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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 30  |  Issue : 4  |  Page : 372-375

Study of salivary flow rate in type II diabetics: A case–control study


1 Department of Oral Medicine, Modern Dental College, Indore, Madhya Pradesh, India
2 Department of Oral Medicine, Darshan Dental College, Udaipur, Rajasthan, India
3 Department of Prosthodontics, Modern Dental College, Indore, Madhya Pradesh, India
4 Department of Periodontics, Govt. Dental College and Hospital, Jaipur, Rajasthan, India

Date of Submission21-Sep-2018
Date of Acceptance14-Oct-2018
Date of Web Publication17-Jan-2019

Correspondence Address:
Dr. Arpita Srivastava
301-Konark Apartment, 16/2 Manoramaganj, Geetabhavan, Indore, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_159_18

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   Abstract 


Context: Diabetes mellitus is one of the most common chronic metabolic disorders, which may cause irreversible complications. It affects the salivary glands and thereby affects oral health. Among physical and chemical alterations, changes in the salivary flow rate are particularly important. Hyposalivation is one of the main problems caused due to altered flow rate of stimulated and unstimulated whole saliva in type II diabetic patients. Aim: The aim of this study was to measure the salivary flow rate in type II diabetic patients and to compare with healthy sex- and age-matched controls. Materials and Methods: Whole unstimulated and stimulated saliva was collected from 30 patients with type II diabetes and 30 healthy controls, using the spitting method after it had been pooled for 5 min in the oral cavity. Statistical Analysis: Results were subjected to statistical analysis using Student's t-test and Chi-square test. Results: The results of the study suggested that diabetic patients had significant reduction in salivary flow rate when compared with healthy individuals. Conclusion: The salivary flow rate decreases in patients with diabetes type II in comparison to healthy individuals. Further investigations with larger sample sizes are needed to substantiate the findings of this study.

Keywords: Hyposalivation, salivary flow rate, type II diabetics


How to cite this article:
Srivastava A, Padmavathi B N, Shrivastava R, Srivastava R, Mathur S. Study of salivary flow rate in type II diabetics: A case–control study. J Indian Acad Oral Med Radiol 2018;30:372-5

How to cite this URL:
Srivastava A, Padmavathi B N, Shrivastava R, Srivastava R, Mathur S. Study of salivary flow rate in type II diabetics: A case–control study. J Indian Acad Oral Med Radiol [serial online] 2018 [cited 2019 Jun 26];30:372-5. Available from: http://www.jiaomr.in/text.asp?2018/30/4/372/250253




   Introduction Top


Type II diabetes is an endocrine disease which also affects the oral cavity, and the most common alteration, at a stomatologic level, includes periodontal diseases, caries, candidiasis, commissural cheilitis, and sialomegaly which are linked to xerostomia and glandular hypofunction which have inverse correlation with each other.[1]

Negative effects of diabetes mellitus on sympathetic and parasympathetic nervous system, microangiopathy, dehydration, and hormonal changes may cause discrepancies in the salivary flow rate with marked salivary hypofunction, altering the unstimulated whole saliva flow rates of <0.1 mL/min and stimulated whole saliva flow rates of <1.0 mL/min.[2],[3]

This study evaluates changes in whole salivary flow rates in type II diabetics and correlates it to blood glucose levels.

Aims and Objectives

The aims and objectives of the study were to measure the flow rate of unstimulated and stimulated whole saliva in type II Diabetics and control group, to compare salivary flow rates in type II diabetics and healthy individuals, and also to correlate salivary flow rates and blood glucose levels in type II diabetics.


   Materials and Methods Top


Study design

The sample size of a total of 60 patients was calculated based on the power of the study, which was 80%, and the alpha level used in the study in determining the sample size was 0.05. Hence, 30 patients with type II diabetes mellitus and 30 healthy controls were included in the study in the age range of 30–95 years. The inclusion criteria were type II diabetic patients and healthy individuals who were willing to participate in this study. Those included in the control group were healthy individuals who had normal fasting blood glucose and their age and sex matched the type II diabetic patient group. They had no systemic disease or condition and had not used any medication in the past 6 months. The exclusion criteria used for both the groups were use of alcohol, smoking, pregnancy, history of radiotherapy, psychiatric disorder, and presence of any oral mucosal lesion. All the participants of the study were asked to avoid eating, drinking, and brushing 1 h before collecting saliva.

