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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 30  |  Issue : 4  |  Page : 385-391

Oral manifestations in diabetic patients under treatment for ischemic heart diseases: A comparative observational study


1 Department of Oral Medicine and Radiology, St. Joseph Dental College, Eluru, Andhra Pradesh, India
2 Department of Oral Medicine and Radiology, Vishnu Dental College, Bhimavaram, West Godavari, Andhra Pradesh, India

Date of Submission17-Jul-2018
Date of Acceptance29-Nov-2018
Date of Web Publication17-Jan-2019

Correspondence Address:
Dr. Myla Swathi
Senior lecturer, Department of Oral Medicine and Radiology, St. Joseph Dental College, Eluru, West Godavari, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaomr.jiaomr_123_18

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   Abstract 


Objective: To assess the oral and dental manifestations in the nondiabetic and diabetic groups who were under treatment for ischemic heart disease (IHD) patients. Materials and Methods: A total of 167 IHD patients who were under treatment for IHDI s were considered for the study. After seeking permission from various hospitals in and around Bhimavaram, both inpatients and outpatients-files were screened-for presence of IHD from the available data. After selecting the study population, patients were checked for absence of diabetes and grouped accordingly. Subjective symptoms such as dry mouth, taste changes, and tongue or mucosal pain were evaluated and recorded as present or absent in the pre – prepared proform and dental assessment consisted of decayed, missing, filled, teeth (DMFT) index and Community Periodontal Index (CPI). Results: Subjective oral manifestations of dry mouth, taste changes, and tongue or mucosal pain showed statistically higher score in the diabetic group with a P value of <0.001. The overall DMFT index score was statistically higher in the diabetic group with a P value of <0.001. The overall CPI index score was statistically higher in the diabetic group with a P value of <0.001. Conclusion: From the study it is concluded that the subjects with IHD are at higher risk for developing periodontal disease, dry mouth, taste changes, and tongue or mucosal pain. The dental and periodontal health status of IHD patients in this study in the diabetic and nondiabetic groups is nearly comparable. Thus, oral health maintenance is of utmost importance in this diabetic group. It is recommended that subjects should be regularly examined by dentists for proper care.

Keywords: Diabetes, decayed, filled, ischemic heart disease, missing, periodontal disease, teeth index


How to cite this article:
Swathi M, Ramesh T, Reddy R S, Begum MR, Rajesh N, Reshmi T. Oral manifestations in diabetic patients under treatment for ischemic heart diseases: A comparative observational study. J Indian Acad Oral Med Radiol 2018;30:385-91

How to cite this URL:
Swathi M, Ramesh T, Reddy R S, Begum MR, Rajesh N, Reshmi T. Oral manifestations in diabetic patients under treatment for ischemic heart diseases: A comparative observational study. J Indian Acad Oral Med Radiol [serial online] 2018 [cited 2019 Jun 25];30:385-91. Available from: http://www.jiaomr.in/text.asp?2018/30/4/385/250245




   Introduction Top


“Mouth is a mirror of the body, which reflects the systemic disease”-Sir William Osler.

It is a well-known fact that most of the systemic diseases manifests in the oral cavity, and the ideal way of managing is to treat the primary cause at first and then the symptomatic therapy. Thus, any systemic disease can manifest its abnormality in oral cavity too. Out of all the systems, cardiovascular system is one of the key systems. Ischemic heart disease (IHD) is one of the most commonly encountered systemic diseases in dental practice in the general population.[1]

All the risk factors causing IHDs, diabetes and its predominant form, type 2 diabetes mellitus, have a distinctive association with congenital heart disease (CHD). The risk of coronary heart disease increases with age in persons with or without diabetes.[2]

Although the oral changes in the individuals with diseased condition, i.e., diabetes mellitus (DM) and IHD patients, have been examined, investigations on diabetic patients with IHD are limited. As the influence of co-existing medical condition, i.e., DM and IHD patients, on oral health requires an updated approach, a need arises to assess the oral health status of diabetic heart disease patients receiving treatment and also to assess whether there are any changes in oral manifestations of IHD patients when comparing diabetic and nondiabetics.


