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Epidemiology of Diabetes Mellitus: I. Review of the Dental Literature
Published in The Journal of Periodontology, Vol. 30, pp. 242-252, July 1959.
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The literature is replete with articles showing that diabetes mellitus is a common disorder. A number of diabetes detection surveys have been made in the general population as well as in selected groups such as the military service, the aged, the obese, and among industrial employees. Interestingly enough, only one survey has been recorded in a dental population–in other words, among individuals who present themselves in a dental clinic because of some oral problem or simply for routine or periodic dental examination. This is worthy of note because, according to leading medical authorities,1 the oral manifestations of diabetes mellitus rank among the most important findings.
On the other side of the ledger, one can note that approximately fifty articles have appeared in the dental literature during the past twenty years concerned directly with the oral manifestations of diabetes mellitus. Very little of the latter information of the past two decades has been in quantitative form and there has been little integration of the observations of the different investigators.
The purpose of these reports, therefore, will be to attempt to answer the following four questions:
- What is the prevalence of diabetes mellitus in a dental population? In other words, how often does an unrecognized diabetic patient appear in the dental office?
- What is the prevalence of oral findings of diabetes mellitus in a dental population? In other words, what symptoms and signs will the unrecognized diabetic patient appear with when he presents himself for oral examination and care?
- Among nondiabetic patients, is there any correlation between blood glucose levels and oral symptoms and signs? In other words, can one observe relationships in the oral cavity to justify the term prediabetes mellitus?
- What is the prevalence of the antithesis of diabetes mellitus? In other words, what are the oral findings in patients with flat glucose tolerance patterns?
This report will simply review the available literature pertaining to the questions which have been raised. A report to follow2 will attempt to answer the above questions from a study of 100 routine dental patients.
Review of Literature
The literature pertinent to this study may be divided into two categories: (1) the criteria for the detection of diabetes mellitus, and (2) the oral manifestations of diabetes mellitus.
Criteria for the Detection of Diabetes Mellitus: A number of epidemiologic studies have been done in the general population as well as in selected groups. These will be considered separately.
General Population Studies: Various methods have been used for screening purposes as well as for the definitive establishment of the diagnosis of diabetes mellitus. Generally speaking, most of the epidemiologic studies performed among the general population have utilized either: (1) urinalysis, (2) blood sugar or glucose, or (3) a combination of urinalysis and blood sugar or glucose as the screening procedure.
Urinalysis as the Screening Procedure: Three studies of considerable size have been reported in which urinalysis was done as the screening test.
Sharkey et al3 studied 69,159 individuals (Table I). The Galatest was utilized. Where positive tests were obtained by the powder method, the patients were also checked by the Clinitest and Benedict methods. An incidence of 4.7 percent of the patients showed melituria. These were recalled for blood sugar determinations. Only 2,024 of the 2,991 with positive urine samples received subsequent blood testing. Of this number, 151 were known diabetic patients and 148 cases of previously unrecognized diabetes mellitus were found. In other words, 0.20 percent of the individuals tested during this diabetic detection drive in Dayton, Ohio, were found to suffer with previously unrecognized diabetes mellitus. The mass testing of Dayton school children during this survey revealed a significant number of newly discovered cases of juvenile diabetes. Of the 38,528 children tested, melituria was noted in 4.8 percent of the cases. Among the 1,022 of the 1,867 school children with positive urine samples who had subsequent blood sugar determinations 18 (1.7 percent) previously unrecognized cases of diabetes mellitus were discovered. Thus, .05 percent of the children tested were found to have previously unknown diabetes mellitus.
Table I–Percentage of new diabetic patients discovered in the general population with the use of urinalysis as the screening method
author(s) | no. of patients screened | percentage of new diabetics |
Sharkey et al3 (1950)
Albrink et al4 (1951) Loube and Alperts5 (1954) |
69,159
1,025 2,657 |
0.20
0.19 0.30 |
Albrink, Parente and Gelperin4 analyzed (Table 1) the results of a diabetic survey in Greater New Haven, Connecticut (a population of 241,542). The total number of persons responding to the drive was 1,025 (.5 percent of the population). Thirty-two of those tested (3.1 percent) were reported to have melituria. All persons showing sugar in the urine were referred to their private physicians for further study. The final diagnosis of the thirty-two patients disclosed eight previously known diabetic patients, seventeen false positive reports, five lost in the follow-up, and two (.19 percent) new diabetic patients.
