International Journal of Nutrition, Pharmacology, Neurological Diseases

: 2022  |  Volume : 12  |  Issue : 2  |  Page : 85--91

Oral Aspects in Diabetes: Decoding the Silent Killer

Krishnendu Debnath1, Debanjan Das1, Nilanjana Goswami2, Sudipto Barai1, Kamlesh Mandriya3, Swet Nisha1,  
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

Correspondence Address:


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.

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 Jul 2 ];12:85-91
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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

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}

 Pathophysiology of Diabetes Mellitus

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

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

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}

 Potential Implications of Diabetes Mellitus

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}

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}

 The Sixth Complication

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

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}

 Diagnosing the Silent Killer

“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}

 Management Plan − Untangled

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}

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

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 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

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}

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

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.


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.


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