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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 29  |  Issue : 4  |  Page : 259-262

Salivary Glucose and Oral Mucosal Alterations in Type II Diabetic Mellitus Patients


Department of Oral Medicine and Radiology, CKS Teja Institute of Dental Sciences and Research, Tirupathi, Andhra Pradesh, India

Date of Submission31-Oct-2016
Date of Acceptance10-Jan-2018
Date of Web Publication15-Feb-2018

Correspondence Address:
Sameeulla Shaik
Department of Oral Medicine and Radiology, CKS Teja Institute of Dental Sciences and Research, Tirupathi, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.JIAOMR_132_16

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   Abstract 

Aim: The study was undertaken: 1) To assess salivary glucose (SaG) levels in diabetic and nondiabetic subjects and to determine if saliva could be used as a noninvasive tool to diagnose and monitor Type II diabetes mellitus. 2) Correlation of SaG levels with serum glucose (SeG) levels in nondiabetic and diabetic patients. 3) To correlate the oral manifestations of diabetes mellitus with serum and SaG levels. Material and Methods: Both fasting and postprandial serum and SaG levels were analyzed from 70 Type II diabetic and 70 nondiabetic subjects. The detailed examination of oral cavity in relation to periodontal and dental status and subjective oral complaints were recorded. The obtained values were subjected to statistical analysis. Results: The mean fasting salivary glucose (FSaG) was 5.469 + 2.347 mg/dL and 7.634 + 4.468 mg/dL in nondiabetic and diabetics, respectively (P = 0.000) and postprandial salivary glucose (PSaG) was 6.434 + 2.111 mg/dL and 8.736 + 4.962 mg/dL in nondiabetic and diabetics, respectively (P = 0.000). The positive correlation was found between SeG levels and SaG in diabetics (P = 0.000). Strong positive correlation was observed between SeG and SaG with oral manifestations in Type II diabetic patients (P < 0.05). Conclusion: Saliva can be a useful tool in regular monitoring of “already diagnosed Type II diabetics” (by their SeG levels) rather than diagnosing subjects with “unknown status of diabetes mellitus.” Strong positive correlation exists between SeG level and SaG level with oral manifestations in Type II diabetic patients.

Keywords: Diabetes, glucose, saliva, serum


How to cite this article:
Shaik S, Jayam R, Bokkasam V, Dirasantchu S, Venkata SS, Praveen S. Salivary Glucose and Oral Mucosal Alterations in Type II Diabetic Mellitus Patients. J Indian Acad Oral Med Radiol 2017;29:259-62

How to cite this URL:
Shaik S, Jayam R, Bokkasam V, Dirasantchu S, Venkata SS, Praveen S. Salivary Glucose and Oral Mucosal Alterations in Type II Diabetic Mellitus Patients. J Indian Acad Oral Med Radiol [serial online] 2017 [cited 2018 Dec 12];29:259-62. Available from: http://www.jiaomr.in/text.asp?2017/29/4/259/225468




   Introduction Top


India is likely to face the epidemic of diabetes mellitus in elderly population.[1] Oral physicians are liable to come in contact with significant number of patients with diabetes mellitus owing to the plethora of oral manifestations that are seen in diabetes mellitus. The global prevalence of diabetes is 6.4% in adult population. Owing to lack of sufficient diagnosis and treatment, diabetes is a major cause of death worldwide. More than half of the diabetics remain undiagnosed especially the patients with Type II diabetes. Without timely diagnosis, complications and morbidity from diabetes rise exponentially.[1]

Currently, a diagnosis of diabetes mellitus is achieved only by analyzing blood glucose levels (random, fasting, postprandial, etc.)[2] which are invasive methods that are physically and psychologically traumatic to the patient, which may discourage the individuals from the investigation. Therefore, a noninvasive, simple, and painless procedure, such as salivary glucose (SaG) estimation, is very desirable.

Saliva is an organic fluid secreted by salivary glands. Saliva can indicate local and systemic alterations, such that the components of saliva can be related to the hormonal, immunologic, neurologic, nutritional, and metabolic state of the individual.[3] Glucose is a small molecule that easily diffuses through semipermeable membranes. Thus, large amounts of glucose become available to saliva when blood glucose levels are elevated, as in diabetes. Alterations in the permeability, occurring as a result of basement membrane changes in diabetes, may be an additional explanation for the increased concentration of glucose in saliva.[4]

Considering the increased incidence of diabetes mellitus worldwide and limited amount of studies carried out, we proposed to conduct a comparative analysis of the considerations of SaG and serum glucose (SeG) on Type II diabetes mellitus patients. The following study explores the possibility of using saliva to reflect the glucose concentration in blood by measuring SaG levels, thereby making measurement of glucose noninvasive and to check whether the levels of SeG and SaG have any effect on oral tissues.