During the Diabetic Detection Week in 1951, a total of 19,828 urine specimens were tested, of which 866 (4.4 percent) were reported positive. Loube and Alpert5 studied a segment (2,657) of this large group (Table 1). The sample was utilized because of the consistency in obtaining and evaluating the urine specimens. All of the analyses had been checked by means of the Galatest powder procedure. Of the 2,657 urine specimens included in this group, 220 (8.2 percent) were found to be positive for sugar. To each of the 220 individuals with a positive test, a letter was sent so that the patient could be further investigated. Of the 220 persons who were sent questionnaires, 174 (79 percent) responded. Some of the patients visited their private physicians and others reported to the laboratory of the investigators for glucose tolerance tests. The conclusion was drawn that approximately 0.30 percent were new diabetic individuals.
Table 1 summarizes the findings from these detection surveys based upon urinalysis for the detection of glucose in the blood. It can be seen that the figures for the different studies are essentially the same. One can also note that the percentage of unrecognized diabetes mellitus according to this detection method is small.
Blood Glucose as the Screening Procedure: Petrie, McLoughlin, and Hodgins6 studied 241,457 persons (Table 2). Each of these individuals received a glucose determination on the venous blood by the Anthrone method.7 If the blood glucose proved to be 160 mg. percent or over, the patient was referred for a subsequent glucose tolerance test. If the individual had not eaten previously, a blood glucose of 120-159 mg. percent was regarded as adequate justification for a glucose tolerance examination. The glucose tolerance test consisted of a fasting blood glucose and determinations at 45 minutes and two hours after the ingestion of 100 grams of glucose. Of these 241,457 persons receiving complete tests, 1.87 percent were referred to their private physicians because of above normal or borderline carbohydrate metabolism.
Table II–Percentage of new diabetic patients discovered in the general population with the use of blood sugar as the screening method
author(s) | number of patients screened | percentage of new diabetics |
Petrie et al6(1954) | 241,457 | 1.87 |
Urinalysis plus Blood Sugar as the Screening Procedure: Wilkerson and Krall8 examined 3,516 of the 4,983 inhabitants of Oxford, Massachusetts. The urine was tested for sugar by the standard Benedict’s qualitative test. If positive, the specimen was examined by a quantitative Benedict’s test. In adult patients the venous blood sugar was measured according to the Folin and Wu method.9 In the case of children, the capillary blood specimen was checked for sugar by the Folin-Malmros10 microsugar technique. The screening level for hyperglycemia was selected as 160 mg. percent for venous blood and 190 mg. percent for capillary blood. If a patient showed any melituria or if the blood sugar proved to be above the levels just described, both the urine and blood were re-checked. If the results of the second test were above the diagnostic level, a diagnosis of diabetes mellitus was made. If a discrepancy showed between the initial and the second test, a dextrose tolerance test was performed. A total of 70 cases of diabetes mellitus was found. This included 40 previously known cases and 30 newly discovered diabetic patients. Thus, 0.8 percent new diabetic patients were recognized during this survey (Table 3).
Table III–Percentage of new diabetic patients discovered in the general population with the use of urinalysis plus blood sugar as the screening method
author(s) | number of patients screened | percentage of new diabetics |
Wilkerson and Krall8 (1947)
Harwood11 (1953) |
3,516
1,957 |
0.8
5.0 |
Harwood11 tested the urine for sugar by means of the Galatest in men and the Clinitest in women in 1,957 individuals. Capillary blood sugar was simultaneously determined by the Wilkerson-Heftmann method.12 A significant hyperglycemia was regarded as 160 mg. percent or greater. He concluded that 5 percent of new diabetic patients were recognized during this survey (Table 3).
