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Table of Contents   
ORIGINAL RESEARCH  
Year : 2012  |  Volume : 23  |  Issue : 6  |  Page : 758-762
Salivary flow and dental caries in Brazilian youth with type 1 diabetes mellitus


1 Pediatric Endocrinology Service, Hospital Universitário Professor Edgard Santos, Faculty of Medicine, Federal University of Bahia, Bahia, Brazil
2 Department of Dentistry, Bahian School of Medicine and Public Health, Salvador, Bahia, Brazil

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Date of Submission22-Apr-2011
Date of Decision27-Nov-2011
Date of Acceptance18-Apr-2012
Date of Web Publication3-May-2013
 

   Abstract 

Background: Although type 1 diabetes mellitus (T1DM) has a significant impact on oral health, its association with dental caries is yet not clear.
Aim: The aim of this study was to evaluate the salivary flow rate and caries in Brazilian youth with type 1 diabetes mellitus.
Setting and Design: A Cross-sectional study was performed in a tertiary university hospital.
Materials and Methods: Fifty-one age matched subjects suffering from type 1 diabetes mellitus were selected for the study and evaluated for the following: salivary flow rate, number of decayed, missing and filled tooth in permanent dentition (DMF-T) and decayed, extracted, filled tooth index in the deciduous dentition (def-t); visible plaque index (VPI) and gingival bleeding index (GBI).
Statistics and analysis: The t test was utilized when the variables showed normal distribution. The Mann-Whitney test was utilized for comparing non-normal variables. Kolmorgorov-Smirnov test was used to assess the normality assumption. The differences were considered significant when P < 0.05.
Results: The age and gender distribution of patients and controls was 11.3 ± 3.4 years (56% males) and 11.9 ± 3.4 years (37% males). The mean glycated hemoglobin value in the diabetics was 9.7 ± 1.9%. Salivary flow rate was lower in the diabetic pateints as compared to controls (P = 0.02). No differences were found in the DMF-T/def-t indices of diabetic and non-diabetic patients (P = 0.43/0.14). VPI was similar in both the groups (P = 0.15). GBI was higher in the diabetics (8.1 vs. 5.18; P = 0.11). There were no differences in the dental caries experience and dental plaque in the two groups.
Conclusion: The lower salivary flow rate in diabetics could have been related to their higher GBI. The higher GBI in the diabetics is a matter of concern in the diabetics and is a sign for higher chances of developing periodontal problems.

Keywords: Caries, dental plaque, salivary flow, type 1 diabetes mellitus

How to cite this article:
Alves C, Menezes R, Brandão M. Salivary flow and dental caries in Brazilian youth with type 1 diabetes mellitus. Indian J Dent Res 2012;23:758-62

How to cite this URL:
Alves C, Menezes R, Brandão M. Salivary flow and dental caries in Brazilian youth with type 1 diabetes mellitus. Indian J Dent Res [serial online] 2012 [cited 2020 Dec 4];23:758-62. Available from: https://www.ijdr.in/text.asp?2012/23/6/758/111254
Dental caries is the localized destruction of susceptible dental hard tissue by acidic byproducts produced by bacterial fermentation of dietary carbohydrates. [1] Cariogenic flora, an adequate substrata and sensitive host are most important factors in the development of carious lesions. [1] Although type 1 diabetes mellitus (T1DM) has a significant impact on the oral health, its association with dental caries is not yet clarified. [1],[2],[3] Various reasons, such as, high glucose concentration and reduced salivary flow in T1DM patients have been postulated to explain the possibility of having a higher incidence of oral problems. [4] On the other hands, there are studies which disagree with this ideology and relate that T1DM patients infact have a lower prevalence of dental caries, [5] owing to a low-carbohydrate diet, and particularly low doses of sucrose - the sugar with the greatest cariogenic potential. [6] Due to these contradictory ideas, the present article aimed to evaluate the frequency of caries, index of visible plaque and gum bleeding, and salivary flow in a group of T1DM patients, and compare them to the values obtained for age-matched controls.


