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Original Article

Prevalence of oral Candida in saliva of uncontrolled and

controlled type 2 diabetes mellitus patients – Beyond
reasonable doubt?

Saramma Mathew Fenn, Mohan Narayanan, Mathew Jacob1

Departments of Oral Medicine and Radiology and 1Oral Pathology and Microbiology, Vinayaka Mission’s Sankarachariyar Dental College,
Vinayaka Mission’s Research Foundation (DU), Salem, Tamil Nadu, India

ABSTRACT
Aim: The aim of this study was to compare the prevalence of Candida in the saliva
of uncontrolled and controlled group of type II diabetic and in nondiabetic individuals.
Settings and Design: This was a cross‑sectional study. Subjects and Methods: Total
study group consists of 75 type 2 diabetic patients, in which 25 patients in Group I were taken
as controlled diabetics, 25 patients in Group II were considered as uncontrolled diabetics,
and 25 patients were considered as nondiabetics, control group in Group III, respectively.
Statistical Analysis Used: Student’s t‑test, Chi‑square test, and one‑way ANOVA test were
used in this study. Results: In this study, a total of 75 patients were included, of which a total
of 30 saliva samples had shown the presence of candidial growth. Out of 25 saliva samples
collected from Group I (controlled diabetic patients), 11 samples showed the presence
of candidial growth and out of 25 samples collected from Group II (uncontrolled diabetic
patients), 19 samples showed the presence of candidial growth. Samples obtained from
Group III (nondiabetic patients) were negative for any candidial growth. A significant difference
was observed in candidial growth from saliva samples obtained between the various study
groups. The uncontrolled diabetic patients group showed a higher candidial colony‑forming unit
when compared with that of controlled diabetic patients group. Conclusion: The prevalence
of Candida in the oral cavity of patients with diabetes is of primary concern for dentists in the
early detection of opportunistic infections, such as oral candidiasis, by understanding the
predisposing local and systemic factors. The habitat provided by the predisposing disease
may, beyond reasonable doubt, reset the microbiological environment to favor the proliferation
and colonization of opportunistic microorganisms such as the oral commensal, Candida.

Key words: Colony‑forming unit, glycosylated hemoglobin, oral Candida

Address for correspondence:

Dr. Saramma Mathew Fenn,
Senior Lecturer, Department of Oral Medicine and Radiology,
This is an open access journal, and articles are distributed under
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Mission’s Research Foundation (DU), Salem, Tamil Nadu, India. the terms of the Creative Commons Attribution-NonCommercial-
E‑mail: drsarammamathewfenn@vmsdc.edu.in ShareAlike 4.0 License, which allows others to remix, tweak, and
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How to cite this article: Fenn SM, Narayanan M, Jacob M. Prevalence

DOI: of oral Candida in saliva of uncontrolled and controlled type 2 diabetes
10.4103/srmjrds.srmjrds_48_18 mellitus patients – Beyond reasonable doubt? SRM J Res Dent Sci
2019;10:1-6.