Studies in Specific Groups: A number of different studies are available based on surveys of selected groups of the population. In some instances the screening procedure was simply an urinalysis and in other instances both urine and blood sugar determinations were employed.
Urinalysis as the Screening Procedure: Gates13 studied 1,800 individuals in an industrial plant who for years had had careful, thorough physical examinations including at least one urinalysis per year (Table 4). Seventy-one individuals gave a positive family history of diabetes mellitus and 46 showed melituria while 8 were known diabetic patients. Glucose tolerance tests were performed on all those with a positive hereditary background and those who displayed melituria. Nine of those with a family history and 11 with sugar in the urine proved to be diabetic. Thus, this investigator found an incidence of 0.9 new diabetic patients in this select population of 1,800 industrial employees.
Table IV–Percentage of new diabetic patients discovered in a selected group of the population with the use of urinalysis as the screening method
author(s) | nature of population | number of patients screened | percentage of new diabetics |
Gates13 (1942)
Blotner and Hyde14 (1943) Spellberg and Leff15 (1945) MacBryde17 (1949) Rochon and Moran18 (1957) |
industrial employees
selectees and volunteers selectees aged, obese, history of family diabetes dental patients |
1,800
45,650 32,033 17,451 3,122 |
0.90
0.30 0.02 0.90 1.20 |
Blotner and Hyde14 studied 45,650 consecutive selectees and volunteers between the ages of 18 and 45 who appeared for final examinations before induction into the armed forces (Table 4). Urinalysis was routinely done, and the urine checked for sugar by Benedict’s qualitative solution. If urinalysis proved positive, the classical three-hour glucose tolerance test was done and the venous blood sample measured according to the method of Folin and Wu.9 These investigators found an incidence of 0.8 percent melituria. If any of the blood samples during the glucose tolerance test reached 180 mg. percent and some or all of the urinalysis showed sugar, then the individual was regarded as diabetic. According to these standards, 0.3 percent of the selectees and volunteers were found to be suffering from diabetes mellitus.
Spellberg and Leff15 studied the urine of 32,033 consecutive selectees processed at the New Orleans induction station (Table 4). All individuals with positive urine samples were subjected to an Exton-Rose16 glucose tolerance test. In this manner, 9 cases (0.02 percent) of diabetes mellitus were noted.
MacBryde17 checked the urine of 17,451 individuals, principally in the old age category, obese persons, and those of diabetic families, in the city of St. Louis, Missouri (Table 4). Melituria was observed in 3.46 percent of the cases by means of the Galatest method. Where possible, blood was drawn two hours after the last meal, and true blood glucose was determined. Whenever the blood glucose sample proved to be 120 mg. percent or more true glucose, the patient was considered to be diabetic. This investigator concluded that there was an incidence of 0.9 percent new diabetic patients.
Rochon and Moran18 routinely examined the urine by the Clinitest procedure of every new dental patient at the University of Detroit School of Dentistry during a 5-year period (Table 4). The 3,122 ambulatory dental patients ranged in age from 12 to 80. Forty-three (1.5 percent) diabetic patients were detected during this study. Only 5 of these 43 persons knew that they had been suffering with diabetes mellitus. Consequently, these investigators found an incidence of 1.2 percent previously unrecognized diabetic patients. The followup on these urinalyses was done by referring the patients to their private physicians.
Urinalysis plus Blood Sugar as the Screening Procedure: Canelo, Bissell, Abrams, and Breslow19 studied 945 employees at 4 industrial plants (Table 5). Urinalysis was performed by means of the Benedict test. The blood sugar values were determined by the standard Folin-Wu9 method. Patients who showed melituria or a blood sugar of 160 mg. percent or over (130 mg. percent if the subject had eaten more than 2 hours previously) were informed that they should consult their private physicians for further examination. The screening urinalysis revealed 5.0 percent patients with positive sugar in the urine and 8.4 percent with a trace of melituria. Precisely what was done by the local physicians to establish a diagnosis of diabetes mellitus is not clear. However, these investigators reported the detection of six previously known and nine not previously recognized cases of diabetes mellitus, giving a total of 0.9 percent new cases.
