Periodontal health can be described as a condition devoid of inflammatory periodontal disease that permits an in-dividual to function properly and not suffer any effects (mental or physical) as a result of previous disease. Periodontal health may be classified into four categories:

1) The lack of clinical inflammation and physiological immune surveillance on a periodontium with appropriate support (no attachment or bone loss ( Kuo et al., 2008 )) is regarded as pristine periodontal health.

2) The absence or presence of a low level of clinical inflammation in a periodontal pocket with adequate support is classified as clinical periodontal health ( Kuo et al., 2008 ).

3) Periodontal disease is associated with a periodontium that is less stable, as well as ( Kuo et al., 2008 ).

4) Remission/control of periodontal disease in a periodontium that has been decreased ( Kuo et al., 2008 ).

Periodontitis is one of the most common oral disorders worldwide, affecting both industrialized and developing nations ( Irwin et al., 2007 ). It’s a bacterial-caused chronic inflammatory condition that affects the gingivae and periodontal tissue ( Katz et al., 1991 ). This inflammatory process is caused by the microflora in dental plaque, which accumulates every day next to the teeth. The toxins produced by the bacteria in dental plaque might eventually cause gingival inflammation if they are not removed on a regular basis ( Kibayashi et al., 2007 ). The gingivae separate from the tooth surface once gingival inflammation develops, causing a periodontal pocket. In this periodontal pocket, bacteria and their toxins are numerous. The periodontal pocket and tooth plaque will be deepened as the disease progresses until it reaches the alveolar bone. Periodontal tissue degradation, alveolar bone loss, and tooth loss all are situations caused by this disease. A vulnerable host is one of the variables that contribute to this form of inflammation in addition to the presence of bacteria in dental plaque.

Diabetic Patients are more likely to develop periodontal disease, according to several researches ( Calsina et al., 2002 ; Dietrich et al., 2007 ; Moore et al., 2000 ). This is especially true for individuals who have poor dental hygiene, poor metabolic management, have had diabetes for a longer time, and are smokers. According to many researches, smoking is a major preventable risk factor for periodontal disease and tooth loss for both diabetic patients and general population ( Berlin, 2008 ; Beziaud et al., 2004 ; Chestnut, 2010 ; Darr et al., 2008 ; Preshaw, 2009 ). Diabetic Patients might benefit from the advice and assistance of their dentist and physician when it comes to quitting smoking. The dentist should be involved in advising these individuals and directing them to a smoking cessation specialist organization ( Ritchie, 2009 ).

The therapy of periodontal disease has an impact on diabetes glycemic management. The efficacy of periodontal therapy on diabetes glycemic control could result in a significant reduction in HbA1c according to a recent meta-analysis evaluation ( Moore et al., 1999 ). As a result, bigger studies are needed to establish the impact of periodontal therapy on glycemic management, as periodontitis and diabetes are linked.

The medical profession does not acknowledge the relationship between diabetes and periodontal disease. Diabetes has been linked to an increased prevalence and severity of periodontal disease ( Teeuw et al., 2008 ). The exact method by which hyperglycemia might cause periodontal damage is unknown. Many ideas, however, suggest that advanced glycation end products and changes in collagen stature are to blame, and impaired polymorphonuclear leukocyte function, which may facilitate bacterial persistence in the tissue and the accumulation of advanced glycation end products caused by prolonged and chronic hyperglycemia and Increased release of proinflammatory cytokines such as TNF- and prostaglandin E-2 ( Pihlstrom et al., 2005 ; de Silva et al., 2006 ).

Collagen metabolism will be harmed by an increase in collagenase activity combined with a decrease in collagen production. As a result, wound healing would be hampered, and periodontal tissue would be destroyed. Periodontitis has a bidirectional influence on glycemic management in diabetic individuals, according to recent research ( Tsai et al., 2002 ). A slew of research findings back up the idea that periodontitis is more common in diabetics with poor glycemic control. Furthermore, there is sufficient data to support the concept that poor periodontal health might exacerbate glycemic control. According to several studies, for gingivitis and periodontitis, diabetes is a risk factor and it is worsened by poor glycemic management ( Lin et al., 2002 ). Diabetes patients have a three-fold increased risk of developing periodontitis compared to the general population ( Khan, 2018 ).

