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 Table of Contents  
Year : 2021  |  Volume : 11  |  Issue : 3  |  Page : 273-280

Smash of diabetes mellitus on smile

1 Department of Endocrinology, Chittagong Medical College, Chattogram, Bangladesh
2 Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kuala Lumpur, Malaysia

Date of Submission25-Apr-2021
Date of Decision03-May-2021
Date of Acceptance06-May-2021
Date of Web Publication14-Jun-2021

Correspondence Address:
Mainul Haque
The Unit of Pharmacology, Faculty of Medicine and Defence Health, Universiti Pertahanan Nasional Malaysia (National Defence University of Malaysia), Kem Perdana Sungai Besi, 57000 Kuala Lumpur
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/aihb.aihb_68_21

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How to cite this article:
Akter F, Haque M. Smash of diabetes mellitus on smile. Adv Hum Biol 2021;11:273-80

How to cite this URL:
Akter F, Haque M. Smash of diabetes mellitus on smile. Adv Hum Biol [serial online] 2021 [cited 2021 Oct 25];11:273-80. Available from: https://www.aihbonline.com/text.asp?2021/11/3/273/318442

Diabetes mellitus (DM) is a chronic metabolic disease characterised by hyperglycaemia due to either a decreased insulin secretion or resistance to the action of insulin or both.[1],[2],[3] Complications of DM significantly impairs, the quality of life, longevity of the diabetic patients', and increases healthcare financial overhead.[4],[5],[6] DM-induced chronic hyperglycaemia predisposes several adverse events, affecting multiple vital organs and deadly affects several physiological functions.[7],[8],[9] In addition, DM involves the oral cavity far before the patient is diagnosed as diabetic.[1],[2],[3],[10],[11],[12] According to the World Health Organization, DM is a silent global epidemic that affects many people around the world.[13] The prevalence of DM has been rising more rapidly in low- and middle-income countries than in high-income countries.[14],[15],[16],[17] Approximately 463 million adults (20–79 years) live with diabetes; by 2045, this will rise to 700 million.[18] The fraction of the general public with Type 2 diabetes is swelling all over the globe.[19] Three hundred and seventy-four million people are at increased risk of developing Type 2 diabetes.[20] The global financial overhead directly related to DM was a minimum of US$760 billion in 2019.[20],[21],[22] Patients with diabetes present impaired function of polymorphonuclear leucocytes including leukocyte adhesion, chemotaxis and phagocytosis, impaired bactericidal activity, altered response to antigens and function of T lymphocytes.[23],[24],[25],[26] Systemic complications of DM include heart attack, kidney disease, amputation of limbs, blindness and peripheral nerve damage [Figure 1].[27],[28],[29],[30]
Figure 1: Pathogenesis of diabetes mellitus and its chronic complications.

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Oral health is a fundamental fragment of overall health.[31],[32],[33],[34] Uncontrolled DM, even somewhat raised blood sugar levels, harms oral health, promoting many oral diseases.[35],[36],[37] O'er 90% of diabetic patients were correlated with oral diseases.[2],[38],[39] Quite a few oral teething troubles are detected in both types of DM such as, Type 1 and type 2 DM, which include periodontal diseases, oral candidiasis, tooth loss, xerostomia, halitosis, delay wound healing, burning mouth syndrome, salivary and taste dysfunction, tooth decay, lichen planus, geographic tongue and complications associated with dental implants [Figure 2].[2],[38]
Figure 2: Oral hurdles in diabetes mellitus.

