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Non-Periodontal Oral Manifestations of Diabetes: a Framework for Medical Care Providers

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Non-Periodontal Oral Manifestations of Diabetes: a Framework for Medical Care Providers In Brief In addition to periodontitis and dental caries, other oral conditions commonly FROM RESEARCH TO PRACTICE / ORAL HEALTH AND DIABETES occur commonly in patients with diabetes. These include fungal infections, salivary gland dysfunction, neuropathy, and mucosal disorders. Many of these lesions can be easily examined and documented by non-dental providers. Non-Periodontal Oral Manifestations of Diabetes: A Framework for Medical Care Providers Evidence that diabetes significantly who are responsible for diagnosing affects oral tissues is supported by and managing patients with diabetes data in an increasing number of pub- Beatrice K. Gandara, DDS, MSD, and pregnant patients can also easily lications. Diabetes causes changes in and Thomas H. Morton Jr., DDS, screen for these oral abnormalities. the periodontal tissues, oral mucosa, MSD Changes in oral soft tissues, in addi- salivary gland function, and oral neu- tion to periodontal tissues, can be ral function and increases the risk for helpful in the diagnosis of diabetes in caries.1–5 Additionally, reproductive undiagnosed patients and may serve as hormone changes during pregnancy aids in monitoring the care of patients significantly affect periodontal with known diabetes.7 health in women with pre-existing The goals of this article are 1) and gestational diabetes.6 These oral to describe soft-tissue disorders in manifestations, their mechanisms, and the oral cavity that are commonly their interrelationships are shown in observed in diabetes and can be easily Figure 1. recognized by all health care providers Although dental care providers either by history or clinical appear- have traditionally played a primary ance, and 2) to provide a checklist to role in the examination and diagno- facilitate oral examination for these sis of the specific disorders of these conditions that may also serve as a tool tissues, other health care providers for communication between medical Figure 1. Oral manifestations of diabetes and their mechanisms and interrelationships. Diabetes Spectrum Volume 24, Number 4, 2011 199 and dental providers. The checklist Low salivary flow rates are sig- can also assist providers in informing Root caries nificant because saliva provides a patients that further oral health evalu- protective coating for the oral mucosa ation and care are indicated. that contains antimicrobial proteins The oral tissues most commonly Calculus and immunoglobulins, buffers acidic affected by diabetes are the peri- Gingival foods and liquids, and contains cal- recession odontal tissues. This can appear as Spacing between teeth cium, which is important for mineral redness and swelling of the gingiva, exchange at the tooth surface.9 Lack of bleeding from the gingiva with minor adequate saliva leads to an increased provocation, looseness and spacing of risk of oral yeast infections, increased teeth, and exposed root surfaces (at Figure 2. Periodontal disease. caries rate, and difficulty with main- risk for caries) that may or may not taining oral hygiene, as well as a carry plaque and mineralized depos- sialoadenosis or noninflammatory, decrease in quality of life because of its (calculus), depending on the oral non-neoplastic enlargement of the discomfort from eating, swallowing, hygiene of the individual (Figure 2).5 parotid salivary glands,13–15 decreased and talking.29 The significance of occurrence and salivary flow rates,16,17 and changes Validated signs and symptoms pathogenic role of periodontitis in dia- in salivary composition.18–20 Bilateral of an abnormally low salivary flow betes are described elsewhere in this enlargement of the parotid salivary rate have been described in the litera- issue (p. 195) and in the scientific lit- glands has been reported to occur in ture.30,31 These signs and symptoms erature.8 The focus of this article will 10–48% of diabetic patients21,22 and (Figure 3) can facilitate the detection be on describing changes in the oral may be more common in patients with of impaired salivary function by health tissues of diabetic patients that include poorly controlled diabetes.23 care professionals and support refer- salivary gland dysfunction, mucosal The enlargements are caused by ral to a dental health care provider changes, and neuropathy. gradual accumulation of fat in the to manage or provide preventive or glands, hypertrophy of the acini intervention care for these conditions. Healthy Oral Mucosa or secreting units, and, eventually, The oral mucosa is normally pro- impaired glandular secretion. These Mucosal Disorders tected by saliva when it is adequate in structural changes may be the result Disorders