SQU Med J, May 2011, Vol. 11, Iss. 2, pp. 179-186, Epub. 15th May 11
Submitted 14th Aug 10
Revision ReQ. 13th Dec 10, Revision recd. 19th Jan 11
Accepted 8th Feb 10

Diabetes mellitus is a growing public health concern and a common chronic metabolic disease worldwide.1-4 Diabetes 
mellitus represents a group of metabolic diseases 
that are characterised by hyperglycaemia due to a 
total or relative lack of insulin secretion and insulin 
resistance or both. The metabolic abnormalities 
involve carbohydrate, protein and fat metabolism. 
Diabetes mellitus affects all age groups, but is more 
common in adults. The World Health Organization 
(WHO) has recently declared it to be a pandemic.2 
Its prevalence has increased dramatically over the 
past few decades and it is expected to triple in 
the next decade. Diabetes mellitus is considered 
a leading cause of death due to its microvascular 
and macrovascular complications.5,6  The most 
common types of diabetes are type 1 (also known 
as insulin dependent) and type 2 (also known 

as non-insulin-dependent).7,8 Type 2 is the more 
prevalent type. Countries with the highest rates 
of diabetes in the Eastern Mediterranean region 
and the Middle East are the United Arab Emirates, 
Saudi Arabia, Bahrain, Kuwait and Oman.9 Oman 
is one of the countries that has a high prevalence 
of diabetes mellitus, especially type 2 diabetes, and 
its prevalence is expected to increase in the next 
twenty years.10,11

Various inflammatory diseases and soft tissue 
pathologies in oral cavities are associated with 
diabetes mellitus;12-14 however, awareness of these 
complications is lacking worldwide.15-18 Periodontal 
diseases have been proposed as the sixth most 
prevalent complication of diabetes mellitus 
following the other diabetic complications.19 It has 
been reported as a more frequent oral complication 
of diabetes compared to other oral manifestations 

1Department of Oral Health, Sultan Qaboos University Hospital, Muscat, Oman; 2Department of Medicine, College of Medicine and 
Health Sciences, Sultan Qaboos University, Muscat, Oman.
*Corresponding Author email: mmaskari@squ.edu.om

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
:مفتاح الكلمات

aBstract: Diabetes mellitus is a chronic disease affecting all age groups. It is one of the leading causes of 
mortality and morbidity worldwide. Many chronic macrovascular and microvascular complications of diabetes 
have been reported in the literature with few reports about oral complications. This article aims to review and 
increase the awareness of oral manifestations and complications of diabetes mellitus and to stimulate research on 
the subject. It treats in depth some of the complications such as periodontal disease, fungal infection and salivary 
dysfunction while other complications are mentioned briefly.

Keywords: Diabetes Mellitus; Oral; Complications; Periodontitis; Taste; Fungal

REVIEW

Oral Manifestations and Complications of 
Diabetes Mellitus

A review 
Awatif Y. Al-Maskari,1 *Masoud Y. Al-Maskari2, Salem Al-Sudairy1



Oral Manifestations and Complications of Diabetes Mellitus 
A review 

180 | SQU Medical Journal, May 2011, Volume 11, Issue 2

such as dry mouth and caries. Periodontitis is more 
frequent and severe in patients with diabetes with 
poor glycaemic control. Early identification and/or 
management of these oral manifestations may help 
in the early diagnosis of diabetes and in attaining 
better glycaemic control.20 Therefore, diabetic oral 
complications need to be identified and included 
in the ultimate care of diabetes in order to fight this 
chronic metabolic disease effectively.

Oral Complications and 
Manifestations of Diabetes 
Mellitus
Several soft tissue abnormalities have been reported 
to be associated with diabetes mellitus in the oral 
cavity. These complications include periodontal 
diseases (periodontitis and gingivitis); salivary 
dysfunction leading to a reduction in salivary 
flow and changes in saliva composition, and taste 
dysfunction. Oral fungal and bacterial infections 
have also been reported in patients with diabetes. 
There are also reports of oral mucosa lesions in 
the form of stomatitis,  geographic tongue, benign 
migratory glossitis, fissured tongue, traumatic 
ulcer, lichen planus, lichenoid reaction and angular 
chelitis.21-25 In addition, delayed mucosal wound 
healing, mucosal neuro-sensory disorders, dental 
carries and tooth loss has been reported in patients 
with diabetes.26 The prevalence and the chance of 
developing oral mucosal lesions were found to 
be higher in patients with diabetes compared to 
healthy controls.27

