Nine out of ten patients with type 2 diabetes examined in Yogyakarta were found to carry colonies of Candida in their oral cavities. Not all showed symptoms, and not all experienced discomfort, but the fungus was there. This finding emerged from research led by Prof. Dr. drg. Dewi Agustina, MDSc, from the Department of Oral Medicine, Faculty of Dentistry, Universitas Gadjah Mada, and published in the April 2023 edition of Indonesian Dentistry Magazine.
The question is no longer simply whether people with diabetes are susceptible to oral fungal infections. The questions now are: which species dominate, who is most at risk, and is blood glucose really the primary determinant?
What Was Found in the Oral Rinses of 100 Patients?
The study involved 100 patients with type 2 diabetes aged 45 to 89 years from three healthcare facilities in Yogyakarta: Qta Minomartani Clinic in Sleman, Wirosaban Regional Hospital, and Mantrijeron Community Health Center. Participants were asked to rinse their mouths with sterile saline for 15 seconds. The rinse fluid was then centrifuged and cultured using CHROMagar Candida to identify the fungal species living in their mouths.
The results: 89 out of 100 patients tested positive for Candida colonies. The most frequently detected species was Candida albicans, with a mean colony count of 349.96, followed by C. glabrata (225.97), C. krusei (144.91), C. tropicalis (3.67), and other species (2.02).
Interestingly, the species distribution changed depending on blood glucose control. Among patients with controlled diabetes, C. albicans predominated. In patients with uncontrolled diabetes, however, C. glabrata was more prevalent. This is not merely a difference in numbers. C. glabrata is known to be more aggressive, produce thicker biofilms, and be more difficult to treat with standard antifungal medications.
Women, Older Adults, and Risks That Cannot Be Ignored
Two findings were statistically significant, and both were associated with characteristics of the patients rather than the severity of their diabetes.
First, female patients had a substantially higher mean Candida colony count (859.51) than male patients (299.21), with p = 0.009. This difference is thought to be associated with the hormone estrogen, which is known to increase the virulence of C. albicans while also increasing glycogen production in the mucosa, providing nutrients needed for fungal growth.
Second, the geriatric group (83 of the 100 participants) had a higher mean colony count (761.77) than the non-geriatric group (545.71), although the difference did not reach statistical significance (p = 0.060). Age-related immune decline, polypharmacy, and deteriorating dental health may help explain this tendency.
“The determination of a treatment plan for diabetic patients with oral candidiasis varies depending on the etiology, risk factors, and characteristics of the predominant species in each patient.” — Prof. Dr. drg. Dewi Agustina, MDSc, and the research team, Indonesian Dentistry Magazine, 2023
Why Blood Glucose Levels Are Not the Only Determining Factor
One of the findings that makes this study particularly noteworthy is one that contradicted common assumptions. Statistically, there was no significant difference in the number of Candida colonies between patients with controlled and uncontrolled diabetes (p = 0.175).
This suggests that blood glucose control alone may not be sufficient to prevent fungal growth in the oral cavity. Other factors, including oral hygiene, denture use, salivary conditions, smoking habits, and the balance of the oral microbiome, may play a greater role than previously thought. Unfortunately, these variables were not fully explored in the study, and the researchers themselves identified them as important areas for future investigation.
Implications for Clinical Management and Healthcare Services
These findings are more than laboratory data. For clinicians, identifying the predominant Candida species in a particular population is essential for selecting appropriate antifungal therapy. Each species has a different resistance profile; a dose that is effective against one species may be inadequate against another. C. glabrata, for example, which was more frequently observed in patients with uncontrolled diabetes, may require a different treatment approach from C. albicans.
Furthermore, the study sends an important message to dental healthcare professionals: examining the oral condition of patients with diabetes cannot stop at the teeth and gums. The oral cavity contains a complex ecosystem, and in people with diabetes, this ecosystem can shift into a genuine health threat even before symptoms become apparent.
Yogyakarta, with its high proportion of older adults, provides a particularly relevant context for research of this kind. The 89% prevalence of Candida among patients with diabetes mellitus in this setting is not merely a statistic; it reflects a hidden health burden developing alongside a chronic condition that is already challenging enough to manage.
Source DOI: DOI: http://doi.org/10.22146/majkedgiind.76176
Authors: Anny Anggraini; drg. Achmad Zam Zam Aghasy, M.Kes.
Photo: Freepik