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We have some natural commensal bacteria in our mouth.[40],[41] Starches and sugars in foods and beverages interact with these bacteria.[42],[43] The higher the blood sugar level, the greater the supply of sugars and starches, which fuels more acid formation, ensuring a damaging effect on the teeth.[44] Dental caries result from a complex interaction between acid-producing bacteria in the plaque and fermentable carbohydrates such as sucrose, fructose and glucose.[45],[46],[47] In the healthy status, there is a balance between the bacterial biofilm and the tooth minerals.[48],[49] Disruption of this harmony is known as ecological shift.[50],[51] The ecological shift led to the formation of dental biofilm that includes Streptococcus mutans, other closely related Streptococci, and some Lactobacilli produce a sticky polysaccharide matrix and acids, causing demineralization of the hard dental enamel.[52],[53],[54] This leads to cavitation. The aciduric microbes demineralize dental surfaces as long as they remain on the surface and receiving sufficient nutrition, mainly sucrose.[45],[46],[55],[56] Furthermore, as human teeth are composed of non-shedding tissue, thereby, dental biofilm can exists easily otherwise physically removed.[49],[57],[58],[59] Thus, poor oral hygiene and consistent high intake of sucrose-rich or other fermentable carbohydrates-containing food, snacks, and sugar-sweetened beverages (SSBs) promote low pH and several adverse events towards poor oral health.[42],[60],[61],[62],[63] Furthermore, high intake of SSBs and other sucrose increases are often reported to be cariogenic.[64],[65],[66] The process of demineralization can be stopped or even reversed, as there is a balance between demineralization and remineralization, which is influenced by the supply of calcium, phosphate and fluoride, the composition and quantity of saliva that serves as a buffer, diet and the presence of cariogenic bacteria in the dental plaque.[49],[67],[68],[69] In this way, physical, biological, environmental and behavioural risk factors are involved in caries development.[70],[71] Conceivably, diabetic patients are more prone to developing novel and repeated dental caries.[1] Improper toothbrushing and protecting dimensions of the saliva, high-level sugar and sugar-containing food (fermentable carbohydrate), particularly SSBs in the saliva, presence of the high number of oral yeasts, mutant streptococci, lactobacilli and chronic hyperglycaemia increases the possibilities of severe deterioration oral health including tooth.[2],[42],[72],[73],[74],[75]

DM reduces the ability to fight against bacteria.[76] The persistent plaque will harden and make tartar (Dental calculus), which irritates gingival tissues gums around the base of teeth.[77] Thereby, chronic irritation led to gingival inflammation (gingivitis) and swollen gum easily bleeds.[78],[79],[80] Periodontitis has been identified as the sixth[81] complication of diabetes, and the rest are retinopathy, neuropathy, nephropathy, cardiovascular disease, and peripheral vascular disease.[27],[82],[83],[84] There is a complete two-way hook-up between the degree of hyperglycaemia and periodontal disease.[35],[36],[85] Duration of diabetes is also proportional to the intensity of complication.[86] The periodontitis amongst diabetic individuals has been reported to be as high as 34%–68%.[39],[87] In addition, there has been reported that poorly controlled DM individual often develop destructive features of periodontal disease.[88],[89] Those dangerous characteristics of periodontal disease include irreversible loss of attachment of tooth, alveolar bone loss and periodontal pocket formation.[90],[91] Another independent research reported that the risk of periodontitis increases. The risk of alveolar bone loss is 11 times higher amongst poorly controlled diabetes Type 2 patients' than healthy individuals.[92] Possible mechanisms of increased susceptibility to periodontal diseases amongst DM patients include alterations in host defence response, microflora, collagen defect, vascularity and gingival crevicular fluid.[1],[35],[36],[93] The production of antibodies in response to microorganisms in periodontal tissues, and the presence of natural killer T cells, autoreactive T cells and B-cells, antineutrophil cytoplasmic autoantibodies, heat shock proteins, autoantibodies and predisposing genetic factors provide the basis for an autoimmune role in the pathogenesis of the periodontal disease.[94],[95] It can also be inherent. Autoimmune components are accredited equally for periodontal disease and DM.[96] In addition, poor oral hygiene and metabolic control, long-standing diabetes, obesity, age and smoking remain principal triggering factors.[96],[97],[98]

Diabetic patients also experience dry mouth due to salivary dysfunction, such as decreased salivary flow and change in its composition, known as xerostomia.[99],[100] The projected global prevalence of xerostomia amid both Type 1 and 2 DM (adult and paediatric) cases arrays between 14% and 62%.[1],[39],[101],[102],[103],[104] The patient experiences difficulties in eating, swallowing and even speaking, negatively affecting the patients' quality of life. The aetiology of salivary dysfunction amongst DM cases is not well defined but may be related to polyuria, autonomic neuropathies, microvascular changes, and alterations in the basement membranes of salivary glands.[99],[105] The degree of xerostomia is significantly associated with salivary glucose levels.[105],[106] Another common oral complication of diabetes is oral candidiasis, an opportunistic fungal infection.[107] Candida infection is more prevalent in diabetic patients who smoke, wear dentures, have inadequate glycaemic control and use steroids or broad-spectrum antibiotics.[108],[109] Signs of thrush include painful white or red patches inside the mouth.[110],[111],[112] Neuropathic pain amongst DM patients can manifest as a burning mouth, tingling or even electric shock or stabbing sensation that is very debilitating.[1],[113] Delayed healing of soft and hard tissues in diabetic patients is a well-known complication of oral surgeries.[1],[101] Delayed or diminished vascularisation, hypoxia, a reduction in innate immunity, decreased growth factor production and psychological stress are the main contributing factors.[114]

