|Year : 2021 | Volume
| Issue : 3 | Page : 301-305
Candida prevalence in the saliva of controlled and uncontrolled diabetic patients – A clinical study
Mehta Ruchi1, K Bains Sandeep2, Bhatia Archana3, Dua Nisha4, Mahajan Sukriti5, Deepika6
1 Department of Oral Medicine and Radiology, Himachal Institute of Dental Sciences, Paonta Sahib, Himachal Pradesh, India
2 Department of Oral Medicine and Radiology, Dasmesh Institute of Research and Dental Sciences, Faridkot, Punjab, India
3 Department of Periodontology and Implantology, Dasmesh Institute of Research and Dental Sciences, Faridkot, Punjab, India
4 Department of Oral Medicine and Radiology, Sri Sukhmani Dental College and Hospital, Dera Bassi, Mohali, Punjab, India
5 Department of Oral Medicine and Radiology, BRS Dental College and Hospital, Barwala, Panchkula, Haryana, India
6 Department of Prosthodontics, Sri Sukhmani Dental College and Hospital, Dera Bassi, Mohali, Punjab, India
|Date of Submission||04-Aug-2020|
|Date of Decision||25-Feb-2021|
|Date of Acceptance||06-Aug-2021|
|Date of Web Publication||28-Sep-2021|
Dr. Mehta Ruchi
Department of Oral Medicine and Radiology, Himachal Institute of Dental Sciences, Paonta Sahib, Himachal Pradesh - 173 025
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Context: Diabetes mellitus is a major cause of mortality and morbidity worldwide. The health of oral tissue is related to saliva and both the composition and flow of saliva are altered in diabetic patients. Aim: This study aims to assess the prevalence of Candida in diabetic patients and non-diabetic controls and to assess the relationship between the candidal carriage and glycemic control, the relationship between the oral prevalence of Candida species, and clinical candidal infection, and the effect of antidiabetic therapy and smoking on candidal infection. Settings and Design: This cross-sectional population-based study was conducted on 100 diabetic and 50 non-diabetic (control) patients. Methods and Material: Saliva samples were collected and the concentrated oral rinse technique was used for quantitative oral candidal isolation. A digital colony counter enumerated several candidal colonies on each plate. Statistical Analysis Used: Chi-square test and Mann–Whitney test are used. Results: Colony-forming units (CFU/ml) in diabetics were 3131.14 and in control was 986.8. Out of 55 diet control patients, 30 had a candidal carrier; out of 44 patients on oral hypoglycemic, 30 had candidal carrier; and out of 1 patient on insulin, 1 had a candidal carrier. Out of 19 diabetics (good control), 8 had candidal carrier; out of 28 (moderate control), 12 had candidal carrier; and out of 53 (poor control), 41 had a candidal carrier. Out of 14 smokers, 8 had candidal carriers, and out of 36 nonsmokers, 11 had candidal carriers. Conclusions: Diabetic patients carry a higher number of candida in their oral cavity.
Keywords: Candida, diabetes, smokers
|How to cite this article:|
Ruchi M, Sandeep K B, Archana B, Nisha D, Sukriti M, Deepika. Candida prevalence in the saliva of controlled and uncontrolled diabetic patients – A clinical study. J Indian Acad Oral Med Radiol 2021;33:301-5
|How to cite this URL:|
Ruchi M, Sandeep K B, Archana B, Nisha D, Sukriti M, Deepika. Candida prevalence in the saliva of controlled and uncontrolled diabetic patients – A clinical study. J Indian Acad Oral Med Radiol [serial online] 2021 [cited 2022 Dec 7];33:301-5. Available from: http://www.jiaomr.in/text.asp?2021/33/3/301/326895
| Introduction|| |
Diabetes mellitus is a significant global public health problem and is a major source of morbidity and mortality.,
The health of oral tissue is related to saliva and both the composition and flow of saliva may be altered in diabetic patients., Uncontrolled diabetes mellitus is a predisposing factor to fungal infections, especially those caused by Candida species., The present study was carried to assess the prevalence of Candida in diabetic patients and nondiabetics, the relationship between the candidal carriage and glycemic control, the relationship of Candida species and clinical candidal infection, and the effect of antidiabetic therapy and smoking on candidal prevalence.
Study design and settings
This study was conducted on randomly selected 100 diabetic patients of both genders.
Sample size estimation
The sample size for the study was calculated considering 80% power at 5% α error (i.e. the false positive rate, as large as we can tolerate, almost always, α=5%) to be as N=100 based on the studies conducted previously by Abu Elteen KH et al.
Inclusion and exclusion criteria
Inclusion criteria selected in the study were diabetic patients irrespective of their glycemic control in the age range of 30–70 years and 50 non-diabetic patients in the same age range as controls. Patients were classified into diabetics and non-diabetics (control) based on glycated hemoglobin values (HbA1c).