Periodontal Diseases

pat h o p h y s i o l o g y l o g y o f 
p e r i o d o n t i t i s

Periodontitis is one of the most widespread 
diseases in the world affecting the oral cavity, 
and is highly prevalent in both developed and 
developing countries.28 Periodontitis is a chronic 
inflammatory disorder affecting the gingivae and 
the periodontal tissue initiated by bacteria.29 The 
micro-flora in the dental plaque that forms daily 
adjacent to the teeth causes this inflammatory 
process. Eventually, the toxins that are released 
by the microorganisms in the dental plaque will 
start the gingival inflammation as a result of failure 

to remove the dental plaque on a daily basis. A 
periodontal pocket is formed as a result of the 
progression of the gingival inflammation causing 
the gingivae to detach from the tooth surface. 
This periodontal pocket is filled with bacteria 
and its toxins. As the disease worsens, the pocket 
will get deeper carrying the dental plaque until it 
reaches the alveolar bone that will eventually be 
destroyed with the periodontal attachment. This 
process is very common and causes destruction 
of periodontal tissues, loss of alveolar bone and, 
finally, tooth loss [Figure 1]. There are many 
factors contributing to this type of inflammation 
beside the presence of bacteria in dental plaque; a 
susceptible host is one of them.  

p e r i o d o n t i t i s a n d d i a b e t e s 
m e l l i t u s

The link between diabetes mellitus and periodontal 
disease is not well recognised by the medical 
community. Periodontal disease has been reported 
with increased prevalence and severity in patients 
with type 1 and type 2 diabetes.30 The mechanism 
by which hyperglycaemia can induce periodontal 
destruction is not yet fully understood. However, 
there are many theories which propose factors 
such as advanced glycation end products, 
changes in collagen statue, and altered immune 
function that causes impaired polymorphonuclear 
leukocyte function which may facilitate bacterial 
persistence in the tissue and the accumulation of 
advanced glycation end products, which results 
from prolonged and chronic hyperglycaemia and 
increased secretion of pro-inflammatory cytokines 
such as tumour necrosis factor-α and prostaglandin 
E-2.31,32 The increase in collagenase activity 
together with the reduction in collagen synthesis 
will adversely influence collagen metabolism. This 

Figure 1. Radiographic appearance of diabetic patient 
with sever periodontal destruction and bone loss.



Awatif Y Al-Maskari, Masoud Y Al-Maskari and Salem Al-Sudairy

review | 181

significant reduction in HbA1c.50 However, they 
also recommended that the results need to be 
viewed with caution due to a lack of strength and 
limitations in the designs of some of the studies 
included. Periodontitis and diabetes are related 
to each other therefore further larger studies are 
required to determine the effect of periodontal 
treatment on glycaemic control. 

Salivary and Taste 
Dysfunction

s a l i va r y d y s f u n c t i o n
Saliva has a major role in maintaining a healthy 
oral cavity. Saliva is produced by major salivary 
glands (parotid, sub-mandibular and sub-lingual) 
and numerous minor salivary glands distributed 
in the oral cavity. Salivary dysfunction has been 
reported in patients with diabetes.51,52 A cross 
sectional epidemiological study was conducted in 
2001 to look at the prevalence of hyposalivation 
and xerostomia (dry mouth) and to determine 
the relationship between salivary dysfunction and 
diabetes complications. This study was conducted 
in type 1 diabetics and control subjects without 
diabetes. They found that symptoms of reduced 
salivary flow rate and xerstomia were more 
frequently reported by patients with diabetes than 
the controls, especially by those diabetics who had 
developed neuropathy.53   Other studies conducted 
in type 2 diabetics also confirmed that xerostomia 
and hyposalivation were more prevalent in this 
group of patients.54 It has been shown that poorly 
controlled type 2 diabetics have a lower stimulated 
parotid gland flow rate compared to well-controlled 
patients and patients without diabetes.55 An 
increase in salivary pathogens was also reported 
in these patients.56 Patients with diabetes usually 
complain of xerostomia and the need to drink 
very often (polydypsia and polyuria). The constant 
dryness of the mouth would irritate the oral soft 
tissues, which in turn will cause inflammation 
and pain. Patients with diabetes with xerostomia 
are more predisposed to periodontal infection 
and tooth decay. The cause of this is not yet fully 
understood in patients with diabetes, but may be 
related to polydypsia and polyuria or alternation in 
the basement membrane of the salivary glands. It 
is known that diabetes mellitus is associated with 

would result in compromised wound healing as well 
as periodontal tissue destruction. Recent studies 
indicate that periodontitis has a bidirectional effect 
on glycaemic control in patients with diabetes.33 
There is a cluster of research studies, which support 
the hypothesis of periodontitis occurring more 
frequently in patients with diabetes with poor 
glycaemic control.33-38 In addition, there is enough 
evidence to support the hypothesis that poor 
periodontal conditions could worsen glycaemic 
control as well. Many studies report that diabetes 
is a risk factor for gingivitis and periodontitis and it 
is more severe with poor glycaemic control [Figure 
2].39 The risk of developing periodontitis in patients 
with diabetes has been reported to be three times 
higher than the general population.40

