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J Bagh College Dentistry Vol. 24(special issue 1), 2012 The relationship between
Orthodontics, Pedodontics, and Preventive Dentistry108
The relationship between the dental caries and the blood
glucose level among type II non insulin dependent diabetic
patients
Hawraa Khalid Aziz, B.D.S., M.Sc. (1)
ABSTRACT
Background: Diabetes mellitus is one of the most common chronic diseases in the general population that effects the
oral cavity so the probability of detecting an increased of dental caries in diabetic patients is more controversial. The
aims of this study to compare the dental caries among the diabetic and non diabetic patients and its relation with
the blood glucose level, medical history and oral health behaviors among type II non-insulin dependent diabetic
mellitus patients.
Materials and methods: The samples were composed of 180 subjects of diabetic patients and 180 subjects of non
diabetes. Both gender and age range 40 -70 years for both groups. The data were gathered by questionnaire,
clinical examination and laboratory investigations included frequency of oral hygiene practices, caries experience
using the DMFT Index, blood glucose including the fasting blood glucose level, and random blood glucose level.
Independent t-test, Chi-square, correlation coefficient, as well as Z-proportion tests were used for statistical
comparisons.
Results: It indicated that there was no significant difference in DMFT between the diabetic and non-diabetic groups.
In addition to blood glucose level was higher in diabetes than non diabetes with increased dental caries with the
increase of blood glucose level either random or fasting blood glucose level.
Conclusion: This study indicated that the presence of dental caries is not significantly elevated in most diabetics but
the blood glucose level and the age effect on the dental caries as well as diabetic subjects should improve their oral
hygiene practices.
Key words: dental caries, diabetes mellitus, blood glucose level, oral hygiene. (J Bagh Coll Dentistry 2012; 24(sp.
Issue 1):108-114).
INTRODUCTION
Diabetes mellitus (DM) is a common chronic
metabolic disorder which affects millions of
people. The prevalence of diabetes for all age
groups worldwide was estimated to be 2.8% in
2000 and may reach 4.4% by 2030. Additionally,
the diabetic population is expected to rise from
171 million in 2000 to 3666 million by 2030 (1).
Roglic reported that the almost 3 million deaths
per year are attributed to diabetes, equivalent to
5.2% of all deaths (2). There are two basic types of
the diabetes mellitus: type I diabetes mellitus is
caused by autoimmune damage to the pancreatic
beta cells resulting in failure of insulin production
and secretion leading to absolute insulin
deficiency. Hence individuals with type I diabetes
are prone to ketosis in the basal state and depend
on life exogenous insulin injection to prevent
ketosis and sustain health. It occurs primarily in
persons younger than 40 years but also occur at
any age. While type II diabetus mellitus occurs as
aresult of insuln resistance with relative isulin
dificincy. Patients with type II are not ketosis-
prone under normal condition. The majoraty of
type II diabetes are adult above 40 years of age.
However occure in younger age groups. The
globel prevelance of young type II inceased in last
two decades (3) .
(1)Lecturer. College of Health and Medical Technologies
Foundation of Technical Education. Baghdad.
As a systemic disorder, the disease affects the
oral cavity. Investigators have reported several
oral lesions and conditions associated with the
disease. These include among others, xerostomia,
burning mouth, altered taste sensation, gingivitis,
periodontal disease, candidal infection and lichen
planus (4-6) .
However, among researchers there was a
lack of consensus about the relationship between
DM and dental caries. They reported increased (7-
9), decreased (10) and similar (11,12) caries
experiences between those with and without
diabetes.
Taylor and others concluded in their literature
review that there was insufficient evidence to
determine whether a relationship exists between
diabetes and coronal or root caries risk,and they
recommended that further investigations should
be carried out (13) .