   Materials and Methods Top


The present collaborative study was conducted in the department of Oral Medicine and Radiology, CKS Teja Dental College and Hospital and RIA Research Laboratory, Tirupathi. Both fasting and postprandial serum and saliva were collected from 70 Type II diabetic and 70 nondiabetic subjects for measuring glucose levels. The detailed examination of oral cavity in relation to periodontal, dental status, and subjective oral complaints were recorded.

Inclusion criteria

  1. Healthy control subjects: Nondiabetic with SeG levels within normal limits
  2. Diabetic subjects as per the criteria established by expert committee on diagnosis and classification of diabetes mellitus in 1980.


Exclusion criteria

  1. Patients with any other systemic disease
  2. Patients with habit of tobacco, alcohol, and smoking.


Saliva collection

The patients were given detailed information about the collection protocol. The saliva collection was standardized as far as possible. In this study, the unstimulated whole saliva was taken for the estimation of SaG as with stimulation there are alteration in the salivary composition, hence the diagnostic possibility lies more with unstimulated saliva than stimulated saliva.[5] They were instructed to exclude brushing teeth before the collection and to avoid food and fluid (apart from water) ingestion or chewing gum for at least 30 min before collection and to rinse the mouth with water. The saliva was collected in clean sterile containers by spitting method.

Glucose estimation

In the present study, serum and SaG levels were analyzed by glucose oxidase end point assay. Glucose oxidase is an enzyme extracted from the growth medium of Aspergillus niger. Glucose oxidase catalyze the oxidation of beta-D-glucose present in the plasma to d-glucono--1,5-lactone with the formation of hydrogen peroxide; the lactone is then slowly hydrolyzed to D-gluconic acid. The hydrogen peroxide produced is then broken down to oxygen and water by a peroxidase enzyme. Oxygen then reacts with an oxygen acceptor such as ortho-toluidine which itself gets converted to a colored compound, the amount of which can be measured colorimetrically.

Statistical analysis

The data was entered separately for diabetic and nondiabetic individuals, tabulated, and subjected to statistical analysis by using SPSS software. The mean, standard deviation, and P value were assessed by applying student T-test and Pearson correlation for blood glucose levels in fasting and postprandial state with SaG levels in fasting and postprandial state. For correlation of oral manifestations with salivary and serum glucose levels Mann–Whitney U-test and nonparametric tests were used.


   Results Top


The diabetic subjects were further categorized based on their fasting serum glucose (FSeG) and fasting salivary glucose (FSaG) for comparison with oral manifestations. Subjects with FSeG ranging from 126 mg/dL to 200 mg/dL were grouped as FSeG Group I, and with FSeG above 200 mg/dL were grouped as FSeG Group II. Subjects with FSaG ranging from 0 mg/dL to 7 mg/dL were grouped as FSaG Group I, and with FSaG above 7 mg/dL were grouped as FSaG Group II. The results of the present study are given in [Table 1], [Table 2], [Table 3].
Table 1: Comparison of salivary glucose levels in nondiabetic and diabetic patients

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Table 2: Correlation of salivary glucose levels with serum glucose levels in nondiabetic patients and diabetic patients

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Table 3: Correlation of oral manifestations with fasting serum glucose levels and fasting salivary glucose levels in diabetic patients

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   Discussion Top


Saliva is a clinically informative, biological fluid (bio-fluid) that is useful for novel approaches to diagnosis, monitoring, management, and prognosis of patients with oral and systemic diseases. The determination of SaG levels and its clinical significance has been debated for years. The findings of the present study reveal that the SaG levels (fasting and postprandial) is significantly higher (P = 0.000) in diabetics compared to nondiabetic subjects, which could be attributed to various following reasons.

Diabetes alters the constitution and flow of saliva. The increase, though, is neither significant nor consistent, biologically, it could be anticipated that SaG levels in diabetics are higher than those in nondiabetics. The serum constituents in saliva are derived from the local vasculature of the salivary glands as well as from gingival fluid. The increased SaG evident in the whole saliva can be due to several contributing factors or it could be a simple reflection of the blood glucose levels since saliva is an ultra-filtrate of plasma. The salivary analytes are derived from plasma generally by three mechanisms (passive diffusion, active transport, and ultrafiltration) and are thus found in saliva.[6]

Further, glucose being a small molecule diffuses easily through the semi-permeable membranes. This explains presence of glucose in saliva. In diabetics, large amounts of glucose become available to salivary glands. Alterations in the permeability, occurring as a result of basement membrane changes in diabetes, could be an additional explanation for increased concentrations of glucose in saliva.[7] Additionally, the elevated SaG levels in diabetics could be due to altered micro-circulation, autonomic neuropathy, or direct changes in the salivary glands such as damaged basement membranes. Longer duration of diabetes may result in irreversible damage to the basement membrane of salivary glands, which may probably explain higher SaG value in diabetics under treatment than in newly diagnosed diabetics.[8]

Though the difference in mean SaG levels (fasting and postprandial) of diabetics and nondiabetics was statistically significant, there was considerable overlap of the range of values between the two groups. Moreover, the mean fasting SaG levels in diabetics of the present study [Table 1] differed widely with the previous studies conducted by Darwazeh et al. (0.76 mg/dL);[9] Lopez ME et al. (2.05 + 1.63 mg/dL);[10] BalanP et al. (4.95 mg/dL);[11] Indira M et al. (8.45 + 4.59 mg/dL);[12] Bakianian et al. (18.67 + 16.54 mg/dL).[13] However, the mean fasting SaG levels in nondiabetics, postprandial SaG levels in diabetics, and nondiabetics in the present study was in agreement with the previous literature.