Numerous risk factors have been reported that 
make patients with diabetes more susceptible to 
periodontal disease, especially those with poor oral 
hygiene, poor metabolic control, longer duration 
of diabetes and who are smokers.41-43 Smoking 
was identified in many studies as being a major 
preventable risk factor for periodontal disease 
and tooth loss in the general population and in 
patients with diabetes.44-48 The dentist and the 
physician should play an important role in advising 
and supporting patients with diabetes regarding 
smoking cessation. The dentist should be engaged 
in counselling these patients and referring them to 
a specialist organisation which deals with smoking 
cessation.49

Several studies showed that the treatment of 
periodontal disease has an influence on glycaemic 
control in both type 1 and type 2. A recent meta-
analysis of the efficacy of periodontal treatment 
on glycaemic control in patients with diabetes 
suggested that such treatment could lead to a 

Figure 2. Clinical photograph showing periodontal 
abscess in poorly controlled diabetic patient. 



Oral Manifestations and Complications of Diabetes Mellitus 
A review 

182 | SQU Medical Journal, May 2011, Volume 11, Issue 2

chronic complications such as neuropathy, micro-
vascular abnormalities and endothelial dysfunction 
that lead to deterioration of microcirculation and 
this may play a role in reduction of the salivary 
flow rate and composition.57,58 Sialosis is defined as 
asymptomatic, non-inflammatory, non-neoplastic, 
bilateral chronic diffuse swelling mainly affecting 
the parotid glands. Sialosis has been found to be 
more prevalent in patients with diabetes mellitus.59  

ta s t e d y s f u n c t i o n
There are many factors that have been implicated 
in altered taste sensation in the oral cavity.  
Metabolic and endocrine diseases were proposed  
as causative factors for this disturbance; 
nevertheless, salivary dysfunction can contribute 
to altered taste sensation or elevation of detection 
thresholds.60, 61 Taste dysfunction has been reported 
to occur more frequently in patients with poorly 
controlled diabetes compared to healthy controls.62 
Diabetic patients who suffer from neuropathy have 
a higher taste threshold. Taste disturbance has also 
been reported to lead to poor glycaemic control by 
inhibiting the ability to maintain a good diet.63 

Oral Infection

f u n g a l i n f e c t i o n s
Oral candidosis is an opportunistic infection 
frequently caused by Candida albicans species. 
Many predisposing factors can lead to this 
infection; these include smoking, xerostomia and 
endocrine and metabolic diseases.64 Other factors 
were also implicated such as old age, medications, 
Cushing’s syndrome, malignancies, and the use of 
dentures.65 Oral candidosis has been classified into 
primary and secondary. Primary oral candidosis 
is subclassified into acute (pseudomembranous 
and erythematous), chronic (pseudomembranous, 
erythematous and hyperplastic) and candida 
associated lesions. 

Pseudomembranace candidosis is also known 
as oral thrush. It is characterised by the presence of 
a creamy white patch which, when wiped, reveals 
underlying erythematous and bleeding oral mucosa. 
The soft palate is the most commonly affected area 
followed by the cheek, tongue and gingivae. It could 
be chronic in immuno-compromised patients.66 
Erythematous candidosis can present as acute or 

chronic infection. It is believed to result from the 
usage of steroid and broad spectrum antibiotics 
and mainly affects the tongue.66 Hyperplastic 
candidosis is known as candidal leukoplakia. It 
appears as an irregular whitish raised plaque-
like lesion commonly seen in the buccal mucous 
membrane near the commissures. 

Candida associated lesions include denture 
induced stomatitis, angular chelitis and median 
rhomboid glossitis which have mixed bacterial 
and fungal etiology. Denture induced stomatitis 
is mainly seen in full denture wearers in the 
underlying surface of the upper denture. Angular 
chelitis is seen in the lip commissures as an 
erythematous crusting lesion. The lesion has been 
reported to occur in diabetics with poor glycaemic 
control. Median rhomboid glossitis is seen on 
the dorsal surface of the tongue as adepopulated 
erythematous diamond-shaped patch at the 
midline.

