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 Table of Contents  
ORIGINAL ARTICLE
Year : 2015  |  Volume : 13  |  Issue : 4  |  Page : 393-398

Periodontal status among type II diabetic and nondiabetic individuals in Chennai, India: A comparative study


1 Department of Public Health Dentistry, Thai Moogambigai Dental College and Hospital, Chennai, Tamil Nadu, India
2 Department of Public Health Dentistry, Meenakshi Ammal Dental College and Hospital, Chennai, Tamil Nadu, India
3 Department of Public Health Dentistry, Narayana Dental College and Hospital, Nellore, Andhra Pradesh, India

Date of Web Publication7-Dec-2015

Correspondence Address:
R Kesavan
Department of Public Health Dentistry, Thai Moogambigai Dental College and Hospital, Golden George Nagar, Mogappair, Chennai, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2319-5932.171167

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  Abstract 

Introduction: Periodontitis is referred to as the sixth complication of diabetes mellitus. If left untreated, periodontitis can lead to tooth loss, thereby compromising a patient's ability to maintain a proper diet and affecting the quality of life. Aim: To assess the periodontal status among type II diabetic and nondiabetic individuals in Chennai city. Materials and Methods: A hospital based cross-sectional comparative study was conducted among diabetics and nondiabetic population attending a government hospital in Chennai city. The WHO Oral Health Assessment Form (1997) was used to assess the periodontal status. The final sample size of the study was 1000 which included 500 diabetics and 500 nondiabetics. Results: This study showed a significant association between the diabetic status and periodontal disease. The severity of periodontal disease was high among diabetics when compared to nondiabetics. The mean number of sextants with shallow pockets was 0.76 ± 1.20 among diabetics and 0.49 ± 0.86 among nondiabetics (P < 0.0001). The mean number of sextants with Loss of Attachment score of 1 (4–5 mm) was 0.67 ± 1.05 among diabetics and 0.32 ± 0.70 among nondiabetics. Conclusion: Periodontal disease was more frequent and severe in diabetic patients as compared to nondiabetics although there are a number of questions need to be answered in future research.

Keywords: Dental hygiene, diabetics, loss of attachment, periodontal pocket


How to cite this article:
Kesavan R, Chaly PE, Reddy V C, Mary A V. Periodontal status among type II diabetic and nondiabetic individuals in Chennai, India: A comparative study. J Indian Assoc Public Health Dent 2015;13:393-8

How to cite this URL:
Kesavan R, Chaly PE, Reddy V C, Mary A V. Periodontal status among type II diabetic and nondiabetic individuals in Chennai, India: A comparative study. J Indian Assoc Public Health Dent [serial online] 2015 [cited 2018 Nov 17];13:393-8. Available from: http://www.jiaphd.org/text.asp?2015/13/4/393/171167


  Introduction Top


Periodotal diseases are bacterially induced chronic inflammatory diseases affecting the tissues surrounding and supporting the teeth. The lesion begins as gingivitis, an inflammation of the gingival tissues only, and may progress to periodontitis, where destruction of connective tissue attachment and alveolar bone can eventually lead to tooth loss.[1] Periodontitis was referred to as the sixth complication of diabetes mellitus.[2] In the 1997 report of the Expert Committee on the Diagnosis and Classification of Diabetes Mellitus, periodontitis was cited as one of the pathological conditions often found in patients with diabetes.[3] Indeed, multiple studies have provided conclusive evidence that the prevalence, severity, and progression of periodontal disease are significantly increased in patients with diabetes.[4] If left untreated, periodontitis can lead to tooth loss, thereby compromising a patient's ability to maintain a proper diet and affecting the quality of life.

India, with 62 million diabetic individuals as on 2014, currently has the highest incidence of diabetes worldwide; these numbers are predicted to increase to 80 million by the year 2030.[5] The prevalence of diabetes is increasing in view of more and more urbanization, industrialization and change in lifestyle. It is imperative that earlier the disease is diagnosed, the easier it is to treat effectively and greater the chances of avoiding the development of serious complications.[6]

Diabetes is considered by Carranza as a systemic promoting factor creating suitable conditions for local agents producing gingivitis and periodontitis.[7] Chennai is the fourth largest city in India and the prevalence of diabetes in Chennai is 13.5% as on 2014.[5] There are not many studies conducted in Chennai to assess the oral health status of diabetes patients and hence this study was an attempt to examine the type II diabetic patients and to assess the possible relationship between diabetes mellitus and the development of periodontal disease.