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Fenn, et al.: Oral Candida in saliva of type 2 DM
INTRODUCTION
Diabetes mellitus is clinically and genetically an heterogeneous
metabolic disease characterized by abnormally elevated
blood glucose levels with dysregulation of carbohydrate,
protein, and lipid metabolism.[1] Recent theory suggests
that the glycosylation of immunoglobulins in uncontrolled
diabetic patients renders diabetic patients more susceptible
to infections with hyperglycemia the primary cause for
continuity of diabetes.[2] Diabetic patients are prone to a
higher risk of developing opportunistic infections, one such
being oral candidiasis caused by the commensal organism
Candida. The candidial density has also been reported
to be higher in diabetes mellitus than in non diabetic
participants. Although saliva provides efficient antibacterial
and antifungal activity, mucins and other specific agglutinins
tend to cause the aggregation of microorganisms.[3] Changes
in salivary flow impact antimicrobial proteins and enzymes
in the saliva, potentially increasing the risk of colonization
and secondary infection. Candidial counts were observed to
be higher in patients with low salivary flow rates as well as in
patients exhibiting a poor glycemic control.[4] According to
Stehr et al., certain gene expression (LIP) has been detected
in oral candidiasis which plays a major role in localization
of infection with their maximum activity found at pH of 7
and with a maximum growth at 72 h. Virulence factor that
contributes to the process of pathogenicity is the hydrolytic
enzyme, such as secreted aspartic proteinase, which is
produced by Candida species. Tsang et al. have stated that
the enzymatic activity of Candida albicans isolates obtained
from type 2 diabetes is much higher than normal patients.
Adherence of Candida to host tissue is the first step, and
the enzymes facilitate the adherence by damaging cell
membranes. Apart from these, the salivary proteins such as
mucins and statherins also act as adhesion receptors used
by the mannoproteins present in Candida species which is
seen the saliva of diabetic patients favoring the growth of
Candida.[5]
SUBJECTS AND METHODS
Outpatients visiting the Department of Oral Medicine and
Radiology, who were under the age of 35–65 years with a
history of diabetes for the past 5–7 years under medication,
were included in the study. Patients with any known
history of other systemic disease or conditions or with oral
ulcerations, history of any antibiotic/steroid therapy, usage
of any antiseptic mouthwashes from the start of the study,
and denture wearers, smokers, and alcoholics were excluded
from the study. Informed consent was obtained from all the
patients and the study was conducted following approval
from the Institutional Ethics Committee of the respective
institution where the study was conducted.
A total of 75 patients were divided into three groups
based on glycated hemoglobin values (American Diabetes
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SRM Journal of Research in Dental Sciences | Volume 10 | Issue 1 | January-March 2019
Association Glycemic Targets: Standards of Medical Care in
Diabetes – 2018), Group I, Group II, and Group III, each
comprising of 25 patients.
• Group  I  –  25  patients  –  Diabetic patients with  <6%
value of glycosylated hemoglobin (controlled diabetic
patients)
• Group II – 25 patients – Diabetic patients with more
than 6% value of glycosylated hemoglobin (uncontrolled
diabetic patients)
• Group III – 25 patients – Control group: Non diabetic
participants with normal range of blood glucose
level (postprandial blood glucose).
Collection of blood samples
For estimation of postprandial blood sugar (PPBS),
1.5 ml of venous blood was drawn 2 h after a meal in
ethylenediaminetetraacetic acid (EDTA) tubes under aseptic
techniques. For estimation of glycosylated hemoglobin,
ion‑exchange resin method was used. Around 1.5 ml of
venous blood was withdrawn and collected in EDTA tubes
under aseptic techniques for estimation and the values were
calculated by the following formula:
% glycohemoglobin (GHb) (% hemoglobin A) = Absorbance
GHb/absorbance total Hb × factor (4.61).
Conversion chart is used for obtaining values from
glycosylated hemoglobin A1% to glycosylated hemoglobin
A1c (HbA1c) %.
Saliva collection
Saliva was collected from all three groups. Each patient was
allowed to rinse the mouth with distilled water to remove
any food debris. After rinsing the mouth 60 s thoroughly, the
patient was asked to expel around 3 ml of saliva into a sterile
container. Saliva was collected between 9 and 11 am and
the samples were transported to the laboratory within 1 h.
Candida estimation
The sample containing saliva was taken with 3.26‑mm
