Alveolar bone loss Patients with diabetes mellitus are at increased risk for having periodontal disease that is more virulent and has an increased rate of bone resorption compared with patients without diabetes mellitus. The extended hyperglycemic state of diabetes decreases the development of osteoblasts, and consequently, their role in the formation of bone (Wang et al., 2020). The underlying mechanism of action may be related to the effect that diabetes has on the bone-forming cells (osteoblasts) and the Gingivitis The development of periodontal disease always follows the various phases of gingival inflammation known as gingivitis . Gingivitis is defined as the inflammation of the gingival tissues without the loss of any of the supporting alveolar bone. The degree of gingival inflammation is measured by the gingival index, which was initially established by Löe & Silness in 1963 and modified in 1967, and which is still in use today (Löe, 1967). Gingival inflammation is scored on a scale of 0 to 3, with higher values assigned to progressive inflammation, increasing erythema, and a progressive tendency to bleed on probing. A study was conducted among type 2 diabetics to determine the efficacy of nonsurgical periodontal therapy upon glycemic control. Patients were randomly divided into three groups, each
bone-resorbing cells (osteoclasts). The formation of osteoclasts is enhanced in patients with diabetes compared with those without diabetes, and is also associated with an increase in apoptosis (programmed cell death) of the osteocytes (Rathinavelu et al., 2018). Thus, bone resorption is greater than bone deposition, resulting in a net loss of alveolar bone. The progressive resorption of bone leads to an increase in the mobility of teeth and ultimately the potential for their loss. with a specific nonsurgical periodontal treatment regimen. The regimen for Group A was scaling, rinsing with mouthwash, and toothbrushing; the Group B regimen was rinsing with mouthwash and toothbrushing only; and Group C’s regimen consisted of toothbrushing only. The mouthwash employed in the study was 0.12% chlorhexidine gluconate. The results of the study showed that a statistically significant reduction in the gingival index, plaque index, and periodontal pocket depth correlated with a statistically significant reduction in fasting blood sugar and glycated hemoglobin (HbA1c) among Group A and Group B, the groups with combined regimens of periodontal therapy. A significant reduction in gingivitis seems to be commensurate with good glycemic control (Naiff et al., 2018).
OTHER ORAL MANIFESTATIONS ASSOCIATED WITH DIABETES
Alterations of the oral mucosal tissue occur with a higher prevalence in patients with diabetes than in those without diabetes. Among the most common oral manifestations Xerostomia Xerostomia is a common complaint among patients with uncontrolled diabetes. The polyuria and dehydration that accompany decreased glycemic control figure prominently in this disorder (Miller & Ouanounou, 2020.) Patients with diabetes and poor glycemic control commonly have lower stimulated parotid flow rates than patients with well-controlled diabetes and control subjects without diabetes (Khan, 2018). Pathological changes in the microvasculature, neuropathy, accumulation of fat within the salivary glands, and hypertrophy of the acini (secreting elements) are common causes of salivary gland dysfunction among diabetics, especially those with poor glycemic control (Rohani, 2019). Reduced salivary flow promotes the adherence of Oral candidiasis Xerostomia also promotes the propagation of Candida albicans, a microorganism that normally inhabits the mouth, and can result in the development of oral candidiasis, or thrush. Saliva contains proteins that control the population of C. albicans (Fenn et al., 2019). Thus, a decrease in salivary volume, with a commensurate reduction in the salivary proteins that discourage colonization of this opportunistic fungal pathogen, is favorable to the proliferation of C. albicans and the development of oral candidiasis. Furthermore, saliva contains mucins that bind with the cell membrane of C. albicans , causing cellular death. When saliva level is reduced, so are the amounts of mucins, which results in the proliferation of oral microbes, including C. albicans (Fenn et al., 2019). Use of partial or complete dentures is another factor that contributes to the development of oral candidiasis in patients with diabetes (Khan, 2018). The acrylic surface of the denture, which is in direct contact with the mucosal tissues of the hard palate and/or the mandibular edentulous ridge, may appear smooth, but it includes numerous microscopic porosities in which the C. albicans organisms can reside. The coupling of this natural topography with the hyposalivation that is experienced by some patients with diabetes can cause the tissue that underlies the prostheses to become infected with oral candidiasis. Treatment with antifungal medications must address both the afflicted tissues and the tissue- bearing surfaces of the prostheses. If the latter are not treated for fungal contamination, they will be a source of reinoculation of C. albicans and will
of diabetes beyond gingivitis and periodontal disease are xerostomia and fungal infections (Rohani, 2019).
bacterial plaque to the teeth and increases the risk of developing dental caries, gingivitis, and periodontal disease (Lima et al., 2017). Patients who use partial or complete dentures may experience functional difficulties, as these prostheses rely on an adequately moistened mucosal surface for proper adaptation of the underlying tissue foundation and for general comfort. Oral mucosal tissues that are inadequately lubricated are less flexible and more prone to trauma. Such patients may benefit from artificial saliva substitutes to provide the mucosal tissues with adequate lubrication and topical fluorides to decrease the potential for the development of carious lesions (ADA, 2019; Kumar, 2017). contribute to a case of oral candidiasis that can be refractory to treatment. Fungal infections should be diagnosed and aggressively treated. To diminish the fungal population, the insides of dentures can be rinsed with a 1:10 hypochlorite (bleach) solution and then thoroughly cleaned before the denture is reinserted. The antifungal preparation nystatin, as an ointment, can also be placed inside the denture in a fashion similar to a denture adhesive as an additional antifungal medication (Shaikh et al., 2021). Another option is to soak the denture overnight in a liquid suspension of nystatin (Wynn et al., 2019).). Any denture adhesive residue must be removed from the denture and/or the tissue-bearing surface beneath the denture to maximize the contact of this antifungal preparation with the C. albicans colonies. Angular cheilitis, a fungal infection at the commissures of the lips, is also common in patients with diabetes with poor glycemic control and poor oral hygiene (Rani et al., 2019). This condition is frequently associated with dentures that are ill fitting due to an inadequate vertical dimension. Angular cheilitis is caused by fungal organisms in the saliva invading the fissures at the commissures of the lips. It is important to note that systemic antifungal medications must be used with due diligence, as they can react adversely with many prescribed medications (Revankar, 2019). Patients with oral candidiasis that does not resolve should be referred to a specialist.
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