Patients presently on antibiotic therapy, steroid therapy, chemotherapy, antiseptic mouthwashes, radiation therapy, hormonal supplements, and pregnant patients were excluded from the study.
Ethical clearance, informed consent
The approval for the study was obtained before starting the study from the Institutional ethical committee (vide reference letter no. – 446 A, Dated 6-2-20). The ethical standard of study was as per the guidelines provided by The Committee for the Purpose of Control and Supervision of Experiments on Animals (CPCSEA) and “World Medical Association Declaration of Helsinki on Ethical Principles for Medical Research involving Human.” All patients were informed regarding the study and their consent was obtained.
General details of patients, such as name, age, and gender were recorded.
Collection of blood sample
Five millimeters of venous blood was taken from median cubital vein under sterilized conditions and blood investigations such as fasting blood sugar and glycosylated hemoglobin level were measured. The serum sample was analyzed using the standard glucose oxidase method. Glycosylated hemoglobin was estimated by an ion-exchange method using a commercial kit—Lifechem GHb.
For diabetics. the HbA1c value >6.5% and for control HbA1c value <5.7% were considered. Based on HbA1c value, good control: 6.0–8.0%; moderate control: 8.0–10.0%; and poor control: >10%.
A thorough intraoral examination was carried out for various conditions like median rhomboid glossitis, atrophic glossitis, fissured tongue, pseudomembranous candidiasis, and angular cheilitis.
Collection of saliva samples
Unstimulated mixed saliva was analyzed in this study. Saliva samples were collected in the morning hours between 9 am and 11 am. Before the collection of the saliva samples, patients were refrain from eating and drinking anything for at least 90 minutes before the procedure. The concentrated oral rinse technique was used for quantitative oral candidal isolation. The sample thus obtained was then centrifuged at 3000 rpm for 15 min. The supernatant was discarded and the rest was diluted with 1 ml phosphate-buffered saline for optimal microbial disaggregation.
A spiral platter was used to inoculate 50 μl of the rinse onto Sabouraud's dextrose agar using the pour-plate technique [Figure 1] under sterile conditions in an ultraviolet inoculation chamber. The plates were then incubated aerobically at 37°C for 48 h. After incubation, the growth of Candida was identified by smooth, white, or creamy-colored buttery colonies [Figure 2].
Several candidal colonies on each plate were enumerated by a digital colony counter [Figure 3] and several CFU/ml of oral rinse were derived by the formula: CFU/ml = 1000 × number of colonies/4.
The data thus obtained were tabulated and statistically analyzed using mean, standard deviation, Chi-square test, and Mann–Whitney test.
| Results|| |
There were 61 (61%) candidal carriers in diabetic and 19 (38%) in control. The difference was significant (P < 0.05) [Table 1]. There were 31 (57.4%) candidal carrier males and 30 (65.2%) females in diabetics. The difference was nonsignificant (P > 0.05) [Table 2]. There were 11 (35.4%) candidal carrier males and 8 (42.1%) females in controls. The difference was nonsignificant (P > 0.05) [Table 3].
Colony-forming units (CFU/ml) in diabetics were 3131.14 and in control were 986.8. Mann–Whitney test revealed significant differences in both groups (P < 0.05) [Table 4], [Graph 1].
Out of 55 diet control patients, 30 (54.5%) had candidal carrier; out of 44 patients on oral hypoglycemic, 30 (68.1%) had candidal carrier; and out of 1 patient on insulin, 1 (100%) had a candidal carrier. Chi-square test showed nonsignificant difference (P > 0.05) [Graph 2].
Out of 19 diabetics (good control), 8 (42.1%) had candidal carrier; out of 28 (moderate control), 12 (42.8%) had a candidal carrier; and out of 53 (poor control), 41 (77.3%) had candidal carrier [Table 5]. Intergroup comparison between good and moderate control diabetics was nonsignificant (P: 0.95), moderate and poor was significant (P: 0.005); and good and poor had a significant (P: 0.002) difference.
Out of 14 smokers, 8 (57.1%) had candidal carriers and out of 36 nonsmokers, 11 (30.5%) had candidal carriers. The difference was nonsignificant (P > 0.05) [Graph 3]. [Graph 4] shows that out of 61 diabetic carriers, 18 (29.5%) had clinical candidal infection and out of 19 control carriers, 3 (15.7%) had a clinical candidal infection. The difference was nonsignificant (P > 0.05).
| Discussion|| |
It is well established that uncontrolled diabetes mellitus is a predisposing factor to fungal infections, especially those caused by Candida species. The course of infection is also more complicated in these patients. Several factors are associated with the oral carriage of Candida in diabetic patients such as type of diabetes, degree of glycemic control, mode of treatment, and various other local predisposing factors like oral hygiene, smoking, and presence of dentures in the mouth. The present study was carried to assess the prevalence of Candida in the saliva of diabetic patients and controls, to find out the relationship between the candidal carriage and glycemic control, to investigate the relationship between the oral prevalence of Candida species and clinical candidal infection; and the effect of antidiabetic therapy and smoking on candidal prevalence.