   Methods Top


Ethical aspects

The present study was reviewed by our institution of Medical Research Ethics Committee as per the guidelines of the 1975 Declaration of Helsinki, (revised in 1983) and approved by the board. The parents/guardians of the participants have given their free and informed consent to authorize the participation of the children in the study.

Study design

A Cross-sectional study was carried out between December/2007 and July/2008, comparing the T1DM patients and non-diabetic controls for the prevalence of dental caries and salivary flow.

Study population

The study population was comprising of children and adolescents with T1DM, and aged between 6-18 years (n = 51). The participants were followed-up at the Pediatric Endocrinology Service of Hospital Geral Roberto Santos, and 51 age-matched non-diabetic individuals were also included for the comparison and as controls. T1DM diagnosis was obtained according to the criteria of the American Diabetes Association. [7] Glycemic control was established by the determination of glycated hemoglobin concentration based on high performance liquid chromatography (HPLC), a test that evaluates the average amount of glucose in the blood over the last 2-3 months. The patients and their families had a similar socioeconomic status and lived in the same geographic area.

Data collection

The parents-guardians of the participants completed a questionnaire providing demographic information such as the age, sex, family income and presence or absence of diabetes in the child. [8] Clinical examination of the teeth was performed by two of the authors (RM and JA) under standard conditions using a dental chair, reflector (Dabi Atlante), suction apparatus and compressed air. Prior to the clinical examination, water jet was sprayed onto the teeth using a triple syringe. Teeth were carefully dried during the examination with the help of a dental mirror positioned against the buccal mucosa. The evaluation of the visible plaque index (VPI) and gingival bleeding index (GBI) was performed according to the technique described by Ainamo and Bay. [9] The first tooth examined was the tooth furthest to the right upper semi-arch, with the mesial, vestibular and distal faces checked until the mean line. Then, all the teeth in the left upper semi-arch were examined in the same way. Afterwards, the palatal surfaces were examined until the last tooth of the right upper semi-arch. After the completion of the examination of the upper arch, the lower arch was examined in the same way. GBI was evaluated by gently running a probe graduated in mm (Williams graduated probe) in the gingival sulcus after carefully washing and drying the surfaces to be examined. The presence of plaque and gum bleeding was recorded on the patient's medical chart. The DMF-T index (D: decayed; M: missing; F: filled; T: teeth of permanent dentition) and def-t index (d: decayed; e: extracted; f: filled; t: teeth of deciduous dentition) were assessed as described by Klein and Palmer. [10] After the completion of the study, the participants were informed on their oral health and advised on proper oral hygiene. Nonstimulated salivary flow was examined under standard conditions, between 8-10 a.m., at least 1 hour after breakfast. During the collection, the participants were in a relaxed sitting position with the arms resting on the knees, and the head lowered and inclined to the front; then, after swallowing all the saliva inside the mouth, the patients were told to allow the saliva to accumulate in the floor of the mouth and to expel it into a every 60 seconds for 5 minutes. The total saliva collected was aspirated into the collection reservoir using a 5 mL disposable syringe (Becton-Dikinson-BD, São Paulo-SP). The amount of saliva, in millimeters, divided by the collection period, constituted the measurement of the salivary flow. The reference value for nonstimulated salivary flow was considered as 0.3 ml/minute. [4]

Statistical analysis

The sample size to estimate the mean difference between the two groups, with 95% confidence interval and type II error of 0.20, was calculated as 38 participants per group. The data were analyzed using software Statistical Package for Social Sciences (SPSS, Chicago, IL) version 14.0. The comparisons of the means were performed using the t test when the variables showed normal distribution, and using a non-parametric Mann-Whitney test for comparing non-normal variables. Kolmorgorov-Smirnov test was used to assess normality assumption. The differences were considered significant when P < 0.05.


   Results Top


56.9% of the diabetics and 37.3% of the non-diabetics were male. The average age of the diabetics was 11.3 ± 3.4 years, and that of non-diabetics was 11.9 ± 3.4 years. The majority of the participants earned an income of 1-3 minimum wages (74.5% diabetics and 65.9% non-diabetics). The percentages of case and control individuals grouped by age range and income are described in [Table 1].
Table 1: Distribution of diabetics and non-diabetics subjects by age range, gender and familial income in the study

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The mean glycated hemoglobin value in the diabetics was 9.7 ± 1.9%, reflecting an inadequate control of their diabetes. Of those, eighty-five per cent had glycated hemoglobin higher than 8%.