   Materials and Methods Top


Source of data

The study consisted of 167 patients who were under treatment for IHDs. Study populations were recruited from various private hospitals which are located in and around Bhimavaram, and were divided into two groups.

Group I: Nondiabetic patients with IHD

Group II: Diabetic patients with IHD.

The study protocol was approved by the Institutional Ethical Review Board [(IRB) Ref No: IRB/VDC/MDS14 OMR2] of Vishnu Dental College, Bhimavaram, Andhra Pradesh, India, before commencement of the study. The study was carried out within a period of 1 year 6 months.

All the subjects were explained about the observational study in local vernacular language and consent was taken.

Inclusion criteria

  • Nondiabetic patients with IHDs
  • Type 2 diabetic IHD patients with a history of at least 6 months of diabetes
  • IHD patients with first attack who were under treatment with or without diabetes.


Exclusion criteria

  • Patient who received radiation therapy for head and neck cancer
  • Patient on medications such as tricyclic antidepressants, anticholinergics and antihistamines
  • Patients with a diabetic history of <6 months.


Methods

Screening

After seeking permission from various hospitals in and around Bhimavaram, both inpatients and outpatients files were screened for the presence of IHDs from the available data. IHD was diagnosed and confirmed by the physician with the help of electrocardiogram, cardiac markers, and angiography. After selecting the study population, patients were checked for oral and dental manifestations. Patients were further screened for the presence and absence of diabetes and grouped accordingly.

Oral manifestations

The specific oral manifestations were classified into subjective and objective findings. The subjective findings that were included are dry mouth, taste change, tongue or mucosa burning sensation, and pain. To assess the subjective findings, each patient was asked questions regarding the symptoms and was recorded as present or absent in the preprepared proforma.

Dental manifestations

Dental health assessment consisted of two parts: DMFT index and Community Periodontal Index (CPI).

All the data, parameters, signs, and symptoms are recorded for each patient in a specifically modified World Health Organization proforma.

Thus the recorded data were converted to numerical data and subjected to statistical analysis. Statistical analysis had been carried out in the present study. The statistical software, Statistical Package for the Social Sciences (SPSS, version 20.0, SPAA Inc., Chicago, IL, USA), was used for analysis of data.

Chi-square test has been used to find out the significance of frequency distribution of study parameters between the non-diabetic and diabetic groups. Student's t-test has been used to find the significance of mean values of study parameters between the non diabetic and diabetic groups.

For all the tests, a P value of ≤0.05 was set for statistical significance and a value of ≤0.01 represents a highly significant relation.


   Results Top


In this study, 164 diabetic and nondiabetic IHD patients receiving treatment were included. Out of 164, 81 are non diabetic patients with IHD and 83 are diabetic patients with IHD.

Out of 164 subjects in this study, male patients were more in number in the nondiabetic and diabetic groups. Male patients were 45 in the nondiabetic group and 55 in the diabetic group Female patients were 36 in the nondiabetic and 28 in the diabetic group [Table 1] and [Graph 1].
Table 1: The nondiabetic and diabetic patients categorized according to gender (Chi-square test)

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Smoking, alcohol, tobacco/pan chewing were some of the common habits observed in both nondiabetic and diabetic IHD patients [Table 2] and [Graph 2]. Subjects with smoking habit in the nondiabetic and diabetic groups were 18 (38.3%) and 29 (61.7%) with a P value of 0.09. There was no statistical significance between both the groups. Subjects with alcohol habit in the nondiabetic and diabetic groups were 12 (32.4%) and 25 (67.6%) with a P value of 0.05, which shows statistical significance between both the groups. Subjects with pan or gutka chewing in the nondiabetic and diabetic groups were3 (33.3%) and 6 (66.7%), with a P value of 0.50 and there was no statistical significance between both the groups [Table 3].
Table 2: Comparison of deleterious habits among diabetic and nondiabetic IHD patients