Beside the contradictory findings on caries
prevalence in diabetic populations, similarly
conflicting results have been reported on the
identity of the underlying risk factors of such
relationships (14). It is not clear whether this
variability is mainly related to different patho-
physiologic changes of diabetes such as the type,
duration or degree of control, or is in part a
reflection of racial and environmental differences
among diabetic populations worldwide. Therefore
the association between the variation of the blood
glucose level to assess the degree of the control of
J Bagh College Dentistry Vol. 24(special issue 1), 2012 The relationship between
Orthodontics, Pedodontics, and Preventive Dentistry109
the disease as well as the efforts should be made
to evaluate the etiological risk factor of dental
caries such as oral health among diabetic groups
(15).
By all of the above information, this study was
carried out with the following objectives:
1. To compare between the distibution of the
diabetic and control subjects according to the
age and gender and oral health status.
2. To evaluate the dental caries among the group
of diabetics versus non-diabetic controls and
its relation to the age.
3. To evaluate the blood glucose level among a
group of the diabetics and non-diabetic group
and its effect on the caries experience.
4. To evaluate some selected caries-risk factors
and its relation to dental caries in the sampled
diabetics.
MATERIALS AND METHODS
Study Population
One hundred eighty diabetic patients and 180
healthy controls participated in this study. The
diabetic group was recruited from the diabetic
patients of health care centers and Al-hussain
hospital in Karbala city with age range from 40-
70 years old during sampling day were asked to
participate and 100% of those who were invited to
participate in the study agreed. The control group
included age and gender-matched healthy
volunteers with no history of diabetes. Individuals
who had received antibiotics or steroid therapy or
had been using antiseptic mouthwashes during the
previous 3 weeks were excluded from the study.
Also they had no history of any other systemic
disease, or under medication therapy, no
orthodontic treatment or wearing any
prosthodontic appliance.
Data Collection
The data were gathered through questionnaire,
clinical examination and laboratory
investigations. The questionnaire included
questions on medical history and oral health
behaviors. Medical history records were included
duration of the diabetes, physician follow up,
degree of the control of the diabetic state well
controlled or poor controlled. The oral health
behaviors included the frequency of the tooth
brush per day and the type of oral cleaning
methods tooth brush only or both tooth brush with
dental floss. Also they asked about the regular
dental visit and if they are smokers or not which
are rated on scale yes or no.
Clinical Examination
The clinical examination included an
evaluation of dental caries, by using dental mirror
and dental probe under light source. The dental
caries was assessed using the decayed missing
filled teeth (DMFT) Index according to the
criteria and recommendations of the World Health
Organization (16).
Laboratory examination
The blood samples were collected from each
participant diabetic and non diabetic. The fasting
blood glucose level (FBGL) and random blood
glucose level (RBGL) were assessed by "One
Touch TM®" complete blood glucose monitoring
system, Johnson & Johnson, California, USA. For
diabetic patients, the sample of blood was used to
measure the glycosylated hemoglobin
concentrations (HbA1c) which assess the
glycemic control of that patient by measuring
three fasting blood glucose level (17). Those with
values measures of less than or equal to 7 mmol /
ml (< 120 mg/dl) were classified as indicating
satisfactory ( good ) control of diabetes while the
values more than 7 mmol / ml (>120 mg/dl) were
classified as poor control of diabetes (18).
Statistics
Data were collected and analyzed using SPSS
program version 12. The data were analyzed
descriptively and comparison between the groups
was done using independent t-test, Chi-square,
correlation coefficient, as well as Z-proportion
test whenever applicable.
RESULTS
The distribution of participating subjects
according to the age, gender is shown in (Table1).
The caries experience and its components showed
the mean of DT component for diabetes group
was higher than the mean for the non diabetic,
also the mean of MT component for the diabetes
was higher than those for non diabetes, while the
mean of the FT component for diabetes was lower
than those for control group, finally the mean of
the DMFT for diabetes was more than those for
the non diabetes group. The statistical comparison
of studied variables between the diabetes and non
diabetes showed that there were no significant
differences of the caries experience DT, and
DMFT (P > 0.05) except that there was a
significant difference of MT among diabetes and
control groups (P < 0.05) and highly significant
difference of FT between the two groups (P<0.01)
(Table 2).
