Users Online: 114

Home Print this page Email this page Small font sizeDefault font sizeIncrease font size

Home | About us | Editorial board | Search | Ahead of print | Current issue | Archives | Submit article | Instructions | Subscribe | Contacts | Login 

   Table of Contents      
Year : 2022  |  Volume : 12  |  Issue : 2  |  Page : 85-91

Oral Aspects in Diabetes: Decoding the Silent Killer

1 Haldia Institute of Dental Sciences and Research, Haldia, West Bengal, India
2 Guru Nanak Institute of Dental Sciences and Research, Kolkata, West Bengal, India
3 Centre of Social Medicine and Community Health, Jawaharlal Nehru University, Delhi, India

Date of Submission26-Dec-2021
Date of Decision02-Jan-2022
Date of Acceptance17-Jan-2022
Date of Web Publication10-May-2022

Correspondence Address:
Login to access the Email id

Source of Support: None, Conflict of Interest: None

DOI: 10.4103/ijnpnd.ijnpnd_72_21

Rights and Permissions

Introduction: Diabetes mellitus is a group of metabolic diseases. The potential complications associated with it also reflect on oral health. This review illustrates oral aspects of diabetes and its implications. Methods: This narrative review aims at disclosing the pathogenesis, numerous oral aspects of diabetes, diagnosis, management, and patient education. Articles focusing on the oral aspect of diabetes and its management were considered, and the kaleidoscope model for oral health care is also proposed. Results: The review gives us an idea about the inter-relationship between oral and diabetes mellitus. It emphasizes the need for medical and dental collaborations for better systemic and oral health. Awareness and education of oral aspects in diabetes can help prevent oral complications related to diabetes and maintain oral health. Discussion: Understanding the oral implications of diabetes mellitus will help us better understand the disease. Furthermore, it can be a game changer for patient tutelage by the sense of various models, advanced diagnostic methods, and specialized interventions.

Keywords: diabetes mellitus, kaleidoscope model, oral health, periodontitis

How to cite this article:
Debnath K, Das D, Goswami N, Barai S, Mandriya K, Nisha S. Oral Aspects in Diabetes: Decoding the Silent Killer. Int J Nutr Pharmacol Neurol Dis 2022;12:85-91

How to cite this URL:
Debnath K, Das D, Goswami N, Barai S, Mandriya K, Nisha S. Oral Aspects in Diabetes: Decoding the Silent Killer. Int J Nutr Pharmacol Neurol Dis [serial online] 2022 [cited 2022 Sep 25];12:85-91. Available from:

   Introduction Top

Diabetes mellitus (DM) represents a group of metabolic diseases that are characterized by hyperglycemia due to a total or relative lack of insulin secretion and insulin resistance or both.[1] As DM emerged to be a public health concern, it was declared a pandemic by World Health Organization.[2] Although DM primarily affects the adult population, it has been found that, in general, it affects all age groups. According to a Lancet study, Indians suffering from DM in 1990 was 26.0 million that jumped to 65.0 million by the year 2016.[3] Diabetes warrants both systemic and oral manifestations. Five significant complications are associated with DM that include neuropathy, retinopathy, nephropathy, cardiovascular complications, and finally, complications in the healing of wounds.[4] Recently, periodontitis has been declared as the sixth complication by Loe.[5]

   Classification of Diabetes Mellitus Top

National Diabetes Data group, based on the study of DM, gave a contemporary devised classification of the disease, broadly classified as insulin-dependent DM, and noninsulin-dependent DM. America’s Diabetes Association Expert Committee passed the revised classification [[Figure 1]] based on disease etiology.[6]
Figure 1 Classification of diabetes mellitus.

Click here to view

   Pathophysiology of Diabetes Mellitus Top

Pathophysiology of type 1 DM

Type 1 DM is a chronic autoimmune disorder, and it is associated with the destruction of the beta cells (insulin-producing cells). When the disease is detected clinically, it is generally considered the end-stage beta-cell destruction. Three factors play a vital role in the destruction of the beta cells of the pancreas, which are genetic susceptibility, ineffective defense barriers of the body, and the impaired or ineffective immune response of the body. When these three factors become coherent, the autoimmune process begins in the body. The process acts on both T-lymphocytes and macrophages. The T-lymphocytes further acts on CD4 cells, which further acts of interferon-gamma. These events eventually cause beta-cell destruction. On the other hand, macrophages act to antigens that further incite interleukin 1 response, which destroys the beta cells. The antigens simultaneously initiate tumor necrosis factor-alpha that causes beta-cell destruction. Apart from these, some precipitating factors called stressors aid in beta-cell destruction. Once the end stage of cell destruction is reached (>90%), the onset of type 1 DM begins.[7]