of the oral mucosa com- amount and quality. Saliva provides of alteration in autonomic neuroregu- monly occurring in diabetic patients lubrication, cleansing, pH buffer- lation of the glands and atrophy of include atrophy of the mucosa, can- ing, antimicrobial proteins such as the myoepithelial cells that facilitate didiasis (thrush), and lichen planus secretory IgA, and aggregation and secretion.24 Enlarged parotid glands or lichenoid mucositis.1–3,12 These dis- clearance of bacteria.9 The epithe- are also observed in individuals with orders are related to chronic salivary lium and minor salivary glands in the a history of alcoholism, malnutrition, hypofunction and to the generalized mucosa contribute to innate immu- eating disorders, or medication side immune dysfunction seen in diabetic nity via α- and β-defensins, histatin, effects, and these conditions should patients. and other antimicrobial peptides and be included in a differential diagno- proteins.10 These two major features sis. However, the pathophysiology of Tongue Abnormalities affect the ability of the oral soft tissues these conditions is different.13,25 After periodontal tissues, the oral site to be resilient when challenged by inju- Xerostomia, or the sensation of most frequently affected in diabetes is rious microbes; excessive exposure to dry mouth, is reported to occur in the mucosa of the tongue. Normally, mechanical trauma, which can occur 40–80% of diabetic patients and is the dorsal surface of the tongue has an if there are jagged edges of broken related to decreased salivary flow even distribution of the filiform and teeth, defective dental restorations, or rates, particularly in unstimulated fungiform papilla, giving a textured poorly fitting dentures; or chemical whole saliva (the combination of secre- appearance that is light pink in color. trauma such as that caused by tobacco tions from all the salivary glands in The ventral and lateral surfaces of and excessive alcohol use. The health the mouth).4,17,21 Flow rates have been the normal tongue are smooth, free of the oral mucosa is also maintained reported to be significantly lower in of papilla, and darker pink in color, by good nutritional status11 and ade- patients with poorly controlled diabe- occasionally with prominent veins. In quate oral hygiene practices. tes4,16,17 compared to patients whose a fissured tongue, the smooth texture Because salivary gland function diabetes is controlled or nondiabetic of the dorsum is interrupted with one and immune function are negatively patients. or more fissures that are predomi- affected by diabetes, diabetic patients The mechanism by which salivary nantly aligned along the length of the are at increased risk for mucosal flow is affected in diabetic patients is tongue (Figure 4). lesions and other disorders. This thought to be the result of autonomic This fissuring may be the result has been supported by recent studies nerve dysfunction or microvascular of a chronic low salivary flow rate, showing that oral soft-tissue disease changes that diminish the ability of which alters the environment in the occurs up to 10 times more frequently the salivary glands to respond to neu- oral cavity such that slow-healing in patients with diabetes than in non- ral or hormonal stimulation.26,27 Other soft tissues are more easily trauma- diabetic patients.1–3,12 causes may include dehydration or side tized than in nondiabetic patients.2 A effects of concomitant drug therapy recent study2 of 405 diabetic individu- Salivary Gland Changes commonly used in diabetic patients als showed that 5.4% of patients with The oral manifestations of diabe- (e.g., antihypertensives, diuretics, and type 1 diabetes had fissuring of the tes in the salivary glands include antidepressants).4,22,28 tongue dorsum compared with 0.4% 200 Diabetes Spectrum Volume 24, Number 4, 2011 Diabetes and Oral Health Checklist for Non-Dental Providers FROM RESEARCH TO PRACTICE / ORAL HEALTH AND DIABETES Date of Last Dental Visit _______________ Questions and Signs for Oral Dryness or Neuropathy Do you have trouble swallowing food? Yes No Do you have trouble chewing? Yes No Do you need liquid to help swallow food? Yes No Do you feel you have an adequate amount of saliva? Yes No Do you have a burning sensation of tongue, lips, or palate? Yes No Signs of Salivary Hyposecretion: Wooden tongue blade sticks to oral mucosa Yes No Lack of pooling of saliva under the tongue Yes No Enlargement of parotid glands Yes No Oral Mucosal Changes Tongue: Fissured tongue Yes No Atrophic (“bald”) tongue surface Yes No Median rhomboid glossitis (midline posterior “bald” spot) Yes No Benign migratory glossitis (patchy, irregular, well-demarcated Yes No “bald” areas on tongue) Palate (for edentulous denture wearers—possible candidiasis): Redness of mucosa under upper denture Yes No Swollen appearance of
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