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International Medical Journal Vol. 20, No. 4, pp. 443 - 445 , August 2013
INTERNAL MEDICINE
Comparison of Decayed, Missing or Filled Teeth (DMFT)
Indexes between Diabetic and Non-Diabetic Patients
Ninin Sukminingrum, Izana Ishak, Sam'an Malik Masudi, Mohammad Khursheed Alam
ABSTRACT
Background: Diabetes Mellitus (DM) Type 2, which is characterized by defects in both insulin secretion and action, accounts
for the greater part of cases of diabetes. The prevalence of type 2 DM is increases with age.
Objective: This study was to compare DMFT index among non-diabetic and diabetic patients with non-insulin dependent DM.
Materials and Methods: This cross-sectional study was carried out in Hospital Universiti Sains Malaysia. The study includes
49 randomly sampled dentate adults aged 35 years old to 65 years old including 23 diabetic and 26 non-diabetics patients.
Questionnaires were used to collect data on oral self care, self perceived oral health and problems faced by diabetic patients.
The presence of dentine caries was clinically diagnosed on tooth surfaces by visual examination and probing, following the
guidelines of the WHO (1987).
Results: The main finding is that DMFT index in diabetic patients was higher (P < 0.05) compared to non-diabetic patients.
The mean value of decay was significantly higher in the diabetic group that was 6.70 (SD = 2.067) compared to non-diabetic
group 3.81 (SD = 1.772). The means for DMFT was significantly higher in diabetic group 13.52 (SD = 3.694) than in the non-dia-
betic group 9.73 (SD = 2.496) and this affected a total DMFT means of 11.33 (SD = 2.787).
Conclusion: The frequency of sugar consumption was higher in patients with diabetes than in controls. In diabetes group,
caries development was a result of the combination of the disease-related factors and oral hygiene management, which at the
end of the day comes back to personal behavior.
KEY WORDS
diabetes mellitus, DMFT index, oral hygiene
Received on August 3, 2012 and accepted on November 20, 2012
School of Dental Sciences, Universiti Sains Malaysia, USM Health Campus
16150 Kubang Kerian, Kelantan, Malaysia
Correspondence to: Ninin Sukminingrum
(e-mail: drninin@kb.usm.my)
443
INTRODUCTION
Dental caries is an infectious, communicable disease resulting in
destruction of tooth structure by acid-forming bacteria found in den-
tal plaque, an intra-oral biofilm. Diabetes mellitus is the most com-
mon endocrine disorder and is a condition of impaired carbohydrate
utilization (impaired glucose tolerance) caused by an absolute or rela-
tive deficiency of insulin from variety of causes. Diabetes mellitus is
characterized by increased levels of glucose in the blood (hypergly-
caemia) and abnormalities in the metabolism of lipid protein induced
by diminished levels or total absence of insulin1). The aetiology of
diabetes seems to be a combination of intrinsic (genetic) and environ-
mental factors. According to Second National Health and Morbidity
Survey, the prevalence of diabetes mellitus in Malaysia was 8.2%2).
Diabetes has 2 main type of primary (idiopathic) are insulin-depen-
dant juvenile (type 1 or IDDM) and maturity onset the non-insulin
dependant (type 2 or NIDDM).
Oral health in patients with diabetes mellitus has received sub-
stantial attention in the dental literature throughout the years. It is
generally accepted that diabetic patients are susceptible to periodon-
tal disease, while the issue of dental caries seems more controversial.
Many cross-sectional studies have reported low caries prevalence in
diabetes mellitus and this has mainly been explained by the sucrose-
restricted diet that is a part of the life-long treatment. Other investi-
gators have related caries development to the level of metabolic con-
trol3,4), indicating a higher caries incidence in cases with poor control
compared to those with a well-balanced disease. A higher caries risk
among diabetic patients than healthy controls has also been demon-
strated by other studies5-8), but in contrast, some studies have found
even less caries in diabetic patients than in controls9). A 2- to 4-year
follow-up studies have revealed either lower5) or similar10) or slightly
higher11) caries increments in diabetic children or adults compared to
controls. Most of the studies have compared patients with diabetes to
controls, but their results have been somewhat contradictory12). The
present study examines whether patients with type 2 DM present a
greater DMFT index than non-diabetic individuals, and explores oral
health knowledge as well as other oral manifestation of diabetic
patients.