Aim

To assess the periodontal status among type II diabetic and nondiabetic individuals in Chennai city.

Objectives

  • To evaluate the periodontal status among type II diabetics and nondiabetics
  • To assess the oral hygiene status among diabetics and nondiabetics
  • To compare the periodontal status of diabetics and nondiabetics.



  Materials and Methods Top


A hospital based cross-sectional comparative study was conducted among diabetics and nondiabetic population attending the Government Stanley Hospital in Chennai city. Ethical clearance was obtained from the Institutional Review Board. Permission to examine the patients and record their personal data was obtained from the concerned authorities of the hospital. Training exercises were first carried out in the department on the out-patients under the guidance of an experienced person. A group of 10 subjects were examined on successive days to assess the consistency of inter examiner reproducibility. The agreement for most assessments was found to be 85%. For the pilot study, 50 diabetic and 50 nondiabetic subjects were examined for periodontal status according to the WHO Basic Oral Health Assessment (1997).[8]

Inclusion criteria

For diabetics

  • Subjects with type II diabetes
  • Should have a minimum of 16 functional teeth in the oral cavity
  • Individuals in the age group of 35–74 years
  • They should be free of major health problems
  • Not taking any medications other than vitamins or occasional analgesics.

    For nondiabetics

  • Nondiabetic control group should have no symptoms of diabetes and random blood sugar level <200 mg/dl
  • Should have a minimum of 16 functional teeth in the oral cavity
  • Individuals in the age group of 35–74 years
  • They should be free of major health problems
  • Not taking any medications other than vitamins or occasional analgesics.


Exclusion criteria

  • History of cardiovascular diseases
  • History of epileptic disorders
  • History of systemic antibiotic administration within the last 3 months
  • Presence of hematological disorders like leukemia
  • Specific conditions like pregnancy, concurrent infections
  • Periodontal surgical treatment 6 months prior to the study
  • Patients with poor dexterity in performing oral hygiene practices.


Sample size estimation

To evaluate the proportions of periodontal disease in people with type II diabetes and nondiabetics with a P < 0.05 and 90% power, the required sample size was calculated. The prevalence of periodontal disease was calculated from the pilot study. Although the minimum sample size required for each group based on 90% power was only 377 it was decided to examine 500 individuals to increase the power of the study. Therefore, the final sample size of the study was 1000 which included 500 diabetics and 500 nondiabetics.

Sampling methodology

Patients attending the diabetic OP and who are fulfilling the inclusion criteria were randomly selected for the study. Nondiabetics (control group) were selected from the individuals accompanying the patients (i.e., attendants, relatives, friends, spouses, etc.) and were matched by age and sex. The nondiabetics were tested for random blood sugar level using a glucometer (Acu-Check Active).

Collection of data

The study subjects were first explained about the purpose and nature of the study. After obtaining expressed oral consent, a face to face interview was conducted to get the information regarding their demographic details and to assess their oral hygiene practices. A semi closed ended questionnaire was used to collect information about age, sex, and level of education and occupation.[9] The questionnaire is filled by the examiner to ensure uniformity in data collection and to avoid misinterpretation of the questions by the study subjects. The questionnaire was pretested during the pilot study.

The interview was followed by the clinical examination, which was conducted by a single examiner who was trained and calibrated. Subjects were seated comfortably on an ordinary chair. The examination was done under natural daylight using plane mouth mirror and explorer (type III examination). Oral hygiene status was assessed using Oral Hygiene Index - Simplified.[10] Periodontal status was assessed by the Community Periodontal Index (CPI), and loss of attachment (LOA) using mouth mirror and CPI Treatment Needs C probe.[8]

Statistical analysis

Statistical analysis was done using SPSS (Statistical Package for Social Sciences) Statistics for Windows, Version 17.0, SPSS Inc., Chicago. Comparison of proportions of various characteristics was done using Pearson's Chi-square test and Fisher's exact test. Mean values were compared between the study groups using Student's independent t-test. In this study, P < 0.05 was considered as the level of significance.