The incidence of fungal infections in patients 
with diabetes mellitus has been recognised for 
many years.67 Candidal infection is reported to be 
more prevalent in patients with diabetes especially 
in those patients who smoke, wear dentures, 
have poor glycaemic control and use steroids and 
broad spectrum antibiotics.68 In addition, salivary 
dysfunction in patients with diabetes can also 
contribute to higher carriage of fungi in this group 
of patients. It is clear from these studies that both 
local and systemic predisposing factors might 
increase candidal carriage rate and hence increase 
the risk of oral candidal infection in patients with 
diabetes.69-71

b a c t e r i a l i n f e c t i o n s
Patients with diabetes are more susceptible to 
developing oral bacterial infections. They are well 
known to have an impaired defense mechanism 
hence considered to be immuno-compromised. 
Diabetics with diabetic complications and poor 
metabolic control are more prone to spreading 
and recurrent bacterial infection. Several studies 
have reported that patients with diabetes are 
more prone to deep neck bacterial infection 
compared to patient without diabetes.72,73 A four-
year prospective study by Rao et al. investigated 
the severity of maxillofacial space infection of 
odontogenic origin, the type of micro-organism, 
the sensitivity of the micro-organisms to 



Awatif Y Al-Maskari, Masoud Y Al-Maskari and Salem Al-Sudairy

review | 183

especially in type 1 diabetes. In addition, acute 
hyperglycaemia causes alteration in the immune 
responsiveness in diabetes mellitus. Atrophic-
erosive oral lesions are more common in patients 
with diabetes with OLP.77 

Neuro-Sensory Oral 
Disorder
Oral dysesthesia or burning mouth syndrome 
(BMS) is a painful condition affecting the oral 
cavity (palate, tongue, throat and gingivae).78,79 
Other abnormal oral sensations may co-exist with 
the burning mouth sensation such as tingling, 
numbness, dryness or sore mouth at the same time.  
The exact cause of BMS is unknown, but it has been 
attributed to several conditions such as dry mouth, 
menopause, candidal infection, diabetes mellitus, 
cancer therapy, psychological problems and acid 
reflux.  BMS is classified into two types: primary 
idiopathic, and secondary as a result of a systemic 
process; secondary BMS has been reported to 
occur with diabetes mellitus. It could adversely 
affect the ability to maintain good oral hygiene in 
patients with diabetes. Diabetic neuropathy could 
be the underlying cause of BMS in patients with  
diabetes.  The nerve damage in diabetic neuropathy 
has been reported to show an increase in the 
Langerhans cells that are associated with immune 
disturbance.80, 81 Therefore, it is crucial to screen 
patients who have symptoms of BMS for diabetes 
mellitus. 

Dental Caries and Tooth 
Loss
It is well known that patients with diabetes are 
susceptible to oral infections that lead to tooth 
decay and loss.82 Salivary secretion dysfunction, 
periodontal and sensory disorders could increase 
the likelihood of developing new and recurrent 
dental caries and tooth loss [Figure 3]. The 
relationship between diabetes and development 
of dental caries is still unclear.  It is well-known 
that the cleansing and buffering capacity of the 
saliva is diminished in patients with diabetes 
mellitus resulting in increased incidence of dental 
caries, especially in those patients who suffer from 
xerostomia.  

antibiotics, and the length of hospital stay of 
patients with diabetes compared with patients 
without diabetes. They concluded that the spread 
of the bacterial infection to the submandibular 
space was more common in patients and controls 
and that the second commonest area was the 
buccal space. Streptococcus species was more 
commonly isolated in both groups. Patients with 
diabetes were found to stay longer in hospital due 
to more severe infection and required more time to 
control their blood glucose levels.74

Poor Oral Wound Healing
Poor soft tissue regeneration and delayed osseous 
healing in patients with diabetes are known 
complications during oral surgery. Therefore, 
the management and treatment of patients with 
diabetes undergoing oral surgery is more complex. It 
was reported that delayed vascularisation, reduced 
blood flow, a decline in innate immunity, decreased  
growth factor production, and psychological stress 
may be involved in the protracted wound healing of 
the oral cavity mucosa in patients with diabetes.75

Non-Candidal Oral Soft 
Tissue Lesion
Oral lesions that are not caused by candidal 
infection have been reported to occur in patients 
with diabetes such as fissured tongue, irritation 
fibroma and traumatic ulcer. These lesions were 
more prevalent in diabetes compared to the 
controls.27 Altered or delayed wound healing may 
play a role in traumatic ulcer. 

Oral Mucosal Disease 
Both lichen planus and recurrent apthous 
stomatitis have been reported to occur in patients 
with diabetes.76,77 Oral lichen planus (OLP) is a skin 
disorder that produces lesions in the mouth. OLP 
is reported to occur more frequently in patients 
with type1 diabetes compared to type 2 diabetes.76 

The reason for this is that type 1 diabetes is 
considered an autoimmune disease, and OLP has 
been reported to have an underlying autoimmune 
mechanism. Patients with diabetes are subjected to 
a prolonged state of chronic immune suppression 



Oral Manifestations and Complications of Diabetes Mellitus 
A review 

184 | SQU Medical Journal, May 2011, Volume 11, Issue 2

Conclusion
Diabetes mellitus is a chronic, non-communicable 
and endemic disease. Type 2 compared to type 1 
diabetes mellitus is more prevalent worldwide and 
increasing, especially in Oman. Oral manifestations 
and complications in patients with diabetes mellitus 
have been recognised and reported recently as a 
major complication of diabetes mellitus. There is 
increasing evidence that chronic oral complications 
in patients with diabetes adversely affect blood 
glucose control. Prevention and management of 
oral complications, especially periodontal disease, 
in patients with diabetes is important due to their 
possible adverse effect on glycaemic control. 
Promotion of a healthy oral cavity in patients 
with diabetes is paramount. Epidemiological and 
research data on this problem in Omani patients 
with diabetes should be expanded by further studies. 