Saliva plays an important function in the oral cavity’s health. Saliva is generated by the parotid, submandibular, and sublingual salivary glands, as well as a number of smaller salivary glands throughout the oral cavity. In individuals with diabetes, salivary dysfunction has been documented ( Tsujimoto et al., 2016 ; Cicmil et al., 2018 ). Salivary dysfunction reveals itself in a variety of ways, including taste impairment, changes in saliva content and decreased salivary flow ( Cicmil et al., 2018 ).

A variety of variables have been linked to changes in taste perception in the oral cavity. Salivary dysfunction can cause a change in sense of taste or an increase in detection thresholds ( Al-Maskari et al., 2011 ; Cicmil et al., 2017 ). Salivary dysfunction can contribute to altered taste sensation or elevation of detection thresholds when endocrine diseases and metabolic have been proposed as causal factors for this disturbance. However, Patients with poorly managed diabetes have been found to have a higher rate of taste impairment than healthy controls. 5.7 percent of diabetes or prediabetic patients had a sweet taste issue, and 8.6 percent had a salt taste disorder, according to cross-sectional research. The taste thresholds of diabetic individuals with neuropathy are greater. A change in taste experience or a rise in detection thresholds can be caused by salivary malfunction. This sensory malfunction can make it difficult to stick to a healthy diet and cause problems with glucose management ( Sudarshan et al., 2015 ).

Salivary dysfunction is common in diabetics, and it can result in reduced salivary flow and a change in saliva composition.

To find out the link between salivary dysfunction and diabetic complications and the prevalence of hyposalivation and xerostomia (dry mouth), some researchers conducted a cross-sectional epidemiological study in 2001. Diabetics and non-diabetic patients were included in this investigation. Diabetes patients, particularly those with acquired neuropathy, reported xerostomia symptoms and reduced salivary flow rate more frequently than healthy controls. Xerostomia and hyposalivation are also more common in those with diabetes, according to other studies. The stimulated parotid gland flow rate is lower in diabetic patients than non-diabetic patients. There was also an increase in salivary pathogens in these people. Because of the constant dryness, the soft tissues of the mouth are feeling irritated and discomfort. Gum disease and tooth decay are more common in diabetics and xerostomia patients. The origin of this in diabetics is unknown; however, it could be related to polydipsia and polyuria, as well as a change in the salivary glands’ basement membrane ( Hsu et al., 2019 ). Diabetes mellitus is known to create chronic issues such neuropathy, microvascular abnormalities, and endothelial dysfunction.

Tongue anomalies are common among diabetic patients. Fissured tongue is a common deformity among diabetics. In this case, the dorsal tongue surface has grooves of various depths and sizes. When material becomes trapped in these cracks, symptoms appear ( Villa et al., 2014 ; Erriu et al., 2016 ). It was discovered in a study of 2015 that reported fissured tongue was linked to Diabetes Mellitus. Xerostomia and a reduced salivary flow rate can cause fissured tongue development ( Dotiwala & Samra, 2021 ). Another research published in 2019 discovered a bluish tongue with thick yellow hairs in diabetics and recommended tongue screening for early identification of Diabetes Mellitus ( Bihari et al., 2014 ).

A Candida infection in the oral cavity induces rhomboid glossitis in a diabetic patient ( Khan, 2018 ). Glossitis can be defined as an erythematous tongue lesion anterior to the circumvallate papillae. It is found on the dorsal surface of the tongue along the midline ( Al Mubarak et al., 2013 ). Patients with Diabetes Mellitus might also develop Benign Migratory Glossitis ( Buranasin et al., 2018 ). This benign disorder is characterized by redness (erythema), atrophy of the filiform papillae, and a serpiginous, whitish, and hyperkeratosis border ( Huang et al., 2005 ).

Diabetics, on the other hand, are more susceptible to bacterial infections in the mouth. Immunodeficient patients are those who have a weaker immune system ( Utkarsh & Srinath, 2007 ; Rao et al., 2010 ). To spread and recurrence of bacterial infections, Diabetic patients are more vulnerable. Diabetes patients are more likely than non-diabetic individuals to have a deep neck bacterial infection, according to several studies ( Abiko & Selimovic, 2010 ; Rathee & Sapra, 2021 ). The submandibular region was shown to be the most prevalent site of bacterial infection in both patients and controls, with the buccal space coming in second ( Lima et al., 2017 ). Both groups had a higher percentage of Streptococcus species isolated. Diabetic patients are required to admit in the hospital for longer periods to control their blood glucose levels for avoiding any kind of serious infection.