  Results Top


Among diabetics; 28.8% (144) were in the age group of 35–44, 37.6% (188) were in the group of 45–54, and 9.8% (49) were in the age group of 65–74. Among nondiabetics; 33% (165) were in 35–44 age group, 42.6% (213) were in the age group of 45–54, and 8.2% (41) were in the group of 65–74 [Table 1].
Table 1: Distribution of study subjects according to age and gender

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Among the diabetics; 15.6% (78) were illiterate, 23.8% (119) had completed secondary school and 7.8% (39) had done graduation. Among the nondiabetics; 10% (50) were illiterate, 27.8% (139) had completed secondary school, and 12.6% (63) had done graduation [Figure 1].
Figure 1: Distribution of study subjects based on educational level

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Among the diabetics; 15.6% (78) were nonskilled workers, 20% (100) were skilled workers and 18% (90) were businessmen; and among nondiabetics; 13.8% (69) were nonskilled workers, 23.6% (118) were skilled workers, and 18.3% (92) were businessmen. Most of the women in both the groups were housewives [Figure 2].
Figure 2: Distribution of study subjects based on occupation

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Among the diabetics; 5.8% (29) had good oral hygiene, and 22% (110) had poor oral hygiene. Among nondiabetics; 5% (25) had good, and 37% (185) had poor oral hygiene. The difference was found to be statistically very highly significant [Figure 3].
Figure 3: Oral Hygiene status among the study subjects

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Among the study population, 57.4% (287) of diabetics and 64.2% (321) of nondiabetics had a highest CPI score of 2 (calculus). The difference was statistically significant (P = 0.03). 3.8% (19) of diabetics and 1.4% (7) of nondiabetics had a highest score of 4 which was statistically significant (P = 0.03) [Table 2].
Table 2: Distribution of periodontal status (highest CPI scores) among the study subjects

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The mean number of sextants with shallow pockets was 0.76 ± 1.20 among diabetics and 0.49 ± 0.86 among nondiabetics. The difference noted was statistically very highly significant (P< 0.0001). The mean number of sextants with deep pockets was 0.06 ± 0.39 among diabetics and 0.02 ± 0.20 among nondiabetics, which was statistically significant (P< 0.05) [Table 3].
Table 3: Mean number of sextants affected by different periodontal conditions among the study subjects

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Among the study population, 63% (315) of diabetics and 77% (386) of nondiabetics had a highest LOA score of 0 (0–3 mm). 28.2% (141) of diabetics and 15% (77) of nondiabetics had a highest LOA score of 1 (4–5 mm). The differences were statistically very highly significant (P< 0.0001). The differences were not significant for other scores of LOA [Table 4].
Table 4: Distribution of LOA (highest LOA scores) among the study subjects

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The mean number of sextants with an LOA score of 0 (0–3 mm) was 5.08 ± 1.42 among diabetics and 5.49 ± 1.11 among nondiabetics. The mean number of sextants with LOA score of 1 (4–5 mm) was 0.67 ± 1.05 among diabetics and 0.32 ± 0.70 among nondiabetics. The differences noted were statistically very highly significant (P< 0.0001). No statistical difference was noted for other scores of LOA [Table 5].
Table 5: Mean number of sextants affected by different LOA scores among the study subjects

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  Discussion Top


Diabetes mellitus is a clinically and genetically heterogeneous group of metabolic disorders manifested by abnormally high levels of glucose in the blood. There are many reports in the literature concerning the influence of diabetes on oral health.[1],[2],[3],[4] However, the spectrum of examinations was very narrow, and the choice of indices was diverse in character.[1],[2],[4] Therefore, this study was conducted to assess and compare the periodontal status of diabetic patients with that of nondiabetics, to provide additional information to the existing literature.

The study consisted of equal number (250) of males and females in both the diabetic and nondiabetic group. The subjects were selected based upon certain inclusion and exclusion criteria. The age of the study population ranged from 35 to 74 years, and most of the subjects were in the age group of 45–54 years. This was done to minimize bias due to misclassification of diabetes type. More than 95% of individuals in the world with diabetes who are 45 years of age and older have type II diabetes. [11] Therefore, the effect of type II diabetes on oral health can be monitored among these age groups.