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Table 3: Comparison of combination of deleterious habits among diabetic and nondiabetic groups with IHD

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Subjective symptoms considered in this study were dry mouth, taste, and tongue or mucosal pain. Subjects with dry mouth were 23 (28.4%) and 58 (71.6%) in the nondiabetic and diabetic groups with a P value of 0.01, which shows statistical significance between both the groups. Subjects with taste changes in the nondiabetic and diabetic groups were 10 (23.8%) and 32 (76.2%) with a P value of 0.01, which shows statistical significance between both the groups. Individuals with tongue or mucosal pain in the nondiabetic and diabetic groups were 3 (21.4%) and 11 (78.6%) with a P value of 0.05, which shows statistical significance between both the groups [Table 4] and [Graph 3].
Table 4: Comparison of subjective symptoms in both the groups

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When decayed, missing, filled, teeth (DMFT) index among the subjects were compared, the mean value of decayed teeth in the nondiabetic and diabetic groups were 2.93 and 2.53 with a standard deviation of 1.69 and 2.72, respectively; there was no significant difference with decayed teeth between the nondiabetic and diabetic groups, showing a P value of 0.27. The mean value of missing teeth in the nondiabetic and diabetic groups were 3.16 and 10.46 with a standard deviation of 5.01 and 12.99, respectively; there was statistically significant difference with missing teeth between the nondiabetic and diabetic groups, showing a P value of <0.01. The mean value of filled teeth in the nondiabetic and diabetic groups were 0.81 and 0.57 with a standard deviation of 1.39 and 1.03, respectively; there was no significant difference with filled teeth between the nondiabetic and diabetic groups with a P value of 1.93. There was no statistical significance with respect to decayed and filled teeth diabetic and nondiabetic patients [Table 5] and [Graph 4].
Table 5: Comparison of DMFT score between two groups

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The frequency distribution of DMFT score showed no difference among the different ranges of scores categorized as 1–10, 11–20, 21–30, and >30 between the nondiabetic and diabetic groups. Overall, the DMFT score was significantly higher in the diabetic group. But overall, the DMFT score showed high significance between the nondiabetic and diabetic groups [Table 6] and [Graph 5].
Table 6: Comparisons of frequency distribution of DMFT score between two groups

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Subjects with CPI score 0(healthy gingival) in the nondiabetic and diabetic groups were 14 (24.1%) and 44 (75.86%), respectively. Significant P value of <0.01 was found with presentation of healthy gingiva in the nondiabetic and diabetic groups. Subjects with CPI score 1(bleeding gums) in the nondiabetic and diabetic groups were 17 (14.5%) and 100 (85%), respectively. Significance was found with CPI score (bleeding) showing P value of <0.01. Subjects with CPI score 2(calculus) in the nondiabetic and diabetic groups were 25 (19.8%) and 101 (80%), respectively, with significant P value of <0.01. Subjects with CPI score 3 (pocket depth of 4–5 mm) in the nondiabetic and diabetic groups were 21 (15.3%) and 116 (85%), respectively, with significant P value of <0.01. Subjects with CPI score 4 (pocket depth of 6 mm or more) in the nondiabetic and diabetic groups were 6 (35.3%) and 11 (64.6%), respectively, with significant P value of <0.01. Subjects with CPI score X (excluded teeth, missing teeth) in the nondiabetic and diabetic groups were 15 (10.6%) and 126 (89.4%), with significant P value of <0.01. Overall CPI score showed highly significance between the nondiabetic and diabetic groups [Table 7] and [Graph 6].
Table 7: Comparison of CPI scores between two groups

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   Discussion Top


Recognizing the oral manifestations of underlying systemic disease is challenge. In this study oral manifestation of comorbid condition of IHD and DM is assessed. The present study shows male predominance in gender distribution between nondiabetic and diabetic groups. Males were more in number in both diabetic and nondiabetic groups [Table 1] and [Graph 1]. This reveals that gender does not play any role in this study, which is in accordance with the study conducted by Jousilahti et al.[3] these findings are in contrast with previous studies conducted by Huxley et al.,[4] who stated that relative risk of IHD associated with diabetes was about 50% higher in women than men.