On the other hands, the result of the
distribution of the caries experience (for both
groups) according to the age showed the mean
J Bagh College Dentistry Vol. 24(special issue 1), 2012 The relationship between
Orthodontics, Pedodontics, and Preventive Dentistry110
values of DMFT index were increased when the
age increased from 40 years to 70 years as shown
in (Figure1). Statistically the correlation between
the DMFT teeth and age showed there was highly
significant correlation for both diabetic and non
diabetic groups (P<0.01) (Table 3).
The results of the oral health behavior
questionnaire are illustrated in (Table 4). The
results showed better oral health habits regarding
brushing frequency among the non diabetic group
in comparison to the diabetic patients. The
majority of subjects who brushed twice daily were
in the non-diabetic group with high significant
difference in distribution regarding to tooth brush
frequency between the two groups (P<0.01),
while the results showed there were no
association regarding to the cleaning methods as
well as the dental visits among the studied groups.
The result of the tobacco use showed there was
higher percentage of the smoking among the
diabetic group than non diabetic with high
significant difference in distribution between
diabetic and control groups.
The mean values of the blood glucose level
both fasting and random blood glucose level for
both group diabetic and non diabetic group were
shown in (Table 5) that was showed the mean
values of both the fasting and random blood
glucose level was higher in the diabetic group
than the non diabetic group with high significance
between them. In the relation of the blood glucose
level and the dental caries the results showed the
caries experience (DMFT) was increased with the
increase of the blood glucose level either fasting
or random blood level among the diabetic group
as shown in (Figure 2). Statistically, there were
highly significant correlations between the DMFT
teeth and fasting blood level and significant
relation of dental caries and random blood level
among the diabetic group (Table 6).
The distribution of diabetic patients in relation
to duration of the disease, physician fellow up,
and degree of diabetic control were shown in
(Table 7). Statistically, the Z- test showed there
was an association between the diabetic patients
in relation to duration of disease, the physician
fellow up, and the degree of the diabetic control
among the diabetic patients.
In the relation of the duration of the disease
with caries experience the results showed that the
mean values of DMFT was lower in the group of
diabetes less than 5 years than those with duration
from 5-10 years while the highest mean DMFT
for the diabetes more than 10 years (Figure 3) but
statistically, there was not significant correlation
between the DMFT and duration of the disease
(Table 6).
As well as the comparison of caries
experiences among the diabetic patients according
to the degree of the control the results showed that
the mean values of the DMFT was higher in well
controlled group than poorly controlled group, but
statistically there was non significant difference
between the two groups (P<0.05) (Table 8).
DISCCUSION
Studies that address the association between
diabetes mellitus (DM) and dental caries are
many, but their results have not revealed any
strong pattern of association (8-11). Diabetes
mellitus is a chronic disease that may impact on
personal behavior. Therefore, caution should be
taken when assessing the impact of the
pathophysiology of diabetes on oral health status
when these factors are not considered (12) .
The results of this study showed that there was
no significant differences of dental caries between
the diabetic and non diabetic groups this result
agreed with other studies (11,19) and disagreed
with other who found that an increase in
dental caries in permanent teeth was observed
among diabetics (18). One more study showed
that diabetics have higher DMFT values as
compared to control group children (20). Also a
study demonstrated that diabetic patients have
more active dental caries than control subjects (21).
This may be attributed to low-carbohydrate
diabetic diets should theoretically reduce caries
prevalence. As well as authors usually attribute it
to the fact that diabetics have traditionally been
counseled to consume a diet low in refined
carbohydrates, especially sucrose, and have been
advised to have an increased protein intake which
enhances the buffering capacity of saliva(13).
On the other hands, the result of the
distribution of the dental caries for both groups
according to the age showed the mean values of
DMFT Index were increased when the age
increased with strong correlation this result agreed
with many others who reported high caries
prevalence among older diabetics (10,12), but
disagreed with Arrieta-Blanco and others who
found no significant differences in the number of
caries, missing teeth and fillings in different age
groups of the diabetic population (6).