In the present study, we observed Candida was more prevalent in the oral cavity of diabetics (61%) than controls (38%). This is following the observations by Taper Jones et al.
CFU is usually recorded to obtain the clinical data, essentially to establish a clinical diagnosis of oral candidiasis. The total number of Candida present in the oral cavity is thought to be important in the development of infection. There were 31 (57.4%) candidal carrier males and 30 (65.2%) females in diabetics. There were 11 (35.4%) candidal carrier males and 8 (42.1%) females in controls. Epstein et al. have demonstrated that carriers and patients with oral candidiasis can be reliably distinguished based on quantitative cultures. In the present study, the mean candidal load for diabetic patients was 3131.14 CFU/ml, and for non-diabetic controls, the mean value was 986.84 CFU/ml, thus showing that CFU of Candida was significantly higher in diabetic patients than in controls.
It is established that diabetes predisposes to the high oral candidal carriage. If so, the question arises whether control of diabetes mellitus with antidiabetic therapy could prevent the carriage of Candida. We found that out of 55 diet control patients, 30 (54.5%) had candidal carrier; out of 44 patients on oral hypoglycemic, 30 (68.1%) had candidal carrier; and out of 1 patient on insulin, 1 (100%) had a candidal carrier. We have established that there was no relationship between the oral candidal carriage and the antidiabetic therapy. Kumar et al. classified patients according to antidiabetic therapy used. It was found that in four diabetic patients, only one (25%) male had an oral candidal carriage. It was observed that in patients on diet alone, only four males and three females showed oral candidal carriage. In diabetic patients having controlled on diet with oral antidiabetic drugs, the oral candidal carriage was observed in 14 (73.68%) male cases out of 19 cases and in 15 (71.43%) female cases out of 21 cases. They did not find any relationship between antidiabetic therapy and oral candidal carriage. Bhuyan et al. also observed that the method of diabetic treatment appeared to have no relationship with oral candidal carriage.
Being diabetic may not place a person at increased risk of fungal infections, unless diabetic control is very poor. In the present study, out of 19 diabetics (good control), 8 (42.1%) had candidal carrier; out of 28 (moderate control), 12 (42.8%) had candidal carrier; and out of 53 (poor control), 41 (77.3%) had a candidal carrier. We observed that although the number of patients having clinical candidal infections was more in the diabetic group as compared to the control group and most of them belonged to poorly controlled glycemic group, the difference in results between the two groups was not statistically significant. This is following Tapper Jones and Willis. Many aspects of oral manifestations of diabetes are related to local factors which are not associated with the disease, if well controlled. Thus, a high frequency of clinical candidiasis was not observed in the whole of the poorly controlled group. The development of oral candidiasis is not the result of a single entity, but a combination of risk factors.
We found that out of 14 smokers, 8 (57.1%) and out of 36 nonsmokers, 11 (30.5%) had candidal carriers. Out of 61 diabetic carriers, 18 (29.5%) had clinical candidal infection and out of 19 control carriers, 3 (15.7%) had a clinical candidal infection. The difference was nonsignificant (P > 0.05).
Darwazeh et al. found that 42 (84%) of the smokers and 37 (74%) of the nonsmokers had candidal species. The mean CFU/ml was 333 in smokers and 268 in nonsmokers. The author suggested that tobacco smoking did not appear to increase oral colonization with Candida species in nonsmokers. In the present study also, we found a nonsignificant difference of Candida species in smokers and nonsmokers which was following Rasool et al. and Conley et al.
Limitations and Future Prospects
Information on the candidal carriage in diabetic patients is often contradictory, possibly because of a variety of sampling techniques that have been employed and also to the different patient and control populations chosen by various investigators.
The shortcoming of the present study is a small sample size. The variation in the results may be because of the specific technique used.
Both local and systemic factors play a role in establishing clinical candidiasis and so the diabetic patients carrying a higher number of Candida in their oral cavity were encouraged to control local factors by maintaining adequate oral hygiene. However, more studies are necessary to determine the relations between other important combinations of risk factors and oral Candida.
| Conclusion|| |
Oral candidal prevalence was higher in diabetic patients than in control patients. The carriage rate in the oral cavity increased as the glycemic control becomes worse. No significant association was found between the candidal carriage and antidiabetic therapy and smoking and clinical candidal infections.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]