According to the previous literature various deleterious habits were associated with the IHD patients. In the present study, smoking, alcohol, tobacco/pan chewing were common habits observed in both the diabetic and nondiabetic groups. Taylor et al. stated that there is a probable interaction between alcohol and tobacco on risk of heart disease resulting from narrowing of the arteries that supply blood and oxygen to the heart. The relationship between alcohol use and cardiovascular risk factors is not so clear[5] Incidence of subjects with smoking habit has no statistical significance between both the groups IHD [Table 2] and [Graph 2]. These results are in contrast to the previous literature. Cigarette smoking generally increases insulin resistance by altering the distribution body of fat or by exerting a direct toxic on pancreatic tissue. A chemical component of cigarettes may directly alter intracellular glucose transport, or may indirectly change serum chemistry or diminished vascular blood flow.[6] In our study we did not find any relationship between risks of myocardial infarction with the current or former status of smoking, type of tobacco and smokeless tobacco use, and previous history of habit of smoking. In contrary to the present study results, Morrish et al. stated that smoking was significantly associated with an increased risk for CHD in diabetic patients.[7] Incidence of subjects with alcohol habit shows statistical significance between both the groups [Table 2] and [Graph 2]. This reveals that heavy alcohol consumption increases the rate of nonfatal IHD and consequently sudden cardiac death, independent of blood pressure and smoking, which is in accordance to the study conducted by Wilhemsen et al.[8] In contrast to the results of the present study, St Leger et al. found a significant negative correlation between alcohol consumption and IHD patients.[9] Incidence of subjects with pan, gutka chewing, or tobacco chewing was not statistically significant between both the groups [Table 2] and [Graph 2]. Smokeless tobacco also leads to a wide variety of mechanistic disruptions platelet activation and thrombogenesis, endothelial dysfunction, accelerated atherogenesis, inflammation, sympathoadrenal activation, arrhythmogenesis, insulin resistance, and hyperlipidemia, all of which can contribute to cardiovascular disease.[10] Though we have more number of male subjects in both the groups due to small sample size, we got statistical insignificance, which is in accordance to the study conducted by Boffetta et al. and Gupta et al.[11],[12] In contrast to the results of the present study, Persson et al-in his study found statistical significant association between IHD and smokeless tobacco.[13] But till date, studies comparing the various deleterious habits leading to IHD were not reported in the literature, and to the best of our knowledge, the present study could probably be the first study of such kind.

In our study various subjective symptoms considered were dry mouth, taste, and tongue or mucosal pain. In our study subjects with dry mouth show statistical significance between both the groups [Table 4] and [Graph 3]. This reveals that xerostomia is frequent among DM patients. In addition, DM patients presented lower salivary flow rates than non-DM population. The sensory and autonomic neuropathies characteristics of DM together are associated with impaired renal function, which results in dehydration and xerostomia.[14] In our study statistically significant results were found between two groups, in accordance to the study conducted by Fricton et al.[15] Syrjala found statistically significant results between the diabetic and nondiabetic heart disease patients, which is in contrast to the present study results.[16] Incidence of taste changes in the present study showed statistically significant results. Subjects with taste changes showed statistical significance between both the groups [Table 4] and [Graph 3]. Diabetes and natural aging process may be the conditions associated in the general population with diminished sense of taste. Damage to the salivary glands reduces the production of saliva; saliva is the solution in which chemoreceptors of taste buds bind their receptor molecules. Results of our study are in accordance to the studies conducted by Boyce et al., Mann et al.[17],[18] noted that patients do not often report problems with taste, particularly if other stroke symptoms are present. A subject with tongue or mucosal pain in the nondiabetic and diabetic groups shows statistical significance between both the groups [Table 4] and [Graph 3]. Burning sensation of the oral soft tissues is a frequent complaint in diabetic patients. A neuropathic basis is supported by observations that the burning sensations in diabetic patients are frequently accompanied by changes in taste (dysgeusia) or other sensory distortions. Sensations of burning in the soft tissues of the oral soft cavity will be helpful to determine the possible presence of candidiasis, lichen planus, oral dryness, or neuropathy, all of which may assist in evaluation of irregular glycemic control. Previous study supports higher incidence of stomatitis in diabetic patients than nondiabetic patients. Tongue or mucosal pains are in accordance to the study conducted by Malberg et al.[19]