Most of the study subjects had secondary school education and few of them were illiterate. Skilled and nonskilled workers constituted the majority of the study population. Among female subjects, more than 70% were housewives.

The oral hygiene status was better among diabetics when compared to nondiabetics. Only 22% of diabetics had poor oral hygiene compared to 37% among nondiabetics which was significantly high. This was in contrast to the study conducted by Hintao et al.[12] where nondiabetics had better oral health status. Kawamura et al.[13] in Japan found no statistical difference in oral hygiene status among the study population.

This study showed a significant association between diabetic status and periodontal disease. The severity of periodontal disease was high among diabetics when compared to nondiabetics.

There was no statistical difference in the distribution of the highest CPI code of 0 (healthy) and 1 (bleeding) between the two groups. But the mean number of sextants having CPI code of 0 was significantly less among diabetics than nondiabetics, which coincides with the studies conducted by Al-Khateeb et al.[14] and Reddy and Maurya.[15] This may be due to the high prevalence of periodontal disease among diabetics.

The mean number of sextants having CPI code of 1 was also significantly lower in diabetics when compared to nondiabetics which are consistent with the findings of Al-Khateeb et al.[14] and Reddy and Maurya.[15] In contrary to the above finding, bleeding on probing was more common and frequent among diabetics compared to nondiabetics in studies conducted by some authors.[12],[13],[16],[17] Similar studies conducted by Collin et al.[18] and Moore et al.[19] showed no difference in bleeding scores among the study subjects.

The distribution of the highest CPI code of 2 (calculus) was significantly lower among diabetics when compared to nondiabetics. But there was no statistical difference in the number of sextants with a CPI code of 2 between the groups. These findings were in agreement with the studies of Collin et al.[18] and Campus et al.[20] But studies conducted among the Arabian community,[14] Gila River community [21] and Japanese community [13] showed that the calculus score was significantly higher among nondiabetics. This may be due to the fact that the diabetics are more prone for dental problems which made them to visit the dentists more often when compared to nondiabetics. In this study, there was no statistical difference in the distribution of highest CPI code of 3 (shallow pockets) among the study subjects. Contradictory to the above finding, a study conducted by Reddy and Maurya [15] showed that the distribution of the highest CPI code of 3 was significantly more among diabetics. The distribution of the highest CPI code of 4 (deep pockets) was more among diabetics which is similar to the study conducted by Reddy and Maurya.[15] The mean number of sextants with shallow pockets (code 3) and deep pockets (code 4) was significantly higher among diabetics than nondiabetics. These findings were similar to the studies conducted by most of the authors.[14],[16],[17],[18],[20] Similar studies conducted by Mattout et al.[22] and Collin et al.[18] showed no significant difference in the prevalence periodontal pockets among diabetics and nondiabetics.

Among the 1000 study population examined, subjects with no LOA (code 0) was more among nondiabetics when compared to diabetics. The mean number of sextants with LOA code of 0 was also more among nondiabetics. The distribution of the highest LOA code of 1 (4–5 mm) and the mean number of sextants with code 1 was higher among diabetics than nondiabetics. Similar findings were observed in studies conducted among other populations.[1],[12],[15],[17],[22],[23] But a study conducted by Collin et al.[18] showed no significant difference in LOA scores among diabetics and nondiabetics. No statistical difference was noted for other scores of LOA in this study, but a study conducted by Emrich et al.[21] showed that LOA >5 mm was more among diabetics.

The literature on diabetes mellitus is abounding with conflicting results of studies designed to investigate the association between it and dental disease in different communities. This apparent conflict might, however, be more readily acceptable if it was also accepted that the condition of diabetes mellitus itself might be due to genetic and environmental factors which vary from one community to another.[14] The findings of this study confirmed that in an Indian community, the experience of periodontal disease is greater in diabetic patients, and it occurs in more severe forms in this group than in nondiabetics.

Limitations

It must be emphasized that the results of this study may not be directly comparable with the results of others. This is due to many differences such as the population size, selection criteria for diabetic and nondiabetic groups, types of periodontal assessment performed, number of examiners, blinding of examiners, and intra- and inter-subject variations in measurements.