Methodology

  • Dental examination and oral health status were recorded in all 60 participants including the random blood sugar assessment (according to the American Diabetes Association) with handheld easy touch glucometer (Accu-Chek Active, Roche Diagnostics, Switzerland) [Figure 1]
  • All the participants answered the questionnaire regarding oral dryness; the questions were modified from Fox et al. to assess the patient's feeling of mouth dryness which are as follows:


    1. Does your mouth feel dry when eating a meal? Yes/No
    2. Do you have difficulty swallowing dry foods? Yes/No
    3. Do you sip liquids to aid in swallowing dry foods? Yes/No
    4. Do you feel that the amount of saliva in your mouth is too little most of the time? Yes/No
    5. Does your mouth usually feel dry at night or when u first waken? Yes/No.
Figure 1: Glucometer for blood glucose estimation

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Whole unstimulated and stimulated saliva was collected using the spitting method after it had been pooled for 5 min in the oral cavity.[4],[5]

Collection of whole unstimulated saliva

  • Step I: For collection of whole unstimulated saliva, participants were instructed to rinse their oral cavity with plain water to remove any loose debris
  • Step II: Patient was instructed to pool saliva in oral cavity for 5 min
  • Step III: Saliva was collected by spitting method in a beaker
  • Step IV: 5 mL of saline was added to collected saliva
  • Step V: The saliva sample was transferred to a measuring cylinder and recorded [Figure 2].
Figure 2: Armamentarium for collection of stimulated and unstimulated saliva

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Collection of whole stimulated saliva

  • Step I: For collection of whole stimulated saliva, participants were instructed to rinse their oral cavity with plain water to remove any loose debris
  • Step II: A drop of lemon juice on the tip of the tongue was used as a stimulant [Figure 3]
  • Step II: The patient was instructed to pool saliva in oral cavity for 5 min
  • Step III: Saliva was collected by spitting method in a beaker [Figure 4]
  • Step IV: 5 mL of saline was added to the collected saliva.
  • Step V: The saliva sample was transferred to a measuring cylinder and recorded.[6]
Figure 3: Saliva stimulation using lemon

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Figure 4: Saliva collection in measuring cylinder

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   Results Top


This study consisted of 30 diabetics and 30 controls with a mean age of 54.73 ± 15.66 and 44.9 ± 13.1 years, respectively. Blood glucose levels and unstimulated and stimulated saliva of type II diabetics and healthy participants were measured and compared, and the results obtained were subjected to statistical analysis using Student's t-test and Chi-square test.


   Discussion Top


The focus of this study was the change in salivary flow rate in type II diabetic patients and whether the hyperglycemic state influences the salivary output. This study consisted of 30 type II diabetic patients who were on hypoglycemic drugs with a mean age of 54.73 ± 15.66 years. The control group consisted of healthy individuals with a mean age of 44.9 ± 13.1 years, respectively; in type II diabetic group, there were 17 males and 13 females and in control group there were 18 males and 12 females. When the blood sugar was assessed with glucometer in type II diabetics and control group subjects, there was significant difference between the random blood sugar values in control (106.35 ± 16.80) and diabetics (207.42 ± 81.38). It was more in diabetics in comparison to controls [Table 1], and a significant difference (P < 0.001) in blood sugar values between diabetics and controls was noticed in this study.
Table 1: Comparison of RBS between healthy and type II subjects

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A questionnaire regarding oral dryness was recorded in both type II diabetics in the study group and healthy individuals in the control group and an affirmative reply to one or more questions regarding the subjective experience of dry mouth to correlate the salivary gland function was given by type II diabetics and 0% controls. Seven (23.33%) subjects with type II diabetes presented with dryness of mouth while eating meal, 6 (20%) type II diabetics presented with difficulty in swallowing food, 13 (43.33%) diabetics presented with amount of saliva too little most of the time, and 3 (10%) presented with mouth feels dry at night.[7],[8],[9]

Studies have found salivary glands to be affected by this disease with relative defects in functions such as swallowing and speech. All participants underwent routine dental examination, and on examination of salivary glands, of 30 type II diabetics in the study group 13 (43.33%) subjects had inflamed duct opening, and subjects in control group did not have inflamed duct opening [Table 2]. The findings were similar with other studies.[10]
Table 2: Percentage of inflamed duct opening in diabetic and control

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A significant difference (P < 0.001) in whole unstimulated salivary flow rates between diabetics and controls was noticed in this study with a mean unstimulated salivary flow rate of 0.57 ± 0.46 mL/min in diabetics and 1.09 ± 0.70 mL/min in controls [Table 3]. A similar observation was seen in previous studies.[11],[12]
Table 3: Comparison of unstimulated saliva in healthy and type II diabetics

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A significant difference (P < 0.05) in whole stimulated salivary flow rates between diabetics and controls was noticed in this study with a mean stimulated salivary flow rate of 2.17 ± 0.91 mL/min in diabetics and 2.93 ± 1.29 mL/min in controls [Table 4]. A similar observation was seen in previous studies.[13],[14],[15]
Table 4: Comparison of stimulated saliva in healthy and type II diabetic

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The probable reasons for reduced salivary flow rate in type II diabetics as observed in this study are as follows:

Diabetic subjects are susceptible to dehydration associated with elevated blood glucose that might increase osmotic ingredients within the salivary glands, thereby limiting secretion.[16],[17]

Neuropathy is the most common complication in type II diabetes mellitus, affecting more than half of the patients with 10 years duration of the disease.

Salivary gland secretion is mainly under the autonomic nervous system, and it was observed in this study that autonomic neuropathies that diminish the ability of salivary glands to respond to a salivary stimulus or microvascular changes that compromise the ability of salivary glands to respond to neural or hormonal stimulation in diabetic patients could explain the significantly lower salivary flow rates in diabetics.