Patients with uncontrolled diabetes have been found to have poor oral wound healing, as well as long-term consequences ( Jeong & Park, 2017 ). Poor oral wound healing is a documented hazard for diabetes people undergoing oral surgery. As a result, diabetes individuals having oral surgery require more extensive care and therapy. Delay in vascularization, reduced blood flow, a loss of innate immunity, decreased growth factor production, and psychological stress have all been associated to prolonged oral wound healing in diabetic patients.

It is an infectious disease of the teeth in which the tooth structure is demineralized and bacteria stick to the tooth and produce acid from sugar, primarily Streptococcus mutans. The common factors that contribute to dental caries are microbial flora: cariogenic, fermentable sugar, and environmental variables etc. ( Sampaio et al., 2011 ). In Diabetes Mellitus, lower saliva flow, impaired salivary buffering function, high glucose levels in saliva, changes in the molecular composition of saliva, cariogenic food, poor oral hygiene and existing dental plaque have all been linked to dental caries formation ( Moin & Malik, 2015 ). Diabetic patients are more prone to develop dental caries than non-diabetic patients ( Seetha Lakshmi et al., 2016 ). Caries in the cementum of teeth become more common as people get older, and diabetic patients have been identified with caries in the radicular portion of the tooth. Hyposalivation is identified as a cause of poor oral hygiene in diabetic patients ( Abikshyeet et al., 2012 ). Sugar-free toothpaste lowered salivary glucose levels and enhanced salivary pH in people with Diabetes Mellitus, indicating that blood glucose levels should be closely monitored to preserve oral hygiene ( Hariharavel et al., 2017 ).

Patients with Diabetes Mellitus are more likely to develop dental caries due to reduced salivation and high glucose levels in saliva, which may be the result of an Insulin deficit ( Latti et al., 2018 ). Saliva in diabetics loses its protecting, buffering, and cleaning functions ( Cicmil et al., 2018 ). Damage to the microvasculature causes alterations in the basement membrane of the salivary gland. As a result, glucose leakage from duct cells increases, causing glucose levels in saliva and crevicular space to rise.

The activity of fibroblasts diminishes as a result of this shift, leading in greater plaque development. Dental plaque converts glucose in saliva into lactic acid, reducing salivary pH ( Al-Maskari et al., 2011 ). The low pH leads to the growth of aciduric bacteria, while the expansion of acidogenic bacteria suppresses the defense bacteria in the mouth. The natural environment’s equilibrium has shifted in favor of the bacteria that cause tooth decay. The pH is subsequently reduced even further, and the cycle continues. Diabetic people are more likely to acquire new or recurring dental caries. Increased levels of oral yeasts, mutans streptococci, and lactobacilli, as well as decreased saliva cleaning and buffering ability, can contribute to an increase in the prevalence of tooth decay ( Ship, 2003 ). Chronic hyperglycemia can also lead to permanent pulpitis and pulp necrosis ( Khan, 2018 ). Apical periodontitis and radiolucent periapical lesions are more prevalent in diabetics than in non-diabetics, according to several studies ( López-López et al., 2011 ).

Diabetics, on the other hand, are more likely to develop oral infections, which can result in tooth decay and loss ( Kamala et al., 2016 ). New and recurrent dental caries, as well as tooth loss, have all been associated to salivary secretory dysfunction, periodontal disease, and sensory issues. The link between diabetes and dental caries development is currently unknown ( Nada et al., 2020 ). The cleaning and buffering ability of saliva is known to be reduced in people with diabetes mellitus, leading to an increased prevalence of dental caries, particularly in those with xerostomia.