There are several clinical implications from this 
review. These include: 1) a lack of  awareness of oral 
complications among both diabetics and health 
providers; 2) an understanding of the way diabetes 
affects oral health is necessary for both clinicians 
and patients, therefore research in this field should 
be encouraged; 3) the need for regular follow-up of 
patients with diabetes mellitus by both dentist and 
physicians; 4) the major role that dentists should 
play in recognising the signs and symptoms of 
diabetes and their oral complications; 5) advice and 
counselling for diabetic smokers regarding smoking 
cessation, and 6) vigorous treatment of oral 
infection either bacterial or fungal in these patients, 
especially if they have poor glycaemic control.

References
1. Diabetes—a global threat. Lancet 2009; 373:1735.

2. World Health Organization. Global Prevalence of 
Diabetes: Estimates for the Year 2000 and Projections 
for 2030. Geneva: World Health Organization, 2009.

3. Mokdad AH, Ford ES, Bowman BA, Nelson DE, 
Engelgau MM, Vinicor F, et al. Diabetes trends in the 
US: 1990 to 1998. Diabetes Care 2000; 23:1278–83.

4. Abegunde DO, Mathers CD, Taghreed A, Ortegon M, 
Strong K. The burden and costs of chronic diseases 
in low-income and middle-income countries. Lancet 
2007; 370:1929–38.

5. Moore PA, Zgibor JC, Dasanayake AP. Diabetes: A 
growing epidemic of all ages. J Am Dent Assoc 2003; 
134:11–15.

6. Shelesh J, Swarnlata S. Type 2 diabetes mellitus – 
Its global prevalence and therapeutic strategies. 
Diabetes Metab Syndr 2010; 4:48–56.

7. Report of the Expert Committee on the Diagnosis 
and Classification of Diabetes Mellitus. Diabetes 
Care 1997; 20:1183–97. 

8. Report of the Expert Committee on the Diagnosis 
and Classification of Diabetes Mellitus. Diabetes 
Care 2003; 26:S5–20.

9. Saadi H, Carruthers S. G, Nagelkerke N, Al-Maskari 
F, Afandi B, Reed R, et al. Prevalence of diabetes 
mellitus and its complications in a population-based 
sample in Al Ain, United Arab Emirates. Diabetes 
Res Clin Pract 2007; 78:369–377.

10. Asfour MG, Lambourne A, Soliman A, Al-Behlani 
S. High prevalence of diabetes mellitus and impaired 
glucose tolerance in the Sultanate of Oman: Result of 
the 1991 national survey. Diabet Med 1995; 12:1122–
5.

11. Al-Lawati JA, Al Riyami AM, Mohammed AJ, 
Jousilahti P. Increasing prevalence of diabetes 
mellitus in Oman. Diabet Med 2002; 19:954–7.

12. Bell G, Large D, Barclay S. Oral health care in 
diabetes mellitus. Dent Update 1999; 26:322–30.

13. Baldwin E. Oral health. Lancet 2009; 373:628–9.

14. Vernillo AT. Dental considerations for the treatment 
of patients with diabetes mellitus. Am Dent Assoc 
2003; 134:24–33.

15. Yuen HK, Wolf BJ, Bandyopadhyay D, Magruder 
KM, Salinas CF, London SD. Oral health knowledge 
and behavior among adults with diabetes. Diabetes 
Res Clin Pract 2009; 86:239–46.  

16. Al Habashneh R, Khader Y, Hammad MM, Almuradi 
M. Knowledge and awareness about diabetes and 
periodontal health among Jordanians. J Diabetes 
Complications 2010; 24:409–414.

17. Mirza KM, Khan A, Ali MM, Chaudhry S. Oral health 
knowledge, attitude, and practices and sources of 
information for diabetic patients in Lahore, Pakistan. 
Diabetes Care 2007; 30:3046–7. 

18. Moore PA, Orchard T, Guggenheimer J, Weyant 
RJ. Diabetes and oral health promotion: A survey 

Figure 3. Clinical photograph of diabetic patient with 
poor oral hygiene, showing dental carries and tooth 
loss. 