The result of the oral health behavior
questionnaire showed better oral health habits
regarding brushing frequency among the non
diabetic group in comparison to the diabetic
patients this result agreed with other study that
was showed the frequency of the tooth brushing
was high among the non diabetic patients (22),
while the result showed there were no association
regarding to the cleaning methods and also for the
J Bagh College Dentistry Vol. 24(special issue 1), 2012 The relationship between
Orthodontics, Pedodontics, and Preventive Dentistry111
regular dental visits between the non diabetic and
diabetic group this results disagreed with other
study which was found the use of dental floss and
dental visits are better among the non diabetic
group(23), other result showed the diabetics were
somewhat less likely to visit their dentists for
routine examination(24) the possible explanation,
apart from their medical status, was a lack of
dental health education among the diabetic group.
Regarding to the tobacco use the result showed
there was high difference in the distribution of
smoking in the diabetic group than control this
result disagreed with Moore et al. study which
was found that tobacco use in diabetic subjects
and oral health behavior were similar to those of
non-diabetic subjects. (25).
Regarding to the blood glucose level the
values of FBGL and RBGL were higher among
diabetics than non-diabetic subjects. It is well-
established that poor glycemic control among the
diabetic patient than non diabetic patients(22). In
this study, it was observed the severity of dental
caries increased with the increase in the blood
glucose level with positive correlation. This
finding is an indicator of the need for improving
oral health status among diabetic patients. This
may be attributed to elevated salivary glucose
levels and xerostomia may predispose this
population to caries because of lack of insulin or
insulin resistance, as seen in DM, results in an
inability of insulin-dependent cells to use blood
glucose as an energy source and an elevation in
blood ketones leads to diabetic ketoacidosis. As
blood glucose levels become elevated
(hyperglycemia), glucose is excreted in the urine
and increased fluid loss leads to dehydration and
excessive thirst (21, 26) . As a part of the oral
manifestations of diabetes, some authors reported
changes in the salivary gland, such as increase in
size, with alteration of its histology and changes
in salivary flow rate and in the composition(18).
Salivary buffering capacity is an important
parameter for the maintenance of normal pH
levels in saliva and plaque. With decrease the
salivary flow rate there is increased in dental
caries because the deficient in the salivary flow
rate which is high important in clearing the
cariogenic food from the mouth and neutralizing
effect (27).
Regarding to the effect of the duration of the
disease on caries experience the results showed
that there was no correlation between DMFT teeth
and the duration of the disease this results agreed
with some studies who considered that there was
no relationship between the diabetes duration and
caries experience (6,7) and disagreed with other
study which reported greater experience in
subjects with a longer duration (8). In the
comparison of caries experiences among the
diabetic patients according to the degree of the
control showed that there was non significant
difference between them this result agreed with
several studies that found there were no
associations between the metabolic control of
disease and dental caries in the studies groups
(6,8,11,12), and disagreed with other study that was
found the risk of dental caries was increased
among poorly controlled patients than well-
controlled DM and non diabetic control subjects
(28).
The present study confirmed that the presence
of dental caries was not significantly elevated in
most diabetic patients, but suggested that it
increased with age as well as with the increase of
the blood glucose level. Furthermore the diabetic
patients should be improving the general and oral
health behaviors.