Table V–Percentage of new diabetic patients discovered in a selected group of the population with the use of urinalysis plus blood sugar as the screening method
author(s) | nature of population | number of patients screened | percentage of new diabetics |
Canelo et al19 (1949)
Tabor and Frankhauser20 (1950) Kenny et al21 (1951) Harting and Glenn25 (1951) Kenny and Chute27 (1953) Carroll et al28 (1954) Chesrow and Bleyer29 (1955) |
industrial employees
over age 40 above preschool age above age 25 above the age of 6 above age 16 nondiabetic above age 60 |
945
550 4,419 3,186 6,673 5,708 1,000 |
0.9
2.9 0.5 2.2 0.5 0.4 6.4 |
Tabor and Frankhauser20 studied the blood sugar determinations by the Folin-Malmros procedure10 of 550 patients over the age of 40 (Table 5). Those individuals with blood sugar levels above the screening level (150 mg. percent) were requested to return for followup studies. Fasting blood sugar determinations and urinalysis were done. Those with a fasting sugar level of greater than 120 mg. percent and those with a fasting melituria were asked to have a sugar tolerance test. A total of twenty-two cases of diabetes mellitus was discovered. This included six previously known and sixteen newly discovered cases. This number represents an incidence of four percent among this group with a percentage of 2.9 newly recognized cases.
Kenny, Chute, and Best21 examined 4,419 persons in all age groups except the preschool category (Table 5). Urine samples were tested qualitatively for reducing substance by means of the Clinitest method. True blood glucose was measured in capillary blood samples according to the Somogyi-Nelson method.22,23,24 All measurements were made immediately after breakfast or lunch. If the blood glucose values were in excess of 160 mg. percent between 1 and ½ hours after a meal and the values proved to be 150 mg. percent between 1½ and 2 hours or the levels were over 120 mg. percent 2 hours after a meal or in a fasting state, the screening tests were considered abnormal. Such persons and those with melituria were subjected to a 2-hour glucose tolerance test: A diagnosis of diabetes mellitus was made if the blood glucose values proved to be 200 mg. percent or more on two occasions or during the glucose tolerance test. Diabetes was also regarded as being present if both the peak was above 200 mg. percent and the 2-hour test greater than 120 mg. percent. A fasting blood sugar of more than 120 mg. percent was also considered as evidence of diabetes mellitus. These investigators claimed a total incidence of 0.5 percent previously unrecognized diabetic patients.
Harting and Glenn 25 studied 3,186 persons over the age of 25 by means of urinalysis (Galatest procedure) and capillary blood sugar (Folin and Malmros method).10 Most of the subjects presented themselves for the initial test with preparatory instructions. Preliminary screening levels were selected from the initial blood sugar readings. Patients were recalled for further determinations if the initial blood sugar was 160, 150, 140, or 130 mg. percent ½ to 1½, 1½ to 2½, 2½ to 3½ or more than 3½ hours later respectively. All patients with melituria were also recalled. Of the 3,186 patients, 10.6 percent showed a blood sugar greater than the established screening levels, and 14.1 percent of the subjects had melituria. These individuals were recalled, at which time capillary and venous blood specimens were taken and each analyzed by the Folin-Malmros,10 Folin-Wu,9 and Somogyi-Nelson26 methods. Of the 3,186 persons over 25 years of age examined, 71 (2.2 percent) newly discovered diabetic patients were detected by using both blood sugar and urine sugar as the original screening procedure.
Kenny and Chute27 studied the prevalence of diabetes mellitus in two Ontario towns (Table 5). A total of 6,673 persons over the age of 6 were tested as reported earlier.21 They found 0.5 percent new diabetic patients.
Carroll, Kurlander, and Nester28 examined 5,708 individuals above the age of 16 by means of urinalysis (Clinitest) and blood sugar (Wilkerson-Heftmann tablet method12) using 180 mg. percent as the critical threshold (Table 5). However, later in their study they used values above 130 mg. percent as indicative of diabetes mellitus. According to their calculations, there were 0.4 percent previously unrecognized patients with diabetes mellitus.