Awatif Y Al-Maskari, Masoud Y Al-Maskari and Salem Al-Sudairy

review | 185

periodontal treatment on glycemic control of 
diabetic patients: A systemic review and meta-
analysis. Diabetes Care 2008; 33:421–7.

34. Pihlstrom BL, Michalowicz BS, Johnson NW. 
Periodontal diseases. Lancet 2005; 366:1809–20.

35. De Silva NT, Preshaw PM, Taylor JJ, Jayaratne 
SD, Heasman PA, Fernando DJS. Periodontitis: 
A complication of type 2 diabetes in Sri Lankans. 
Diabetes Res Clin Pract 2006; 74:209–10.

36. Tsai C, Hayes C, Taylor GW. Glycemic control of 
type 2 diabetes and severe periodontal disease in 
the US adult population. Community Dent Oral 
Epidemiol 2002; 30:182–92.

37. Davies RM, Davies GM. Periodontal disease and 
general health. Dent Update 2005; 32:438–42.

38. Taylor JW. Periodontal treatment and its effects 
on glycemic control a review of the evidence. Oral 
Surg Oral Med Oral Pathol Oral Radiol Endod 1999; 
87:311–6.

39. Taylor GW, Borgnakke WS. Periodontal disease: 
Associations with diabetes, glycemic control and 
complications. Oral Dis 2008; 14:191–203.

40. Ryan ME, Carnu O, Kamer AA. The influence of 
diabetes on the periodontal tissues. J Am Dent Assoc 
2003; 134:34–40.

41. Irwin BC, Mullally B, Ziada H, Allen E, Byrne PJ. 
Periodontics: 2. Risk factors and susceptibility in 
periodontitis. Dent Update 2007; 34:270–6.

42. Katz PP, Wirthlin MR, Szpunar SM, Selby JV, Sepe 
SJ, Showstack JA. Epidemiology and prevention of 
periodontal disease in individuals with diabetes. 
Diabetes Care 1991; 14:375–85.

43. Kibayashi M, Tanaka M, Nishida N, Kuboniwa M, 
Kataoka K, Nagata H, et al. Longitudinal study of the 
association between smoking as a periodontitis risk 
and salivary biomarkers related to periodontitis. J 
Periodontol 2007; 78:859–67.

44. Calsina G, Ramon J-M, Echeverrıa J-J. Effects of 
smoking on periodontal tissues. J Clin Periodontol 
2002; 29:771–6.

45. Dietrich T, Maserejian NN, Joshipura  KJ,  Krall EA, 
Garcia RI. Tobacco use and incidence of tooth loss 
among US male health professionals. J Dent Res 
2007; 86:373–7.

46. Moore PA, Orchard T, Guggenheimer J, Weyant 
RJ. Diabetes and oral health promotion: A survey 
of disease prevention behaviors. J Am Dent Assoc 
2000; 131:1333–41.

47. Berlin I. Smoking-induced metabolic disorders: 
Diabetes Metab Syndr 2008; 34:307–14.

48. Beziaud F, Halimi JM, Lecomte P, Vol S, Tichet J. 
Cigarette smoking and diabetes  mellitus. Diabetes 
Metab 2004; 30:161–6.

49. Chestnutt I. Tobacco usage: The role of the dental 
team in smoking cessation. Dent Update 2010; 
37:55–62.

50. Darr L, Vergnes JN, Gourdy P, Sixou M. Efficacy 
of periodontal treatment on glycaemic control in 
diabetic patients: A meta-analysis of interventional 

of disease prevention behaviors. J Am Dent Assoc 
2000; 131:1333–41.

19. Löe H. Periodontal disease: The sixth complication 
of diabetes mellitus. Diabetes Care 1993; 16:329–34.

20. Teeuw WJ, Gerdes VEA, Loos BG. Effect of 
periodontal treatment on glycemic control of 
diabetic patients: A systemic review and meta-
analysis. Diabetes Care 2008; 33:421–7.

21. Sandberg GE, Sundberg HE, Fjellstrom CA, Wikblad 
KF. Type 2 diabetes and oral health: A comparison 
between diabetic and non-diabetic subjects. Diabetes 
Res Clin Pract 2000; 50:27–34.

22. Chomkhakhai U, Thanakun S, Khovidhunkit S-P, 
Khovidhunkit W, Thaweboon S. Oral health in Thai 
patients with metabolic syndrome. Diabetes Metab 
Syndr 2009; 3:192–7.

23. Collin HL, Niskanen L, Uusitupa M, Töyry J, Collin 
P, Koivisto A-M, et al. Oral symptoms and signs in 
elderly patients with type 2 diabetes mellitus. Oral 
Surg Oral Med Oral Pathol Oral Radiol Endod 2000; 
90:299–305.