Dental caries

There was no difference in the total DMF-T and def-t index values in diabetics and non-diabetics [Table 2]. Analysis of DMF-T showed a higher percentage of the filled component in diabetic individuals and a higher percentage of the caries component for the non-diabetic individuals [Table 3]. Using the World Health Organization goal aiming at a DMF-T index lower than 3 [11] in our descriptive analysis of the DMF-T values by age range, we found that the diabetic individuals aged 10-14 years and 15-18 years showed higher levels of DMF-T as compared to the goal, and has been described in [Table 4].
Table 2: DMF-T/def-t indexes in the diabetics and non-diabetics subjects in the study

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Table 3: Percentage of the individual components of DMF-T index in diabetics and non-diabetics in the study

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Table 4: Diabetics and non-diabetics: Age range vs. DMF-T index in the study

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The visible plaque index and gingival bleeding index

The visible plaque index (VPI) was similar for the two groups (38.0 in diabetic individuals and 30.2 in non-diabetics; P = 0.15). The gingival bleeding index (GBI) was higher in diabetic individuals (8.1 v. 5.1; P = 0.11).

Salivary flow

The diabetics had a lower salivary flow rate compared to the non-diabetic individuals. A statistically significant difference (P = 0.02) was found between the salivary flow rates of diabetics (mean of 0.26 ± 0.14 mL, minimum of 0.01 mL and maximum of 0.64 mL) and non-diabetics (mean of 0.41 ± 0.28 mL, minimum of 0.06 mL and maximum of 1.4 mL). There was no difference in the salivary flow rates within and between groups (diabetics and non-diabetics) with respect to the gender. The mean salivary flow rate for male and female diabetics was 0.27 ± 0.15 mL and 0.22 ± 0.13 mL, respectively (P = 0.62); whereas in the non-diabetics group, the mean salivary flow rate for males was 0.38 ± 0.25 mL, and 0.42 ± 0.30 mL for females (P = 0.56).


   Discussion Top


The findings of the present study demonstrated a higher overall DMF-T and higher filled component of the DMF-T index in the diabetic individuals when compared to the non-diabetics. However, these results were not statistically significant, which is consistent with the results of previous studies. [6] On the other hand, Siudikiene et al., [4] Do Amaral et al., [1] Orbak et al.[12] and Siudikiene et al.[3] reported a lower prevalence of caries in diabetics than in non-diabetics; whereas Miralles et al., [13] Patiño Marin et al., [14] Miko et al.[15] described a greater frequency of caries in diabetics. The observed higher percentage in the filled component of the DMF-T index in diabetics could be due to better access to dental treatment. A higher percentage of diabetics were found with a DMF-T level > 3 as their age increased. Siudikiene et al., [4] Do Amaral et al.[1] and Orbak et al.[12] also found an association between the number of caries lesions and aging. This increasing rate of caries associated with the aging process is, however, a common phenomenon considering the cumulativeness of DMF-T/def-t.

Measurement of glycated hemoglobin showed that the diabetic subjects had, in average, inadequate glycemic control (85% with glycated hemoglobin >8.0%). Some studies have described a positive association between caries risk and metabolic control, [4],[16] while other did not report any association between glycemic control and the DMF-T index. [1],[17] Dental plaque is essential for the development of caries, and an important factor in the periodontal disease. It is characterized as a soft, sticky bacterial mass that is deposited continuously under the dental surface, and not removed by air jet, mouthwash water, or by chewing hard foods. It was recently established that the dental plaque forms biofilms, that is, - communities of bacteria that build complex structures of extracellular polymers. The biofilm is difficult to be eliminated and is attached to any solid surface of the oral cavity. The VPI evaluates the accumulation of clinically visible plaque in the dental surface, without the use of dyes. In the present study, the VPI was similar among diabetics and non-diabetics (38.0 vs. 30.2, P = 0.35).

