INFLUENCE OF SALIVARY GLUCOSE ON THE GROWTH OF CANDIDA ALBICANS IN TYPE I AND TYPE II DIABETES

NTRODUCTION

Diabetes mellitus(DM) is a complex multisystemic metabolic disorder characterized by a relative or absolute insufficiency of nsulin secretion and/or concomittant resistance to metabolic action of insulin on target tissues. Globally 180 million people are estimated to have DM. This metabolic disorder is a burden on both patient and society because of the high morbidity and mortality associated with nfections, and renal,retinal and vascular complication.

CLASSIFICATION
Etiologic classification of Diabetes mellitus(as per American Diabetes Association) 1. Type I Diabetes Mellitus(10%) [ called as insulin dependent or juvenile-onset diabetes] Type II Diabetes Mellitus(80%) [called as non insulin dependent or maturity onset diabetes] Other specific types of Diabetes(10%) Disease of exocrine gland like pancreas(e.g. chronic pancreatitis etc.) Endocrinopathies(e.g. acromegaly etc.) 4. Gestational Diabetes

Diabetes has variable and sometimes profound, effects on the oral tissues. o Patients with poor glycemic control are particularly prone to severe and /or recurrent oral infections. o Oral candidiasis, in particular, is reported to be more prevalent among these individuals. o The frequent occurrence of Candidal infections in patients with diabetes mellitus has been recognized for many years.
o

 The carriage of Candida in the oral cavity of diabetic subjects is claimed to be higher. The candidal density has also been reported higher in diabetes mellitus than in non-diabetic subjects Primary prevention of the disease and the prevention of diabetic complications are of great practical importance.

AIM AND OBJECTIVES

The present study was undertaken to estimate the prevalence of Candida carriage and their colonization in oral cavity of diabetic subjects and made an attempt to find the relationship of oral carriage of Candida in diabetics with their degree of diabetic control and with normal patients.

DIAGNOSTIC CRITERIA FOR DIABETES

For this study 2 ml peripheral venous blood was collected from every patient. o RNFPG level were measured using glucose oxidase method. o Subjects with RNFPG>140 mg/dl were diagnosed as diabetics. o Subjects with RNFPG between 70-140 mg/dl were considered as non diabetics.
o

MATERIALS AND METHODS

The study population included diabetic patients (n=30) and non diabetic/ contolled patients(n=30) attending the OPD of Department of oral and maxillo-facial pathology. o Verbal consent was obtained from every individual participating in the study.
o

 The subjects were divided into 3 groups: 1.group 1 was controlled diabetics n=15 who were being treated for diabetes and had random non fasting plasma glucose(RNFPG) values>140mg/dl and <200mg/dl; group 2 included patients with uncontrolled diabetes n=15 composed of patients who were being treated for diabetes and had RNFPG values>200mg/dl; group 3 were selected as non diabetics/controlled patients n=30 composed of non diabetic patients with RNFPG 70-140mg/dl.

SALIVA COLLECTION
o

Patient were asked to have their breakfast and to abstain from eating for 2 hours before the sample collection o Unstimulated saliva was collected using ''spit technique'' o The patient was asked to sit in the chair with the head tilted forward and instructed not to speak, swallow, or do any head movement. o Then the patient was instructed to spit in a sterile graduated container every minute for 3 minutes.

MEASUREMENT OF SALIVARY GLUCOSE LEVEL

Glucose level of unstimulated saliva was measured using glucose oxidase method in a semi automated analyzer. The saliva sample(100 microleter) was mixed with the reagent in 1:3 ratio and incubated for 5 minutes at 37 degree Celsius. The absorbance value of standard and the sample against the reagent blank was measured. The glucose standard was diluted 10 times for estimation of salivary glucose levels.

SALIVA SAMPLING AND ASSESSMENT OF SALIVARY YEAST COUNT

Saliva sampling for estimation of colony forming unit(CFUs) of candida was performed using oral rinse technique. All subjects rinsed their mouth for 60 seconds with 10 ml sterile phosphate-buffered saline. Each subject returned the rinse to a sterile container.

 The rinse was immediately concentrated by centrifugation at 2000rpm for 10 minutes. The supernatant was discarded and .001 microliter deposits was collected and was spread using inoculating loop onto Sabouraud dextrose agar plates supplemented with chloramphenicol. CFUs were counted manually and the number was multiplied by 1000 and expessed as CFU/ml

STATISTICAL ANALYSIS
LINEAR REGRESSION ANALYSIS
a 0.63 0.397 MODEL R R SQUARE STD. ERROR OF ESTIMATE

1799.292

0.859

0.738

1774.256

0.835

0.697

589.243

Groups

Controlled diabetics(a)

Uncontrolled diabetics(b)

Non diabetics/control (c)

Number of patients

15

15

30

Range of salivary glucose

1-18.9

1.5-25.6

.2-7.7

average of salivary glucose

11

21

*CFU range

200-8000

100-25000

100-5000

Average of CFU

2223.33

9553.33

1210.5

*CFU -colony forming unit

RESULTS
Salivary glucose level was significantly higher in diabetic subjects than in non diabetic subjects. The median (range) of unstimulated salivary glucose(USSG) level was highest in group 2 [21mg/dl (1.5-25.6mg/dl)] followed by group 1 [11mg/dl (118.9mg/dl)] and group 3 [3mg/dl(.2-7.7mg/dl)]. Significant differences in USSG between all groups was observed.

 Increase in salivary glucose level was directly related with increase in candida carriage more in uncontrolled diabetic patients than in controlled diabetic and non diabetic patients The median(range) CFU was significantly higher in group2 [9553CFU/ml(100-25000)] than in group 1 [2223CFU/ml(200-8000)] and group3 [1210CFU/ml(1005000)]

DISCUSSION
Detected salivary glucose level was significantly higher in diabetic subjects(group2>group1) than in non diabetic subjects(group3). This increase in salivary glucose level with increase in blood glucose level has been suggested to be attributed to leakage across the basement membrane of the salivary glands, particularly the Parotid gland when blood glucose level increase beyond a threshhold value.

 Analysis of salivary glucose level shows a positive correlation between glucose level and RNFPG in uncontrolled diabetics subjects , not in non diabetic subjects and control diabetic subjects. Candida CFUs were significantly higher in diabetic subjects (group2>group1) compared with non diabetic subjects (group3)

 Candida CFUs were significantly higher in diabetic subjects (group2>group1) compared with non diabetic subjects (group3) There was a significant positive correlation between salivary glucose and CFU of candida. High level of salivary glucose increase candidal adherence to buccal epithelial cells.

CONCLUSION
Increase in salivary glucose is suggestive of increase in candida carriage suggesting diabetic status and proneness for infections.