J Bagh College Dentistry

Vol. 22(2), 2010

Salivary physicochemical

Salivary physicochemical properties in relation to caries-experience among type 1 insulin-dependent diabetic children
Nadia Al-Rawi M.Sc., Ph.D (1) Sulafa El-Samarrai M.Sc., Ph.D
(2)

ABSTRACT
Background: Changes in the salivary physiochemical proprieties has been reported among diabetic patients and it is considered as a risk factor affecting the severity and occurrence of dental caries. The aims of this sudy was to investigate the severity of dental caries in relation to organic and inorganic factors (glucose, total protein, calcium and phosphorous ion) in addition to insulin hormone in stimulated saliva among type 1 insulin dependent diabetic children in comparison to non diabetic group matching with age and to investigate changes of the salivary variables (pH, flow rate and buffer capacity). Patients and methods: The study group included 60 children, with an age range of 11-13 years of both sexes. They were with confirmed diagnosis of type 1 insulin dependent diabetes mellitus. Children were divided into two groups according to the duration of the disease. The control group included 30 children matching with age and gender with the two study groups. Assessment and recording of caries experience were through the application of decayed, missing and filled surface index (DMFS&dmfs). The collection of stimulated salivary samples was performed under standardized condition. Salivary samples were chemically analyzed for detection of selected organic and inorganic constituents. Results: A high severity of dental caries was seen among diabetic group compared to the control, differences were statistically highly significant in permanent dentition. Highest values of buffer capacity, pH and salivary flow rate were seen in the control group compared to diabetics, with statistically significant difference. In all three groups a negative correlation coefficient was seen between caries-experience and salivary flow rate. Inverse correlations were observed between dental caries and nearly all salivary constituents. Conclusions: A changes in the physiochemical properties of saliva was recorded among diabetic children, affecting the severity of caries experience. Key words: Diabetes mellitus, saliva, dental caries. (J Bagh Coll Dentistry 2010;22(2):113-117).

INTRODUCTION
Diabetes was considered as a risk factor for the impaired oral health (1). The association between diabetes mellitus and pathologic changes in the oral cavity, affecting the soft and hard tissues, has been the subject of many reports in the dental literature (1&2). There are several diabetes related factors such as the age at the diagnosis, duration of illness and the degree of diabetic control (3). Saliva is a complex secretion that plays a major role in maintaining the oral and dental health. Saliva unlike the other body fluid, is a difficult subject to study because of the wide intra and inter individual variations regarding both composition and physical proprieties (4). Studying these variables may focus the light on changes of oral disease pattern among those diabetic patients and their role as a risk factor on the increase of the severity of oral and dental disease.

The aims of the study were to estimate the occurrence and severity of dental caries among type 1 Insulin Dependent Diabetic children and to study the relation with organic and inorganic factors in stimulated saliva, in addition to salivary variables.

PATIENTS AND METHODS

The study group included 60 children, with an age range of 11-13 years of both sexes. The children were examined at the Diabetic Center, AL-Yarmook Teaching Hospital in Baghdad City. Children were all with confirmed diagnosis of type 1 insulin dependent diabetes mellitus (IDDM). Children were divided into two groups according to the duration of the disease, a group with long duration diabetes mellitus (more than four years), and the other with newly diagnosed diabetes mellitus. The control group included 30 children matching with an age with the two study groups. Diabetic children were attended diabetic center for routine check up of fasting serum glucose level, which was estimated in the laboratory in the same day of oral examinations. The collection of stimulated salivary samples was performed under standard condition following instruction cited by Tenovuo &

(1) PhD student, dep. of Preventive and pediatric dentistry, college of dentistry, University of Baghdad (2) Professor, dep. of Preventive and pediatric dentistry, college of dentistry, University of Baghdad

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Lagerlof (5). Assessment and recording of caries experience were through the application of Decayed, Missing and Filled Surface Index (DMFS&dmfs) (6). Salivary flow rate was expressed as ml / min and salivary pH was measured using an electronic pH meter. Buffering capacity of the sample was assessed according to the method described by Ericsson (7). The salivary samples were then taken to the laboratory for biochemical analysis. Salivary glucose level was measured by enzymatic method (glucose-oxidase method) (8). Glucose level concentrations of saliva were expressed in mg/dl. Salivary total protein was measured by colorimetric method (9) and expressed in mg/dl. The inorganic phosphate concentration was measured by colorimetric method (10&11). The salivary calcium concentration was measured by colorimetric method without deproteinization (12). Salivary and serum insulin hormone were measured by Insulin-G which is a solid phase enzyme immunoassay employing recombinant human insulin for the quantitative detection of antibodies against human insulin in human serum and saliva, the assay is a tool in the diagnosis of insulin dependent diabetes mellitus (AIDA, Autoimmune diagnostic assays) (13). The Statistical Package for Social Sciences (SPSS) version 15 was used to analyze data. Analysis of variance (ANOVA), Students t-test, was applied, in addition to Spearmans and Parsons correlation. The confidence limit was accepted at 95% (P <0.05).