Chesrow and Bleyer29 studied 1,000 patients ranging in age from 60 to 110 (Table 5). Between 2 and 2½ hours after a meal, venous blood was drawn and the sugar concentration measured by the Wilkerson-Heftmann tablet method.12 The reducing substances in the urine were determined qualitatively with Clinitest tablets. Patients whose blood sugar screened above 130 mg. percent or who had a trace or more of reducing substances in the urine were given a glucose tolerance test of the 3-hour type. In all blood samples of the glucose tolerance test, the true blood sugar was determined by the Somogyi23 and Folin-Wu9 procedures. These investigators reported an incidence of 6.4 percent previously unrecognized diabetic individuals.
Oral Manifestations of Diabetes Mellitus
A study of the dental literature for the past twenty years discloses a list of about fifty publications directly related to diabetes mellitus and the oral cavity. Those of particular importance in this discussion may be divided into three groups: (1) oral symptoms, (2) oral signs, and (3) oral roentgenographic evidence of diabetes mellitus.
Oral Symptoms: The most common subjective complaints reported in the literature are: (1) dry mouth, (2) burning mouth, (3) tender gingiva, (4) pain with percussion of the teeth, and (5) dry sockets.
Dry Mouth: Frequent reference is made to the association of xerostomia and diabetes mellitus. Sheppard30 examined a group of 100 diabetic patients including 12 under the age of 21 and 4 above 70 years of age. This author divided the diabetic individuals into 3 categories which he referred to as mild, moderate, and severe diabetes. However, no mention is made in his report as to the criteria for this classification. Sheppard reported dryness of the mouth as constant or almost so in 6 percent of the cases, occasionally present in 20 percent, and only rarely observed in 8 percent. Banks31 and Amies and Park,32 without citing figures, also reported the association of xerostomia and diabetes mellitus.
Burning Mouth: Sheppard,30 in his study of 100 diabetic patients, made mention of the fact that 2 percent of his cases complained with a burning sensation in the oral cavity.
Tender Gingiva: Rudy and Cohen33 studied 403 diabetic patients. They simply mention the fact that gingival tenderness is a common complaint. Rutledge,34 in his study of 20 diabetic children between the ages of 8 and 19 years, also made mention of the presence of tenderness of the gingiva. Lovestedt and Austin35 studied the incidence of periodontoclasia in a group of 503 diabetic and 1,023 nondiabetic patients and observed the symptom of gingival tenderness. Amies and Park32 analyzed the oral findings in 32 diabetic children age 6 to 14 years attending a diabetic camp and made casual mention of tenderness of the gingiva. Kaplan,36 Rudy and Cohen,37 and Aboul-Ela 38 made similar observations without citing specific data.
Pain with Tooth Percussion: Rudy and Cohen33,37 Kaplan,36 Rutledge,34 Pollack, Person, and Knishkowy,39 and Martinez40 observed sensitivity of the teeth to percussion. However, the frequency of this symptom nor its method of appraisal are not considered in any of these reports.
Dry Sockets: Banks31 mentioned the fact that alveolar osteitis occurs with greater frequency in diabetic patients. Krongold41 indicated specifically that dry socket occurs more often even in patients with controlled diabetes mellitus. Zerbe42 reported that alveolar osteitis is twice as frequent in diabetic as against nondiabetic patients.
Oral Signs: The most common oral areas discussed in connection with diabetes mellitus are: (1) lips, (2) gingiva, (3) tongue, and (4) teeth.
Lips: Martinez40 mentioned, without citing figures or criteria, the frequent occurrence of dryness of the lips.
Gingiva: A number of interesting gingival signs of disease have been observed and described in diabetic patients. They include: (1) swelling, (2) bleeding, (3) violaceous hue, (4) pocket formation, and (5) recession.