   Pathophysiology of type 2 DM Top

Type 2 DM is also known as noninsulin-dependent DM (NIDDM). The two most common factors responsible for NIDDM are insulin resistance and insulin deficiency. The pathophysiology of type 2 DM is described in the following paragraph. The establishment of DM in the body starts with impaired insulin secretion from the pancreas (insulin resistance and insulin deficiency), leading to increased glucose production in the liver. As the level of glucose increases in the body, the increased glucose causes defects at the receptor and postreceptor levels. Eventually, insulin resistance grows in the muscles/peripheral tissues causing type 2 DM.[8]

   Signs and Symptoms of Diabetes Mellitus Top

Diabetes even after being a chronic disease, there are no direct and immediate manifestations of the disease. As a result, people disregard the condition. It is imperative to diagnose the signs and symptoms [[Figure 2]] of the disease early to prevent and control it effectively.[9]
Figure 2 Signs of diabetes mellitus.

Click here to view

   Potential Implications of Diabetes Mellitus Top

The DM has both systemic and oral manifestations. The complications manifested as both acute and chronic expressions.[6] The existing complicated mechanisms behind diabetes are responsible for various effects of diabetes on systemic and oral health.

Systemic manifestations

The systemic manifestation of DM occurs at the microvascular and macrovascular levels. The destruction of beta cells of the pancreas in type 1 DM and insulin resistance in type 2 DM results in hyperglycemia.[10] This eventually caused the liberation of free fatty acids and dyslipidemia. Now both dyslipidemia and hyperglycemia cause immune dysfunction through inflammation and infection. Because of this, DM shows systematic manifestations that result in macrovascular and microvascular complications [[Figure 3]].[11]
Figure 3 Systemic complications of diabetes mellitus.

Click here to view

Oral manifestations

The DM being a common chronic disorder, it is essential to know the oral manifestation in the body. The intensity of complications of DM shares a directly proportional relationship with the duration and degree of hyperglycemic state. The numerous significant complications of DM are described in [Figure 4] but not limited to these.[12]
Figure 4 Oral complications of diabetes mellitus

Click here to view

   The Sixth Complication Top

Harald Loe, in 1993, described periodontitis as the sixth complication of DM. After Loe suggested this, the periodontitis and DM relationship became one of the most crucial research concepts. DM is considered to be a risk factor for periodontal diseases. Periodontal disease causes change in defense of the host immune systems by different means, viz., dysfunction of the circulating neutrophils. Simultaneously, it also alternates microflora at the subgingival level, vascularity of the gingiva, collagen metabolism process, gingival crevicular fluid (GCF) levels, etc. The longer the duration of diabetes, the increased chances of alterations. These all-over changes due to DM can be held responsible for the development of periodontitis.[5] Apart from the changes mentioned earlier, several other risk factors are also responsible for developing periodontitis, viz., poor oral hygiene, poor metabolic control, and smoking history.[13]

   Periodontitis and Diabetes Mellitus: The Potential Mechanism of Bidirectionality Top

Both DM and periodontitis are considered to be chronic diseases. Based on epidemiologic studies, it has been continuously found that DM increases the risk for periodontitis. In the last 20 years, the concept of diabetes has been shifted from “glucocentric„ to “adipocentric.„[14] The adipocytic molecules present in the body are known as adipokines. These adipokines play a significant role in altering body insulin levels resulting in diabetes. They are also responsible for modified immune response in terms of the changed level of growth factors, interleukins that cause periodontal destruction. On the other hand, the bacterial toxins released by the bacteria biome in periodontitis also bring changes at the immune level [[Figure 5]], causing insulin resistance and DM.[15]
Figure 5 Bidirectionality between diabetes and periodontitis.

Click here to view

   Diagnosing the Silent Killer Top

“Prevention is better than cure.„

–Desiderius Erasmus

As Erasmus said, it is always better to diagnose a chronic disease early before it progresses to affect all the body systems in some way or the other. The available methods of diagnosing DM are broadly classified into two categories, viz., invasive procedures and noninvasive practices.

The invasive methods of blood glucose diagnosis include measuring the fasting blood glucose level, oral glucose tolerance test level, and glycated hemoglobin level. The noninvasive diagnostic method of blood sugar levels is a gingival crevicular blood (GCB) and salivary glucose levels. The glucose level detected by GCB is not an alternative to the existing standard methods. However, significant association was found between salivary blood glucose levels and capillary blood glucose levels, indicating its adjuvant role in diagnosing blood sugar levels. The strength of the noninvasive technique lies in fast chairside diagnosis of DM through measuring blood sugar levels. [16,17] The standard and abnormal values of standardized tests are shown in [Figure 6].
Figure 6 The diagnostic values of standardized tests.