Taste recognition follows an inherited characteristic but can be influenced by the advent of DM-induced neuropathies.[115],[116],[117] The sensory dysfunction because of DM can impede preserving a good dietary practice and impair adequate glycaemic management.[117],[118] Moreover, taste aberration amongst diabetic people often causes obesity.[117],[119],[120],[121]. Researchers revealed that machinery behind oral complications amongst the diabetic folk includes compromised neutrophil physiological activity, amplified collagenase functionality, and a drop in collagen formation, microangiopathy and neuropathy.[1],[122],[123],[124] Multiple studies reported that two principal mechanisms are intricate in the pathogenesis of diabetic complications. First, the polyol pathway converts glucose into sorbitol by enzyme aldose reductase that causes tissue damage and numerous other diabetic complications.[125],[126],[127] Second, the formation of advanced glycosylation end products (AGEs) results in altering structures and functions and their deposition in specific organs that causes various complications.[128],[129],[130] Hyperglycaemia results in altered cellular immunity, the proliferation of bacteria, and the formation of AGEs.[131],[132] They altered cellular immunity results in cellular dysfunction, inflammation and subsequent degradation of supporting connective tissue.[133],[134] Excess glucose forms AGEs combine with structural proteins, stimulates endothelial receptors and perpetuates a series of inflammatory events by attracting monocytes, leading to the degradation of the attachment apparatus.[135],[136] Furthermore, hyperglycaemia impairs fibroblasts' activity that predisposes collagen degradation by matrix metalloproteinase enzymes, thereby preventing tissue repair and regeneration and promoting dental decay tooth loss [Figure 3].[137],[138]
Figure 3: Pathogenesis of complications of diabetes mellitus and its relationship with dental disease.

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In addition, microbial proliferation further exacerbates, resulting in periodontal destruction.[139],[140],[141],[142] It has been suggested that there is a degree of synergism between DM and periodontal microbial disease[35],[36] and increases the possibility of impairing the metabolic control of diabetes.[96],[143] Periodontal infections affect glycaemic control and serve as a chronic systemic infection and inflammation source.[96],[144],[145] Periodontal pathogens – especially Gram-negative bacteria – stimulate periodontal tissue cells to synthesize and release local proinflammatory mediators.[146],[147] These mediators and bacteria and their by-products circulate through the bloodstream and activate a systemic inflammatory response in the liver.[148] This systemic inflammation can reduce tissue response to circulating insulin, reducing glucose uptake by cells and causing hyperglycaemia.[149],[150],[151] Multiple studies reported that the effective management and prevention of periodontal diseases improves glycaemic control.[152],[153],[154],[155],[156],[157],[158],[159] Henceforth, appropriate management of periodontal disease, especially of infective disorders amongst DM individual, remain as the most issue for better outcome.[160],[161]

Awareness and understanding of the possible associations between diabetes, oral health and general health need to be increased amongst diabetic patients.[162] Unfortunately, many diabetic patients are not cognizant of the connotation flanked by DM and oral health, and only a minor diabetic folk (14%–19%) visit a dental clinic for regular evaluations.[38],[163],[164] Positive lifestyles, reasonable control of diabetes and self-care practices, regular dental appraisal with particular emphasis on periodontal evaluation, and strengthening oral health instructions can effectively prevent oral complications of DM.[165],[166]

DM is a public health crisis, and health-care professionals should play their roles to prevent and control the disease and its oral and other systemic complications.[38],[167] Oral health problems exert a deleterious effect on a patient's health-related quality of life, loss of working hours and are often expensive to treat.[168],[169] Oral health remains an under-recognised and neglected global health issue. Averting and treating periodontitis with consistent dental scaling and root scheduling can progress metabolic control.[170] Effective management of diabetic patients requires cooperation between the patient, the doctor, the dentist and other health-care professionals.[171] A better understanding of the pathophysiology, indexes and management of different types of diabetes-related orofacial infection by the endocrinologist and the dentist is essential for optimising the care of diabetic patients.[2] Meticulous oral hygiene is crucial; tooth brushing with fluoride toothpaste twice a day and dental floss once a day should be emphasised to ensure plaque control. Changing toothbrushes at least three months apart, recognising early signs of gum disease, scheduled dental checkups, regular monitoring of blood glucose to keep it within the target range and quitting smoking is the utmost priority to have a lifetime of healthy teeth and gums for a diabetic patient. The Internet can educate DM patients because of its growing use amongst people. Managing diabetes is a lifelong commitment, and efforts will be rewarded with an impeccable, eye-catching glamorous smile.

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