|Year : 2015 | Volume
| Issue : 3 | Page : 297-301
Glycemic control and periodontal disease in type 2 diabetes mellitus patients: A cross-sectional study
Vaibhav Tandon1, Pradeep Tangade1, Ravishankar Telgi Lingesha1, Amit Tirth1, Sumit Kumar Pal1, Vipul Yadav2
1 Department of Public Health Dentistry, Kothiwal Dental College and Research Centre, Moradabad, Uttar Pradesh, India
2 Department of Public Health Dentistry, Maulana Azad Institute of Dental Sciences, New Delhi, India
|Date of Web Publication||14-Sep-2015|
Department of Public Health Dentistry, Kothiwal Dental College and Research Centre, Moradabad, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: Diabetes mellitus (DM) is a chronic, noncommunicable disease with concomitant oral manifestations that impact on dental care. Aim: To determine the correlation between glycemic control and periodontitis among 35-45 years aged patients with DM type 2 (DM2). Materials and Methods: A convenient sample of 40 subjects aged 35-45 years with DM2 on oral medication were recruited for the study. Glycosylated, hemoglobin(HbA1c), probing pocket depth (PPD), gingival index (GI), plaque index (PI), and the relevant drug history were recorded. The data were analyzed using unpaired student t-test to compare the means of PPD, GI, PI between different HbA1c levels, gender, and duration of drug, and the Pearson correlation was used to find correlation between HbA1c and PPD, GI, PI, duration of drug. Results: With the increase in HbA1c values there was a significant rise in PPD, PI scores, and GI scores (P < 0.001). Diabetic males had a higher PPD, PI, and GI score as compared to females. With the increase in duration of the drug, there was an increase in PPD, which was found to be statistically nonsignificant. Conclusion: Patients are having poor glycemic level had more severe periodontitis as compared to patients having a fair glycemic level.
Keywords: Diabetes mellitus type 2, glycosylated, hemoglobin A, periodontitis
|How to cite this article:|
Tandon V, Tangade P, Lingesha RT, Tirth A, Pal SK, Yadav V. Glycemic control and periodontal disease in type 2 diabetes mellitus patients: A cross-sectional study. J Indian Assoc Public Health Dent 2015;13:297-301
|How to cite this URL:|
Tandon V, Tangade P, Lingesha RT, Tirth A, Pal SK, Yadav V. Glycemic control and periodontal disease in type 2 diabetes mellitus patients: A cross-sectional study. J Indian Assoc Public Health Dent [serial online] 2015 [cited 2019 Dec 9];13:297-301. Available from: http://www.jiaphd.org/text.asp?2015/13/3/297/165279
| Introduction|| |
Diabetes mellitus (DM) is a chronic, noncommunicable disease and also one of the major global public health issues. It is defined as a clinical syndrome characterized by hyperglycemia due to absolute or relative deficiency of insulin. An elevation of blood glucose level (hyperglycemia) is the primary feature of DM and results from a defect in insulin secretion by pancreatic β cells, a decrease in insulin sensitivity, or a combination of both.  The most common form of DM is DM type 2 (DM2), which accounts for 85% of all diabetes patients.  DM currently is the twelfth leading cause of death in the world. The prevalence of DM has risen dramatically in recent years, resulting in a rapid increase in diabetic patients. Asia, in particular, has the highest prevalence of diabetes in the world. Countries exhibiting the fastest rate in diabetic population growth include India and China, among many other developing countries. 
Hyperglycemia triggers a wide variety of long-term complications in diabetics such as large vessel diseases, cardiomyopathy, and kidney and eye impairments.  Periodontal disease is the most prevalent oral complication in patients with DM2. The risk of developing periodontitis may be greater in patients with diabetes who have poor glycemic control than that in patients with well-controlled diabetes. In the Third National Health and Nutrition Examination Survey, which included thousands of Americans, adults with poorly controlled diabetes had an almost three-fold increased risk of having periodontitis compared with that in adult subjects without diabetes, while subjects with diabetes and good glycemic control had no significant increase in risk. 
When oral hygiene is compromised, oral bacteria may form a plaque biofilm, which is resistant to chemicals and immune cells. , Without mechanical debridement, the plaque biofilm matures and causes gingivitis in a few days. Gingivitis represents chronic but reversible inflammation and can be usually treated by proper plaque control. Gingivitis typically extends to irreversible periodontitis for months or years. , This accumulation of plaque acts as a local irritant in the oral cavity.