Click here to view

   Management Plan − Untangled Top

General management of diabetic patients

The concept of management of the diabetic patient is quite intertwined, having various directions. The core of the treatment lies in combining multiple approaches [[Figure 7]] to one and applying them to the individual suffering from chronic diseases. From the US population-based cross-sectional studies, we can find the concept of screening.[18]
Figure 7 General management plan for diabetes mellitus.

Click here to view

Screening happens at two levels:Early screening by physicians

Screening at the dental clinic during a regular dental checkup.

This leads us to the concept of interprofessional collaboration, that is, cooperation between professionals of the two branches of evidence-based medicine (physicians and dentists).

Apart from these, the other available conventional methods, viz., modification of the lifestyle of the patient (passive to active), prevention of complications that arise due to the chronic disease, and the use of therapeutics, viz., sulfonylurea, meglitinide, biguanide, a thiazolidinedione, dipeptidyl peptidase 4 inhibitor, and sodium–glucose cotransporter inhibitor.[17] The improvement of the glycemic level eventually improves oral health and vice versa.

   Kaleidoscope model for management of diabetes mellitus Top

The way DM is disease inclusive and dependent on various factors, the management of the disorders also depends on several factors. All the factors when putting together show changing patterns just like a kaleidoscope. The treatment plan should be adjusted accordingly. The above-mentioned proposed model is called kaleidoscope model.[19] Kaleidoscope model is the newest proposed psychosocial model. There are some other existing psychosocial models, namely:Empowerment philosophy − which focuses on a patient-centric approachHealth belief model − which is hypothesized the concept of three simultaneous factor occurrences namely belief on sufficient motivation, the belief of vulnerability or faith of sequelae to disease, the idea of health recommendationCommon sense model − which is proposed by Leventhal and described the cognitive representation of illness

Chronic care model − which highlights the different needs of treatment for a chronic disease

The kaleidoscope model has considered the essential bits of all the existing models and combined them to give a holistic model. Kaleidoscope model has three core beliefs, namely:Motivating the patientCreating trust in the patientUnderstanding the feeling of the patient

All the three factors together help to change the patient’s behavior. These factors are additionally ascended by certain other factors, such as regimen, behavioral, and extrinsic.

The details of this proposed model are described in [Figure 8].
Figure 8 Kaleidoscope model for diabetes management.

Click here to view

Kaleidoscope model for oral health management

The existing kaleidoscope model, an extensively comprehensive model, is widely applied. By applying the model to understand the psychology and behavior of the patient regarding dental treatment and oral health maintenance, devising the external factors and associated regimen factors to improve oral hygiene is possible. It is also possible to find the underlying cause for the ignorance of oral health, remove those factors, and eventually change the patient’s attitude using this model.

   Diabetic Patient Education Top

Based on Bartol’s extensive study and assessment of diabetic patients, the most effective strategy devised for the treatment of diabetes and educating the patient about the treatment is active learning methodology.

[20] This approach generally divides treatment into four stages, namely meal, motion, medication, and monitoring called together as 4M of Patient Management

[21] [[Figure 9]].
Figure 9 4M of patient management.

Click here to view

The active learning methodology describes the following:

Meal: Calculating and formulating the carbohydrate intake and distribution plan.

Motion: Motivate the patient to shift them toward an active lifestyle.

Medication: Self-injection of insulin, education about medication intake, and storage.

Monitoring: Self-performed blood glucose monitoring, regular checks on various signs and symptoms.

Apart from these, improvement of oral health, quitting derogatory oral habits, frequent visits to the dentist, treatment of periodontal diseases, and maintenance of good oral health subsequently will improve the general diabetic health of the patient.

   Implications of Diabetes in Clinical Dental Practice Top

Each patient needs to be assessed for glycemic levels before initiating any treatment. This can help in diagnosing undiagnosed diabetes cases. For uncontrolled diabetes patients, referral to physicians and reducing blood glucose levels can improve oral health status. Dental collaboration with a medical specialist is highly recommended. Patient education on diabetes–oral health interrelation can improve both systemic and oral care.