RESULTS
Results showed that the mean values of cariesexperience for primary and permanent dentition were the highest in the long duration diabetic group followed by the newly diagnosed diabetic group then the control group; differences were statistically highly significant in the permanent dentition only (Table 1). The control group showed the highest value of salivary pH while the newly diagnosed diabetic group exhibited the lowest on, with statistically significant difference between the three groups. Salivary flow rate mean value was the highest in

the newly diagnosed diabetic group, while the lowest value was among the long duration diabetic group, with statistically highly significant difference. Regarding buffer capacity, results showed a high value recorded among the control group with statistically highly significant differences between groups (Table 2). In general a weak and not significant correlations were recorded between all salivary variables and caries-experience with various directions of the correlations, except for pH, a positive significant correlation was seen with dmfs, among the long duration diabetic group (r=0.456, P= 0.033). Calcium ions showed a decreased concentration in saliva of the long duration diabetic group compared to the other two groups, difference between the diabetic and the control groups was statistically significant. Phosphorous ions showed the opposite, an increase concentration in the saliva of the long duration diabetic group compared to the other two groups, statistically highly significant difference between groups were seen (Table 3). Statistically significant correlation was recorded between calcium ion concentration and (DMFS) in the long duration diabetic group (r=0.435, p= 0.016), strong positive significant correlation was recorded in phosphorous ion with (dmfs) in the control group (r= 0.509, P= 0.044). The highest glucose value was represented in the saliva of the long duration diabetic group, followed by the newly diagnosed group then the control, difference was statistically highly significant. Salivary total protein showed its highest value in the control group, difference between groups however was statistically not significant (Table 4). No significant correlations was existed between dental caries and both glucose and protein in the three groups. The mean value of salivary insulin hormone was higher in the control group compared with the two diabetic groups with statistically highly significant differences. A higher mean value of serum insulin hormone was seen in the long duration diabetic compared to the other diabetic group, with statistically highly significant differences (Table 5).

Table 1: CariesExperience of Primary and Permanent Teeth (Mean and Standard Deviation) among Study and Control Groups
dmfs DMFS Mean SD *Mean SD Long duration diabetics 8.965.12 13.705.95 Newly diagnosed diabetics 7.213.97 11.373.09 5.943.87 7.274.00 Control Groups
* F = 5.463, df = 2, P = 0.006 Highly Significant

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Table 2: Salivary Partial Hydrogen (pH), Flow Rate and Buffer Effect (Mean and Standard Deviation) among Study and Control Groups
Groups Long duration diabetics Newly diagnosed diabetics Control Flow rate (ml/min) Buffer capacity pH * Mean SD ** Mean SD ^^Mean SD 6.800.38 6.720.42 6.990.41 0.680.23 0.860.19 0.830.30 4.490.81 4.210.52 5.140.87

* F=3.556, df =2, P= 0.033 Significant ** F=4.824, df =2, P= 0.010 Highly Significant ^ ^F=12.316, df =2, P= 0.000 Highly Significant

Table 3: Salivary Calcium & Phosphorous (Mean and Standard Deviation) among Study and Control Groups
Calcium ion (mmol/L) Phosphorous ion (mmol/L) * Mean SD **Mean SD Long duration diabetics 0.770.38 3.760.65 Newly diagnosed diabetics 0.950.40 3.140.73 Control 1.080.52 3.070.70 Groups
* F = 3.996, df = 2, P =0.022 Significant **F = 9.149, df = 2, P =0.000 Highly Significant

Table 4: Salivary Glucose Level, and Total Protein (Mean and Standard Deviation) among Study and Control Groups
Glucose (mg/dl ) Total Protein (mg/dl) *Mean SD Mean SD 110.9640.17 243.06111.63 Long duration diabetics 73.4110.73 211.77096.86 Newly diagnosed diabetics 51.0721.18 261.09138.44 Control Groups
*F = 37.858, df = 2, P = 0.000 Highly Significant

Table 5: Salivary and Serum Insulin Hormone (Mean and Standard Deviation) among Study and Control Groups
** Serum ^^ Salivary Insulin hormone U/ml Insulin hormone U/ml Groups **Mean SD ^^Mean SD 2.3181.478 24.42912.985 Long duration diabetics 2.4153.746 10.3604.675 Newly diagnosed diabetics 4.7582.148 -------Control
^^F = 8.250, df = 2, **t = 5.584, df = 58, P = 0.001 Highly Significant P = 0.000 Highly Significant