The other change in salivary gland in diabetics is sialosis which generally involves glandular hypertrophy, produced either by adipose infiltration or by acinar hypertrophy. There are authors who accept the coexistence of both modifications, while others deny such a possibility and the fact is that acinar hypertrophy is not always present in sialosis; as a consequence, some authors center their attention on the glandular dysfunction which is generally manifested as salivary hypofunction and xerostomia.[17]


   Conclusion Top


Hyposalivation and xerostomia were significantly higher in diabetic subjects with reduced unstimulated and stimulated salivary flow rates. Normal salivary functions are essential to the preservation of the integrity of teeth and oral soft tissues. Hence, in diabetic patients, proper care and management of xerostomia with general treatment strategies such as regular visits to dentist, maintaining good oral hygiene, avoiding sugar-containing food and liquids, avoiding caffeine, use of humidifier, and use of sugar-free salivary substitute and stimulants should be done.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Hoseini A, Mirzapour A, Bijani A, Shirzad A. Salivary flow rate and xerostomia in patients with type I and II diabetes mellitus. Electron Physician 2017;9:5244-9.  Back to cited text no. 1
    
2.
Carda C, Mosquera-Lloreda N, Salom L, Gomez de Ferraris ME, Peydró A. Structural and functional salivary disorders in Type II diabetic patients. Med Oral Patol Oral Cir Bucal 2006;11:E309-14.  Back to cited text no. 2
    
3.
Grisius MM, Fox PC. Salivary gland diseases. In: Greenberg MS, Glick M, editors. Burket's Oral Medicine: Diagnosis and Treatment. 10th ed. Hamilton, Canada: BC Decker, Inc.; 2003.  Back to cited text no. 3
    
4.
Engelen L, Tekamp AF, Bilt A. The influence of product and oral characteristics on swallowing. Arch Oral Biol 2005;50:739-46.  Back to cited text no. 4
    
5.
Lee SK, Lee SW, Chung SC, Kim YK, Kho HS. Analysis of residual saliva and minor salivary gland secretions in patients with dry mouth. Arch Oral Biol 2002;47:637-41.  Back to cited text no. 5
    
6.
Dawes C. Physiological factors affecting salivary flow rates, oral sugar clearance, and the sensation of dry mouth in man. J Dent Res 1987;66:648-53.  Back to cited text no. 6
    
7.
Carda C, Mosquera-Lloreda N, Salom L, Gomez de Ferraris ME, Peydró A. Structural and functional salivary disorders in Type II diabetic patients. Med Oral Patol Oral Cir Bucal 2006;11:E309-14.  Back to cited text no. 7
    
8.
Obradovic B, Cekic-Arambasin A. Oral manifestations in diabetes. Acta Stomatol Croat 1991;25:59-63.  Back to cited text no. 8
    
9.
Costa CC, Resende GB, Souza JM, Tavares SS, Almeida IC. Study of the oral manifestations in diabetic children and their correlation variables. Arq Bras Endocrinol Metabol 2004;48:374-8.  Back to cited text no. 9
    
10.
Ben-Aryeh H, Serouya R, Kanter Y, Szargel R, Laufer D. Oral health and salivary composition in diabetic patients. J Diabetes Complications 1993;7:57-62.  Back to cited text no. 10
    
11.
Chavez EM, Borrell LN, Taylor George W, Ship JA. A longitudinal analysis of salivary flow rate in control subjects and older adults with Type II diabetes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:166-73.  Back to cited text no. 11
    
12.
Dodds MW, Yeh CK, Johnson DA. Salivary alterations in Type II (non-insulin-dependent) diabetes mellitus and hypertension. Community Dent Oral Epidemiol 2000;28:373-81.  Back to cited text no. 12
    
13.
Chavez EM., Borrell LN., Taylor George W, Ship JA. A longitudinal analysis of salivary flow rate in control subjects and older adults with Type II diabetes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:166-73.  Back to cited text no. 13
    
14.
Dodds MW, Dodds AP. Effects of glycemic control on saliva flow rates and protein composition in non-insulin-dependent diabetes mellitus. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1997;83:465-70.  Back to cited text no. 14
    
15.
Chavez EM, Borrell LN, Taylor George W, Ship JA. A longitudinal analysis of salivary flow rate in control subjects and older adults with Type II diabetes. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:166-73.  Back to cited text no. 15
    
16.
Moore PA, Guggenheimer J, Etzel KR, Weynaut RJ, Orchard T. Type 1 diabetes mellitus, xerostomia, and salivary flow rates. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2001;91:281-91.  Back to cited text no. 16
    
17.
Carda C, Mosquera-Lloreda N, Salom L, Gomez de Ferraris ME, Peydró A. Structural and functional salivary disorders in Type II diabetic patients. Med Oral Patol Oral Cir Bucal 2006;11:E309-14.  Back to cited text no. 17
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]
 
 
    Tables

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



 

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