Gingival Swelling: Rudy and Cohen,33,37 Kaplan,36 Rutledge,34 Lovestedt and Austin,35 Banks,31 Pollack, Person, and Knishkowy,39 Amies and Park,32 and Aboul-Ela38 all have mentioned the common occurrence of gingival edema. Ziskin, Siegel, and Loughlin43 specifically indicated a 15 percent incidence of spongy gingiva in their series of cases.
Gingival Bleeding: Rudy and Cohen,33,37 Kaplan,36 Rutledge,34 Lovestedt and Austin,35 Banks,31 Amies and Park,32 Martinez,40 and Aboul-Ela38 have all indicated the common association of easy gingival bleeding and diabetes mellitus. Ziskin, Siegel, and Loughlin43 specifically indicated a 32 percent occurrence in the 94 children in their series.
Violaceous Gingival Hue: Ziskin, Siegel and Loughlin43 indicated gingival discoloration in 92 percent of their series of 94 diabetic children. Pollack, Person, and Knishkowy39 and Aboul-Ela38 simply commented on the presence of a violaceous hue to the gingival tissues without establishing the frequency.
Pocket Formation: Ziskin, Siegel and Loughlin43 cited an incidence of 89 percent of diabetic children with periodontal pockets. Banks31 simply mentioned the association.
Tongue: A number of interesting lingual signs of disease have been observed in diabetic individuals. They include: (1) smoothness of the dorsum of the tongue, (2) geographic pattern, (3) tongue coating, (4) redness, (5) enlargement, and (6) fissures of the tongue.
Smooth Tongue Surface: Sheppard30 pointed out that migratory areas of denudation on the dorsal surface of the tongue may be associated with diabetes mellitus.
Coated Tongue: Sheppard30 reported that the most common oral finding was that of coated tongue in 92 percent of his cases. However, he felt that this finding is insignificant in his chronically ill hospitalized series of patients.
Red Tongue: Sheppard30 and Banks31 simply pointed out the association between diabetes mellitus and lingual erythema.
Enlarged Tongue: Sheppard30 and Banks31 claimed macroglossia as a diabetic finding.
Fissured Tongue: Sheppard,30 Banks,31 Pollack, Person, and Knishkowy39 and Martinez40 reported fissuring of the tongue as a sign of diabetes mellitus.
Teeth: A number of interesting dental observations have been made and reported in the literature. They include: (1) increased tooth mobility, (2) increased tooth loss, and (3) caries experience.
Increased Tooth Mobility: Rudy and Cohen,33,37 Kaplan,36 Rutledge,34 and Martinez40 all reported loosening of the teeth.
Tooth Loss: Lovestedt and Austin35 reported a greater incidence of tooth loss in diabetic patients than in their observed nondiabetic population.
Caries Experience: Whether there is increased dental caries or not in the diabetic individual is still an open question. Krongold,41 and Cohen44 claimed an increase in dental caries. In contrast, Ziskin, Siegel, and Loughlin,43 Banks,31 Sindoni,45 and Aboul-Ela38 concluded that there is no increase in the caries experience.
Roentgenographic Findings: The two most discussed roentgenographic findings are: (1) alveolar bone atrophy, and (2) marginal widening of the periodontal membrane.
Alveolar Bone Atrophy: Rudy and Cohen,33 Kaplan,36 Pollack, Person, and Knishkowy,39 Stahl,46 Golomb,47 Martinez,40 and Person48 all have claimed that diabetes mellitus is associated with increased bone atrophy. Rudy and Cohen,37 in a subsequent report, disagreed with their own earlier report and claimed no bone loss. Rutledge34 observed bone loss in 10 of 20 children in his group. Lovestedt and Austin35 claimed that there was no significant roentgenographic difference in a group of 503 diabetic and 1,023 nondiabetic patients.
Marginal Periodontal Widening: Rutledge34 observed this finding in 14 of the 20 diabetic children in his study. Rudy and Cohen37 also noted this change. However, Ziskin, Siegel, and Loughlin43 could not demonstrate marginal periodontal widening in their series of cases.