internal diameter inoculating loop, which holds a drop of
saliva. Onto the Sabouraud’s dextrose agar plate, drop of
saliva 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 37°C
for 48 h. After 48 h of incubation, the growth of Candida was
identified by the smooth, white or creamy colored buttery
colonies [Figure 1]. The number of candidial colonies on
each plate was counted and recorded.
Statistical analyses
The values obtained from the various study groups were
calculated using the Chi‑square test to assess the nature of
candidial growth between the three groups. Student’s t‑test
was applied to evaluate the gender predilection with respect
to age, PPBS, HbA1c values, and candidial growth in saliva
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Fenn, et al.: Oral Candida in saliva of type 2 DM
and one‑way ANOVA was used to determine the significance
in age and PPBS among three groups.
RESULTS
From the total of 75 patients included in the study, a
total of 30 saliva samples had shown the presence of
candidial growth. Out of 25 saliva samples collected from
Group I (controlled diabetic patients), 11 samples showed
the presence of candidial growth and out of 25 samples
collected from Group II (uncontrolled diabetic patients),
19 samples showed the presence of candidial growth.
Samples obtained from Group III (non diabetic patients)
showed no presence of candidial growth.
The values obtained from the study groups were subjected
to the Chi‑square test to assess the nature of candidial
growth between the three study groups. There was a
significant difference in the nature of candidial growth
between the uncontrolled and controlled group and normal
participants (P < 0.001) as shown in Table 1 and Figure 2.
The nature of candidial growth was also assessed between
the uncontrolled and controlled group and was found to be
statistically significant with P < 0.021.
Student’s t‑test was used to evaluate the gender predilection
with respect to age, PPBS value, HbA1c value, and candidial
growth in the saliva of uncontrolled and controlled diabetes.
In Group I (controlled diabetic patients), although no
statistical significance was observed in any of the parameters,
Figure 1: Colony‑forming unit in saliva
Table 1: Comparison of candidial colony forming units among three groups
Group CFU (colonies)
No growth, n (%)
Controlled diabetes (<6 HbA1c) 14 (18.67)
Uncontrolled diabetes (>6 HbA1c) 6 (8.00)
Normal 25 (33.33)
Total 45 (60.00)
**Significant at 1%. p<0.05, Statistically significant. CFU: Colony‑forming unit, HbA1c: Glycosylated hemoglobin A1c
SRM Journal of Research in Dental Sciences | Volume 10 | Issue 1 | January-March 2019
the PPBS and HbA1c had shown an increased mean value
in males when compared to females. The colony‑forming
unit (CFU) mean value was found to be increased in
females (2.90) when compared to that of males (1.20). In
Group II (uncontrolled diabetic patients), no statistical
significance was observed with respect to age to any of
the above‑mentioned factors. The PPBS mean value for
females was found to marginally higher than males while
the males showed a higher HbA1c % when compared to
females. The mean value of CFU was found to be increased
in males (41.93) when compared to females (37.50).
The CFU mean values obtained from Student’s t‑test in
Group II were found to be 40.16, which were shown to be
significantly higher when compared to the mean value of
Group I which was 1.88. The computed values were found
to be statistically significant [Table 2].
The one‑way ANOVA test was applied to determine the
statistical significance in mean score values in age and
postprandial glucose values among the three groups. The
mean value with regard to age in Group I (controlled) was
55.92. In Group II (uncontrolled), the mean value is 56.24
and in Group III, (normal) it was 50.64. The mean difference
is not statistically significant among the three groups with
P = 0.102 as shown in Figure 3.
DISCUSSION
The normal oral flora comprises more than 700 microbial
species of bacteria, virus, and fungi. The Candida species
Figure 2: Graphical representation ‑ Association between the
nature of Candida growth in study Groups 1, 2, and 3
Total, n (%) χ2 P
Growth, n (%)
11 (14.67) 25 (33.33) 30.33 <0.001**
19 (25.33) 25 (33.33)
25 (33.33)
30 (40.00) 75 (100.00)
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Fenn, et al.: Oral Candida in saliva of type 2 DM
Table 2: Comparison of CFU with glycosylated hemoglobin in controlled and uncontrolled diabetes mellitus
Group
CFU (colonies) Controlled diabetes (<6% HbA1c)
Uncontrolled diabetes (>6% HbA1c)
**Significant at 1%, p<0.01, Statistically significant. HbA1c: Glycosylated hemoglobin A1c, CFU: Colony‑forming unit, SD: Standard deviation, SE: Standard error
Figure 3: Comparison of glycosylated hemoglobin with age in