MATERIALS AND METHODS
This cross-sectional study was carried out in Dental Clinic,
Hospital Universiti Sains Malaysia (HUSM), Kubang Kerian,
Kelantan from. The study includes 49 randomly sampled dentate
adults aged 35 years old to 65 years old including 23 diabetic type 2
and 26 non-diabetics patients. Age group was decided based on age at
onset of diabetes type 2 was over 35 year old13,14,2). All patients were
informed about the aim of the study and its voluntary nature. Criteria
for diabetic type 2 patients were a random blood glucose = 11.1
mmol/l or fasting level = 6.7 mmol/l; and patients on anti-diabetic
C 2013 Japan International Cultural Exchange Foundation
&Japan Health Sciences University
444
medication from medical clinic HUSM regularly15). The exclusion cri-
teria were type 1 diabetes, pregnancy, or the use of other medication
in addition to diabetic drugs. The control group consist of 26 patients
which their age and gender were matched with diabetic subjects.
Criteria for non-diabetic patients were a random blood glucose = 11.1
mmol/l or fasting level = 6.7 mmol/l with no diabetic symptoms or
history of taking anti-diabetic medicine. Patients of control group
were collected from the register-list at HUSM medical outpatient
clinic.
Clinical examination was carried out in the dental chair under
condition of good illumination, in both groups of subject. The pres-
ences of dental caries were clinically diagnosed on tooth surfaces by
visual examination and dental probing, following the guidelines of
the WHO16). No x-rays were taken. Decayed (D), filled (F) or Missing
(M) indices of teeth of each individual were recorded, calculated and
the means of the indices were used in analyses. Mobility test was test
in each tooth of subjects using mouth mirror and dental probe. The
presence or absence of plaque was evaluated and recorded.
Interview and questionnaire
All patients were received dental treatment from Dental Clinic
HUSM. Subjects who agree to contribute to the study were inter-
viewed on oral health status, which includes oral manifestation, fre-
quency of brushing, frequency of flossing, frequency of visiting den-
tist and their mouth condition. Questionnaire were used to collect
data on oral self care, self perceived oral health and problems faced
by diabetic patients.
Ethical consideration was obtained from the Human Research &
Ethics Committee of USM [USMKK/PPP/JEPeM-213.315)]. All infor-
mation was kept confidential and only accessible to researchers, and
only group information was reported, and published.
RESULTS AND DISCUSSION
The study includes 49 randomly sampled dentate adults aged 35
years old to 65 years old including 23 diabetic and 26 non-diabetics
patients. The mean age of the patients (8 females and 15 males) was
53.74 years, and they had had their diabetes for an average of 9.35
years. The control group consist of 26 non-diabetic patients who were
age and gender-matched. There were 11 females and 15 males with
mean age of 45.04 years in the control group. The means for DMFT
was 13.52 (SD = 3.694) in diabetic group, significantly higher (P <
0.05) than 9.73 (SD = 2.496) in the non-diabetic group as shown in
Table 1. Higher mean DMFT in diabetic patients is in agreement with
earlier report3,4,17). The finding to a certain extent can be explained by
the fact that excess glucose enters into the oral cavity through the
saliva and gingival crevicular fluid in metabolically unbalanced
cases18).
Sukminingrum N. et al.