The evidence of a direct relationship between periodontal disease and diabetes, gathered from thorough reviews, is strong.  It appears that diabetics have an increased susceptibility to periodontitis that is related to diabetes control  and duration of disease.  The objective of the present study is to determine the correlation between glycemic control and periodontitis among 35-45 years aged patients with DM2.
| Materials and methods|| |
A cross-sectional study was designed with a convenient sample of 40 patients aged 35-45 years that was estimated on the basis of previous studies.  A patient who came to Diabetic Centre, Moradabad for their routine checkup, and investigation were screened for DM2 and Periodontitis. Patients who fulfilled the eligibility criteria and signed the informed consent were recruited in the study. This study was reviewed and approved by the Institutional Ethical Review Committee.
The inclusion criteria included: Blood sugar controlled only with oral hypoglycemic agents and no systemic antibiotic administration or periodontal treatment within the last 6 months. The exclusion criteria included: Patients with known systemic diseases other than DM2, tobacco, and alcohol users and patients who were suffering from an oral disease that need emergency treatment such as endo-perio lesion, periodontal abscess.
Before starting the study, the examiner was calibrated so as to achieve a minimum kappa value of 0.80. In order to ensure intra examiner consistency, a randomly selected group of 6 patients was examined and re-examined for the plaque index (PI) score, gingival index (GI) score, and probing pocket depth (PPD) in mm. The scores were assessed for reliability by applying the kappa statistic. The kappa value for intra examiner reliability ranged from 0.89 to 0.92.
Glycemic status was assessed by the glycelated hemoglobin (HbA1c) and fasting blood sugar level. Participating subjects were interviewed for the demographic data, medical history, duration, and the frequency of a drug and were cross-verified with the hospital records.
The oral examination was conducted in dental clinical wing of the diabetic center. Periodontal pocket depth was assessed by measuring PPD with the UNC-15 probe at six points for each tooth, and the arithmetic mean value of all the teeth was considered. Gingival status was assessed by GI, Loe and Silness.  Dental plaque was assessed by PI. 
In the present study, unpaired t-test was applied to find the statistical difference in PPD, GI, and PI with glycemic level (HbA1c), gender, and duration of the drug. GraphPad QuickCalcs: t test calculator" (GraphPad Software Inc., USA)  is also used to find the Pearson correlation between PPD, GI, PI, and duration of the drug with HbA1c. Statistical significant was set at P = 0.05.
| Results|| |
The present study was carried out with an objective to find the correlation between the HbA1c and periodontitis among the 40 patients (26 males and 14 female) with a mean age of 38.4 years. The PPD ranged from 3.9 mm to 6.19 mm with a mean of 5.08 mm while GI score ranged from 1.7 to 2.43 with the mean of 2.16 and PI score ranged from 1.3 to 2.4 with the mean of 1.89.
[Table 1] shows that patients with poor HbA1c value (≥8.2%) had greater mean PPD, GI score, and PI score as compared to the patients having fair HbA1c value (<8.2%) and this was found to be statistically significant (P = 0.0001). A strong positive correlation was also found between HbA1c and PPD (r = 0.85), GI (r = 0.82), and PI (r = 0.75) [Figure 1] [Figure 2] [Figure 3].
|Figure 1: Correlation between probing pocket depth and glycosylated hemoglobin (HbA1c)|
Click here to view
|Figure 2: Correlation between gingival index and glycosylated hemoglobin (HbA1c)|
Click here to view
|Figure 3: Correlation between plaque index and glycosylated hemoglobin (HbA1c)|
Click here to view
When males and females are compared for PPD, GI and PI, males were found to have higher PPD as compared to females, while there was a slight rise in GI scores and PI scores in males as compared to female patients. Though, there was a rise in PPD, GI and PI in males as compared to a female this rise was be statistically nonsignificant [Table 1].
|Table 1: Comparison of periodontal parameters with glycemic level, gender, and duration of drug |
Click here to view
Of 40 subject, 15 patients those who were on medication for more than 5 years showed higher mean PPD (P = 0.0230), GI (P = 0.0472), and PI (P = 0.0460) and this rise was found to be statistically significant. While a moderate correlation (r = 0.52) was seen between the duration of drug and PPD [Figure 4].
| Discussion|| |
Very often, course of the periodontal disease is modified by the systemic disorders of patients. These systemic disorders exert the effect in a generalized manner and therefore also affect the occurrence and management of the periodontal conditions. One of such systemic conditions playing an important role in the etiology of the periodontal disease is DM. 