DISCUSSION
A reduction in the flow rate of saliva was reported among children with long duration diabetic. This observation was not recorded among the newly diagnosed diabetic group, who show a flow rate of saliva similar to the control group. This may give an indication that the

duration of disease has an influence on salivary flow rate. One previous study by Moore et al. (2) stated a possible explanation for the hyposalivation associated with neuoropathy of salivary gland. Another explanation for this reduction of flow rate can be applied, is that the increase in glucose concentration in the blood

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may increase the osmolality of the glomerular filtrate and thus prevent the reabsorption of water as the filtrate passes down the renal tubular system. This in turn leads to loss of water and minerals which results in low flow rate of body fluid among diabetics (14,15). Hyposalivation as reported by present study among long duration diabetic patients, may give an explanation to the increase of the severity of dental caries among this group. The reduction in the salivary secretion may affect the cleansing properties as well as may decrease the clearance of food remaining, sugar and other noxious substances from oral cavity, therefore may increase the risk to dental caries (16). The reduction of flow rate of saliva may also explain the variation in the acidity (pH) of saliva between the three groups. A lower pH value was reported among diabetic groups compared to the control, differences between them were statistically highly significant. Further more changes in the buffer capacity was reported by the current study as a high significant difference in this capacity was reported between the three groups. The depletion in the buffer capacity among diabetic groups may give another explanation for the increase in the acidity of saliva. A positive correlation coefficient was reported between salivary flow rate and buffer capacity for all the three groups. One can assume that the reduction in the salivary flow rate may be the reason for increase acidity, thus increase severity of dental caries. The main buffer in stimulated saliva is bicarbonate/ carbonic acid (17), which was not studied here due to the technical difficulties. Other buffers as total protein and phosphorous was studied (18). Results of the present study showed a high mean value of total protein expressed in mg/dl among the control group compared to the other diabetic groups. A positive correlation was found between salivary total protein and both pH and buffer capacity. So one can suggest that the reduction in the protein may diminish buffer capacity in the saliva of diabetic patients which in turn affect the severity of dental caries. This study demonstrated a high concentration of phosphorous in diabetic patients compared to the control group, with statistically highly significant difference. However a negative correlation was reported with the salivary flow rate. Also a negative correlation was recorded with buffer capacity among diabetic patients. Thus one can conclude that phosphorous play an insignificant role on the buffer capacity of the saliva collected for the present study. Results also showed that with the increase in the phosphorous

concentration in the saliva among diabetic patients, there were a noticed reduction in the calcium concentration compared to the control group, difference was statistically significant. The reduction in the salivary calcium concentration may also explain the increase of caries experience among diabetic patients. The role of calcium in relation to remineralization of the outer enamel surface is well substantiated (19). Another possible cause for the higher severity of dental caries is the increase of salivary glucose concentrations, thus providing favorable conditions for cariogenic microorganisms. The present study demonstrated a high level of glucose in stimulated salvia measured in (mg/dl) in stimulated saliva of diabetic groups compared to the control. It was expected for the diabetic patients to have this high concentration of glucose as salivary samples were taken before insulin medication. Hyperglycemia may be the main cause of the increase of glucose level in saliva, however, the present study did not show a strong and significant correlation between saliva and serum glucose concentration, Chatterton et al.,(20) stated that salivary gland act as filters of blood glucose that would be altered by hormonal or neural regulation. Glucose level in saliva of long duration diabetic group was recorded to be statistically significantly higher compared to the newly diagnosed one. Thus the duration of the disease seems to have an impact on salivary gland leading to increase concentration of glucose in saliva. Salivary insulin level has been evaluated in the present study. Mean level of insulin hormone concentration in saliva was higher in the control group compared to the both diabetic groups and the lowest value in the long duration diabetic children, with highly significant differences between control and both diabetic groups. Unfortunately no previous studies were able to be found regarding salivary insulin hormone in relation to the type 1 diabetic children to compare with. Salivary insulin hormone in spite of its low level among diabetic children showed a negative correlation coefficient with caries- experience which was significant in the long duration diabetic group. It is not known if insulin hormone has any protective effect against dental caries. A positive correlation between salivary and serum insulin hormone was reported between both diabetic groups, but statistically not significant. This may be attributed to that, most of serum parameters are proteins, and these proteins are too large to reach saliva by means of passive diffusion across cells or by ultrafiltration, and the detection of these proteins in saliva is primarily due to

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contamination from serum through gingival crevicular fluid (GCF) or oral wounds (21). Therefore, serum levels of protein cannot be accurately monitored by means of salivary analysis.

20-Chatterton RT, Vogelsong KM, Lu YC, Ellman AB, Hudgens GA. Salivary as a measure of endogenous adrenergic activity. Clin Physiol 1996; 16: 433-48. 21-Vining RF, McGinley RA. The measurement of hormones in saliva. Possibilities and pitfalls. J Steroid Biochem 1987; 27: 81-94. (abstract).

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