among patients with diabetes. In this study also, this alteration was more common in patients with diabetes (16%) than that in the nondiabetics. A statistically significant association between poor metabolic control and fissured tongue was observed. Lingual varicosity was diagnosed in 36 patients, corresponding to approximately 9% of the total abnormalities. A prevalence of 36.6% was seen in a study by Vasconcelos et al.[10] and 20.5% in a study by de Souza Bastos et al.[29] The literature studied does not have a factor that links this abnormality to diabetes. Supposedly, this abnormality is related to the fact that it is a frequent semiological finding in the elderly patients. This abnormality may also be related to the circulatory abnormalities typical of diabetes.[10] These assumptions need further studies to be confirmed or to be ruled out. Many authors showed an association between melanin pigmentation and diabetes.[4],[29] But in this study, not much difference was observed among cases (10.25%) and controls (9%). Traumatic ulcer was seen in nearly 1% cases, which was similar to other studies.[10] The literature consulted did not reveal any factors that could relate this abnormality with diabetes.

    Prevalence of denture stomatitis and geographic tongue in our study was more among the nondiabetics, in contrary with the other studies.[8],[29],[30] Shulman and Carpenter[31] in their study also did not find any significant association of geographic tongue with diabetes. Phelan and Levin[32] showed no significant increase in the prevalence of denture stomatitis in those subjects with either previously diagnosed DM or elevated plasma glucose levels when compared with subjects with normal glucose metabolism.

    This study did not find any association between type 2 DM and potentially malignant disorders. An association has been reported between DM and premalignant oral lesions by Dikshit et al.[33] in Keralite population. According to their study, patients with diabetes were two times more likely to develop leukoplakia and three times more prone to develop erythroplakia. Another study by Ujpál et al.[22] also showed an incidence of 6% leukoplakia and 2% erythroplakia among patients with diabetes. Meta-analysis carried out by Gong et al.[34] showed a positive association between type 2 DM and risk of oral precancerous lesions. Leukoplakia was diagnosed in 2.7% of patients with type 2 diabetes, with no significant difference from the control group in a study by de Souza Bastos et al.[29] The high prevalence of leukoplakia in the aforementioned study could be attributed to a high number of smokers among the diabetics. The prevalence of leukoplakia in the study was only 0.75% in the individuals with type 2 diabetes, with no significant difference as compared with that in the nondiabetics (0.25%). Our study had less number of smokers compared with the other similar studies. A study by Saini et al.[30] also showed no association between DM and oral precancerous lesions. Many authors have reported an association between lichen planus and DM.[35],[36] de Souza Bastos et al.[29] in their study reported a significantly higher prevalence of lichen planus in patients with type 2 DM (6.1%) than that in control subjects. In this study, lichen planus was diagnosed in 1.25% of patients with type 2 diabetes, with no significant difference from the nondiabetic group. This was in accordance with other studies.[4],[8],[30] Prevalence of mucosal lesions in patients with diabetes may be due to slower healing rates, leading to a longer duration of a given lesion.[8]

      Conclusion Top

    Prevalence of oral lesions was significantly high (P < 0.05) in the patients with type 2 DM than that in the nondiabetics in the study sample. In our study, the prevalence of oral mucosal lesions was significantly higher in patients with type 2 diabetes than that in nondiabetic subjects (P = 0.000). No significant (P > 0.05) association was found between type 2 DM and potentially malignant oral mucosal lesions.

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      [Table 1], [Table 2], [Table 3], [Table 4]


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