According to the International Association for the Study of Pain, it is a neuropathic oro facial sensory disease. Burning mouth syndrome is characterized by oral mucosal burning pain involving the anterior 2/3rd of the tongue without evident mucosal pathology ( Costa et al., 2019 ). There is no obvious reason to experience a tingling, burning sensation in the mucosa of the oral cavity ( Colak, 2013 ). In type 2 diabetes, substantial predictors of burning mouth syndrome are found. Increased excitability of the trigeminal nerve in diabetic peripheral neuropathy is found in the oral cavity of patients with diabetic peripheral neuropathy and healthy people comparing the nociceptive activity of the Trigeminal nerve ( Khandelwal et al., 2013 ). Hyperesthesia and discomfort in the oral cavity in diabetics with peripheral neuropathy can be caused by burning mouth syndrome. Long-term searing discomfort in the mouth makes it difficult to maintain oral hygiene, which can lead to additional deterioration in diabetic patients’ oral health.

Halitosis or foul breath is one of the early diabetes symptoms which is a common ketone smell in diabetics. Sulfide compound odor can also be caused by periodontal disease. Methyl nitrate in the blood promote oxidative stress and high levels of fatty acids are the common factors of halitosis ( Atefi et al., 2012 ). 23.3 percent of diabetic patients have developed halitosis.

Lichen planus is a long-term skin inflammatory disorder ( Iqbal et al., 2020 ). In the oral cavity, white raised lines appear, forming a lace-like pattern that is symmetrical and bilateral ( Uma Maheswari & Chaudhary, 2020 ). Diabetes patients have oral lichen planus ( Gupta & Jawanda, 2015 ; Irwin et al., 2007 ). Another mucosa-related modification has a negative impact on diabetes patients. Oral hypoglycemic drugs are the oral lichenoid reaction ( Katz et al., 1991 ; Kibayashi et al., 2007 ).

Mouth lichen planus is an autoimmune disease in which cytotoxic T lymphocytes kill the oral epithelium’s basal cells ( Calsina et al., 2002 ). Patients with oral lichen planus may have discomfort and a burning sensation in their mouth, making eating and swallowing difficult. Because oral lichen planus can turn malignant, it’s vital to diagnose it early and treat it to avoid developing oral squamous cell carcinoma.

Diabetes patients are more likely to develop periodontal disease as a result of a number of risk factors, including poor dental hygiene, poor metabolic management, diabetes over a longer period of time, and smoking ( Dietrich et al., 2007 ; Moore et al., 2000 ; Berlin, 2008 ). Smoking is a major preventable risk factor for periodontal disease and tooth loss in the general population as well as diabetes patients ( Beziaud et al., 2004 ; McIntyre, 2001 ; Samaranayake, 1990 ; Akpan & Morgan, 2002 ). Counseling and aiding diabetes patients who want to quit smoking should be a priority for dentists and physicians ( Lamey et al., 1988 ). The dentist should help these patients quit smoking by counseling them and referring them to a smoking cessation expert.

Candida albicans species cause oral candidiasis, which is an opportunistic infection. Smoking, xerostomia, and endocrine and metabolic illnesses are also risk factors for this infection ( Willis et al., 1999 ). Old age, drugs, Cushing’s syndrome, malignancies, and the usage of dentures have all been implicated ( Hill et al., 1989 ). Oral candidiasis is divided into two types: primary and secondary. Acute (pseudomembranous and erythematous), chronic (pseudomembranous, erythematous, and hyperplastic), and candida-related lesions are the three kinds of primary oral candidiasis ( Khosravi et al., 2008 ).

Angular cheilitis appears as an erythematous crusting lesion in the lip commissures. Diabetics with inadequate glycemic control have been found to develop the lesion. On the dorsal surface of the tongue, median rhomboid glossitis appears as a depopulated erythematous diamond-shaped region near the midline.

For many years, it has been known that people with diabetes mellitus are more likely to develop fungal infections ( Soysa et al., 2006 ). Candida infection is more common in diabetic patients, particularly those who smoke, wear dentures, have poor glycemic control, and take steroids and broad-spectrum antibiotics ( Huang et al., 2005 ). Furthermore, salivary dysfunction in diabetic individuals might lead to greater fungus carriage in this group of patients.

Oral thrush is another name for Pseudomembranous candidiasis. When wiped, it leaves a creamy white surface with underlying erythematous and bleeding oral mucosa ( Khosravi et al., 2008 ). The most commonly affected areas are the soft palate, cheek, tongue, and gingivae. In immune-compromised people, it may be persistent. Erythematous candidiasis is a kind of infection that can be acute or persistent. It is caused by long-term use of steroid and broad-spectrum antibiotics, and it primarily affects the tongue.