Discussion
Several points are worthy of mention in the review of the detection of diabetes mellitus. First, the evidence suggests that the more elaborate the screening procedure, the greater the detection of previously unrecognized diabetic patients. This is borne out by a comparison of Tables 1, 2, and 3. By simply utilizing the examination of urine samples, the percentage of new diabetic patients is about 2 per 1,000. By means of blood sugar screening procedures, the figure rises to almost 2 per 100. By the use of blood sugar and urine techniques, the incidence increases to 5 per 100. Secondly, it is evident that the more select the sampling of the population, the greater the differences in the incidence of unrecognized cases. Thus, the higher the age group, the greater the number of previously unrecognized cases (Table 5). For example, Kenny et al21 and Kenny and Chute27 found only 0.5 percent in groups excluding only preschool children. In contrast, Harting and Glenn,25 Tabor and Frankhauser,20 and Chesrow and Bleyer29 found increasing numbers of diabetic patients as older groups were studied. Thirdly, the more rigid the requirements for diabetes mellitus, the smaller the percentage of positive screenees will prove to be true diabetic patients. Finally, mention should be made of the fact that but one study is reported in a dental population,18 and it is based only on urinalysis as the screening technique.
It is interesting to observe that a number of oral findings have been associated with diabetes mellitus. These, as reported earlier in this paper, may be divided into: (1) oral symptoms, (2) oral signs, and (3) oral roentgenographic pathoses.
There is no question but that it is extremely difficult to quantitate symptoms since their presence is largely derived from the patient’s statements. None the less, one cannot ignore the presence of symptoms, and it is of note that a number of investigators have attempted to relate various complaints to diabetes mellitus. Thus, from the review of the literature it appears that approximately 6 percent of diabetic patients complain with constant dry mouth and 20 percent with occasional xerostomia. Presumably, 2 percent of diabetic individuals report burning mouth. Apparently, dry sockets seem to occur twice as often in diabetic versus nondiabetic patients.
Signs of disease are somewhat easier to measure since the examiner has the opportunity of observing them directly. Only rarely have investigators attempted to quantitate changes in the oral cavity with the diabetic pattern. Gingival swelling has been reported in 15 percent of one series of cases. Gingival bleeding has been claimed to be present in approximately one-third of a group of diabetic children. One group of investigators have noted a violaceous hue of the gingiva in approximately 92 percent of their series of diabetic individuals.
The two most commonly discussed roentgenographic findings are alveolar bone loss and marginal periodontal widening. There is still no agreement as to whether these findings occur. In one study 50 percent of a group of children were observed to have abnormal alveolar bone loss. This same investigator reported 70 percent of a group of diabetic children with marginal periodontal widening.
It is clear from the review of the literature and this brief discussion that the evidence seems to indicate that oral findings are associated with diabetes mellitus. However, most of the publishable material must be recognized as being in the realm of opinion rather than fact. It would be extremely helpful to observe a group of patients who present themselves for routine dental care and to study the frequency with which the previously described oral symptoms and signs and roentgenographic findings occur. This will be described in the report to follow.2
Summary
- The evidence from leading medical authorities seems to indicate that some of the most commonly occurring symptoms and signs of diabetes mellitus appear in the oral cavity.
- During the past two decades approximately 50 articles have appeared in the dental literature dealing with the oral manifestations of diabetes mellitus. Very little of the material is of a quantitative nature and, therefore, it is difficult to draw any definite conclusions.
- Of the many epidemiologic studies performed in diabetes mellitus, only one has been reported in a dental population. This particular study utilized urinalysis as the screening procedure.
- The evidence is quite clear that the more sophisticated the screening technique, the greater the detection of diabetes mellitus.
- A report to follow2 will analyze the oral clinical and roentgenographic findings in the light of the three-hour true glucose tolerance test.
This investigation was supported in part by a traineeship grant (2G-1 S) from the Epidemiology and Biometry Section, Public Health Service.
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- Kenny, A. J., Chute, A. L. and Best, C. H. “A study of the prevalence of diabetes in an Ontario community.” Canad. Med. Assn. Jour. 65: #3, 233- 241, September 1951.
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