As this study was conducted in a government hospital, most of the subjects are of lower socioeconomic status. This could prevent the generalization of the findings to the entire population which can be a limitation of the study.

Recommendations

  • There is an absolute necessity for adopting preventive dental health care programs among diabetics so as to minimize the prevalence of periodontal disease
  • Longitudinal studies of the natural course of periodontal disease in subjects suffering from various types of diabetes and with varying degree of diabetic control comparing the results obtained with those recorded in systematically healthy subjects would be particularly interesting
  • As diabetes and periodontal disease are chronic diseases, the subjects in future studies should be homogenized according to age groups, with each group compared with different variables such as type, duration, and diabetic complications.



  Conclusion Top


This study confirmed previous controlled studies indicating that diabetes increases the prevalence and severity of periodontal disease. Periodontal disease is more frequent and severe in diabetic patients as compared to nondiabetics. Therefore, the effect of diabetes on periodontal tissues comprises a serious problem and should become the scope of intensified preventive and therapeutic activities of diabetologists and dental practitioners.

Acknowledgment

The authors would like to thank the Government Stanley Medical College and Hospital, Chennai.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Lalla E, Park DB, Papapanou PN, Lamster IB. Oral disease burden in Northern Manhattan patients with diabetes mellitus. Am J Public Health 2004;94:755-8.  Back to cited text no. 1
    
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Report of the expert committee on the diagnosis and classification of diabetes mellitus. Diabetes Care 1997;20:1183-97.  Back to cited text no. 3
    
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Mohan V, Deepa M, Deepa R, Shanthirani CS, Farooq S, Ganesan A, et al. Secular trends in the prevalence of diabetes and impaired glucose tolerance in urban South India – The Chennai Urban Rural Epidemiology Study (CURES-17). Diabetologia 2006;49:1175-8.  Back to cited text no. 6
    
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Hintao J, Teanpaisan R, Chongsuvivatwong V, Dahlen G, Rattarasarn C. Root surface and coronal caries in adults with type 2 diabetes mellitus. Community Dent Oral Epidemiol 2007;35:302-9.  Back to cited text no. 12
    
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Kawamura M, Fukuda S, Kawabata K, Iwamoto Y. Comparison of health behaviour and oral/medical conditions in non-insulin-dependent (type II) diabetics and non-diabetics. Aust Dent J 1998;43:315-20.  Back to cited text no. 13
    
14.
Al-Khateeb TL, Al-Amoudi NH, Fatani HH, Mira SA, Ardawi MS. Periodontal diseases and caries experience of diabetic patients in an Arabian community. Saudi Dent J 1990;2:91-5.  Back to cited text no. 14
    
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Reddy CV, Maurya M. A comparative study to assess the oral health status and treatment needs of diabetics and non-diabetic population attending some of the hospitals in Mysore city. J Indian Assoc Public Health Dent 2008;12:1-14.  Back to cited text no. 15
    
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Javed F, Näsström K, Benchimol D, Altamash M, Klinge B, Engström PE. Comparison of periodontal and socioeconomic status between subjects with type 2 diabetes mellitus and non-diabetic controls. J Periodontol 2007;78:2112-9.  Back to cited text no. 16
    
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Moore PA, Weyant RJ, Mongelluzzo MB, Myers DE, Rossie K, Guggenheimer J, et al. Type 1 diabetes mellitus and oral health: Assessment of periodontal disease. J Periodontol 1999;70:409-17.  Back to cited text no. 19
    
20.
Campus G, Salem A, Uzzau S, Baldoni E, Tonolo G. Diabetes and periodontal disease: A case-control study. J Periodontol 2005;76:418-25.  Back to cited text no. 20
    
21.
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22.
Mattout C, Bourgeois D, Bouchard P. Type 2 diabetes and periodontal indicators: Epidemiology in France 2002-2003. J Periodontal Res 2006;41:253-8.  Back to cited text no. 22
    
23.
Bridges RB, Anderson JW, Saxe SR, Gregory K, Bridges SR. Periodontal status of diabetic and non-diabetic men: Effects of smoking, glycemic control, and socioeconomic factors. J Periodontol 1996;67:1185-92.  Back to cited text no. 23
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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