Oral bacterial infections are more common in diabetic patients. They are referred to as immunocompromised since they have a weaker immune system. Diabetics with diabetes problems and poor metabolic control are more susceptible to bacterial infection spreading and recurrence. According to several studies, Diabetes patients are more prone to have a deep neck bacterial infection than non-diabetic patients ( Vernillo, 2003 ; Lamster et al., 2008 ). In both patients, diabetic and non-diabetic, the common location is the submandibular region and the second most common location is the buccal space ( Lalla & D’Ambrosio, 2001 ). In both groups, Streptococcus species were isolated more frequently. Diabetes patients are required to stay longer in the hospital to avoid more severe infections and to control their blood glucose levels.

As a result, it is critical to raise diabetes patients’ understanding of mouth cleanliness and oral health care. Dentists can also help diabetic individuals become more conscious of their condition. The purpose of this study is to find out how common oral problems are among diabetes patients in Bangladesh.

To assess the prevalence and pattern of oral complication among diabetic patient in Dhaka city.

$n=\frac{z^2\times pq}{d^2}=\frac{{\left(1.96\right)}^2\times \left(0.80\right)\left(1-0.80\right)}{0.0064}=96$

Here,

n = desired sample size (when the population > 10,000).

Z = standard normal deviation; usually set at 1.96, which corresponds to 95% confidence level p = level of oral complication among DM Patients 80%/0.80.

q = 1 − p.

d = degree of accuracy required, usually set at 8% level.

By calculating the sample size is 96 and considering 20% will be non-responsive, so it will be 115.

Finally, we were able to collect 44 samples.

The study participants will be selected according to the following inclusion criteria:

Unable or not interested in participating in the study.

Convenience sampling will be used to collect data.

A pretested and validated structured face-to-face questionnaire will be used to collect data. The study’s questionnaire will be divided into three pieces (A, B, C). Section A will cover socio demographic characteristics (C1 - C8), section B will cover lifestyle and health characteristics (L1 - L10) and section C will cover diabetes mellitus related factors with oral complications (D1 - D24).

Socio-demographic characteristics (C1 - C8) such as age, sex, education, residence, employment status, and working location will be collected using a structured questionnaire.

Characteristics of a person’s lifestyle and behavior (L1 - L10) furthermore, they are prone to oral infections, and taste abnormalities cause them to consume more sugar and salt, causing their glycemic control and, as a result, the health of their oral cavities to deteriorate further.

Diabetes Mellitus related factor (D1 - D24) includes duration of Diabetes Mellitus, level of HbA1c (complications in controlled or complications in uncontrolled), type of Medication—(Insulin/Oral Glycemic Medicine).

The questionnaire will include 45 closed-ended questions aimed at increasing people’s awareness, understanding, and practice of oral complications of diabetic patients, their signs and symptoms, and risk factors. As socio-demographic data, age, sex, employment, and educational level will be collected. Editing and data entering will be part of the recorded response. For data entry, processing, and analysis, Microsoft Word, Microsoft Excel, and SPSS will be used.

The supervisor will provide frequent assistance and direction to achieve quality control and assurance. Before collecting data from the field, the chosen questionnaire will be pre-tested to determine its usefulness. In both English and Bangla, the questionnaire will be conducted in easy language. To ensure the greatest possible quality of data, the researcher will gather it themselves. Before any data is collected, all reports will be made with the respondents. Data will be cross-checked for accuracy.

Because the researchers’ goal is to improve society, they will not force anybody to complete the questionnaire and will ensure that all personal information is kept private. The North South University officials will provide its approval to the study procedure. The study participants will also get a full consent form.

Although frantic effort was made to reduce bias and errors in the research however there were some limitations that was always be there despite all the effort. Some of the limitation of this type of research included non-response by some of the respondents. Some of them were not able to respond because of their medical condition, fragility, cognitive deficit and general weakness among others. Apart from non-response another limitation was that some respondents misinterpret ed the questions and this might have influenced their response and subsequently the result. However, subjecting the questionnaire to reliability and validity test minimized this.