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Table 1: The distibution of the diabetic and control subjects according to the age and gender
Patient
condition Age
( years) No. % Gender No. %
Diabetic
patient
40-50 60 33.3% Males 76 42.2%
51-60 60 33.3% Females 104 57.8%
61-70 60 33.3%
Total 180 100% Total 180 100%
Non
diabetic
patients
(Control)
40-50 60 33.3% Males 70 38.9%
51-60 60 33.3% Females 110 61.1%
61-70 60 33.3 %
Total 180 100 % Total 180 100%
Table 2: The mean value of the dental caries among diabetic and non-diabetic patients
Caries
experience Patient
condition No. Min. Max. Mean ± SD t - test
DT Diabetic 180 0 11 2.11 1.46 NS
Control 180 0 7 1.93 1.63
MT Diabetic 180 0 32 10.84 7.27 2.32 *
Control 180 0 28 9.17 6.32
FT Diabetic 180 0 6 1.03 1.37 2.843 *
Control 180 0 7 1.47 1.56
DMFT Diabetic 180 2 34 14.04 7.06 NS
Control 180 1 28 12.65 8.22
* Significant, P< 0.05
** Highly significant, P< 0.01
Table 3: Correlation between the DMFT and age among diabetic and control groups
Patient condition r-value P-value Significance
Diabetic 0.531 0.000 Highly significance
Control 0.482 0.000 Highly significance
J Bagh College Dentistry Vol. 24(special issue 1), 2012 The relationship between
Orthodontics, Pedodontics, and Preventive Dentistry113
Table 4: Oral health behavior among diabetic and non diabetic patients
Variables Diabetic patients Non diabetic (control) P -value
No. % No. %
Tooth brushing frequency
X² = 14.79**
P = 0.005
df = 4
NON 72 40 46 26
1/ day 43 24 48 27
2/ day 23 13 44 24
3/ day 6 3.3 2 1.1
irregular 36 20 40 22
Oral cleaning methods
X² = 4.711
P = 0.09 NS
df = 2
Brush 87 48 80 44
Brush + floss 21 12 36 20
No 72 40 64 36
Regular dental visit
X² = 0.93
P = 0.062 NS
df = 2
Yes 15 8.3 20 11
No 79 44 80 44
Sometimes 86 48 80 44
Smoking
X² = 12.33**
P = 0.000
df = 1
Yes 43 24 18 10
No 137 76 162 90
** Highly significant, P< 0.01
Table 5: Mean of the blood glucose level among diabetic and non diabetic patients
Blood glucose
level Patient
condition No. Mean ± SD t- test
FASTING BLOOD
GLUCOSE LEVEL Diabetic 180 171.26 48.23 22.495**
Control 180 88.14 11.46
RANDOM BLOOD
GLUCOSE LEVEL Diabetic 180 265.75 70.93 26.251**
Control 180 123.31 16.37
** Highly significant, P< 0.01, df = 358
Table 6: Correlation between the DMFT and fasting blood level, random blood glucose level,
duration of the disease among diabetic groups
Patient Variable r-value p-value Significance
Fasting blood glucose level 0.198 0.008 Highly significance
Random blood glucose level 0.186 0.024 Significance
Duration of the disease 0.079 0.293 Non significance
Table 7: Medical characteristic of the diabetic group
Variables Diabetic patients z-test p-value
No. %
Disease duration ( years)
< 5 years 102 56.7 2.462 0.048*
5 – 10 years 56 31.1 2.147 0.049*
> 10 years 22 12.2
Physician follow up
< 3 month 78 43.3 4.985 0.028*
3 month- 1 year 28 15.6 4.023 0.031*
> 1 year 74 41.1
Degree of the control of the
diabetic state
Well controlled 119 66.1 3.024 0.044*
Poor controlled 61 33.9
* Significant, P< 0.05
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Table 8: Comparison between the DMFT of the well diabetes control and poor diabetes control
Patient condition No. Min. Max. Mean ± SD t-test
Well Diabetic Control 119 2 34 13.92 7.74 NS
Poor Diabetic Control 61 6 28 14.28 5.59
Figure 1: Distribution of the dental caries according to the age among diabetic and non diabetic
patients
Figure 2: The relation between the blood glucose level ad dental caries among diabetic patient
Figure 3: The relation between the dental caries and the duration of the diseases in diabetic
patient
0
2
4
6
8
10
12
14
16
18
40-50 51-60 61-70
Age (years)
DMFT
DMFT of diabetic DMFT Non diabetic
0
50
100
150
200
250
300
350
400
0-5 6−10 11−15 16-20 21-25 26-30 31-35
DMFT
Blood glucose level
FBGL RBGL
11.61
14.36
18.73
0
2
4
6
8
10
12
14
16
18
20
< 5 years 5-10 years > 10 years
duration of the disease
DMFT
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