24. Guggenheimer J, Moore PA, Rossie K, Myers 
D, Mongelluzzo MB, Block HM, et al. Insulin-
dependent diabetes mellitus and oral soft tissue 
pathologies: I. Prevalence and characteristics of non-
candidal lesions. Oral Surg Oral Med Oral Pathol 
Oral Radiol Endod 2000; 89:563–9.

25. Guggenheimer J, Moore PA, Rossie K, Myers 
D, Mongelluzzo MB, Block HM, et al. Insulin-
dependent diabetes mellitus and oral soft tissue 
pathologies. II. Prevalence and characteristics of 
Candida and candidal lesions. Oral Surg Oral Med 
Oral Pathol Oral Radiol Endod 2000; 89:570–6.

26. Lamster IB, Lalla E, Borgnakke WS, Taylor GW. 
The relationship between oral health and diabetes 
mellitus. J Am Dent Assoc 2008; 139:19–24.

27. Saini R, Al-Maweri SA, Saini D, Ismail NM, Ismail 
AR. Oral mucosal lesions in non oral habit diabetic 
patients and association of diabetes mellitus with 
oral precancerous lesions. Diabetes Res Clin Pract 
2010; 89:320–6.

28. Poul EP. Priorities for research for oral health in the 
21st Century - the approach of the WHO Global 
Oral health program. Community Dental Health 
2005; 22:71–4.

29. Kuo L, Polson AM, Kang T. Associations between 
periodontal diseases and systemic diseases: A 
review of the inter-relationships and interactions 
with diabetes, respiratory diseases, cardiovascular 
diseases and osteoporosis. Public Health 2008; 
122:417–33.

30. Preshaw PM. Periodontal disease and diabetes. J 
Dent 2009; 37:575–7.

31. Ritchie CS. Mechanistic links between type 2 
diabetes and periodontitis. J Dent 2009; 37:578–9.

32. Moore PA, Weyant RJ, Mongelluzzo MB, Myers 
DE, Rossie K, Guggenheimer J, et al. Type 1 diabetes 
mellitus and oral health: Assessment of periodontal 
disease. J Periodontol 1999; 70:409–17.

33. Teeuw WJ, Gerdes VEA, Loos BG. Effect of 



Oral Manifestations and Complications of Diabetes Mellitus 
A review 

186 | SQU Medical Journal, May 2011, Volume 11, Issue 2

studies. Diabetes Metab 2008; 34:497–506.

51. Moore PA, Guggenheimer J, Etzel KR, Weyant RJ, 
Orchard T. Type 1 diabetes mellitus, xerostomia, and 
salivary flow rates. Oral Surg Oral Med Oral Pathol 
Oral Radiol Endod 2001; 92:281–91.

52. Lin CC, Sun SS, Kao A, Lee CC. Impaired salivary 
function in patients with noninsulin-dependent 
diabetes mellitus with xerostomia. J Diabetes 
Complications 2002; 16:176–9. 

53. Sandberg GE, Wikblad KF. Oral dryness and 
peripheral neuropathy in subjects with type 2 
diabetes.  J Diabetes Complications 2003; 17:192–8.  

54. Chávez EM, Borrell LN, Taylor JW, Ship JA. A 
longitudinal analysis of salivary flow in control 
subjects and older adults with type 2 diabetes. Oral 
Surg Oral Med Oral Pathol Oral Radiol Endod 2001; 
91:166–73.

55. Chavez EM, Taylor GW, Borrell LN, Ship JA. Salivary 
function and glycemic control in older persons with 
diabetes. Oral Surg Oral Med Oral Pathol Oral 
Radiol Endod; 89:305–311.

56. Khovidhunkit SO, Suwantuntula T, Thaweboon S, 
Mitrirattanakul S, Chomkhakhai U, Khovidhunkit 
W. Xerostomia, hyposalivation, and oral microbiota 
in type 2 diabetic patients: a preliminary study. J Med 
Assoc Thai 2009; 92:1220–8.

57. Conner S, Iranfour B, Mills J. Alteration in parotid 
salivary flow in diabetes mellitus. Oral Surg Oral 
Med Oral Pathol 1970; 30:55–9.

58. Chomkhakhai U, Thanakun S, Khovidhunkit S-P, 
Khovidhunkit W, Thaweboon S. Oral health in Thai 
patients with metabolic syndrome. Diabetes Metab 
Syndr 2009; 3:192–7.

59. Scully C, Bagán JV, Eveson JW, Barnard N, Turner 
FM. Sialosis: 35 cases of persistent parotid swelling 
from two countries. Br J Oral Maxillofac Surg 2008; 
46:468–72.