The finding that DM2 subjects have an increased prevalence and severity of periodontitis in our study is in accordance with other studies. 
An abundance of recent evidence has consolidated a bidirectional correlation between diabetes and periodontitis. While diabetes is an independent risk factor for periodontitis,  periodontitis as a chronic inflammation has a negative impact on the metabolic control of diabetes.  DM and periodontitis are common multigenetic and multifactorial chronic diseases with a higher incidence at increased age. Both of the morbidities negatively affect periodontal health and systemic health, thus affecting the quality of life. 
As the value of HbA1c increases there is increase in the mean PPD value. This is because hyperglycemia impairs overall cell function, as insulin is required for glucose to enter cells to provide a source of energy. Furthermore, hyperglycemia alters collagen metabolism, which predisposes to impaired wound healing. In general, hyperglycemia results in the formation of proteins known as advanced glycation end products (AGEs). AGEs may be associated with a state of enhanced oxidative stress, thereby accelerating tissue injury. Finally, hyperglycemia and the imbalance in lipid metabolism impair neutrophil and monocytes functioning.  Significant association between DM2 and periodontal disease was found by using the deep periodontal pockets as the clinical parameter for periodontal disease severity.  All of these factors may contribute to DM2 predisposing to the pocket formation.
The PI values were minimum in patients having healthy periodontium but increased gradually with the progress of the periodontal disease except for localized periodontitis. Plaque acts as a local irritant in the oral cavity.
Regarding the influence of diabetes on periodontium, there are two schools of thoughts. One school of thought has reported increased severity of periodontal disease in diabetics not related to increased local irritants. According to them angiopathy, abnormal collagen metabolism, abnormal polymorphonuclear cell function, and altered sulcular microbial flora are found in close association with the severity of periodontitis in diabetic patients. These factors reduce the defensive capacity of tissues and may disturb the tissue response to local irritants.  Another school of thought recognizes no relationship between diabetes and periodontal disease and maintains that when two conditions exist together, it is a coincidence rather than a specific cause and effect relationship. According to them, the distribution and severity of local irritants affect the severity of periodontal disease in diabetics. In the present study, effect of blood glucose level is directly related to the plaque which is similar to the results shown by Southerland et al.  Previous pathological study showed diabetic patients had a larger content of lipid-rich plaque compared with nondiabetic patients.  The result of the study (Ricardo Faria-Almeida, Ana Navarro, and Antonio Bascones, 2006) showed a statistically significant relationship between PI and HbA1C (P = 0.0001) which was similar to our study.
Although, the sex interaction in the present study did not reach statistical significance, the observation that periodontal disease was apparently more strongly associated with incident type 2 diabetes among women may be worthy of note, given recent findings that inflammation was a stronger predictor of type 2 diabetes in women than in men.  Rajhans NS  found that periodontal disease increases in prevalence and severity with the age of the patient which was similar to the result of our study.
Cerda et al.  had concluded that the duration of diabetes was a significant factor for the severity of periodontal disease. Emrich et al. stated that the diabetic status was significantly and strongly related to both prevalence and severity of periodontal disease. The severity of periodontal disease was more prevalent in diabetics who had the disease for >5 years. The finding of our study is consistent with the above studies but contradictory with Faulconbridge et al. 
From the present study, it can be speculated that poorer the control and longer the duration of diabetes, the greater will be the prevalence and severity of periodontal disease.
A limitation of this study is that we did not use a population-based sampling scheme to select DM2 patients. However, patients with DM2 regularly visit hospitals to make use of the laboratory facilities. Thus, selection of DM2 patients from the diabetic center does not mean that only a subset of patients with more severe DM2 patients was selected. The present study concludes that diabetes plays a role in the initiation and progression of periodontal disease along with multiple factors. Particularly poor metabolic control, as well as extended duration of diabetes, is a risk factor for periodontitis when extensive local irritants are present on teeth. The dentist can play an important role in diabetic patients overall health care through recognition and treatment of their periodontal needs understanding it as the "Sixth Complication of DM." The better you control your blood sugar level, the less likely you are to develop dental problems and vice versa.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
American Diabetes Association. Diagnosis and classification of diabetes mellitus (Position Statement). Diabetes Care 2009;32 Suppl 1:S62-7.