Table 1. Mean DMFT value in diabetic and
non-diabetic patients
Health Status N Mean SD
Diabetic 23 13.52 3.694
Non-diabetic 26 9.73 2.496
P value (Student t-test) P < 0.05
Table 2. Mean Decay value in diabetic and
non-diabetic patients
Health Status N Mean SD
Diabetic 23 6.70 2.067
Non-diabetic 26 3.81 1.772
P value (Student t-test) P < 0.05
Table 3. Frequency of brushing in diabetic and non-diabetic
Frequency of tooth brushing N
Every after 3 times 2 times Once Once in
eating a day a day a day 2 days
Health DM 0 2 15 6 0 23
Status
Non- 1 5 18 1 1 26
Diabetic 1 7 33 7 1 49
Figure 1. Hand instruments used in examination of DMFT
Table 4. Root caries experience in diabetic and non-diabetic
patients
Root Caries N
None Less than 3 teeth
3 teeth and more
Health Status DM 6 13 4 23
Non-Diabetic 20 5 1 26
Total 26 18 5 49
Table 5. Mobility of teeth in diabetic and non-diabetics patients
Mobility Teeth N
None Less than 3 teeth
3 teeth and more
Health Status DM 2 3 18 23
Non-Diabetic 24 0 2 26
Total 26 3 20 49
Table 6. Problem faced by diabetic patients
Problem Yes No
Altered taste 82.6% 17.4%
Halitosis 95.7% 4.3%
Swelling and gum bleeding 95.7% 4.3%
Difficulty in chewing 78.3% 21.7%
Dental pain 100% 0%
Mobility of teeth 100% 0%
445
The mean decay value of dental caries in diabetic group is also
significantly higher (P < 0.05) compared to non-diabetic group as
shown in Table 2. The mean decay value was 6.70 (SD = 2.067) in
the diabetic group and 3.81 (SD = 1.772) in non-diabetic group,
meaning that diabetic patients have a higher caries activity increased
with age. In contrast, Pohjamo et al.11) reported only fewer decayed
teeth in adults with diabetes compared to controls. A possible expla-
nation for these findings might be due to the differences in the preva-
lence of Streptococcus Mutans and Lactobacilli between the groups
with various blood glucose levels.
Dietary factors are important in the etiology of tooth caries. The
key factors are the consumption and frequency of sucrose or free sug-
ars in their diet19,20). Good glycemic control improves first phase
insulin response to meal challenge in diabetes patients21). In order to
keep the blood glucose levels in balance, diabetic patients usually
have a higher frequency of meals and snacks than non-diabetic sub-
jects. Also, in case of frequent hypoglycaemia episodes, free sugars
might be consumed in an uncontrolled fashion. The frequency of con-
sumption, however, was higher and the meals were longer in patients
with diabetes than in controls. In the case of dental caries, the biolog-
ical effects of diabetes are mainly mediated through alterations in
salivary glands and saliva.
Frequency of tooth brushing (most of the subjects brushed twice
a day) was shown in Table 3. None of the subjects (n = 49) using
dental floss daily, were similar in all groups. All subjects were
received regular dental treatment (at least once a year), and the mean
time elapsed from the last visit to the dentist was approximately 3
months in all the groups.
Swanljung et al22) found the oral hygiene habits to be somewhat
poorer among diabetic patients than controls. In this study group,
caries development was a result of the combination of the disease-
related factors and oral hygiene management, which comes back to
personal behavior. On interview, patients with DM appear to lack
important knowledge about oral health complications associated with
their disease, which further justifies an early dental examination with
targeted oral health education as suggested by Moore et al23).
This study also showed that diabetic patients have other oral
manifestation other than increased risk for dental caries. In this study,
all diabetic patients (n = 23) experienced dental root caries and
mobility of teeth at least once in their life after diagnosed to have
DM type 2 as shown in Table 4 and 5. Most of diabetic patients have
root caries (73.9 %), whereas non-diabetic patients have less root
caries (23%) as shown in Table 4. On the other hand, most of diabetic
patients have at least 1 tooth with mobility (91.3%), but most of non-
diabetic patients have no mobility and only 7% have mobility teeth as
shown in Table 5.
Table 6 showed the problem faced by diabetic patients after diag-
nose to have DM type 2. About 82.6% (n = 22) experienced altered
taste and 82.65% experienced halitosis. About 78.3% experienced
difficulty in chewing and 95.7% have experience of swelling and
gum bleeding, as shown in Table 6.
CONCLUSION
The study has shown that DMFT and Decay values in diabetic
patients are significantly higher than non-diabetic. Diabetic patients
appear to lack of important knowledge about oral health and compli-
cations associated with their disease. However, the number of
patients analyzed was limited, and a study with bigger sample size is
needed to confirm this result.
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Comparison of Decayed, Missing or Filled Teeth (DMFT) Indexes
