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Original Article

Prevalence of Candida in the Oral Cavity of Diabetic


Subjects
BV Kumar*, NS Padshetty**, KY Bai***, MS Rao+

Abstract
Objective: Estimation of prevalence of Candida in the oral cavity of diabetic and non-diabetic subjects.
Material and Methods: One hundred and three subjects of diabetes mellitus (49 Type 1 diabetes mellitus and
54 Type 2 diabetes mellitus) and one hundred non-diabetic subjects (control) were studied.
Results: 41(83.67%) out of 49 Type 1 diabetes mellitus, 37(68.52%) out of 54 Type 2 diabetes mellitus and
27(27%) out of 100 in non-diabetic subjects were found to carry Candida in their oral cavity. Colony Forming
Unit (CFU) of Candida in the oral cavity ranking in groups was Type 1 diabetes mellitus > Type 2 diabetes
mellitus > non-diabetic subjects.
Conclusion: Colonization and carriage of Candida in the oral cavity was found to be higher in diabetic
subjects than in non-diabetic subjects. However anti-diabetic therapy and glycaemic control in diabetes were
found to bear no relation with carriage of Candida in the oral cavity. ©

INTRODUCTION prandial blood sugar estimation. Out of 103 diabetic


subjects 49 were Type 1 and 54 were Type 2. After a
T he frequent occurrence of Candida infections in
patients with diabetes mellitus has been recognized
for many years and oral candidiasis in particular is
detailed history especially of symptoms suggestive of
any chronic complications of diabetes like neuropathy,
cardiovascular complications or nephropathy and
thought to be more prevalent among these individuals.1 associated hypertension, each subject was subjected to
The carriage of Candida in the oral cavity of diabetic a systematic physical examination particularly for the
subjects is claimed to be higher.2-4 The candidal density presence of severe anaemia, oedema, jaundice,
has also been reported higher in diabetes mellitus than lymphadenopathy, abdominal masses, cardiovascular,
in non-diabetic subjects, 2-3 not confirmed by other neurological and respiratory systems. Routine
investigators.5-7 The disparity in results may of course, investigations like urine analysis, complete haemogram,
be due to difference in sampling technique.8 Hence the chest x-ray, ECG (in relevant cases) apart from fasting, 2
present study was undertaken to estimate the prevalence hr. post-prandial blood sugar, glycosylated haemoglobin
of candidal carriage and their colonization in oral cavity and in a few cases lipid profile were done. Besides, where
of diabetic subjects and make an attempt to find the it was felt necessary abdominal ultrasound and blood
relationship of oral carriage of Candida in diabetics with testing for HIV were also done. The glycaemic control
their degree of diabetic control and with anti-diabetic was considered to be good if glycosylated haemoglobin
treatment. was less than 8%, values between 8-10% were regarded
MATERIAL AND METHODS as fair control, and greater than 10% were seen as poor
glycaemic control.9 Individuals were excluded from the
One hundred and three diabetic subjects and one study in either groups if they had received any antibiotic
hundred age and sex matched non-diabetic subjects / steroid therapy or had been using antiseptic
participated in the present study with prior informed mouthwashes or denture wearers. The diabetic subjects
consent. Non-diabetic subjects had fasting and 2 hr. post- who had received both oral anti-diabetic therapy and
insulin are also excluded from the study.
*Former Research Scholar, Gulbarga University and Lecturer, Each individual was supplied with a universal
Dept. of Microbiology, MR Medical College; **Professor, Dept.
of Microbiology, Gulbarga University; ***Former Reader and container containing 10ml. of sterile phosphate buffer
Incharge H.O.D. of Pedodontia, H.K.E.S. S.N.Institute of saline solution (PBS 0.1M pH 7.2), and was asked to
Dental Sciences and Research; +Professor, Dept. of Medicine, rinse mouth in the presence of clinician. After rinsing
M. R. Medical College, Gulbarga. the mouth 60 seconds thoroughly, expelled the mouth
Received : 15.4.2002; Revised : 24.3.2005; Accepted : 31.5.2005
rinse in to a sterile container. Saliva samples were
© JAPI • VOL. 53 • JULY 2005 www.japi.org 599
collected in the morning hours between 9am to 1pm and
oral rinse was vertex mixed prior to plating.
The sample was taken with 3.26 mm internal diameter
inoculating loop, which holds a drop of sample of
Sabouraud's dextrose agar plate from which the
inoculum was spread in a line across the entire plate
crossing the first inoculum streak numerous times to
produce isolated colonies. The plates were then
incubated at 370 C for 48 h. The growth of Candida was
identified by the smooth, white or creamy coloured
buttery colonies (Fig. 1 and Fig. 2). After 48 h. of
incubation, the number of candidal colonies on each
plate was enumerated and the number of CFU per ml. of
oral rinse derived by the formula.10
CFU per ml. = 1000 X number of colonies/4.
Statistical analysis
CFU were expressed as mean ± SD. Student’s t-test
was applied to determine the significance of difference
between Type 1, Type 2 and non-diabetic subjects in both
sexes. Fig. 1 : Growth of Candida on Sabouraud’s dextrose agar.