controlled and uncontrolled diabetes mellitus
form the normal commensal fungi component, and its
activity is regulated by many intrinsic and extrinsic factors.
The pathogenic nature of Candida has been correlated with
various systemic conditions, which in some manner, affect
the immunity of the patients. Moreover, the enzymatic
activity of C. albicans isolates obtained from type 2 diabetes
is much higher than normal patients.[6] Given the favorable
conditions, Candida tends to achieve sufficient growth and
activity, and it is for this reason considered an opportunistic
infection.[7,8] Diabetic patients are predisposed to higher
candidal carriage in oral cavity due to their poor glycemic
control. Several methods are employed in screening and
evaluating the glycemic control, among which glycosylated
hemoglobin HbA1c proves to be one of the reliable and
recommended investigation methods as HbA1c is directly
related to the rise in blood glucose over an interval of time.
Another advantage is HbA1c values are not influenced
by diet, therapy, physical activities, meals, and patient
cooperation at the time of testing. Blood glucose of 120 mg/dl
is approximately equivalent to 6% of HbA1c value which
reflects an efficient long‑term glucose control. Any value of
blood glucose above 120 mg/dl reflects a fair to poor glycemic
control. HbA1c is not used as a diagnostic study for diabetes
because of lack of standardization of test procedures and
overlapping values between normal and diabetic patients
and serves solely to access glycemic control over 6–12‑week
periods. In the present study, the patients were investigated
for postprandial blood glucose to determine the current blood
glucose level serve as a diagnostic test. While glycosylated
hemoglobin HbA1c was used to evaluate the glycemic
control over 3 months to evaluate the association of glycemic
control and oral candidial carriage in diabetic patients.[9]
In the present study, the candidial carriages in the saliva
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SRM Journal of Research in Dental Sciences | Volume 10 | Issue 1 | January-March 2019
n Mean SD SE t P
25 1.88 4.096 0.819 4.07 <0.001**
25 40.16 46.849 9.370
of uncontrolled diabetic patients were found to be higher
when compared to the controlled group of diabetic and
nondiabetic patients, and similar findings observed by other
studies.[10] The mechanism suggested for increased candidial
colony could be attributed to the quantitative and qualitative
production of saliva. Hyposalivation seen in diabetic patients
can be possibly related to polyuria and also the substitution
of normal functioning gland tissue by adipose tissue in major
salivary glands. Thereby, growth of Candida species in the oral
cavity is favored due to decreased production of saliva and
the consequential reduced immunological activity of saliva.
Another suggested mechanism for the prevalence of oral
Candida in uncontrolled diabetic patients when compared
to controlled diabetic patients, whereby the accumulation
of sugar in tissues favors growth and proliferation of fungus
as was observed in the coated tongue of uncontrolled
diabetic patients in their study.[11] The high level of salivary
glucose can increase candidial adherence to the buccal
epithelial cells which form glycosylation products with
the proteins in tissues.[12] Thus, hyperglycemic episodes of
uncontrolled diabetic patients can lead to the accumulation
of glycosylation products which, in turn, increase the receptor
for Candida. Other factors that may influence the candidial
growth are decreased activity of neutrophils and decreased
salivary flow rate as seen in diabetic patients. In the present
study, similar findings were observed in the nature of candidial
growth, wherein the saliva of uncontrolled diabetic patients
showed significant higher candidial growth when compared
to controlled diabetic patients. In the present study, age,
postprandial glucose values, HbA1c values, and CFUs did not
show any significance with relation to gender in controlled
and uncontrolled diabetic patients. Similar findings were
observed by several other studies.[13] Although the results
showed that there was no significant correlation between
CFU and gender in both diabetic groups, the candidial
carriage was found to be increased in females of controlled
group while males showed the predilection for candidial
growth in uncontrolled diabetic patients group. Saliva is a
unique fluid and used as a diagnostic medium. The analysis
of saliva, such as blood‑based analyses, has two purposes: the
first, to identify individuals with disease and second, to follow
the progress of the affected individual under treatment.[14]
Diabetes mellitus is a growing public health concern and
common metabolic disease worldwide. Diabetes mellitus