The GBI, evaluated with a probe graduated in mm, indicates the presence of gingival bleeding (clinical sign of inflammation), which somehow allows us to determine the level of oral hygiene of the patient. The diabetics had a higher GBI than the control group. These results are in agreement with the studies of Siudikiene et al., [4] Lalla et al.[18] and Orbak et al.[12] Since gingival bleeding is an indicator of inflammation, it is important to monitor these patients for a greater risk of developing periodontal disease. [19] Novaes et al.[20] and Lopez et al., [21] demonstrated that the VPI and the GBI were significantly higher among diabetics than in the control group, whereas Costa et al., [6] found that the mean value of VPI was 27.21% and that of the GBI was 10.97% in diabetics. The difference in the index of visible plaque in the referred studies may have occurred because the VPI assessment demonstrates the tooth brushing style of the patients at that precise moment, or may be the result of cognitive impairment, and also problems with self-care associated with persistent hyperglycemia. That's why the GBI is so important, because it provides information whether or not plaque accumulation is continuous leading to gum bleeding, and indicating whether or not there is a presence of inflammation.

Saliva plays a vital role in digestion, mastication and deglutition, and also in maintaining the integrity of the oral mucosa and the teeth. It has an antimicrobial activity and controls the pH of the oral cavity through its inorganic (bicarbonate, phosphate) and organic compounds (urea and sialine). When there is poor glycemic control, the dehydration caused by polyuria probably increases the osmotic gradients of the blood vessels in relation to the salivary glands, limiting the salivary secretion. [4] The poor glycemic control is strongly associated with diabetic nephropathy and salivary gland function is controlled by autonomic innervation. The results of the present study show significant reduction of nonstimulated salivary flow rates in diabetic individuals, which is consistent with the findings of Busato et al., [22] Moreira et al., [23] Siudikiene et al., [4] Siudikiene et al.[3] and Lopez et al.[21] With advancing age, there may be increased glandular changes and modifications in the biochemical components of saliva, which may increase the risk of caries development in diabetic subjects.

Busato el al. [22] reported the negative impact of dry mouth and hyposalivation in the quality of life of adolescents with T1DM. Miralles et al.[24] and Edblad et al.[5] did not find differences in the stimulated and nonstimulated salivary flow among diabetic and non-diabetic individuals. These findings can be related to the methodology use, the difference in the population age and in the sample size. This study suffers from some limitations such as small number of subjects and a small number of diabetics with good glycemic control in order to relate this variable to the patient's oral health. Keeping these limitations in mind, in our study, we did not find any difference between the total DMF-T/def-t indexes of diabetics and non-diabetics. Diabetics aged 10-14 and 15-18 years showed higher levels of DMF-T. The VPI showed no statistically significant difference between the two groups, whereas the GBI was higher among the diabetics. The lower salivary flow rate in diabetics could have been related to their higher GBI. The higher GBI in the diabetics is a matter of concern because of the increased chances of developing periodontal diseases in the future. Longitudinal studies involving a greater number of participants, to provide information on the factors that predispose patients with type 1 diabetes mellitus to dental caries, are needed.


   Acknowledgements Top


CA designed and wrote the paper. RM and MB examined the patients an colected the data.

 
   References Top

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13.Miralles L, Silvestre FJ, Grau DM, Hernández A. Estudio clínico sobre la patología bucodentaria en el paciente diabético tipo 1. Med Oral 2002;7:298-302.  Back to cited text no. 13
    
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18.Lalla E, Cheng B, Lal S, Tucker S, Greenberg E, Goland R, et al. Periodontal changes in children and adolescents with diabetes. Diabetes Care 2006;29:295-9.  Back to cited text no. 18
    
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24.Miralles L, Silvestre FJ, Hernández-Mijares A, Bautista D, Llambes F, Grau D. Dental caries in type 1 diabetics: Influence of systemic factors of the disease upon development of dental caries. Med Oral Patol Oral Cir Bucal 2006;11:256-60.  Back to cited text no. 24
    

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Correspondence Address:
Cresio Alves
Pediatric Endocrinology Service, Hospital Universitário Professor Edgard Santos, Faculty of Medicine, Federal University of Bahia, Bahia
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.111254

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    Tables

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

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