RESULTS
Candidal carriage
While in 100 non-diabetic controls oral candidal
carriage observed in 27 (27%), among diabetic subjects
it was observed in 41 (83.67%) of Type 1 and 37 (68.52%)
of Type 2 diabetics respectively (Table 1).
Candidal colonization
There was no significant difference for the CFU
between the two sexes among diabetics or non-diabetic
control. The mean values for CFU of Candida in non-
diabetic subjects were 103.61 (male) and 89.21 (female).
In Type 1 diabetic subjects the CFU mean values were,
1251.37 (male) and 1243.54 (female) while in Type 2
diabetic subjects the CFU mean values were, 830.37 (male) Fig. 2 : Gram positive round Candida cells.
and 861.96 (female). The mean values of CFU between according to their anti-diabetic therapy (viz., newly
Type 1 and Type 2 diabetic subjects and between diabetic diagnosed, controlled on diet, controlled on diet + oral
and non-diabetic subjects were found to differ anti-diabetic therapy and controlled on diet + insulin
significantly from each other (Table 2). therapy) and assessed for the prevalence of oral candidal
Candidal carriage and anti-diabetic therapy carriage. In newly diagnosed 4 diabetic subjects the oral
Diabetic subjects were divided in to four groups candidal carriage was observed only in 1 (25%) male

Table 1 : Oral candidal carriage in non-diabetic and diabetic subjects


Sl. No Case type Sex No. of cases with oral No. of cases without Total
candidal carriage candidal carriage
1. Non-diabetic Male 15 (27.78) 39 (72.22) 54
controls Female 12 (26.09) 34 (73.91) 46
Total 27 (27.00) 73 (73.00) 100
2. Type 1 diabetics Male 22 (81.48) 5 (18.52) 27
Female 19 (86.36) 3 (13.64) 22
Total 41 (83.67) 8 (16.33) 49
3. Type 2 diabetics Male 19 (65.52) 10 (34.48) 29
Female 18 (72.00) 7 (28.00) 25
Total 37 (68.52) 17 (31.48) 54
Grand total 78 (75.73) 25 (24.27) 103
*Results in parenthesis indicate the percentage of cases.

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Table 2 : Colony forming unit (CFU) of Candida in non-diabetic and diabetic subjects
Sl.No. Case type Sex No. of cases *Mean value + SD + SEM F-test
a
1. Non-diabetic control Male 54 103.61 174.78 23.78 Not significant
Female 46 89.21 a 165.14 24.34
2. Type 1 diabetics Male 27 1251.37 b 628.39 120.93 Not significant
Female 22 1243.54 b 525.18 111.96
3. Type 2 diabetics Male 29 830.37 c 619.25 114.99 Not significant
Female 25 861.96 c 561.79 112.35
*Figures indicated by common letters do not differ significantly.