When DMFT index among the subjects were compared, the mean value of decayed teeth shows no significant difference [Table 5] and [Graph 4]. Dental decay may contribute to the risk of IHD. We found no association between extents of active dental decay and risk of IHD. In contrast to the present study results, Mattila et al. and DeStefano et al. in their case–control studies found a strong association between dental disease and acute myocardial infarction.[20],[21] The mean value of missing teeth shows statistically significant difference [Table 5] and [Graph 4]. Tooth loss in people under 60 is usually caused by dental caries. Thus, we cannot rule out the possibility that the increased risk of IHD among subjects with no teeth may have been related to previous dental decay. The mean value of filled teeth shows no significant difference [Table 5] and [Graph 4].

The frequency distribution of DMFT score showed no difference among the different ranges of scores categorized as 1–10, 11–20, 21–30,>30, among the nondiabetic and diabetic groups [Table 6] and [Graph 5]. But overall DMFT score was significantly higher in the diabetic group. Overall DMFT score showed high significance between the nondiabetic and diabetic groups in accordance to the study conducted by Schillinger et al., who demonstrated correlation between myocardial infarction and DMFT index.[22]

The present study demonstrated higher abnormal periodontal indices in patients with IHD than normal groups as independent risk factor. DM is a known etiological factor for periodontitis and tooth loss. Epidemiological studies have demonstrated an association between both types of diabetes and periodontal disease. Individuals with diabetes are typically found to have more periodontal attachment loss than nondiabetic subjects. Even after correcting for possible confounding factors, increased periodontal risk is often related to duration and adequacy of control of the diabetic state.[23]

On assessing the CPI index, both study groups showed statistical differences in all codes of the index [Table 7] and [Graph 6]. This reveals that oral bacteria can affect the heart when they enter the bloodstream, attaching to fatty plaques in the coronary arteries and contributing to clot formation. Researchers have found that people with periodontal disease are almost twice as likely to suffer from coronary artery disease as those without periodontal disease. Gingival pockets with increased depth may form a reservoir for bacteria, enzymes, toxins, and metabolites. This can predispose to transfer of periodontal pathogens to distant organs, including cardiovascular system in accordance to the studies conducted by Janket et al. and Kapłon et al., who found positive association between periodontitis and myocardial infarction.[24],[25] In contrast to the present study result, Tuominen et al. and Joshipura et al. concluded that oral health indicators, including Parkinson's disease (PD), were not independent risk factors for IHD. Taken together, the relationship between PD and CHD is still inconclusive.[26],[27] However, in a study evaluating the dental health status of IHD patients, we found that the IHD diabetic patients are more prone to dry mouth, taste changes, tongue or mucosal pain, and had poor oral hygiene than the nondiabetic IHD patients.


   Conclusion Top


Further research with a larger sample size is required to provide an evidence to strengthen the present study results. More researches in future in this direction should be conducted, especially concerning with associated systemic illness and IHD. The onset of oral manifestations should be studied in a prospective manner, and interventional researches regarding the hypothesis, the removal, or reduction of periodontitis decreases the incidence of IHD. We need to accentuate investigations on oral systemic disease connections, which are a rapidly advancing area of research that may contribute to the early diagnosis and treatment for a number of systemic diseases by the early identification of their oral manifestations.

Oral physician plays a major role in both the management and control of these common oral manifestations of IHD patients, thereby improving the quality of life of individuals with diabetes and IHD. Good oral health is important not only to prevent oral disease but also to maintain good general health. The oral healthcare professionals and the medical professionals should work hand-in-hand for better planning of prevention programs.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7]



 

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