can predispose patients to various opportunistic infections
and is related either directly or indirectly to the glycemic
control. As the oral fluid, often called the “mirror of the
body,” is a perfect medium to be explored for health and
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Fenn, et al.: Oral Candida in saliva of type 2 DM
disease surveillance. The oral biofluid is readily available
through noninvasive collection is helpful to monitor
systemic diseases and conditions. Almost, anything
measured in blood can be measured in saliva. The advantage
of easy collection, storage, transport, low cost, sufficient
and quantities for analysis, reduces anxiety and discomfort,
does not clot, less invasive, less expensive, less risk, and
procurement of repeated samples makes the saliva superior
in diagnostics.[15] Discrete lesions can begin as benign
colonization as a result of increased candidial carriage
which in time can progress to pathological overgrowth. As
oral candidial carriage may be increased in uncontrolled
diabetic patients, dentists should be aware of the risk of oral
candidiasis in uncontrolled diabetic patients.
In sustained diabetic patients, there is increase in the
deposition of advanced glycation end products which hamper
the normal homeostatic transport across the membrane
resulting in higher production of vascular endothelial growth
factor, which adds on to the microvascular complications
of diabetes. The presence of oral manifestations in
patients of diabetes mellitus indicates poorly controlled
glycemic status and requires evaluation to detect long‑term
complications.[16] Mucosal disorders such as oral candidiasis,
in diabetes mellitus patients, primarily occur due to chronic
immunosuppression and diabetes associated hyposalivation.
There is a proportional increase in the incidence of oral
candidiasis with hyperglycemia observed in uncontrolled
diabetes. Apart from these, the commensals residing on the
surface of oral mucosa are maintained in a state of hemostasis.
The balance is sustained between the virulent potential of
microorganisms and the inflammatory and phagocytic
activity of neutrophils, lymphocytes, and macrophages.[17]
It is when the fungal load exceeds the immunomodulatory
threshold of the oral mucosa along with contributory factors
such as dentures which act as candidial reservoirs that the
disease manifests itself. There is a threshold for the amount
of C. albicans that is tolerated by the host with the alteration
in the innate‑mediated immunity of the host, and the
invasion of the Candida from superficial lining to underlying
layers has extensively utilized for identification and detection
by pattern recognition receptors present on the surface of
microbes such as the established toll‑like receptors, the
C‑type lectin receptors, and the nod‑like receptors.
The immunomodulatory activity is performed
neutrophils, macrophages, natural killer cells, and certain
lymphocytes (CD4+, CD8+ T‑cells) that are recruited
from the proximity blood vessels as well the inherent
nonkeratinocyte defense cells in oral mucosal linings. The
direct antifungal activity includes the neutrophil cidal
activity on the organisms and the clearing mechanism of
macrophages by phagocytosis. These defense cells also
signal lymphocytes to produce antibodies by secretion of
chemotactic factors, cytokines, and antigen‑presenting
factors. These defense mechanisms prevent the invasion
SRM Journal of Research in Dental Sciences | Volume 10 | Issue 1 | January-March 2019
of the candidial hyphae from the superficial lining to
underlying spinous layers of oral mucosal, particularly of the
nonkeratinized mucosa. The volume and density of saliva
form a regulatory and dense mechanism not only against
Candida but also other pathogenic organisms. Hyposalivation
observed in diabetic patients is due to reduced salivary gland
function due to fibrosis causing increase in density and along
with polyuria attributes to the reduced volume of overall
reduction in saliva secretion. The impaired immune function
of defense cells, hyposalivation, and the hyperglycemia each
by itself contribute to the prevalence of oral candidiasis in
diabetes mellitus.[18]
CONCLUSION
Diabetes Mellitus can predispose patients to opportunistic
oral infections such a oral candidiasis caused by Candida.
Beginning as a benign asymtomatic colonization, these
organisms with a favorable habitat can progress to a
pathological overgrowth. Dentist should be aware of such
factors that can predispose patients with type 2 Diabetes
Mellitus and provide a holistic treatment that cater to
the dental needs and also at the same time prevent the
occurrence of such infections.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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