Table 3 : Oral candidal carriage in diabetic subjects according to their anti-diabetic therapy
Sl.No. Case type Sex No. of cases with No. of cases without Total
oral candidal carriage oral candidal carriage
1. Newly Male 1 (25.00) 3 (75.00) 4
diagnosed Female 0 0 0
Total 1 (25.00) 3 (75.00) 4
2. Controlled Male 4 (66.67) 2 (33.33) 6
on diet Female 3 (75.00) 1 (25.00) 4
Total 7 (70.00) 3 (30.00) 10
3. Controlled on Male 14 (73.68) 5 (26.32) 19
diet + oral anti- Female 15 (71.43) 6 (28.57) 21
diabetic drugs Total 29 (72.50) 11 (27.50) 40
4. Controlled on Male 22 (81.48) 5 (18.52) 27
diet + insulin Female 19 (86.36) 3 (13.64) 22
Total 41 (83.67) 8 (16.33) 49
 Results in parenthesis indicate the percentage of cases.

Table 4 : Oral candidal carriage in diabetes: in relation to glycaemic control


Sl.No. Glycosylated Sex No. of cases with No. of cases without Total
haemoglobin oral candidal carriage oral candidal carriage
1. Less than 8% Male 8 (72.72) 3 (27.27) 11
(Good control) Female 5 (83.33) 1 (16.66) 6
Total 13 (76.47) 4 (23.52) 17
2. 8-10% Male 16 (66.67) 8 (33.33) 24
(Moderate control) Female 16 (72.72) 6 (27.28) 22
Total 32 (69.69) 14 (30.43) 46
3. More than 10 % Male 17 (80.95) 4 (19.04) 21
(Poor control) Female 16 (84.21) 3 (15.78) 19
Total 33 (82.50) 7 (17.50) 40
 Results in parenthesis indicate the percentage of cases.

case. In diabetic subjects who were controlled on diet DISCUSSION


alone, the oral candidal carriage was observed in 4
(66.67%) male diabetic subjects out of 6 cases and in 3 The present study has confirmed that Candida is more
(75%) female diabetic subjects out of 4 cases. In diabetic prevalent in the oral cavity of diabetics than non-
subjects having controlled on diet with oral anti-diabetic diabetics as observed by earlier workers.2-4 Only Type 1
drugs, the oral candidal carriage was observed in 14 diabetic subjects were studied in an earlier Indian study.3
(73.68%) male cases out of 19 cases and in 15 (71.43%) The present one studied both types of diabetic subjects
female cases out of 21 cases. In diabetics controlled on with good number of controls. However the carriage rate
diet and insulin, the oral candidal carriage was observed of Candida in the oral cavity was different in various
in 22 (81.48%) male cases out of 27 cases and in 19 studies. This could be due to the different methods of
(86.36%) female subjects out of 22 cases (Table 3). samplings (such as swabs, water and buffer etc) used by
different workers. The oral rinse technique with
Oral candidal carriage with glycaemic control phosphate buffer saline was used for sampling in the
Oral candidal carriage was observed in 13(76.47%) present study since this is known to be a sensitive
out of 17 in good controlled, 32(69.69%) out of 46 in technique for estimating the oral candidal carriage.11 Bai
moderate controlled and 33(82.50%) out of 40 in poorly et al. (1995) 3 used water and Samaranayeke et al (1986)11
controlled diabetic subjects (Table 4). used phosphate buffer saline in their study. There was a
significant difference in the carriage rate of Candida in

© JAPI • VOL. 53 • JULY 2005 www.japi.org 601


the oral cavity between Type 1 (83.67%) and Type 2 subjects received or the glycemic control that was
(75.73%) diabetic subjects vis-à-vis the non-diabetics achieved. In clinical terms, equal attention should be
(27%). Such higher rate of carriage in Type 1 diabetic given to both local and systemic predisposing factors to
subjects compared to Type 2 diabetic subjects was suppress the candidal density and hence reduce the risk
observed by previous workers also.12-13 of oral candidiasis in diabetes mellitus.
Colony forming unit (CFU) is usually recorded to
obtain the clinical data essentially to establish a clinical
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