   Conclusion Top

Uncontrolled diabetes has several oral manifestations. Frequent dental visits and customized or individualized treatment plans can help manage oral and periodontal health. Physician consultation and collaboration is essential component of control, and those aspects need to be strengthened in the hospital or private practice setup. Patient education and psychology need to be addressed, which can help in proper assessment and care.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Al-Maskari AY, Al-Maskari MY, Al-Sudairy S. Oral manifestations and complications of diabetes mellitus: a review. Sultan Qaboos Univ Med J 2011;11:179-86.  Back to cited text no. 1
Mokdad AH, Ford ES, Bowman BA et al. Diabetes trends in the US: 1990 to 1998. Diabetes Care 2000;23:1278-83.  Back to cited text no. 2
Tandon N, Anjana RM, Mohan Vet al. The increasing burden of diabetes and variations among the states of India: the global burden of disease study 1990–2016. Lancet Glob Health 2018;6:e1352-62.  Back to cited text no. 3
Leite RS, Marlow NM, Fernandes JK, Hermayer K. Oral health and type 2 diabetes. Am J Med Sci 2013;345:271-3.  Back to cited text no. 4
Loe H. Periodontal disease. The sixth complication of diabetes mellitus. Diabetes Care 1993;16:329-34.  Back to cited text no. 5
Lalla RV, D’Ambrosio JA. Dental management considerations for the patient with diabetes mellitus. J Am Dent Assoc 2001;132:1425-32.  Back to cited text no. 6
Homsi M, Lukic ML. An update on the pathogenesis of diabetes mellitus. Int J Diabetes Metab 1993;1.  Back to cited text no. 7
Ozougwu JC, Obimba KC, Belonwu CD, Unakalmba CB. The pathogenesis and pathophysiology of type 1 and type 2 diabetes mellitus. J Physiol Pathophysiol 2013;4:46-57.  Back to cited text no. 8
Ramachandran A. Know the signs and symptoms of diabetes. Indian J Med Res 2014;140:579-81.  Back to cited text no. 9
[PUBMED]  [Full text]  
Verhulst MJL, Loos BG, Gerdes VEA, Teeuw WJ. Evaluating all potential oral complications of diabetes mellitus. Front Endocrinol 2019;10:56.  Back to cited text no. 10
Mora C, Navarro JF. Inflammation and diabetic nephropathy. Curr Diab Rep 2006;6:463-8.  Back to cited text no. 11
Indurkar MS, Maurya AS, Indurkar S. Oral manifestations of diabetes. Clin Diabetes 2016;34:54-7.  Back to cited text no. 12
Trentin MS, Verardi G, De C Ferreira M et al. Most frequent oral lesions in patients with type 2 diabetes mellitus. J Contemp Dent Pract 2017;18:107-11.  Back to cited text no. 13
Tsai C, Hayes C, Taylor GW. Glycaemic control of type 2 diabetes and severe periodontal disease in the US adult population. Community Dent Oral Epidemiol 2002;30:182-92.  Back to cited text no. 14
Rose LF, Mealey BL, Genco RJ, Cohen DW. Periodontics: Medicine, Surgery, and Implants. St Louis, MO: Elsevier Mosby 2004. p. 789-880.  Back to cited text no. 15
Gupta S, Nayak MT, Sunitha JD, Dawar G, Sinha N, Rallan NS. Correlation of salivary glucose level with blood glucose level in diabetes mellitus. J Oral Maxillofac Pathol 2017;21:334-9.  Back to cited text no. 16
[PUBMED]  [Full text]  
Miller A, Ouanounou A. Diagnosis, management, and dental considerations for the diabetic patient. J Can Dent Assoc 2020;86:k8.  Back to cited text no. 17
Borgnakke WS, Genco RJ, Eke PI et al. Oral health and diabetes. Diabetes Am 2018;3:Chap 31.  Back to cited text no. 18
Barnard KD, Lloyd CE, Dyson PAet al. Kaleidoscope model of diabetes care: time for a rethink? Diabet Med 2014;31:522-30.  Back to cited text no. 19
Bartol T. Putting a patient with diabetes in the driver’s seat. Nursing 2002;32:53-5.  Back to cited text no. 20
Darbishire PL, Plake KS, Nash CL, Shepler BM. Active-learning laboratory session to teach the four M’s of diabetes care. Am J Pharm Educ 2009;73:22.  Back to cited text no. 21


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9]


    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

  In this article
    Classification o...
    Pathophysiology ...
    Pathophysiology ...
    Signs and Sympto...
    Potential Implic...
    The Sixth Compli...
    Periodontitis an...
    Diagnosing the S...
    Management Plan ...
    Kaleidoscope mod...
    Diabetic Patient...
    Implications of ...
    Article Figures

 Article Access Statistics
    PDF Downloaded99    
    Comments [Add]    

Recommend this journal