60. Ship JA, Chavez EM. Special Senses: Disorders of 
Taste and Smell. In: Silverman S Jr, Eversole LR, 
Truelove EL, Eds. Essentials of Oral Medicine. 
Hamilton, London: BC Decker Inc., 2001. Pp. 279–
80.

61. Negrato CA, Tarzia O. Buccal alterations in diabetes 
mellitus. Diabetes Metab Syndr 2010; 2:3.

62. Lalla RV, D’Ambrossio JA. Dental management 
considerations for the patient with diabetes mellitus. 
J Am Dent Assoc 200; 132:1425-32.

63. Ship JA. Diabetes and oral health: An overview. J Am 
Dent Assoc 2003; 134:4-10s.

64. McIntyre G. Oral candidosis. Dent Update  
2001; 28:132–9.

65. Samaranayake LP. Host Factors and Oral Candidiasis. 
In: Samaranayake LP, MacFarlane TW, Eds. Oral 
Candidosis, 2nd ed. London: Butterworth & Co. Ltd, 
1990. Pp. 145–7.

66. Akpan A, Morgan R. Oral candidiasis. Postgrad Med 
J 2002; 78 :455-459.

67. Lamey PJ, Darwaza A, Fisher BM, Samaranayake LP, 
MacFarlane TW, Frier BM. Secretor status, candidal 

carriage and candidal infection in patients with 
diabetes mellitus. J Oral Pathol 1988; 17:354–7.

68. Willis AM, Coulter WA, Fulton CR, Hayes RJ, Bell 
PM, Lamey PJ. Oral candidal carriage and infection 
in insulin treated diabetic patients. Diabet Med  
1999; 16:675–9.

69. Hill LV, Tan MH, Pereira LH, Embil JA. Association 
of oral candidiasis with diabetic control. J Clin Pathol 
1989; 42:502–5.

70. Khosravi AR, Yarahmadi S, Baiat M, Shokri H, 
Pourkabireh M. Factors affecting the prevalence of 
yeasts in the oral cavity of patients with diabetes 
mellitus. J Mycol Med 2008; 18:83–8.

71. Soysa NS, Samaranayake LP, Ellepola NB. Diabetes 
mellitus as a contributory factor in oral candidosis. 
Diabet Med 2006; 23:455–9.

72. Huang TT, Tseng FY, Liu TC, Hsu CJ, Chen 
YS. Deep neck infection in diabetic patients: 
Comparison of clinical picture and outcomes with 
nondiabetic patients. Otolaryngol Head Neck Surg  
2005; 132:943–7.

73. Uthkarsh L, Shrinath N. Diabetic challenge in 
maxillofacial infection. Int J Oral Maxillofac Surg 
2007; 36:1040.

74. Rao DD, Desai A, Kulkarni RD, Gopalkrishnan K, 
Rao CB. Comparison of maxillofacial space infection 
in diabetic and nondiabetic patients. Oral Surg Oral 
Med Oral Pathol Oral Radiol Endod 2010; 110:7–12.

75. Abiko Y, Selimovic D. The mechanism of protracted 
wound healing on oral mucosa in diabetes: Review. 
Bosn J Basic Med Sci 2010; 10:186–91.

76. Amerikanou CP, Markopoulos AK, Belazi M, 
Karamitsos D, Papanayotou P. Prevalence of oral 
lichen planus in diabetes mellitus according to the 
type of diabetes. Oral Dis 1998; 4:37–40.

77. Torrente-Castells E, Figueiredo R, Berini-Aytés L, 
Gay-Escoda C. Clinical features of oral lichen planus 
- A retrospective study of 65 cases. Med Oral Patol 
Oral Cir Bucal 2010; 15:685–90.

78. ADA Division of Communications. Burning mouth 
syndrome. J Am Dent Assoc 2005; 136:1191.

79. Scala A, Checchi L, Montevecchi M, Marini I, 
Giamberardino MA. Update on burning mouth 
syndrome: Overview and patient management. Crit 
Rev Oral Biol Med 2003; 14:275–91.

80. Moore PA, Guggenheimer J, Orchard T. Burning 
mouth syndrome and peripheral neuropathy in 
patients with type 1 diabetes mellitus. J Diabetes 
Complications 2007; 21:397–402.

81. Tavakoli M, Boulton AJ, Efron N, Malik RA. Increased 
Langerhans cell density and corneal nerve damage in 
diabetic patients: Role of immune mechanisms in 
human diabetic neuropathy. Cont Lens Anterior Eye 
2010; [Epub 2010 Sep 16].

82. Collin H-L, Uusitupa M, Niskanen L, Koivisto A-M, 
Markkanen H, Meurman JH. Caries in patients 
with non-insulin-dependent diabetes mellitus. Oral 
Surg Oral Med Oral Pathol Oral Radiol Endod  
1998; 85:680–5.