This shows that there is wide variation of mean fasting SaG values reported in literature. Added to this, the superimposed range of values between diabetics and nondiabetics makes the diagnosis of “diabetes mellitus” a difficult task solely based on SaG levels. Correlation of SaG levels with serum glucose levels in diabetic and nondiabetics was done in the present study. There was no positive correlation obtained between salivary and serum glucose levels in nondiabetics. However, there was a strong positive correlation (statistically significant, [Table 2]) observed in diabetics (both fasting and postprandial), which indicated that as the serum glucose levels are elevated there is a corresponding elevation in SaG levels, which implicates that saliva can be a useful tool in regular monitoring of “diabetes mellitus.”

In the present study, we also correlated the oral manifestations with fasting serum and SaG levels in diabetic patients. A strong positive correlation (statistically significant; [Table 3]) was observed which implicated that as the serum and SaG values raised, there are higher chances of diabetics suffering from the oral manifestations (except for lichen planus and candidiasis in the present study). Furthermore, these findings also consolidate the fact that the patients with poor glycemic control (FSeG >200 mg/dL; fasting SaG >7 mg/dL) have greater incidence of oral manifestations in diabetes mellitus patients.


   Conclusion Top


Saliva can be a useful tool in regular monitoring of “already diagnosed Type II diabetics” (by their serum glucose levels) rather than diagnosing subjects with “unknown status of diabetes mellitus.” Strong positive correlation exists between serum and SaG levels with oral manifestations in Type II diabetic patients.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Diamond J. Medicine: Diabetes in India. Nature 2011;469:478-9.  Back to cited text no. 1
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2.
Manfredi M, McCullough MJ, Vescovi P, Al-Kaarawi ZM, Porter SR. Update on diabetes mellitus and related oral diseases. Oral Dis 2004;10:187-200.  Back to cited text no. 2
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Kaufman E, Lamster IB. The diagnostic applications of saliva-- A review. Crit Rev Oral Biol Med 2002;13:197-212.  Back to cited text no. 3
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Kjellman O. The presence of glucose in gingival exudate and resting saliva of subjects with insulin-treated diabetes mellitus. Sven Tandlak Tidskr 1970;63:11-9.  Back to cited text no. 4
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Harrison R, Bowen WH. Flow rate and organic constituents of whole saliva in insulin-dependent diabetic children and adolescents. Pediatr Dent 1987;9:287-91.  Back to cited text no. 5
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Aydin S. A comparison of ghrelin, glucose, alpha-amylase and protein levels in saliva from diabetics. J Biochem Mol Biol 2007;40:29-35.  Back to cited text no. 6
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7.
Goodson JM. Gingival crevice fluid flow. Periodontol 2003;31:43-54.  Back to cited text no. 7
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8.
Ben-Aryeh H, Cohen M, Kanter Y, Szargel R, Laufer D. Salivary composition in diabetic patients. J Diabet Complications 1988;2:96-9.  Back to cited text no. 8
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9.
Darwazeh AM, MacFarlane TW, McCuish A, Lamey PJ. Mixed salivary glucose levels and candidal carriage in patients with diabetes mellitus. J Oral Pathol Med 1991;20:280-3.  Back to cited text no. 9
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10.
Lopez ME, Colloca ME, Paez RG, Schallmach JN, Koss MA, Chervonagura A. Salivary characteristics of diabetic children. Braz Dent J 2003;14:26-31.  Back to cited text no. 10
    
11.
Balan P, Babu SG, Sucheta KN, Shetty SR, Rangare AL, Castelino RL, et al. Can saliva offer an advantage in monitoring of diabetes mellitus? - A case control study. J Clin Exp Dent 2014;6:e335-8.  Back to cited text no. 11
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Indira M, Chandrasherker P, Kattappagari KK, Chandra LK, Chitturi RT, Bv RR. Evaluation of salivary glucose, amylase, and total protein in Type 2 diabetes mellitus patients. Indian J Dent Res 2015;26:271-5.  Back to cited text no. 12
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13.
Bakianian Vaziri P, Vahedi M, Mortazavi H, Abdollahzadeh SH, Hajilooi M. Evaluation of salivary glucose, IgA and flow rate in diabetic patients: A case-control study. J Dent (Tehran) 2010;7:13-8.  Back to cited text no. 13
[PUBMED]    



 
 
    Tables

  [Table 1], [Table 2], [Table 3]



 

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