Mealy B. Diabetes mellitus. In: Greenberg MS, Glick M, editors. Burket′s Oral Medicine Diagnosis and Treatment. 10 th
ed. New York: B.C. Decker Inc.; 2003. p. 563-77.
Awuti G, Younusi K, Li L, Upur H. Epidemiological survey on the prevalence of periodontitis and diabetes mellitus in Uyghur adults from rural Hotan area in Xinjiang. Exp Diabetes Res 2012;2012:1-7.
Cerbone AM, Macarone-Palmieri N, Saldalamacchia G, Coppola A, Di Minno G, Rivellese AA. Diabetes, vascular complications and antiplatelet therapy: Open problems. Acta Diabetol 2009;46:253-61.
Tsai C, Hayes C, Taylor GW. Glycemic control of type 2 diabetes and severe periodontal disease in the US adult population. Community Dent Oral Epidemiol 2002;30:182-92.
Feres M, Figueiredo LC. Current concepts in the microbial etiology and treatment of chronic periodontitis. J Int Acad Periodontol 2009;11:234-49.
Highfield J. Diagnosis and classification of periodontal disease. Aust Dent J 2009;54 Suppl 1:S11-26.
Rees TD. The diabetic dental patient. Dent Clin North Am 1994;38:447-63.
Tervonen T, Oliver RC. Long-term control of diabetes mellitus and periodontitis. J Clin Periodontol 1993;20:431-5.
Belting CM, Hiniker JJ, Dummett CO. Influence of diabetes mellitus on the severity of periodontal disease. J Periodontol 1964;35:476-80.
Kiran M, Arpak N, Unsal E, Erdogan MF. The effect of improved periodontal health on metabolic control in type 2 diabetes mellitus. J Clin Periodontol 2005;32:266-72.
Loe H, Silness J. Periodontal disease in pregnancy. I. Prevalence and severity. Acta Odontol Scand 1963;21:533-51.
Silness and Löe H. The gingival index, the plaque index and the retention index systems. J Periodontol 1967;38 Suppl: 610-6.
Rajhans NS, Kohad RM, Chaudhari VG, Mhaske NH. A clinical study of the relationship between diabetes mellitus and periodontal disease. J Indian Soc Periodontol 2011;15:388-92.
Taylor GW. Bidirectional interrelationships between diabetes and periodontal diseases: An epidemiologic perspective. Ann Periodontol 2001;6:99-112.
Grossi SG, Genco RJ. Periodontal disease and diabetes mellitus: A two-way relationship. Ann Periodontol 1998;3:51-61.
Brown LJ, Brunelle JA, Kingman A. Periodontal status in the United States, 1988-1991: Prevalence, extent, and demographic variation. J Dent Res 1996;75:672-83.
Janket SJ, Jones JA, Meurman JH, Baird AE, Van Dyke TE. Oral infection, hyperglycemia, and endothelial dysfunction. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2008;105:173-9.
Sandholm L, Swanljung O, Rytömaa I, Kaprio EA, Mäenpää J. Periodontal status of Finnish adolescents with insulin-dependent diabetes mellitus. J Clin Periodontol 1989;16:617-20.
Southerland JH, Taylor GW, Offenbacher S. Diabeties and periodontal infection. Clin Diabetes 2005;23:171-8.
Moreno PR, Murcia AM, Palacios IF, Leon MN, Bernardi VH, Fuster V, et al.
Coronary composition and macrophage infiltration in atherectomy specimens from patients with diabetes mellitus. Circulation 2000;102:2180-4.
Desvarieux M, Schwahn C, Völzke H, Demmer RT, Lüdemann J, Kessler C, et al.
Gender differences in the relationship between periodontal disease, tooth loss, and atherosclerosis. Stroke 2004;35:2029-35.
Cerda J, Vázquez de la Torre C, Malacara JM, Nava LE. Periodontal disease in non-insulin dependent diabetes mellitus (NIDDM). The effect of age and time since diagnosis. J Periodontol 1994;65:991-5.
Faulconbridge AR, Bradshaw WC, Jenkins PA, Baum JD. The dental status of a group of diabetic children. Br Dent J 1981;151:253-5.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]